Non-Technical
Skills in Trauma and Disaster Response: Mapping
Decision-Making, Communication, and Team Dynamics
Abdullmajid Eissa Alenazi1*, Saud Ali AlOthaimin2,
Abdullah Naif M Alanazi3, Abdullah Hamad Albuzaya4, Naif
Mohammed Altehani5
1 Emergency Medical Specialist, Prince Sultan Military
Medical City, Riyadh, Saudi Arabia
Abdullmajid-ems@hotmail.com
2 Emergency Medical Specialist, Prince Sultan Military
Medical City, Riyadh, Saudi Arabia
3 Emergency Medical Specialist, Prince Sultan Military
Medical City, Riyadh, Saudi Arabia
4 Emergency Medical Technician, Prince Sultan Military
Medical City, Riyadh, Saudi Arabia
5 Health Informatics System, Prince Sultan Military Medical
City, Riyadh, Saudi Arabia
Abstract: Along with clinical
experience and technical competency, non-technical skills (NTS) are crucial to
trauma and disaster response efficacy and safety. Responders' capacity to make
good judgments, communicate well, and work together affects patient outcomes
and mission success in high-risk, time-sensitive, and resource-constrained
circumstances. This research examines non-technical abilities in trauma and
catastrophe scenarios, focusing on decision-making, communication, and
teamwork. Situational awareness, prioritizing, and adaptive judgment are needed
to make decisions in uncertain, incomplete, and fast changing situations.
Multidisciplinary and multi-agency teams benefit from verbal and nonverbal
communication, which reduces mistakes and promotes coordination. Operational
efficiency and responder resilience depend on team dynamics including
leadership, trust, role clarity, and coordination. The research shows how
inadequacies in one fundamental non-technical domain might affect response
performance by mapping their interrelationships. The concept emphasizes
systematic training, simulation-based learning, and standardized evaluation
techniques to improve trauma and disaster responders' non-technical skills.
Adding non-technical skills to disaster planning frameworks may increase system
resilience, minimize mistakes, and improve patient and responder safety in
complicated emergency situations.
Keywords: Non-technical skills;
Trauma response; Disaster management; Decision-making; Communication; Team
dynamics; Human factors; Emergency preparedness
INTRODUCTION
It is not easy to manage a patient who has experienced
trauma. Performing life-saving treatments on an unstable patient, making
time-sensitive judgments, and dealing with limited information all while under
tremendous time constraint necessitates swift and precise clinical evaluation.
This calls for a concerted effort by the teams in the OR and the emergency
room. Members of these interdisciplinary teams range from highly-motivated
general practitioners to nurses with extensive training in a variety of medical
subspecialties, and they work together to solve complex medical problems. In
most cases, everyone has gone to some kind of training program in the past to
hone their particular set of abilities.[1]
But just because someone is an expert in their field
doesn't mean they can form an expert team. According to research on surgical
complications, the most common reasons for medical mistakes are lapses in
communication, planning, coordination, and task management. In addition,
communication breakdowns are common during healthcare transitions, and several
studies have shown that they are the root cause of the most serious trauma
resuscitation mistakes.
Trauma operating room teams are understudied compared
to emergency room trauma teams, yet they are just as important. Elective OR
teams may be more like the emergency room team in terms of dynamics than
regular OR teams. Emergency room and operating room trauma teams are put
together on short notice, and its members may not have regular training
together or even know each other before the team is formed. Still, they're
under pressure to act quickly while performing potentially dangerous treatments
and making judgments with significant consequences. Because of this, "a
perfect storm" of mistakes and bad results is imminent. [2]
Teams and non-technical skills (NTS) have been known
to help airlines reduce risks for a long time. Crew resource management, also
known as crisis resource management (CRM), has greatly improved the safety of
air travel. Applying this concept to the medical field, particularly in the
area of non-technical skill training, has shown excellent results. The use of
NTS in healthcare has undeniably improved patient safety.
