Medical leadership during cardiac arrest

[toc]

Question 3 from the first paper of 2001 (and no other question since) asked the candidates about the role and responsibilities of the medical team leader in a cardiac arrest. It is unlikely to ever appear again. If it does, I expect the successful candidate will extrude a page of unbearable motivational team-building gibberish. Specific keywords to include in such spooge would be "situational awareness", "skill mix management ", "closed-loop communication", "collective interaction patterns" and  "adaptive leadership behavior".

The answer below is concocted using the ARC statement as well as a paper by Hunziker et al (2011). The latter is particularly good, and I quote it directly ad libitum throughout this chapter.

Responsibilities of the cardiac arrest team leader

Medical responsibilities

• Assessing the rhythm and evaluating the need for defibrillation
• Ensuring the correct application of ALS and BLS
• Establishing a diagnosis for the cause of the arrest
• Ordering the appropriate investigations
• Ensuring minimal interruptions to CPR
• Ensuring the safety of the resuscitation team
• Ensuring the appropriateness of resuscitative action (i.e. making sure the patient's and their family's wishes are acknowledged)
• Ending the resuscitation attempt when indicated, often in consultation with other resuscitation team members and medical staff otherwise in charge of the patient

Communication responsibilities

• A coordinated rapid and efficient exchange of information, along with continuous CPR
• Communicating information about the arrest between medical and surgical teams, or delegating this and following it up.
• Documentation (including audit forms)
• Organising resuscitation team debriefing.
• Communicating with family and senior members of the primary admitting team

Coordination responsibilites

• Directing and co-ordinating the resuscitation attempt 
• Allocating roles to the rescuers, and coordinating their efforts.
• Recruiting external resources (eg. cardiologists, ICU staff, cardiothoracic surgeons) into the resuascitation effort

Priorities of the team leader in a cardiac arrest situation

As a medical team leader, "what are the priorities of cardiac arrest management which you must help implement?" This sounds complicated, but in fact according to the model answer for Question 3 the college really just wanted you to draw the ALS algorithm. Lets ignore that for a moment. From the team leader's perspective, what are the priorities in a cardiac arrest?

The college answer:

-     immediate basic life support

-     rapid rhythm diagnosis

-     defibrillation for VF, intubation/adrenaline for asystole or PEA

-     continued drug and defibrillation management

-     effective post –resuscitation care

LITFL list a different order:

1.  Immediate Basic Life Support
2.  Rapid rhythm diagnosis with early defibrillation if shockable
3. High quality, appropriately timed CPR (with minimal interruptions) – CAB (new AHA/ILCOR guidelines)
4. Airway and Breathing – intubation and ventilation, titrated FiO2 to SpO2 90%
5. Adrenaline 1mg Q3min IV
6. Correction of cause of arrest
7. Effective post-resuscitation care (therapeutic hypothermia, care of the dead patient and family)

Primate group behaviour at a cardiac arrest

The expectation states theory

• Humans use status indicators to decide how competent a person is.
• These indicators include occupation, sex, race, and physical size.
• Performance expectations are thereby formed; a person who satisfies these status criteria is perceived as being especially qualified.
• Thus, at a cardiac arrest there is a self-organising hierarchy which may not organise around the most competent person, merely the person who appears impressive. Moreover, not everybody will be in agreement as to who that person is. Confusion ensues.

The disadvantages of ad-hoc hierarchy

• Evidence has shown that such ad-hoc hierarchies lead to the performance of poorer quality CPR and delay in the administration of shock and drugs (Hunziker et al, 2009), in comparison to pre-allocated teams.
• When a team leader takes control of an arrest, other team members will defer to this person, and will themselves volunteer fewer ideas.
• For example, highly competent nurses may feel that they are lower in status, and will be less likely to initiate actions.
• Hierarchies lead to the formation of informal rules as to who can and cannot participate in discussion and decisionmaking
• A hierarchy can therefore be an impediment to the exchange of information. The trachea might not be midline, but the airway technician keeps quiet about it because he has been emotionally trampled by the high-powered sociopath from the ICU who has decided that he's leading the arrest.
• Empirical resuscitation studies have shown that providers who openly shared information by thinking aloud, performing periodic reviews of data, and voicing specific findings were found to perform better (Tschan et al, 2006)

Effective leadership behaviour

• Clear and unambiguous instructions. Making use of the expectation states theory, the use of authoritative tone and language are potent status indicators.
• Not getting involved hands-on. One must take an immediately obvious leadership position: i.e. not participating hands-on, but clearly taking a   coordinating role (eg. standing back from the bed with hands behind your back). In fact the team leader's hands-on involvement was so disruptive to the team structure when it happened that the whole resuscitation was performed poorly(Cooper et al, 1999).
• Not getting in the way of the established team leader. When a senior professional arrives, they are better off remaining in a supportive advisory role rather than barging in and making direction-changing statements (Tschan et al, 2006)

Principles of effective teamwork to avoid human errors

• Voice specific findings; avoid interpreting them into a diagnosis (eg. "the trachea is not midline", not "there's a tension pneumothorax"). This is called "explicit communication" rather than "implicit". A study where teams were given an intentionally confusing scenario (Tschan et al, 2009) has demonstrated that explicit communication is less error-prone (the implicitly communicating groups missed the anaphylactic shock in the scenario)
• The leader should ask questions and encourage information sharing,  rather than making statements.
• Think out loud: “talk to the room”
• Encourage the team members to verbalise ongoing observations
• Perform periodic reviews of quantitative information (drug dose, time, and response)
• All members of the team are encouraged to verbalize any doubts.