The trauma team leader is an experienced physician or surgeon that is the “captain” of the trauma team [5]. The training background of the TTL varies by center, but the TTL is often a trauma surgeon or emergency physician. The leader provides expert management of the trauma patient during the resuscitative phase of their care. This includes preparing the team prior to the patient’s arrival (prehospital background such as number of individuals involved, mechanism of trauma, severity of trauma and/or injuries), managing the patient in the trauma bay, caring for the patient during transport and during diagnostic imaging, and providing care until a satisfactory handover has occurred to appropriately skilled personnel, who will continue managing ongoing care requirements. The TTL must have the experience and medical expertise to guide the trauma patient through these phases of care as well as exhibit the ability to work within a team framework and be able to assume its leadership [32]. The TTL must have exceptional skills as a communicator, manager, and collaborator to effectively lead the trauma team. A strictly professional demeanor is essential to maintain the team’s focus. The TTL generally stands at the foot of the patient’s bed, away from direct patient contact, and is thus able to oversee and direct all the activity of the other team members. As highlighted in Chap. 5, this global focus minimizes the likelihood of committing a fixation error (persistent failure to revise a diagnosis or plan in the face of readily available evidence that suggests that a revision is necessary) [33]. The TTL is responsible for directly communicating with the team members, the operating room, the radiology department members, and critical care unit staff. She/he will decide which diagnostic and therapeutic interventions need to be performed and in what order. The TTL is also responsible for ensuring that the major findings, summary of injuries, and treatment plan are documented in the medical record and also communicated to the remainder of the trauma team. In the event that a patient is accompanied by the police or presents with a stab or gunshot wound, the TTL is responsible for interacting with any officer and ensuring compliance with any jurisdictional requirements to notify the police in the setting of such wounds, as well as protecting the safety of trauma team members [34, 35].

The anesthesia representation on the trauma team may consist of a resident. Alternatively, this role may be filled by an emergency medicine attending or senior resident. This person should be positioned at the head of the bed and will be delegated with managing most “airway” issues with the respiratory therapist. The physician will perform endotracheal intubation. One exception to the listed responsibilities for anesthesia may be the “difficult airway” that requires cricothyroidotomy. In many trauma centers, the general surgery team member is responsible for performing surgical airways. In conjunction with the general surgery team, the anesthesia delegate may also be asked to help with managing “circulatory issues.” Particularly, they may be asked to place central venous catheters, transfuse blood products (along with nursing team members), and place arterial lines. Also, as part of the adjuncts to the primary survey of ATLS, anesthesia team members may be asked to place orogastric or nasogastric tubes.

Depending on the hospital and even country, the emergency medicine physician may be the linchpin of the trauma team. Given that they are almost always the first physician present and have a broad spectrum of skills, they often play the TTL role but can effectively substitute for many other team members. Airway management, fluid resuscitation, performing FAST, and even some emergency surgical procedures such as cricothyroidotomy and thoracotomy fall within the scope of a skilled emergency medicine physician. The role they fill as part of the trauma team is therefore variable and often dependent on local medical culture. Some countries involve critical care physicians to fulfill this role.

The respiratory therapist works with anesthesiologist to assist in assessment and management of the airway. They are specifically responsible for setting up equipment including airway devices and adjuncts, ventilators, arterial lines, end-tidal CO₂ monitoring, and drawing and running arterial blood gases. This role will be discussed further in Chap. 9.

The general surgery representation on the trauma team typically consists of a junior resident, senior resident, and/or staff surgeon. In many institutions, the TTL may also be a general surgeon. If multiple residents are present, they should be each positioned at the patient’s sides. Using the ATLS paradigm, the general surgery team members are usually asked to manage “breathing” and “circulation” issues in the primary survey of trauma patients. The general surgery team is usually responsible for placing chest tubes to relieve hemo-/pneumothoraces. For “circulation,” the general surgery team usually participates in the resuscitation of patients in hemorrhagic shock, along with anesthesia and nursing. As part of the resuscitative efforts, the general surgery team is usually responsible for placing central venous catheters (subclavian/femoral). More importantly, the TTL usually delegates the responsibility of localizing and definitively stopping major sources of hemorrhage to the general surgery team; performing the FAST (focused assessment with sonography in trauma) exam is an important part of the general surgery exam for major sources of hemorrhage. When FAST is unavailable or nondiagnostic, diagnostic peritoneal lavage (DPL) may be performed by general surgery in the unstable patient. Major sources of hemorrhage include the thorax, abdomen, retroperitoneum (including the pelvis), extremity, and external sites of bleeding. General surgery, therefore—in collaboration with the TTL—determines whether or not the patient needs to go to the OR for a laparotomy, thoracotomy, or neck exploration, to angiography for embolization, or remain in the trauma bay for a resuscitative thoracotomy. In addition, general surgery is responsible for reviewing any CT imaging of the torso, abdomen, and soft tissues of the limbs (including blood vessels) and neck with radiology. As well, general surgery is responsible for performing the digital rectal exam of the patient during the logroll procedure.