In this narrative review, we will go over the
essential non-technical abilities and how they pertain to trauma. We will
concentrate on the teams working in the OR and the ER, as well as how care is
transferred between the two settings. Additionally, we go into the functions of
NTS training in both undergraduate and graduate programs, as well as the use of
team debriefing. We take a look back at the history of trauma training courses
and how they contributed to the creation of NTS. At last, we touch on the
difficulties that have arisen due to the introduction of trauma hybrid operating
rooms. [3]
Non-technical skills in trauma
Interfering with task performance and completion are
non-technical skills (NTS), which are cognitive and social abilities. For a
team to work well in an emergency room or operating room setting, everyone on the
team, but especially the team leader, has to know their stuff when it comes to
clinical and technical abilities, and they need to recognize how important NTS
is. [4]
The field of trauma management makes use of a number
of NTS:
One definition of situational awareness is "the
perception of elements in the environment within a volume of time and space,
the comprehension of their meaning and the projection of their status in the
near future." Therefore, it is imperative that the practitioner—often the
team leader—goes beyond what is immediately accessible, integrates all current
input with prior knowledge, and expands awareness in both space and time. This
is a crucial NTS that often calls for prior exposure to comparable cases and a
certain level of clinical expertise. However, it is also within the junior
trainee's capabilities to improve with sufficient instruction via simulation. [5]
Prehospital notice initiates situational awareness.
The AT-MIST mnemonic is suitable for providing the prehospital notice. It
stands for Age, Time, Mechanism, Injuries, Signs, and Treatment. While not
conclusive, it may provide a good idea of the patient's probable clinical situation
and what resources, such the trauma operating room, may be required, such as
initiating the large bleeding procedure. At this point, a procedure to mitigate
the harm may be initiated.
When evaluating the patient's reaction to
resuscitation, situational awareness is just as important as it is upon patient
arrival and throughout the main survey. When determining the expected next
step, environmental factors, available physical and human resources, and other
factors are considered. A good usage of situational awareness would be for a
team leader to mentally branch out potential decisions before all the necessary
data is at their fingertips. For example, it is recommended to transport the
patient to the operating room immediately rather than continuing resuscitation
while an eFAST test is being requested for trauma patients. thoracotomy in
cases where eFAST is positive for pericardial fluid, as opposed to laparotomy
in cases where eFAST is positive for peritoneal fluid. This patient may just be
at the eFAST scan phase, and the trauma team leader is likely already thinking
about these possible outcomes and the branching choices that will follow.
Team members may struggle to keep up with the leader's
constant situational awareness during emergency room resuscitation. Actually,
it may not be the best choice, particularly if some of them are carrying out
intricate operations that need close-up eyesight. But the trauma ER team leader
must update everyone on the situation and the strategy at regular intervals. A
Stop process, sometimes known as Team-Time-Out, may do this. This time-out may
be helpful for the whole team to communicate information when it's clinically
feasible (i.e., not getting in the way of emergency resuscitation attempts). [6]
Gaining and keeping everyone on the team informed of
the situation may be challenging during surgery. Surgeon and anesthesiologist
alike will need to keep their eyes focused on the task at hand throughout the
operation, which might lead to a loss of situational awareness. Because of the
potential for unforeseen complications during surgery, it is critical that the
surgeon and anesthesiologist who share leadership responsibilities on the
trauma team be able to switch roles in terms of situational awareness. Routine
status reports, often called "sit reps," are a kind of intraoperative
team time-out that may help avoid this.
The anesthesiologist reports the first three elements
of the TBCS, which pertain to physiological factors. Finally, the surgeon will
present the surgical findings and strategy. Everyone on the trauma operating
room team can stay up-to-date and informed with the help of the TBCS tool. [7]
One additional possibility is for the chief surgeon to
brief the assistant surgeon on the current situation. Particularly when the
operating surgeon is using focus vision, it is beneficial for one of the two
surgeons on the team to be able to keep an eye on the surroundings. However,
intraoperative timeouts are crucial for maintaining situational awareness since
both surgeons' attention may be needed on the operating field at times. One
anesthesiologist may execute operations while the other keeps an eye on the
surroundings; this setup can also function. On the other hand, intraoperative
timeouts should still be used often.
