Teamwork in Resus: Just Like Football?

A few weeks ago I was reading the most excellent Resus Room Management blog.  It’s seriously awesome and you should check it out.  [I’ve decided that all this social media engagement has made me sound decidedly non-English – and I’ve started to use words like ‘awesome’ – many apologies to the English ladies and chaps out there]

I came across a fascinating blog post on why “teamwork doesn’t work in Resus”.  This was an excellent post on a number of levels, not least because of the mention of my beloved Manchester United, but it has also given me some real food for thought.  You see, I’ve spent many years reflecting on ways to improve teamwork in Resus, and on how I can be a better leader in Resus situations.  While I loved the blog post, I have to say that I disagree that there’s no such thing as a ‘team’ in Resus.  I think that working well in the Resus Room is all about teamwork.  So let me tell you where I’m coming from…

Notvery Athletic Football Club

Rick Body, Consultant in Emergency Medicine & Carlos Valderama Wannabe

Rick Body, Consultant in Emergency Medicine & Carlos Valderama Wannabe

One of my biggest interests outside Emergency Medicine is football [I’m the punk in the pic – although I only sport this particular hairdo for special occasions].  Outside of the Resus Room, I’ve captained Notvery Athletic Football Club in a Manchester 5-a-side league for almost 19 years now.  Why am I telling you this?  Well, believe it or not, Sunday league football has taught me a lot about leadership and teamwork that can be translated to the Resus Room.

How, you ask?  Well, let’s examine the skills that are needed in Resus, then we’ll see what I’ve learned from the world of football.

Teamwork In The Resus Room

A ‘team’ is defined as a group of people linked in a common purpose.  That’s exactly what we have in the Resus Room.  Our goal is to resuscitate and care for the patient in front of us.  We may not have had the opportunity to train together like Manchester United.  With every ‘standby’, ‘trauma call’ or ‘red phone’ patient we receive, the group of heterogeneous individuals that assembles may well be entirely different.  We may not have any choice about the skill mix available to us.  We may not even know each other by name, but still our common goal can’t be doubted.

What can football teach us about teamwork in the Resus Room?

Not all football teams are like Manchester United.  My team, the esteemed Notvery Athletic FC, started as a group of school friends and has evolved over the years into a group of loosely connected individuals, united only by one common goal – to play football the right way in accordance with the team’s values, and to beat the opposing Manchester Sunday league team without being killed.  We have players who work shifts or who need to travel regularly with work.  Our team line-up almost inevitably changes every week.  Often we bring in friends of friends, occasionally cousins of cousins, at times anyone who can put on a pair of trainers and play!  [If you fancy a game, give me your number!]  Notvery Athletic FC is just as heterogeneous a group of individuals as a Resus team.  We are, however, as much of a team as Manchester United will ever be and our team spirit is up there with the best of them.

How can a ‘group’ work as a ‘team’ under these conditions? 

a. Leadership

First of all, every team needs a leader.  For Notvery Athletic FC, that’s me.  I’m not suggesting that I’m any good at it, but this is generally what I do each week.  When the heterogeneous group of individuals that I call my team turns up to play football each Sunday, my first job as the captain/team leader is organisation.  All players must be introduced to each other.  Every player is given a chance to express their strengths, weaknesses and preferences for the game ahead.  Once I understand the strengths, weaknesses and needs of my team I can then assign roles.  Who will defend, who will attack?  If we have one weaker player, certain others may need to know (discreetly) that they should pay extra attention to communication, and be aware that they may need to cover for the weaker player when things go wrong.   A big consideration, when I’m assigning roles, is the opposition we’re facing.  Perhaps they have a particularly good forward who likes to try a certain trick.  Perhaps they have specific weaknesses that we can exploit.  I don’t have a week of  training sessions to point this out to my team – we have literally a few minutes to mentally prepare the team for what may lie ahead after the kick off.  Lastly, I need to be clear that everyone understands the rules.  This applies not only to the rules of the game but also the team’s code of conduct – e.g. who will be a substitute at each particular time.