The orthopedic surgery representation on the trauma team may consist of a junior resident, but often, a senior resident may be required especially for the placement of advanced skeletal traction. They should be positioned at the patient’s pelvis, will be delegated specific roles in the assessment and management of “circulatory issues,” and have prime responsibility for “disability” issues in the injured patient. For “circulation,” orthopedics usually will be asked to identify and bind unstable pelvic fractures and identify and splint grossly angulated extremity fractures. For “disability and exposure,” the orthopedic team will specifically examine all extremities, the pelvis and spine. The orthopedic team will be responsible for performing a detailed secondary survey of the musculoskeletal system and will review all extremity imaging and spine imaging. In the event of an injury to the spine, either orthopedics or neurosurgery is generally responsible for managing this injury.

The neurosurgery representation on the trauma team typically consists of a resident. She/he is responsible for the “disability” component of ATLS, including assessment of the spine on logroll when appropriate. They may make recommendations to the TTL regarding the management of any increased intracranial pressure. They are responsible for immediate interpretation of the CT of the head/CT angiogram and discussion with their attending surgeon regarding any operative management or ventricular drainage. Traumatic brain injury is a major cause of death in multiply injured patients, and early neurosurgical evaluation is essential [26].

The role of these nurses includes placing appropriate monitoring on the patient, inserting peripheral intravenous catheters, obtaining blood samples for the laboratory, assistance in patient manipulation including logrolling, and being the non-sterile assistant to a member of the team who is performing an invasive procedure such as chest tube or central line insertion. They are also responsible for administrating any medications or vaccinations. Nursing roles will be further outlined in Chap. 9.

The role of the recording/documenting nurse is just that: to document, on an appropriate trauma medical record, the important findings of the trauma team in their assessment of the patient. This includes recording vital signs, assessments, and nature and type of procedures performed. This nurse is typically situated at the foot of the bed, in proximity to the TTL, so as to gain a view of the vital signs monitors and be able to hear the trauma team’s assessment as it is relayed to the TTL. She/he often works in conjunction with the TTL to facilitate team communication, especially with services/resources not directly present in the trauma bay. As mentioned previously, nursing roles will be further discussed in Chap. 9.

The trauma team is called into action with a trauma team activation (TTA). The TTA may be in response to prehospital information or information obtained when the patient first arrives to the ED. The value of having a trauma team ready and awaiting the arrival of a severely injured patient cannot be understated, as it allows for appropriate preparation of the room and equipment, introduction and organization of the team, and preparation based on the anticipated injuries of the patient from any prehospital information.

A TTA may occur in a tiered fashion or have graded “levels” of response [36]. For example, a patient with prehospital information that suggests a serious likelihood of requiring operative intervention would garner the highest level response. Patients with penetrating torso trauma or multisystem trauma with hypotension are typically included in this category. For these patients, in addition to the standard trauma team, the trauma surgeon, operating theater, blood bank, and intensive care unit may also be notified. For other patients that have evidence of multisystem trauma but are hemodynamically normal, a lesser activation comprising the TTL and the core trauma team members may occur at the discretion of the charge nurse or emergency physician.

Each institution will have its own method for TTA, which may include dedicated pagers, overhead pages, or even “walkie-talkies” for immediate notification. Notification may either alert the trauma team member to proceed immediately to the trauma bay or provide an update on an anticipated trauma with an estimated time of arrival. The developing field of prehospital telemedicine and teleradiology may, in the future, facilitate the transmission of important diagnostic information to the awaiting hospital trauma team so that they may better prepare for the patient’s specific injuries [37].

The criteria for a graded activation must be clearly defined by the trauma center and continuously evaluated by the performance improvement and patient safety program [5]. Inevitably, over-triage (triage decision that classifies a patient as requiring TTA when, in fact, they do not) and under-triage (triage decision that classifies a patient as not requiring TTA when, in fact, they do) will occur, but a trauma system should establish and monitor acceptable rates for these. Obviously, under-triage carries a greater threat to patient care than over-triage. Suggested rates for TTA are >95 % of patients with an ISS ≥ 16, and in <30 % of patients with an ISS ≤ 9 [28]. The ACS/COT suggested TTA criteria that are listed in Table 8.2 [38].