Ep 8 - Trauma Team Leadership

[Music]

Hello and welcome to the St. Emlyn's podcast. I'm Iain Beardsell and I'm Simon Carley. Today we're going to be talking a little bit about trauma teams, trauma team leadership and making things happen in the recess room. Simon, how about we talk about a trauma case? We'll run it through a hypothetical case, a truly hypothetical case. We just want to talk about how we can make things happen in the resus room.

Perhaps we should just give a bit of background to our trauma system in the UK for our international listeners before we start. So major trauma centres is a pretty new thing for us. Yes. In the last couple of years, trauma services across the country have been reorganised in England and they're about to be reorganised in Ireland and Scotland too. Basically what's happening now is the old system where you go to your local hospital regardless of what your level of injury was.

You're being bypassed to major trauma centres. Is it 14 in the UK? Yeah, 13 or 14 I think. Yeah, so there's different models around, so London's got four because obviously London is really important. In the northwest of England we've got three in Manchester. So we have a slightly older model and I think in Southampton you're a major trauma centre there as well. We are and then along the South Coast there's a couple more up to Bristol, up to Oxford, along to Brighton and down towards Plymouth.

So quite geographically spread out for us from major trauma centres. So we're receiving people from quite a distance away now. It's a similar thing in Manchester particularly for the pediatric trauma centre which covers a vast area. But what it means is that we're specialising in trauma, we're getting more people coming through the door, we're getting more expert.

But we're also being looked at a lot more and we're being evaluated through audit and in particular the TARN network, the trauma audit and research network, who've done fantastic work about improving trauma care in both in the UK and across the globe really. And one of the targets for that, one of the things that we thought we'd talk about today if it's okay is a target for getting all major trauma patients into the CT scanner within 30 minutes of arrival which I find quite challenging.

Within that is a huge challenging target. It's another one of those time related targets which were so fond of in the UK. But it may be that this one actually does have some outcome benefits and it's definitely worth working towards. Doing it may be helpful if we just talk through that hypothetical case and we can see how we manage it. We both have to work as trauma team leaders in our centre. So hopefully we'll have some different ideas we can pitch in about how things would go.

Yeah sure, go for it. Alright let's take a trauma case. Purely hypothetical, you've got a 25 year old motorcyclist who's being brought into you by a paramedic crew. They've been called out to the scene. It's not far from the hospital and they've decided to literally scoop and run. We call it a red phone call, some people call it a bat phone call. They've run through and they've told us a few details and we've put out what we call a level one trauma response.

So we've gathered the trauma team into the recess room. I'm not sure who you have for that in Manchester Simon but for us that would be the ED consultant as the trauma team leader. An ED registrar ready to do the primary survey. An anesthesi ready for airway interventions and the presence of a general surgeon and an orthopedic surgeon and one or two other people in the bay ready to go. We've had a briefing. The team's already to go and they wheel in this young man.

So this is his at missed handover that you receive as a trauma team leader Simon. So he's a 25 year old motorcyclist who was hit by a car approximately 40 minutes ago. The pre hospital service which was a paramedic led crew arrived about 20 minutes ago and have done a few interventions.

The mechanism as I say motorcyclist wearing a helmet hit a car, the car pulled out and the motorcyclist didn't see the car, went straight over the bonnet, fell onto the floor, no apparent loss of consciousness at the time. On arrival the injuries that the paramedics found were a probable minor head injuries with some damage to his helmet.

On chest examination he was complaining of chest pain and some shortness of breath and it was felt that he may have had some crackly feeling across the top of his chest. He also complained of some abdominal and pelvic pain and he appeared to have a fracture to his tip fibber, close fracture on the right hand side.

Vital signs he had a pulse of 120, a blood pressure of 150 over 90, sats of 94% on high floor skin and GCS of 15 and the treatments they'd managed to get into him, they'd put an IV cannula in, they'd given him five milligrams of morphine and they'd have normal saline and they'd put a vacuum splint onto his lower leg where that broken bone was. They complete the handover and you get the patient onto the trolley and the clock has started. What's next?

