For the trauma team to be effective it is vital that all members of the team are aware of their role, communicate effectively and are able to operate within an atmosphere of mutual trust and respect. The structure of the trauma team will need to be fluid and adaptable to the resources available at each facility.

Trauma team structure

The trauma team structure will vary according to factors such as the time of day, availability of staff, hospital resources and skill set of the responders (5). This section will describe the makeup and roles in the ‘ideal’ setting and in modified circumstances where only limited resources are available.

The level of training or seniority is not a fixed recommendation, and it is recognised that, at a practical level, ‘emergency clinician’ may equate to ‘emergency registrar’ and ‘anaesthetist’ to ‘anaesthetic registrar’, etc. The assignment of roles in a trauma team need to flexibly focus on optimising the net capabilities of those present and available, rather than being restricted by seniority or craft group. Teams can increase their preparedness for these situations via simulation or training, which can enhance functional team performance ^{(6, 7)}.

Trauma team positions

As general guidance, the ideal trauma team should consist of the following:

Team leader: ED clinician or doctor with the highest level of trauma care skills

Controls and manages the resuscitation.
Remains “hands off”.
Must be clearly identifiable.
Allocates roles to other members of the team.
Ensures that preparation for the patient’s arrival is complete.
Stands at the foot of the bed.
On arrival of the patient, ensures all involved listen to the handover by pre-hospital or retrieval staff, ensuring no one begins working on the patient until complete (hands off, hand over). In certain circumstances, it is appropriate for the team leader to delegate certain skills be performed concurrently with handover.
Directs the resuscitation, makes critical decisions, and prioritises care.

Airway specialist: Anaesthetist, but if not available then it should be the person most experienced in airway management. Consider the assistance of a MICA Paramedic GP, or others

Ensures adequate preparation of airway equipment.
Responsible for assessing and managing the airway and ventilation. Counts the initial respiratory rate.
Administers oxygen therapy, performs suction, inserts airway adjuncts, performs endotracheal intubation.
Maintains cervical spine immobilisation and controls the log roll.
Takes an initial history (AMPLE: Allergies, Medications, Past medical history, Last eaten, Events leading).

Airway assistant: A theatre assistant may assist in this role; if not, then Nurse 1 can assume this role

Assists in preparing equipment for advanced airway intervention.
Assists during interventions (passing tools to the airway specialist).

Doctor 1: Assessment: Emergency clinician/surgeon

Undertakes the primary survey
Reports clinical findings clearly to the team leader and scribe
Conducts FAST exam if suitably qualified and no ultrasonographer present
May be required to perform procedures dependent on whether Doctor 2 is present and on skill set and training

Doctor 2 procedure: Emergency clinician/doctor if available; if not then this role can be divided between Doctor 1 / Nurse 1 or 2 / Paramedic, dependant on skills

Performs procedures dependent on skill set and training – e.g., finger thoracostomy.
Gains intravenous (IV) or intraosseous (IO) access and draws bloods.
Has nasogastric tube (NGT) and in-dwelling catheter (IDC) insertion tubes ready.
Conducts the secondary survey.

Nurse 1: Monitoring: ED nurse / ward nurse / paramedic

Cuts off clothing on the right side.
Places monitoring equipment on the patient (ECG, blood pressure cuff, SpO2, defibrillation pads if necessary).
Takes temperature.
Assists with advanced airway interventions as necessary.
Assists with procedures (NGT / IDC / chest drain) as necessary or medical care as directed by the team leader.

Nurse 2: Circulation: ED nurse / ward nurse / paramedic

Cuts off clothing on the left side.
Attempts IV cannulation or IO access, takes bloods including BSL (if no doctor available to do this).
Commences IV fluid therapy via a warmer if necessary.
Draws up drugs and administers medications as necessary (morphine, anaesthetic induction agents).
Sets up external warming and ensures the patient is kept normothermic during resuscitation.

Scribe: ED nurse / ward nurse / paramedic

Collates all information and records it on trauma charting.
Keeps an accurate record of time of arrival, interventions, and events.
Records drug dosages, time of administration and amounts.
Prepares paperwork for inter-hospital transfer if necessary.
Gathers the patient’s belongings and documents a record of their possessions.
Writes the patient identification wrist band and provides to nurse for application.

Others: Remain outside the area of principal activity and wait to be called by the team leader to assist.

Radiographer:

Takes x-rays as directed by the team leader.

Specialists: General surgeon / orthopaedic surgeon

Assists with the secondary survey and advanced procedures as directed by the team leader.

Modified trauma team positions

Where there are limited resources then individuals in the team will need to assume more than one role. It is important that all staff work collaboratively and communicate effectively.

Major Trauma Guidelines & Education – Victorian State Trauma System