Last but
not least, situational awareness should take into account the team members in
addition to the patient, resources, and context. It is possible that some team
members are underutilized while others are overloaded. All of these things have
the potential to make people lose faith in trauma resuscitation, which might
harm both present and future attempts to save lives. As a result, the team's
leader(s) should be prepared to reorganize responsibilities and delegate more
work as needed. [8]
Role allocation
Due to the
potentially heterogeneous nature of the team in an emergency room scenario,
role allocation is of the utmost importance. Although trauma surgeons or
emergency physicians are often designated as team leaders, the other team
members may be assigned flexibly based on their competence and comfort level.
Anesthesiologists, for instance, are often assigned the post of Airway (A)
doctor because to their exceptional team leadership skills, their proficiency
in managing most airway circumstances, and their knowledge of analgesia and
sedation. In addition, if the patient needs surgical treatment, having the
anesthesiologist on the emergency room trauma team ensures continuity of care. [9]
Allocation of roles might change throughout time.
Managing airways is a prime illustration of this. A reallocation of
responsibilities is necessary for drug administration, physical limitation of
spinal movements, and handling the laryngoscope and tube, among other things,
during drug-assisted intubation, as opposed to simple motions, which the
A-doctor may offer. As an extreme measure, the A-person, who is an experienced
provider, may be temporarily given control of the team. Everyone on the team
will have to find new things to do if they are to help with further operations that
need it, including inserting a pelvic binder or a chest drain. In addition, the
team leader may need to confer with another expert for a moment, temporarily
transfer leadership to another team member, or both to avoid losing situational
awareness.
Positions on the squad should change depending on
what's available in the area. Instead of the other way around, the trauma
team's makeup dictates the training program's simulations at one of the
authors' institutions. With the tagline "We simulate like we work and work
like we simulate," the trauma team training program is guided by a strong
sense of purpose. In contrast to the anticipated success of a more pragmatic
strategy, a strict team structure would be difficult to implement and would
result in poor compliance.
[10]
The operating room (OR) often has more strict and
evident function allocation: surgeons will do the surgery, and the
anesthesiologist will oversee general anesthesia and resuscitation. This is in
contrast to the emergency room (ER), where certain members may do numerous
responsibilities. In the trauma operating room, however, responsibilities must
also be divided; for example, someone must call the blood bank, set up lines,
and bring more equipment. This is best done when the whole operating room staff
is briefed on the patient's condition during the transfer from the emergency
room to the operating room. Anesthesia and scrub nurses should each have their
specific responsibilities laid down, and everyone on the team should be easily
identifiable. Following this first operating room team briefing, the
anesthesiologist and surgeon may provide more detailed briefings to their
respective nursing staffs (see to the six-step approach to perioperative
communication for additional information).
Because the patient can need a surgical airway or
chest decompression for a tension pneumothorax following positive pressure
breathing, the surgeon's involvement during induction also involves allocation.
In case this role becomes necessary, it is important to designate a specific
member of the surgical team to do it.
[11]
Although the most qualified individual should be
assigned to a certain role, there are situations when less experienced or
younger team members may step in to fill the role. This allows for a more even
distribution of responsibilities and exposure. Finding a happy medium between
training concerns and patient demands requires, as always, sound judgment.
Decision-making
A common adage states that as one gains experience,
one is more likely to make poor decisions. Using a neuroscientific lens, we may
classify the mental processes involved in decision-making as either type 1 or
type 2. Pattern recognition underpins type 1 choices, which are intuitive and
need less mental exertion. Useful for routine, everyday activities. Type 2
judgments are slower because they rely on deductive reasoning, are logical and
concept-based, and need mental effort.