Good case. I'm familiar with those sort of things. Just a couple of things. In our team we'd have a number of other people in the room as well. We also have radiologists who attend. Incredibly helpful and we'll come onto wine a minute. We get the needstist. Do you just get one or do you get about ten? We actually get an anestist and an intensive care registrar and an ODP, someone who's an airway assistant. So yeah, there's a fair team at the head end. Have you ever seen an anestist on their own?

They hang around with other people. They like to have somebody with them. I think that's good. But yeah, no, so there's lots of people there. We all listen to your excellent mist handling a bit. We've identified a patient who's potentially got quite significant injuries but doesn't seem to be an extremist at the moment. Would that be a fair summary?

He's definitely been injured. He's talking to you. He's in quite a lot of pain. The morphine's done a little bit but he's still got a pretty high pain score. He's lying there pretty what we describe as although I don't like the word stable. Yeah, I know what you mean, but the potential for things getting worse because he's got an injury to the chest by the time things got abdominal pain has got injury to the lower limbs.

So the likelihood is that there'll be other injuries which aren't terribly obvious. And we've got to think about how we're going to identify those, particularly looking for the life threatening injuries and also look for the more occult injuries which might catch us out later on. In the old days, the traditional approach would be to do quite a lot in the recess room for this patient.

Some imaging, some lachel cervical spine x-rays, some chest x-rays, some pelvic x-rays, take some bloods, give some fluids, log roll the patient, do a PR, undress the patient completely, etc etc etc. And if you are working towards a challenge of getting somebody to the scanner in 30 minutes, I don't think you can do that anymore. Let's go back one step show and just think this guy does need a CT scan, doesn't he? Have you decided that already? He's definitely going to have a trauma scan?

I think so, I think there's good evidence out there now that in these patients you get much better, much quicker, much faster, care through diagnosing early and that means an early. We do a pan CT in this guy, I'd be head to mid-fies. So as the trauma team leader, you've made your first decision, which is I want to get this guy to CT scan, but clearly we need to work out if there's anything that needs to happen so we can get him there safely.

Yeah, absolutely. So what's a structured way that you're going to make these things happen in a time efficient manner and what interventions do you want to make before he gets anywhere near leaving the resuscitation room? I suppose we're looking for any A, B or C, critical injuries or life threatening injuries that need resolving now. Now you've already told me as G-SX-15 and he's talking, we're assuming he's not going to major airway problem.

But I'm a bit worried about the chest. You said he's got some surgical amphacine there and it's been complaining of short and subrethyl 94% sat, it's in a young chap on a high flow oxygen. I'm not really very comfortable with that. So I want to know a little bit more about the chest. From a cardiovascular point of view, his injuries would suggest that he could have a bleeding problem, but his observations are equivocal.

It's a bit tacky-cardic, but is in pain and he's got a normal blood pressure, if not a little bit high. My approach would be to get a good primary survey and then we've got to think about what do we mean by a primary survey. How do you conduct your primary survey in the EED?

Well we have a emergency department registrar who does a relatively traditional primary survey, which is has a listen to the chest, looks for expansion of the lung, sees whether the expansion is equal on both sides, has a feel of the trachea and does some cardiovascular parameters. But I have to say the more I do it, the less valuable I think parts of that are, because there's clearly high wins in parts of that examination, but there's other parts that make no difference at all.

And this is time critical and I want to focus on the things that make a difference. So I think there are certain things that make a difference and certain things that we do just because we still haven't quite become comfortable with not doing them. What sort of things do you think he ran?

I think osculating the chest in a recess room is a pretty tricky skill. I'm not sure how often you can make a definitive diagnostic decision based on osculation, especially if you've got an ultrasound machine just next to you. And I just wonder if this case is one where the ultrasound machine replaces a stethoscope. I think you're absolutely right about clinical examination. There's enough here for us to be worried about it.