In the Resus situation, the team leader is a vital role – but it is virtually identical to the role I play every Sunday in the football league.  Next time you prepare to receive a ‘standby call’ give it a try.  Introduce the team to each other if you need to, give them a chance to break the ice.  Think about their individual strengths and weaknesses and explore their preferences for the Resus ahead.  Think about the opposition you face.   If this is a patient with GCS 3 who you may need to intubate immediately, who is looking after the airway?  Are they a strength or a weakness for your team?  If you spot a potential weakness, who’s going to cover for them in the event of trouble?  Identify them, and let them know.  Make sure everyone in the team knows their role, and mentally prepare the team by discussing what you perceive will be the biggest challenges in the imminent resuscitation.  Be sure that your team knows the ‘rules’ of the game.  In Resus, this may be simply pointing out the basic chains of command and communication, or pointing out that the team leader controls entry to the ‘red zone’ around the patient (often demarcated by a red line) in order that tasks are completed efficiently without crowding the patient.

b. Communication

A football team is highly unlikely to be successful if it’s members don’t communicate effectively.  Of course, this is largely down to individuals.  Some of us will be talkers and natural communicators, others will be quiet and not quite so strong in this situation.   There’s not much you can do about this, but once again, you can be aware of your team and its strengths and weaknesses and adjust for them.  In particular, you can create an atmosphere that fosters communication, that enables team members (including those of lesser ability, who may be less confident) to speak up and communicate with colleagues.  Without effective communication on the football pitch, it takes a split second for the opposition striker to escape the attention of our defender and plant one in the back of the onion bag, as they say.

Resus is exactly the same.  We need to be aware of who is strong at communication, who is a bit loud and who is a bit quiet.  Sometimes the team leader might need to invite communication from the quieter members more than the rest.  We need to promote an atmosphere that facilitates effective communication.  And we need to play our part.  Failure to communicate effectively in football can lead to conceding a goal.  The same failure in the Resus Room could be far more costly.

c. The best laid plans of mice and men…

A wise man once said that “No battle plan survives contact with the enemy”.  You can’t plan for all eventualities.  In football, injuries, sending offs, unexpected scorelines and unanticipated tactics from the opposition all have to be dealt with.  Once again, this calls for strong team leadership, effective communication and togetherness within the team.

A Resus team has to be able to deal with dynamic situations too.  Failure to adapt and change tactics in football can lead to a heavy thumping from the opposition.  In Resus, the consequences of sticking to your initial plans and holding to convictions are far more serious.  All team members should feel empowered to raise valid concerns about the diagnosis and management plan.  Nobody should feel too in awe of the team leader to express this.  (In fact, many plane crashes have been caused by crew members who were too afraid of breaking rank and expressing concerns to the pilot).  A good team leader should always listen to such concerns and consider whether the team needs to change tack.

d. Emotional intelligence

http://www.flickr.com/photos/robom8/4504165421/sizes/z/

http://www.flickr.com/photos/robom8/4504165421/sizes/z/

Now here’s something that’s often underestimated.  I’ll go as far as to suggest that the emotional intelligence of my football team contributes more to its success than the players’ ability.  Football is a game filled with passion.  In a Manchester Sunday league, sometimes this passion can go a little too far!  After a couple of decades in the game, my regular players know that we have to channel our energy into the game itself rather than allowing ourselves to be drawn into confrontations with the opposition or arguments with the referee.  Sometimes our opposition doesn’t have the same emotional intelligence.  If you wish to, you can even manipulate this weakness by allowing the opposition to get wound up and make them underperform!  Other teams have individuals who thrive with confrontation, in which case our players need to bring the emotions down a level by slowing the game down and avoiding situations that encourage confrontation.

Emotional intelligence is also massively important in the Resus Room.  We can modulate the emotions if we recognise them.  If the team is too high on adrenaline or too anxious, we can calm things down.  A good team leader will do this.  It can be difficult, at times.  The last DSI I performed was in a peri-mortem patient who appeared to be breathing their last.  My first job was to bring the team down an emotional level, which enabled us to control the situation and intubate in a safe, systematic and planned manner.  If the patient dies of their condition, that’s very bad.  If you kill them by reacting badly to their condition in an adrenaline-fuelled haze, that’s so-o-o bad that you really don’t wanna know.

Occasionally, you need to apply emotional intelligence the opposite way.  I find that this often happens when managing patients with STEMI.  The urgency of the situation isn’t always apparent to the team, who may amble through their tasks.  In this situation, the team needs bringing up a level – but through motivation, not discipline!

e. Debrief

Every single Notvery Athletic FC football match finishes with a debrief.  We reflect.  We go through the key events.  We talk about our favourite moments, what we did well.  We laugh, we moan, we self-criticise.  And, even if we’ve been crushed 10-0, we leave on a relative high note ready to come back and do it better next time.

In Resus, debriefing and reflection are really important for the team.  Getting feedback from colleagues is crucial, especially for the junior and under-confident members of the team who need reassurance and encouragement.  The debrief should really kick-start the reflection process for each individual.  My Monday morning drive to work is often time for reflection about the Sunday night league game and how I can improve for next time.  Similarly, each Resus team member is likely to go away and reflect (often extensively) on how the case went.  The debrief is a chance to prime that process, to inform and improve it, and perhaps to enable the reflections to be more fulfilling than the sleepless nights I’m sure every emergency physician (including me) endures all too frequently.

