In the Best Emergency Departments, Teams Save Lives – Not Individuals

My emergency physicians group takes teamwork very seriously, and not just amongst providers, but between all members of the healthcare team. That’s because we know well just how big a difference it makes in patient care. Be it the pre-hospital medic team, nursing, techs, scribes, or patient care managers, we recognize that medicine is a team sport, and we are all important and unique in our roles.

I see this in action first-hand all the time at the Emergency Department at Meritus Medical Center. Picture, for example, the following instance (it’s based off a recent incident in the ER, but a few names and details of those involved may be changed):

I was working a regular 8pm – 4am shift, and midway through I heard a medical call – “55 year old male priority 1, CPR in progress, pulse ox of 87%, heart rate of 120, currently PEA, chest compressions, received 1 epinephrine, 12 lead shows sinus tachycardia with T wave inversions in V2 through V5, blood sugar of 120, 5 minute ETA.” From that 30-second call, the medical team knew that this was a previously healthy patient that potentially had a normal life ahead of him – but something had gone seriously wrong in a hurry.

My scribe Danielle and I rapidly made our way to the resuscitation room. Once I arrived, I found Bill, our patient care tech setting up our monitor, Heather, another tech, bringing the EKG machine, John, our respiratory therapist, with a ventilator setting up intubation (breathing tube) equipment, Stacy, the charge nurse drawing up some meds, and Zack another nurse getting IV equipment together – all in preparation for a patient that hadn’t even arrived yet.

When the patient did come in, he was pale and not moving. He was being bagged and receiving chest compressions.The medics reported that the patient recently had a knee replacement and had some difficulty breathing. They also said that when they’d first arrived, he had been laying on the floor, unresponsive. The part of that history that immediately jumped out was the recent surgery. Recent surgery predisposes patients to a life-threatening disease: pulmonary embolism, or a clot in the lung that prevents breathing and blood flow.

Moving to the end of the bed, I asked our respiratory therapist to prepare for intubation and our charge nurse to check pulses while we moved him. I suggested that we should get him on the monitor, make sure our IV’s work, continue chest compressions, and have one milligram of epi ready.

But before I’d even finished my directions, Stacy, the charge nurse, said no pulse, and had him on the monitor with the IV flushed and epi given. Zack was recording the administration of medications, and John, the respiratory therapist, had the intubation equipment ready. Bill was setting up the EKG, and Heather was doing deep compressions. I made my way to the top of the bed, intubated the patient, and John was there to confirm placement and resume bagging.

The next pulse check revealed the patient’s heart had started beating, restoring blood pumping to his brain. I suggested a levophed drip, hypothermia protocol, chest X-ray, EKG, and some sedation medication, and like a well-oiled machine, everyone had everything up and running.

I then asked if we had an ultrasound nearby to evaluate for potential causes of the code, and when I looked out, Danielle (my scribe) had already brought the ultrasound machine down. While the nurses were preparing the hypothermia protocol, I did a bedside echocardiogram showing a massively dilated right ventricle – suggesting a possible pulmonary embolism. I asked Stacy for 50 mg of TPA (a clot-busting medication), and she pulled out her phone, called a pharmacist, and said it would be up in 5 minutes.  True to form, within 5 minutes the TPA was up and running.

As the dust settled, I looked outside the room for some family, and there I saw Donte, one of our family support members, updating the patient’s family on the situation. Donte gathered the family, and brought them to a room where I told them what happened, what we were doing, and what may happen. Donte stayed after I left to provide additional support and resources.

Soon after the patient received the TPA he began to stabilize. He needed less medication to keep his blood pressure up, and his heart rate had slowed down. We took him to the CT scanner where our diagnosis was confirmed – a massive pulmonary embolism.

Keri, our patient care manager, secured an ICU bed, while De, our clerk, paged the Hospitalist and the primary care doctor. Before I knew it, the patient, now stable, alive, and no longer requiring pressor medicine was whisked away to the Intensive Care Unit.

Twenty minutes after the patient had come to the emergency department without a pulse, his heart was beating again. We had addressed and treated the problem that would have killed him otherwise.

A little while ago I received a personal thank you card from the family of a patient who had been in this kind of situation. The letter was made out to me – but thinking back I knew that I was only a small part of the team that had saved their loved one’s life.

The paramedics took the pivotal history of recent surgery and got the EKG that led toward the diagnosis; the patient care techs were doing compressions that saved the patient’s brain function; the nurses administered the medications, often suggesting more, and anticipated next steps; the pharmacist got the medication to us in a timely fashion; the respiratory team made sure the patient continued breathing when everyone else was focused on the heart; the scribe recorded all the information so a legible record of what happened was saved; the family support team updated the family and kept them intimately in the loop; consultants were there to continue the ED care; and patient care managers tracked the patient’s outcome and ensured continued care in the hospital.

Every person on the Emergency Department team is crucial. In medicine, we can’t always ensure good outcomes, but with good teamwork we can ensure the patient has the best chance possible.