The additional approach actually is to do a chest x-ray, but chest x-ray takes time. It often requires some movement of the patient or removal of clothing to get a good image. And my experience of chest x-rays in the recess room is there are a Blicodaco Crapograms a lot of the time. That's not because the radiographers are rubbish, it's just because it's bloody difficult to do. I'm a big fan of ultrasound, because ultrasound can potentially give you a definitive diagnosis.

So if you ultrasounded this guy and he had a new mithorax and he also had fluid in the base, would that be enough for you to go forward and put a chest training without waiting for a chest x-ray or waiting for the CT? And further to that, if you're waiting to get to CT, would you go straight for putting a definitive training or would you put a thoracostomy in first? And then would you have to put a definitive training before going?

Depends if the patient's spontaneously ventilating. If they're intubated, then by all means put a thoracostomy in, but if they're spontaneously ventilating, then you're effectively creating an over-numothorax, so I'd put a training. Okay, so as part of our primary survey, ultrasound of the chest is going to become part of our B-assessment, and we're going to bin the chest x-ray. Does that feel a reasonable way forward?

The evidence would suggest that in skilled hands a recess room ultrasound of the chest is better than doing a chest x-ray, and from the practicalities and the time point of view is definitely better. And of course then you can progress with your ultrasound, and also if it's not going to interfere with the time, perform a fast scan as well. And we say in skilled hands, is your radiologist the guy who's coming in and doing this ultrasound, or is it one of the ED stuff?

Do you know that's really interesting? The radiologist are usually happy to perform a fast scan, although in radiology hands it depends very much on the individual. They sometimes struggle with the fast element of the fast scan, it becomes the slow fast scan, because they look at everything as they go around, they're trained to look at everything, whereas we want very time-focused.

I prefer it when we do it ourselves to some extent, but with the radiologist over the shoulder checking what we're looking at, I think that's really powerful for both teaching education and for the patient. They're very, very unhappy, ultrasounding the chest. Interestingly, I've asked them a number of times, and I'm sure there are many radiologists who are happy, but on many occasions I've asked the radiologist, can you tell me if there's any methorax here? And they go, I don't do chests.

I've asked the radiologist, brought up to believe that these skills are relatively straightforward to teach, and they're quite binary when you can see the pattern. So when you're looking for comet tails or you're looking for the signs of a chest that's down, it's relatively straightforward, isn't it?

I think it's extremely straightforward. I think it's just something which is perhaps not taught in their curriculum, but it is something we do in emergency medicine, so I'm quite happy to continue doing that. So you've got this guy, he's lying nice, he's in quite a lot of pain, and I have to say, when I'm breathing my anaesthetic colleague, they seem very comfortable with everything that starts with A. We've got A way, but I also add in for them analgesia.

So I say to my anaesthes colleague, can you look up to his A way and analgesia? Because often they've got the pain medication at the top end as well. So we've given the guys some more pain relief. Any choice about pain relief? Happy to let them choose. What would you choose? I'm reasonably big fan of opiate surleon. I'm also a big fan of balanced analgesia, so for many patients will give a gram of IV paracetamol as a baseline as well.

If I'm going to proceed and put a chest strain in this guy, which I think we are going to, because we've seen fluid and a new mothorax on the chest, then I think ketamine is ideal for that. I think ketamine is a fantastic agent for putting chest strains in. So you're the trauma team leader, you're conducting this orchestra and you've got the anaesthes helping you out with some analgesia thinking about sedation further down the line.

And you're primarily surveyed doctor, one of your ED staff combined with a radiologist over their shoulder as diagnosed at new mothorax. And we're going to move on to put the chest strain in decision made. And you task one of the members of the team to do that? Who would you choose? Again, it's very interesting, isn't it? In the old days, there are lots of people who have been capable of putting a chest strain in these days, not so much.

We often get surgical members of the team who have just not done them for many, many years. So ordinarily, it's another member of the ED team who does that. And we try and run as many traumas as we can with more than one consultant. So I might be trauma team leading it, but there's almost always another consultant in the department and another consultant who can help. And so either by observing, assisting or by doing such procedures, we can move through those very quickly.