[12]
When we walk down the street, we're demonstrating how
we employ these two processes to execute tasks. We rely on quick, instinctive
brain processes (type 1) when we stroll around our local neighborhoods. It
takes a lot more time and mental energy (type 2) to use deductive reasoning to
navigate our way around a new place when we don't have an internet map.
Type 1 choices are suggested to be made by our brain
under stressful situations for evolutionary reasons, even though we employ both
decision-making processes interchangeably in our everyday lives. The care of a
patient who is bleeding is a prime illustration of the significance of
decision-making. At the outset, both seasoned and novice surgeons will use
basic techniques to reduce bleeding, such as digital or physical compression of
an artery that is bleeding. It is common for inexperienced surgeons to rush into
direct suturing or clamping the artery (type 1 choice), frequently without
enough exposure, proximal or distal control, or team notification. Type 2
choices include pausing to consider alternatives, checking in with the
anesthesiologist to see how the patient is doing, reporting discoveries and the
plan, dividing up responsibilities (such how to increase illumination and
exposure), and gathering more resources.
When it comes to showing how valuable the
decision-making process is, simulation-based learning really shines since it
recreates "under test conditions, phenomena that are likely to occur in
actual performance." Subjected to a crucial situation in a controlled
"classroom" setting, such as a clinical case discussion, participants
will almost always succeed and provide the right answer. Because of this, type
2 judgments are often adhered to. There would be a dramatic increase in the
number of type 1 judgments made if the same clinical situation were presented
in a virtual environment. This is, according to the author, a major benefit of
trauma treatment simulation training.
[13]
Having said that, not every type 1 choice is
incorrect. If a relatively inexperienced practitioner wants to compress
external bleeding or perform a simple airway maneuver like a chin lift or jaw
thrust (with restriction of cervical spine motion), they can do it quickly,
easily, and safely.
usage of intra-resuscitation or intraoperative
time-outs is a useful technique, and training and experience may help reduce
the tendency for recurrent type 1 usage. As a result, everyone in the team may
take stock again and voice their concerns. Just a little break before things
get going.
Crisis containment strategy training is another
instrument. To name one, there's the "surprise and startle" response.
This method has been created to teach flight attendants how to handle serious,
unanticipated emergencies, but it might also work in an operating room setting.
Pilots aboard airplanes learn to quickly recognize an emergency and react accordingly.
They have been taught to follow a process called the
"Stop-Aviate-Navigate-Communicate" routine and should not make hasty
judgments. Training for trauma teams may follow a similar pattern, with an
emphasis on the ABCs in the emergency room and TBCS in the operating room.
Members of the team will put an end to it, shift their attention, and consider
their alternatives if they label the occurrence as unexpected. [14]
The need for a trauma team leader to be clearly
identified in emergency rooms is supported by a wealth of research. While
surgeons make up the majority of trauma team leaders, emergency doctors are as
qualified to fill this position. Being able to facilitate feedback from team
members and employing succinct communication are qualities of an effective
trauma team leader, which are far more important than the specialization
itself. Less time spent resuscitating and making decisions is linked to trauma
teams led by experienced professionals.
Leadership in the trauma operating room is best
shared. While the surgical team leader is ultimately responsible for
determining whether or not to operate (the indication for surgery), they must
collaborate with the anesthesiologist in order to carry out the operation
safely. Arterial pH and lactate, temperature, coagulopathy, and the response to
resuscitation are all physiologic data that the anesthesiology team can quickly
get and update, proving that this is the case. Accordingly, in an ideal
situation, a shared leadership team may think about the patient's physiology in
addition to the surgical area.