Next time you’re part of a Resus team, try to think of Notvery Athletic FC and see if you can apply some of the principles of football teamwork in your Resus scenario.  And please feed back about your thoughts and experiences! Until next time…

Rick

9 Comments

  1. Andy Buck

    Thanks for the link & the excellent discussion of teamwork in resus, this is just what I was hoping resusroom.mx would stimulate. Few points of contention, agreed your football “team” sounds like it can be quite heterogenous, however in your matches, I’d argue that anyone who shows up knows that the aim is to get the ball into the oppositions net, and stop the ball going back into your net, and you can only use your feet. In resus the goals are constantly moving, and it’s not always entirely clear which way you’re meant to kick the ball. You probably don’t have British football players, Aussie Rules football players and American NFL players all showing up wanting to play their style of “football”, and I’m guessing the egos and personality traits on your team may not reflect the wide spectrum of pathological personalities seen in medical folk in resus. You are lucky enough to get a decent briefing in before kickoff, (which establishes leadership), and you and the other team have a fixed, unalterable number of people on the field (barring red cards…)! You don’t have people meandering in, not announcing who they are or what position they play in, who then have a few kicks in the wrong direction, grab the ball and walk off with it, refuse to give it back and won’t tell you why!

    I wholeheartedly agree about creating an atmosphere that fosters communication (there’s an upcoming post about this), and recognising and manipulating the emotion in the room. These are very important skills.

    Sadly (where I work in Australia),workload, time pressures, KPI’s and the dreaded 4-hour rule mean we barely have time to blink after a resus before moving to the next patient, let alone debrief and discuss what happened and critique our own and others performance. Fortunately many ED’s are now doing regular simulation sessions that provide staff with the time and proper guidance to discuss, reflect on and think about ways to improve resus skills.

    I long for the day when the medical industry catches up with aviation, when we can deal sensibly with confidentiality issues, and breach it in the name of safety, and start video-recording resuscitations for review, error detection, teaching and quality assurance. Imagine.

    Again, great post, many excellent points, (although the detailed football analogy may be lost on many of us from the other hemisphere!).

    Cheers

    Andy Buck
    http://www.resusroom.mx

    Reply
    1. richardbody (Post author)

      Hi Andy,

      Thanks a lot for taking the time to reply – your Resus Room Mx post definitely achieved what you set out to, it was very thought provoking, as is the rest of the blog. You also made some great points in your reply! It’s a matter of semantics but I think the problems you have in the Resus Room (which we also have, btw) could be described as dysfunctional teamwork.

      We actually get all the problems you described in my football team. We ask people to play and they don’t turn up, turn up late, or turn up and want to run the show! We have players who like to play with very different styles – from the ‘thou shalt not pass (even if I have to kick you)’ mentality to ‘I shalt not pass (the ball)’. We’ve also had enough egos over the years – why, we’ve had anaesthetists, cardiologists, surgeons, GPs and all sorts playing for us. 😉 I’m also not sure whether all the players realise that the aim is to get the ball in the *opponents’* goal – but that’s another matter!

      These are very similar to the challenges we face in Resus each day – and there is the potential, in both situations, for the team to be dysfunctional. The principles of getting the team to work well together are similar in both situations, though.

      Simon’s also made a really good point about a team leader standing back. Simon and I both work at a Major Trauma Centre and are trauma team leaders. I think we both realise that the team works far better when the leader doesn’t get involved in a hands on manner. This allows the team leader to maintain an overview of what’s going on, to co-ordinate, to prioritise, to make key decisions, to keep tabs on which team members are present, delegate tasks and direct the activities that are going on at the patient’s bedside.

      In the 1980s and early 1990s, professional football (or soccer) had a lot of player-managers. Characters such as Kenny Dalglish, Peter Reid, Ruud Gullitt, Glenn Hoddle and Gianluca Vialli all managed teams while also playing. A couple of decades on and look what’s happened in the world of football management. There isn’t a single player-manager in any of the top leagues internationally, as far as I’m aware. I think that’s because football teams, just like Resus teams, are realising the importance of keeping the leader remote from the action.

      Sometimes, as in the case of Notvery Athletic (on a weekly basis) the leader has to get directly involved. In Resus the team leader may occasionally need to undertake challenging practical procedures, for example. However, this isn’t ideal. In a sweet factory, the leader doesn’t make sweets – they oversee the making of sweets. Resus (and the ED in general) should be just the same!