So it's more and more resource heavy, isn't it, at the moment, we've got all these people. But I think we probably both agree that putting a lot of effort into these young, well not even young, but these trauma patients, we can make a big difference further down the line. And it's worth that investment and doubt of, isn't it? So the anesthesia is doing their thing. Your primary survey doctor's diagnosed in you mothorax, you've tasked a member of the team to crack on, prepare the chest strain.

They're going to have to wash their hands and do all that business to get ready. Because sometimes I've seen these drains thrown in in a relatively stressful situation. And I've been as slightly uncomfortable about how clean the procedure is. So you still keep an emphasis on asepsis and doing this slowly, steadily, but it's an all-fistina lentil thing, isn't it? Slowest, smoothest, fast business.

Yeah, I think to put a chest strain in doesn't take very long actually, but try and keep it as clean as possible. You clean the skin, you put drapes on. If you're set up planned and you practice that, you can still do it very quickly. But then, so that's B, what about C? Are we going to do anything for C in this guy? So for me, he's already got some cannula in from the pre-hospital crew.

I want to try and get another one in it possible, but more important than that is to get something going into the cannula that's working and get somebody thinking about it. He's probably bleeding from somewhere. Would you get him blood? I don't think he would trigger for our major hemorrhage packs at this time. He's not been hypotensive. He's GCS-15. We haven't got an active bleeding source as yet. So probably not.

Okay, so he's going to get maybe a bit of Christloid and we're about to ultrasound his abdomen next stage, if there's any bleeding going on in there? Yep, so C interventions, we're going to look for things so fast again. But I'd also be thinking about putting a pelvic binder on this guy if he's not already had one put on pre-hospital as well. It's got lower abdominal pain. It's a significant mechanism injury. I think we should put one of those on. What do you reckon?

I'd be all for that. And definitely keeping an arm where that pelvic binder goes. They always seem to ride up a little bit high. It's almost uncomfortably low. And I enjoy that picture very much on Twitter that showed these binders. They've been warned very much over the hips, like a young lady who's off out to a party rather than a middle-aged woman who's just been treating a wall veteran to a nice cup of tea.

So we really want them low down over the hips themselves, not higher sort of pulling the stomach together. So pelvic binder, but who's going to do this? We've got loads of interventions. And as a trauma team leader, we've got to make them all happen. That's the key to this. How do we get the pelvic binder on? Whilst the chest drains going in, whilst there's an anestheser trying to give pain relief and somebody's trying to cannulate, who's doing what?

Well, allocated tasks, isn't it? So you allocate a task to a person with clear instructions and get them all get on with it. And as TTL, you'll start at the end of the bed. Usually I don't even put gloves on as trauma team leader anymore because it encourages me not to touch the patient. So I stand at the end of the bed and I direct people, I assist them, I make sure they've got the resources to achieve what they need to do. Clear, loudly as an order with pauses nicely.

All the things Clifford talks about in the making things happen talk and you allocate the roles and you make sure it takes place. And I always using first names. I always try and make sure my breathing that we all introduce ourselves to each other using first names, saying what we expect we're going to do.

And even the professor of surgery, I will tend to say, so, Bobby, do you mind if I call you Bobby? We're going to call you Bobby now. There's something about the team removing that hierarchy and the way they work together that I think it's important. And most of our guys seem very comfortable with that. Although some of my junior colleagues are quite surprised when I start calling the professor of general surgery by his first name, but I think it works.

I agree. And when we're doing these sort of things, what we're trying to achieve is concurrent activity. So we're not trying to do the airway, get all that sorted, then we'll do the breathing, then we'll do the circulation things. That's how we taught in ATLS, but in reality, when you have an efficient trauma team, the trauma team's leaders job is to make sure that as much happens concurrently as possible.

So while those three things are going on, I'm also tasking people say in five minutes, we need to move our CT ready for us. Do the radiologists and the radiographers know about it? Is there enough oxygen on the trolley? Where's the transfer bag? Are they on the trauma mattress? So it's situational awareness about what's going on with the patient, what we're doing about it, what it means, but also where we're going next.