[15]
Anesthesiologists should take the lead during
induction and other crucial times, as well as in the case of serious unforeseen
occurrences like cardiocirculatory arrest, even if the surgeon is ultimately
responsible for the technical conduct. To illustrate the point, the
anesthesiologist may need to signal the use of cross-clamping the aorta as the
only method of managing an abrupt intraoperative hemodynamic collapse. When the
surgeon needs a broader perspective of the case to complete an operation, such
as inserting an intra-arterial shunt, or when their concentration is too
limited to do so, this shift in leadership is also necessary. Another instance
where this occurs is during thoracotomy-based direct cardiac compressions.
Surgeon priorities include maintaining a dry operating area, preventing the
aortic clamp from sliding, and ensuring effective bimanual compressions. The
onus is now on the anesthesiologist to take the lead in determining the appropriate
medications and when to administer the internal paddle defibrillation. The
patient is and always has been the first priority in the operating room, thus
egos should stay out of patient care. As always, this "two-headed"
brain can only function with the full collaboration and clear communication of
the surgeon and anesthesiologist.
When a team's objective is to treat a live patient
with grave injuries and give them the chance to recover in critical care, good
leadership is about more than just getting the job done. Leaders of teams
should also take the time to ask their members how they felt, what they
accomplished, and what they might do better. [16]
Communication
From what has been covered thus far, it is clear that
communication is the most crucial NTS. Efficient communication may be both a
team's strength and its weakness. Indeed, inadequate communication is thought
to be the cause of 70 to 80% of healthcare mistakes. Thankfully, there are
guidelines on how to communicate appropriately in times of crisis.
The concepts of closed-loop communication should be
applied to both peri-resuscitation and perioperative communication. These
principles include:
In the resuscitation environment, closed-loop
communication is linked to faster and more efficient job completion. The
writers draw parallels between closed-loop communication and the instant
messaging application WhatsApp, where the symbols for a sent, received, and
viewed message are readily apparent.
There must be communication before to the surgery,
throughout the procedure, and immediately after its completion. But there have
to be measures to prevent talking too much. Keep in mind that communication is
similar to a medicine or a surgical tool; it has to be administered at the
right time and in the right dose. Distracting the anesthesiologist or surgeon
during a challenging airway or supraceliac aortic clamping procedure is a
certain method to throw off their concentration. At these critical junctures,
only life-altering information should be shared, including a rapid decline in
the patient's condition or major, unanticipated complications during the
procedure. Here we are again with the sterile cockpit rule of aviation: when it
really matters, only pertinent information should be conveyed. [17]
OBJECTIVES
METHODOLOGY
Focusing
on decision-making, communication, and team dynamics, this study used a
qualitative, descriptive, and analytical research approach to investigate the
function of non-technical abilities in catastrophe and trauma response. The
study is based on the Emergency Management Non-Technical Skills (EMNoTS)
framework, which was created by Hayes, Bearman, and Gyles. This framework
defines non-technical skills as behaviors that impact performance in high-risk
emergency situations; they are observable, trainable, and assessable. Analyzing
complicated socio-technical systems, like disaster response operations, is a
strength of this approach, which incorporates ideas from safety science,
cognitive systems engineering, and human aspects. [18]
Sources and Study Scope
A
comprehensive and methodical analysis of secondary data sources, such as
scholarly journals, reports, and conceptual frameworks pertaining to
non-technical abilities in disaster medicine, emergency management, trauma
care, and high-reliability organizations, formed the basis of the study. The
main source was the EMNoTS handbook, which provided a taxonomy of non-technical
skill categories and the behavioral indicators that went along with them. To
put these abilities in perspective and prove their usefulness in catastrophe
and trauma situations, we consulted supplementary literature from domains
including emergency incident management, healthcare collaboration, and aviation
crew resource management.
