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M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Saturday, June 29, 2013

Code Team Leadership
The experiences in trauma team leadership that initiated my interest in code team organization and leadership began several decades ago when I was an emergency medicine resident at Brooke Army Medical Center. Our setting was somewhat unique because the emergency medicine senior resident and attending were responsible for the leadership of all traumas. Surgery residents were part of the team, but they did not formally function as trauma team leaders.
This, as one might expect, did not sit well with the surgery residents. Consequently, they did everything in their power to function independently, usurp team leadership, and steal procedures from the emergency medicine residents. It was a painful experience, to say the least, for a young resident striving to learn the priorities of emergency trauma care and team leadership. After two to three months of losing control of my trauma teams to condescending surgery residents, I had had enough. I carefully analyzed the dynamics of the setting, and learned the essence of code team leadership. It wasn’t long before I had things back under control. Nevertheless, those painful experiences gained under fire changed my approach to resuscitation leadership for the remainder of my emergency medicine career.
What’s so important about code team leadership? High-quality code or resuscitation team leadership is central to good code team organization and a well-run resuscitation. It is has never been studied or proven that good code team organization makes a difference in patient outcomes, but personal experience and face validity would suggest it has many valuable benefits. An adept code team leader can run a smooth, highly efficient, non-stressful, and quiet resuscitation. In contrast to the cacophony and chaos that inexperienced team leaders oversee, a well-run resuscitation can be carried out in a resuscitation room separated only by curtains, and the neighbors can have no idea that life-saving interventions are ongoing next door.
Code teams should function like a racing pit crew. Everyone present should know his role, his position in the room, and how he fits into the team. This ideal state, however, is usually dependent on strong and effective team leaders.
Code Team Leadership Pearls
  • Identify the team leader and prepare for the patient’s arrival using information provided by the prehospital team prior to the patient’s arrival in the room.
  • Identify which ED personnel will be members of your resuscitation team, assign team roles, and clarify room position. Some institutions actually use a wallboard to remind team members of their locations and duties.
  • The team leaders should assume the room position established for code team leaders in your organization. Room position is important to overseeing patient care. The physician leadership should stand in sight of the monitors. A lead nurse role is also important to good team structure, and the person filling that role should be located directly across the patient from the physician team leader.

  • Leaders must act and sound like leaders. Leadership-consistent decibels, speech, and behavior contribute to your leadership credibility. It also may be necessary to advise the team to “only take orders from me” in settings where leadership is constantly being challenged.
  • Communication is a critical element of leadership in any setting. You are not leading if you are not communicating. Talk to your team. The team leader should keep the rest of team informed of the ongoing process. “We are doing the primary survey.”
  • Call out your findings. “Airway is fine; breath sounds are symmetrical.” Ask for team member observations and findings. “What are the current vital signs?”
  • Use your team. Effective delegation is central to a well-run team. Inexperienced team leaders often fail to use their human resources efficiently and maximally. This starts by being team-oriented, focused, and always knowing the available human resources. Situational awareness is critical. Your team cannot be allowed to stand around watching you evaluate the patient.
  • Leadership speed is critical to maintaining control of the resuscitation team. If the leadership pace is slow and inefficient, the dynamics of a resuscitation combined with the personalities of those practicing emergency medicine will result in other team members assuming leadership. The resuscitation team leader must be the dominant “sinus node” pacemaker. “Leadership bradycardia” almost guarantees that other potential team pacemakers will take over.
  • It is important to create your own system and even consider using a mental checklist. Interestingly, an important aid for me to being able to quickly give orders was an internalized checklist wrapped around a mnemonic. Here is one example.
  • Finally, infringements on your leadership are bound to happen. When they do, it is critical to enforce team structure and maintain a clear chain of command. Appropriate interventions to intercept those infringements and regain control don’t have to be ugly, and most professionals will respond to a gentle reminder about where team leadership resides. On the other hand, if resources are available, it is important to temporarily turn over team leadership when the team leader becomes involved in a potentially distracting procedure during the acute phases of resuscitation team operations.
Read an article Dr. Mellick wrote on code team organization at