And I think the TTL, the really efficient TTLs are very, very good at spotting what we're going to be doing in five minutes time, what we're going to be doing in ten minutes time, and making sure that those are facilitated. And I tend to set time related goals that all the team are aware of, and I verbalize those. So like you say, in five minutes, I want us to have got to this stage and be ready to do the next thing.

And setting those goals, I have to again, we don't want to mention them too often, but it's a cliff read thing. I was lucky enough to be a registrar under cliff when all of this was just starting in the UK. And he was way ahead of his time in the way that he did this. And this is one of the things he always used to say to me and we used to do was we set a time goal, something for everyone to work together as that team building, that team bonding, we're going to get to that common goal.

So we've got our motorcyclist, he's still there, he's a pain has been controlled a bit better now by some IV opiates, he's been given a little bit of ketamine too. The chest drains on its way in, we made a decision about that, the pelvic binder, needed a bit of a roll to get it under.

I think you can pretty much do it with no rolling at all by a bit of jiggling usually. So get it into position. In the old days, we used to log all these patients through 90 degrees to examine the back and then insert a finger in the anus. And I'm not a big fan of that, don't you about you? To be honest, this guy's having a bad enough day anyway, isn't he?

He's been ridden, is lovely new motorbike into a car and all of a sudden we've got all these people sticking stuff in him, one in his chest, somebody sticking something in his arm and then just to round it all off, a big, burly surgical doctor decided to insert his large index finger up his bum and say does that feel normal?

And I still maintain that it never feels particularly normal. I don't know that it's going to pick anything up and we should try and think about the sensitivity and specificity of that as a diagnostic test. I think it's pretty poor. So we're not going to do that anymore. No, good. I'm all on board with that. And our scams going to pick up any spinal potential spinal injury and we're protecting his spine anyway.

So everything's happening all at once. Where are we up to now? We're just about got pain relief and chest drainage, I think it's in by now. Yeah, pelvic binders on. Yep. We're about ready to go CT of call for us. They want to take us. They're ready to go. What do you do next?

Well, we should already have been packaging this patient for transport. So I would have members of the team getting them onto the portable monitors. We've got great monitors which are very, very portable that just come straight off the wall onto the bed and go.

I would make sure that the anesthetic team in particular who are very good at helping with facilitating transfers of check that they've got the right amount of kit for them. We've got the right amount of oxygen that we've got rescue medication and that we are transportation to the CT scanner is going to be quick and easy.

And that will depend on your hospital. We're very lucky. We're about 30, 40 meters down the corridor to CT. I know some places are even better. I think the end has a CT scanner in the research room which is amazing. If your CT scanner is a long way away, it obviously can make your transfers quite tricky. Have you ever heard the phrase the CT scanner is the donors of death? Oh, yeah, many times. I think that's ridiculous.

As emergency departments in the UK, and I'm sure it's around the world, CT on radiology suites, that's where definitive diagnosis takes place. It's where definitive intervention takes place. So if we're a resuscitationist, we've got to be able to be mobile resuscitationists. So we've got to be able to transfer the patients safely, but we've also got to be able to continue resuscitation within the CT scanner.

And I think that's a big change in mindset. Certainly in the UK who used to be in the mind, you have to get the patient stable, whatever the hell that means in the research room before you go to CT scanner. So I don't know about you, but I'm finding that I'm taking much more again. I hate the word unstable patients to CT and continuing the resuscitation as we go.

Can't agree more. And more of us ago, we take a team with us to the scanner now, although we do limit the number of people around in the scanner because we want to let the radiographer and radiologist concentrate on which buttons they're pressing to get the right pictures.

But we have somebody who's always eyeballing the airway type issues. We have the team leader goes with the patient. And in essence, the team leader can stays in control throughout the whole process, making sure that everything is happening safely, which should probably just explain my, well, both of us struggle with stable and unstable.