Validity, Reliability, and Ethics
By
comparing ideas across many academic sources and emergency management settings,
methodological triangulation was used to increase the credibility and
reliability of the results. The analysis was even more reliable since it used
an established and empirically based framework like EMNoTS. No human subjects
were directly exposed to any ethical hazards since this research used only
secondary data. Nevertheless, great care was taken to ensure that the results
were faithful to the original authors' intentions and that no conceptual models
were misused. [19]
RESULTS
The
results show that situational awareness, cognitive effort, and time constraints
significantly impact decision-making, a key non-technical competency in disaster
and trauma response. Findings suggest that good decision-making involves
keeping an eye on changing circumstances, ranking conflicting demands, and
adjusting tactics as needed. When conventional protocols are inadequate or
unrealistic, high-performing teams use flexible and adaptable judgment rather
than relying just on preset processes, as shown in the study. On the other
side, bad decisions were often linked to fixation mistakes, putting too much
stock in first assumptions, and missing new dangers. [20]
Communication and Operational Effectiveness
In
the aftermath of trauma and disasters, the ability to communicate effectively
has become an essential non-technical competency for facilitating teamwork,
mutual understanding, and collective action. The findings show that both
individuals and teams benefit from improved situational awareness and more
successful decision-making when communication is timely, clear, and succinct.
In multi-agency settings, structured communication strategies, such as
closed-loop communication and standardized language, were found to lessen room
for misunderstanding by eliminating ambiguity. But there was a constant
correlation between poor communication and operational risk, wasted effort, and
a lack of coordination.
Team Dynamics, Leadership, and Coordination
According
to the results, the success or failure of emergency response operations is
heavily dependent on team dynamics. Under pressure, teams that worked well
together, supported one another, and had distinct responsibilities were more
resilient and flexible. Leadership behaviors are a major factor in creating
productive team dynamics, especially when it comes to creating common
objectives, keeping morale up, and overcoming organizational and hierarchical
barriers to work together. In complicated and fast-paced crisis situations,
teams that practice adaptive leadership a style that combines authoritative
management with consensus-building performed better. [21]
Interdependence of Areas of Non-Technical Competence
The
interconnectedness of team dynamics, communication, and decision-making is a
major takeaway from the research. These non-technical abilities are not
self-contained but rather part of a larger system wherein proficiency in one
area affects competence in another. Open information sharing is made possible
by strong leadership and team collaboration, which in turn improve the quality
of decision-making via increased shared situational awareness and effective
communication. It was shown that shortcomings in any one of these categories
might have a domino effect, causing operational efficiency to drop and risk to
rise during disaster and trauma response.
Consequences for Education and Application
The
findings highlight the need of trauma response and disaster preparation programs
specifically include training in non-technical skills. Skills in
decision-making, communication, and team coordination may be honed with the use
of EMNoTS-aligned assessment tools, scenario-driven exercises, and
simulation-based training. Enhancing overall system resilience, reducing
unnecessary mistakes, and improving safety outcomes for both responders and
impacted populations may be achieved by incorporating these competences into
corporate training and assessment processes. [22]
CONCLUSION
This research shows how important it is to have
non-technical abilities for disaster and trauma response to be successful. How
rescuers handle uncertainty, time constraints, and complicated operational
demands is heavily influenced by factors outside technical knowledge, such as
decision-making, communication, and team chemistry. The EMNoTS framework-based
study shows that these abilities are crucial for high-risk emergency situations
requiring coordination, flexibility, and safety. Strong situational awareness
and cognitive flexibility are crucial for good decision-making, according to
the results. This allows responders to adjust their strategy as situations
change. The importance of effective communication in fostering mutual
understanding and cooperation was highlighted, as was the correlation between
communication breakdowns and operational mishaps. Results demonstrated that
teams with adaptive leadership had higher levels of collaboration, role
clarity, and stress resilience. In sum, the research shows that non-technical
skills are interrelated and that disaster response and preparation systems
should incorporate training and assessment of these skills. Operational
performance, the rate of avoidable mistakes, and the overall resilience of
disaster and trauma management initiatives may all be improved by bolstering
these abilities.
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