Leadership, roles, and responsibilities, as articulated in CRM, provide a framework for trauma team membership. As discussed in the previous chapter, in many emergency department trauma centers, the most basic of trauma teams consist of a leader, three nursing team roles, and often a respiratory therapist. Although this configuration of roles may be somewhat different in different states and countries, consistent membership includes a leader and nursing or other healthcare professionals dedicated to the airway, procedures, and medications. Leadership takes many different approaches. Many trauma team leaders were taught to use an authoritarian approach, and this culture pervades even today. However as education changes, so does the culture within health care; trauma team leaders today are more aware of the need for creating an inclusive context that not only supports all team members, but enhances engagement by providing autonomy within the group [13]. There is a great deal of evidence which supports this leadership style dating to the early 1940s. Kurt Lewin, a German/American psychologist, found that school children did the highest quality work under a democratic leader, but produced the greatest volume of work under an authoritarian leader [14]. Children were least productive under “laissez-faire” leadership. Please see Chap. 3 for a further discussion of leadership styles.

After studying levels of psychological safety, i.e., how group members think they are viewed by others on the team in health professionals in 26 NICUs in the United States, Nembhard and Edmondson reported a relationship between professional designation and level of psychological safety with physicians being the most safe, followed by nurses and then respiratory therapists [15]. They coined the term “leader inclusiveness” to illustrate important behaviors in creating psychological safety among team members. Verbalizing acceptability of team member questions and concerns and actively seeking team member thoughts on treatment decision was viewed as important in establishing leader inclusiveness; in this environment of safety, team members are more willing to speak up when they have information or a concern to share, thereby limiting the possibility of adverse events from occurring. There is preliminary evidence from simulation training showing a relationship between the effectiveness of established trauma teams and the willingness of team members to speak up [16]. Trauma team members thrive in an environment where the leader verbalizes value for team member input; this is especially true in challenging circumstances.

Nursing roles in the trauma team are typically designated by task work: documentation, medication administration, and procedures. Documenters usually position themselves at the foot of the bed where they can retain a visual of the entire context of all team members performing task work and the patient. In most trauma teams the most experienced nurse takes on this role due to its complexity explaining why in some centres this role is referred to as the “Trauma Nurse Leader”. This nurse is responsible for obtaining a history and then recording in real time the primary and secondary survey assessment, including changes in patient condition, and documenting team member interventions. Many trauma team leaders position themselves right next to the documenter to maintain situational awareness. The interdependence between the leadership and documenter allows for clarification on patient condition, completed or not completed interventions, and this supports effective anticipation and planning.

It is very important for the documenter to record the findings verbalized by the leader of the primary and secondary assessment in real time. Unfortunately, due to the intricacy and sometimes the amount of detail required by the trauma record, the documenter focuses on working through the record from initial arrival details, and this can impede the ability to capture the primary and secondary survey in real time. These initial descriptive data points must be recorded quickly or updated after capturing essential assessment data. Repetition of work is distracting and may disrupt the team’s attention as it moves through the expected sequence of primary survey, interventions, and then secondary survey. Additionally, the documenter assumes responsibility for ensuring closed loop communication. The leader orders a team member to complete a task, and the team members acknowledge the order, complete the task, and in an audible voice communicate the completion of the task to both the documenter and leader. When these loops are not closed, it is the responsibility of the documenter to ascertain whether or not the task was completed and inform the leader.

The documenter is also the timekeeper and as a result is responsible for informing the leader and team when time lapse is important in determining further intervention. An example of this is the administration of epinephrine in a resuscitation context. The leader has asked the medication nurse to administer 1 mg of 1:10,000 epinephrine intravenous push every 3 min until the return of spontaneous circulation. The documenter having recorded the time of the last dose would communicate the time lapse and need to repeat the dose after 3 min, if the context still requires that intervention. When patients have emergent needs, team members act in their role simultaneously to improve efficiency and effectiveness of management. The leader often gives the team many different orders, but this type of approach can cause confusion and increased risk for communication breakdown and adverse events to the patient. To alleviate the risk, leaders are encouraged by the documenter to write down the necessary interventions prioritizing behaviors dictated by patient condition. The documenter can then assume responsibility for sharing this priority list of interventions so that team members do not get overloaded in the demands of their role. Experienced team members can help less experienced team members stay on track if they deviate from the care sequence. So too can the team’s collective experience be tapped to help solve unexpected changes in the patient’s condition. Having the most experienced nurse act as a documenter maximizes the stability of the nursing team’s emotional tension. Team members draw on the documenter or leader for clarification of orders, available resources, and reaffirmation of behaviors to optimize task work. The documenter, having had more experience in emergent situations, is usually very aware of the cognitive aids available, the resources, and how to access resources in a timely fashion.

The procedure nurse usually assumes a position on the opposite side of the bed to the medication nurse to support simultaneous task work without crowding other team members. The procedure nurse is responsible for putting the patient on the cardiac monitor, initial assessment of vital signs inclusive of temperature and glucose, and any other procedures ordered by the leader. Other procedures frequently include further intravenous (IV) access (two large-bore IVs), crystalloid or blood administration, procurement of trauma labs, and the insertion of a Foley catheter and nasal or oral gastric tube post-intubation. If the situation requires the use of the rapid pressure infuser, which delivers about 300 ml/min of resuscitation fluids, a fourth nurse may be needed to support the team. The pressure infuser requires the full attention of one nurse to operate and monitor rapid fluid administration safely. The procedure nurse is expected to acknowledge all orders, clarify if necessary, and verbalize clearly the completion of a task as required by all team members.

The third nursing role typically assumed on a trauma team is a medication nurse. Trauma patients are frequently in need of medication support for their emergent needs. Examples include rapid sequence intubation medications, inotrope or vasopressors for hemodynamic support (in special trauma circumstances), volume expanders, antibiotics, tetanus, and resuscitation drugs. This can be a very busy role and is often supported by the procedure nurse if procedure task work is completed or deemed not a priority when compared to medications. The documenter can also support this role as far as checking medication dosages, blood products, and accessing resources. Again it is critical to situation awareness that the medication nurse closes the loop on all medications, including type, dosage, and route, in a manner audible by the entire team. Although all roles require focus, which can impede maintenance of situation awareness, this is more profound in this particular role. This role takes the nurse away from the immediate bedside to the medication cart and pharmacy resources. With their back to the patient, it is critical that the nurse in this role reaffirms the need for the medication before delivering as the context may have changed and the nurse may not be aware of the changes. This adds one extra step to closing the loop. After acknowledging the order and preparing the medication, the nurse should announce the intention to deliver the medication and await affirmation that it is still needed to deliver it, again verbalizing completion of the order once the medication is delivered (Fig. 9.2).

The specific role and presence of the respiratory therapist (RT) varies internationally and even from center to center in some countries. Although there is a paucity of research examining the RT role in trauma management, Steinmen and colleagues report a benefit for early trauma care after a short in situ simulation-based trauma curriculum [1]. In addition, there are several studies that suggest a benefit for using respiratory therapy-driven protocols to improve outcomes [17–19]. This section will describe the roles and responsibilities of a respiratory therapist on a trauma team. It is acknowledged that internationally there is variation in who assumes this role; responsibilities described may be carried out by another experienced team member dedicated to airway and breathing. An emergency physician, anesthesiologist, or critical care physician in centers in Europe or the United States may often assume this role.