And me, the description of stable means that you have a set of observations and five minutes later you have a set of observations, which are the same. They are stable observations, but they could be observations that aren't particularly good. So high-potention, one minute high-potention, five minutes later that's stable. Is that similar to why we're being a bit silly about saying we don't like stable and stable?

And also, stable has this idea that there's nothing serious going on, which again could be completely wrong and unstable has the impression that things are terrible, which again is usually the case. But potentially also sometimes wrong, it's just they're not particularly helpful terms. So I say hemodynamically normal or hemodynamically abnormal. So we've got the patient. Now one thing we do at Southampton, which I think works well.

I'm not sure if you do it up at Manchester is we have a pause before we leave the recess room and we go through a trauma transfer checklist. Quick checklist that just goes through and checks. We've done everything we need to do to take the patient safely from the scanner to the scanner. And we do that religiously for every patient. Some of its administration. So in order to facilitate the scan, our patients need to have patient wrist bands on.

But this does matter. These are the things that stop us getting where we need to be. Some of its clinical. How are that observations now? Have we got all the kit we need? Is the oxygen cylinder full? Where are we going to go once we've had the scan? Because occasionally we'll go straight onto theatre or maybe straight to intensive care. But we do a checklist like that before we leave. Do you do something similar? We don't formalise it actually, but I really like that idea.

I'd love to see them. We should check that on the show notes. Absolutely. And it took a bit of practice for us to get into doing it. But it's a straightforward challenge response checklist now. I'll say what it is that I want and I want somebody to say yes we've got it. And like many of these ideas with checklist and other stuff, I think we're learning an awful lot from the pre-hospital environment.

And a lot of our pre-hospital practitioners, those guys in the military, we've become more and more militaristic in the way we do everything. And I think what we're describing is a very set routine of doing things, little variation between practitioners. And I think that's helped us hugely. I think you're right. And one of the things we say is that we've changed our approach to trauma patients in the recess room to become much more like an advanced pre-hospital trauma team.

So we're doing the minimum required to make sure the patient is safe to transfer to CT. That's a different mindset than the one we had five, ten years ago. And we're behaving much almost as if the recess room is almost the roadside with an advanced trauma team there. And the CT is our definitive diagnosis and our definitive destination. It's really, really interesting. It's mean that we've meant that we've had to stop doing a lot of things. And that's good because they were of no value.

So we're getting our patient off to CT. Do you reckon we've made it in 30 minutes? I think we have. So long as we've not done anything which aren't of particular value. So let's just tick a few of those off. Have we done a lateral sea spine of the neck? No. No film. Because it's of no value. Have we done chest x-ray? Still no. Because it's not particularly of a good value if you've got good ultrasoundography. Have we done a pelvic x-ray? No. And we haven't logged all the patient. Definitely not.

We haven't inserted anything into the rectum. Still no. Good. Any other things that we've not done? What about this leg? He broke his leg and he's just in a splint. Do you not want to stick that in a cast before he goes? Stabilise that fracture? If it's comfortable. Why bother? I couldn't agree more. And these things can wait. But you do have colleagues who might be standing behind you. Maybe the orthopedic colleague who says he's desperate, desperate to feel that dorsalist penis pulse.

That's fine. Don't mind a bit of that. But it is hard to stop them reaching for the plaster trolley sometime. You just send him around in the vacuum splint? Absolutely. Because we can address non-life threatening injuries post CT scan. So he's going round to CT and you'd go with him as a trauma team leader? Absolutely. And who else? Usually anesthesia will come with us. I'll take one of the emergency medicine registrars.

The nursing staff who I don't think we've mentioned enough so far are absolutely essential to this. So we'll take at least two members of the nursing staff through with us. And then to some extent we'll take specialists who we've predict have got involvement in the case. So for instance we do see a lot of stabbing in my neck of the woods. We wouldn't necessarily always take orthopedic surgeons through with us for that.

They might have been called on the trauma team. We'll take general surgeons if we think there's going to be a general surgical problem with us. So we do have a little bit of an assessment. But in general, the senior decision makers from the trauma team come with a patient to CT scanner. And that's hugely helpful when you get those first pictures up with your radiology colleagues. Because if there's something that needs intervention, we don't waste our time going back to the recess room.