      Rick

      Reply
  2. Simon Carley

    Nice one Rick. When I first read this I did wonder whether your analogy of the team leader really fitted with the Carlos Valderama analogy as the player on the pitch. Might it be a better analogy to consider the leadership role as the coach/manager stood on the sidelines and directing play from there?? As you know my preference is to manage critical care by standing at the foot of the bed and ‘directing without touching’ on the basis that it’s difficult to maintain control if you are touching the patient or performing the procedure.

    Then I reflected on what I like to do vs. what I have to do when things get busy, the patient is sick or when things (especially procedures) start to go wrong. At that point the team leader is often the most skilled and able person there and has to step in. using your football analogy it’s the equivalent of Alex Ferguson leaving the bench as the cross goes in and landing the winning goal in the back of the net.

    So, whilst I and many others like to plan and think that we are never on the pitch, leading, dribbling and scoring – life indeed never goes to plan.

    Whilst we are on quotes. Here are some for the resus room and leadership. The first two are on the front page of my Infantry officers handbook from Sandhurst. The last from Eric auf de Heide – my all time favorite for ED planning.

    1. No plan survives contact with the enemy
    2. To fail to plan is to plan to fail.
    3. Plan for what people are going to do, not just what you want them to do.

    S

    Reply
    1. Chris Nickson (@precordialthump)

      1. No plan survives contact with the enemy

      Reminds me of the boxing/ martial arts catchphrase:
      “Everyone has a plan until they punched in the face”

      C

      Reply
  3. Dr. Damian Roland

    Always enjoy these posts that take out the medical context, replace with something everyone knows something about and then place all the key points back in!

    I am really interested in the frame made about how the “leader’ stands back. The point developed discusses player-managers – the Daglish, the Gullit etc. My view would be the best team leader is simply the manager – in the truest sense not actually doing any of the “sport” simply co-ordinating peoples action from the sidelines. Sometimes getting too involved can leads to problems, but if you take your eye off the game equally chaos can ensue. Really important to discuss tactics beforehand and debrief afterwards.

    Should the team leader be the most skilled. Should we be in situations where Alex Ferguson comes on in ‘Fergie’ time to net the winner. Certainly hope not 🙂

    Reply
  4. ellebellucci

    Hi Rick,

    Your post came my way via twitterfeed and I’m so glad. As an ER nurse, I’m seeing more and more how important “the team” is in terms of efficient processes, effective communication, and improved outcomes, for say, a cardiac arrest. The staff mix changes from shift to shift and no team may be duplicated on any given day. For this reason, I agree, the team leader is key, and must establish themselves and lead the ship.

    I’ve given alot of thought to the idea of debriefing, and wish it was established at my institution. Debriefing can provide crucial reflection and feedback to a team’s performance and serve as a teaching tool-like no lecture, no book, no video can provide. Learning often comes through the hard cases and realizing what could have been done differently. How often does debriefing consist of a hot shower and cold thoughts, a blank stare later in the night…thoughts of what could have been done, or mulling over frustrations in regards to a difficult team member or an equipment malfunction? I would love to learn how other hospitals and other teams are implementing debriefing into their ED. How do you take the time when new critically ill patients are rolling in the door?

    Lastly, just wondering if your hospital (or if you know of any others) has a team-based training approach to resus (MDs/RNs/EMTS,etc). I’m really interested in learning more about this and hopefully helping to create a program where I work. Just today I read a tweet from @Dr_CommonSense describing an exciting conference (the ACEP Simulation-based Immersive Medical (SIM) Training Course at NorthShore Center for Simulation and Innovation (NCSI) in Evanston, IL, April 17-19, 2013, http://www.acep.org/sim/ ). From the feedback I’ve gotten from other ED staff members, TIME and SCHEDULING are a major deterrent to consistent team-training like this. But I believe it’s not insurmountable and would like to learn from the successes of other EDs.

    Great post. Thanks for taking the time to write it.

    Sincerely,
    ellebellucci

    Reply
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  6. richardbody (Post author)

    I had a comment offline from Baruch Fertel, an emergency physician from Cincinnati, Ohio, who pointed out that there’s a great book on exactly this topic. It’s called ‘Goal Play’ and is written by Paul Levy, the former CEO of a hospital. The book is about leadership in healthcare settings and the author uses the analogy of football (soccer) coaching, which he has experience of.

    Thanks to Baruch’s recommendation, I now have this book on my Kindle – and the start is excellent. If you’re interested in leadership in healthcare, look out for it!

    Thanks Baruch!

    Rick

    Reply
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