We can get ourselves straight off to theatre or somewhere else. The bit that we then need to just think about is once we've got to CT what happens next. But perhaps that's a thought for another podcast. So Simon, I think we've pretty much covered everything though of how we want to tackle this case. Is there anything else you'd want to add? No, I don't think so. I think these cases have really challenged what we do around trauma.

And it's a good example of why we're not just following 80 less dogma. We are adjusting what we do to make things happen quickly, efficiently, safely. And also as a team leader to try and make everybody feel that they're valued. Yes, we've gone to a militaristic style with one person in overall control. But the best trauma teams are the ones which are collaborative that work well together, which are friendly, which use first name terms. All of those things that you talked about.

I don't want to see people shouting in the recess room. It's bad for everybody. The best recesses, the best trauma teams are the quietest. So the ones that run in almost silence where people just talk quietly and gently to each other. To me, they're the slickest and smoothest. When people start raising their voice, that's the point where I've either lost control or I need to regain control because something's gone wrong.

Absolutely. And from a patient perspective, can you imagine how terrifying it would be to have a bunch of people shouting over the top of you? Whilst you're strapped down in a neck collar on a scoop stretcher or a trauma mattress, being told that you need to have a CT scan to pick up the life threatening injuries that you might have. Whilst you're also on ketamine. I imagine this is not the best place to be. That would be bad practice.

Yeah, and not just that, but the pizza he was delivering, I get in cold as well. And somebody's going to be fine because of the 30 minute wait from the pizza hut. So everything's on his mind. He's worried. So I'm going to drop some sort of crazy question on the end, or do you think we can just gently wind down here? Wish the listeners a happy day and head off? I would never drop anything. I would only make one small comment though. That 30 minute target, it's got to be a safe one.

And I do have slight concerns that sometimes in complex patients, if they have complex airway needs, for instance, we need to take enough time. Therefore, it's not essential that everybody gets there in 30 minutes. They've got to get there safely. That's my final point. Oh yeah, there was one question. Oh, always, always, always. What now? What do you want now? I just want to know what you say.

So you're doing this patient and the orthopedic registrar approaches the patient with his arms extended. And he's heading towards the eye at crests. And he's going to spring the pelvis. Yeah. What do you say? Well, I could just shout, "Stop your lunatic." But I tend not to do that. So hopefully I've got a collaborative thing going on here. I would probably have briefed about that before we start.

And I would have probably said something like, "So, Jimmy, when the patient comes in, we're going to aim to get a pelvic binder on, and then we'll get you the definitive test so we know what's happening with this pelvis. I don't think there's going to be any benefit to us doing anything physical to the patient when they first arrive. And I'm sure you would agree, wouldn't you?" And try and get them on board from there. How would you approach it?

I think very similar to yourself. I would try and be nice. But a good hand on the back of the neck is also quite effective, I find. It's another cliff-reed thing, isn't it? Just a gentle physical reassurance. And by that, I don't mean smack in them. I just mean an arm on the shoulder saying, "Okay, Stevie, let's not do that now. Let's concentrate on this and maybe giving them something else to do."

I tell you what, instead, you couldn't just check that you can feel that dorsalis penis pulse as well, could you? And taking them away from something, we do it in the pre-hospital environment as well, where we have nice people who are around and about who want to help. And just give them a job, give them something else to do to distract them from the job that they'd really like to do. And that often works quite well. So, good luck to everyone with your trauma team leadership.

Whether you're in a major trauma centre or a smaller unit, will all be getting trauma patients at some point in time. And a lot of these skills are things we can use for our general recess patients. And I found, definitely, that as we started doing this, our general behaviour in the recess room has become better and more efficient. So, I hope there's something here for everyone. Good luck with everything you're doing. We'll look forward to speaking to you soon. Take care, no? Have fun. [MUSIC]

[BLANK_AUDIO]