In this post, we’re going to do something a little different. Instead of reviewing a specific Emergency Medicine topic, we’re going to discuss Leadership – How to lead your team and make things happen during a high-stakes resuscitation. As the Leadership principles are transferable between medical and trauma resuscitations, for brevity, we will refer in this article to trauma team leaders (TTLs), trauma resuscitation, and the corresponding terminology. To guide us through these principles, we’ll analyze and apply concepts described in the #1 New York Times bestseller “Extreme Ownership: How U.S. Navy SEALs Lead and Win” written by Jocko Willink and Leif Babin.

The basic concepts, which fundamentally change how we view teams and intensify accountability in leadership are that:

  • Leaders are responsible for everything that impacts their world and the success of their team
    • This is a huge paradigm shift that is easier said than done
    • It is all too easy to assign blame on others or outside circumstances. Extreme Ownership removes these excuses; it takes steps to remove any perceived barriers
  • There are only two types of leaders: Effective and Ineffective
    • Effective leaders lead successful teams that accomplish the task at hand (using whatever means, modifications, and strategies available); Ineffective leaders do not

We will now review the many relevant concepts highlighted in this book. Note: I have no financial or personal conflicts of interest, though I do highly recommend this book.

extreme ownership

Trauma bay at Kings County Hospital. From Wikimedia Commons.

The War Within: Preparing Your Team and Yourself

Extreme Ownership

The goal of Extreme Ownership is to build a high-performance, winning team. Through taking direct control of every aspect of your trauma team’s environment, we shift from a blaming/victim/passive mindset (e.g. it’s someone else’s fault, that’s someone else’s job, the equipment’s not ready, consulting services are not here yet, etc.) to a prepared/active mindset that anticipates and eliminates barriers to effective team activity.

If you cannot change something, then embrace it and mitigate its effect. If you can change an issue, then why haven’t you done this already? For example:

  • If you or your trauma surgeons are unhappy with equipment available to perform a thoracotomy or thoracostomy, develop a working group to create bundles and cross-talk between the ED, the trauma team, the operating surgeons, and the trauma bay nurses so all parties are aware of priorities and requirements
  • If consulting services are consistently not expedient in their response time, develop escalation protocols with the consulting service’s leadership and clear means to communicate urgency or priority
  • Summary: If there are delays or inefficiencies involving any aspect of trauma care, it is the TTLs role (your role) to immediately solve the problem, mitigate the issue if an immediate solution cannot be actioned, or to initiate the process to determine stakeholders, form a working group, and develop a solution

Therefore, the TTL bears full responsibility for the patient’s care, including explaining the case and its objectives, maintaining overall awareness, prioritizing interventions, and ensuring the proper personnel and equipment are available.

No Bad Teams, Only Bad Leaders

  • Under the doctrine of Extreme Ownership, your team’s actions reflect your leadership:
    • This is a difficult and humbling concept for any leader to accept. But it is an essential mind-set to building a high-performance, winning team
    • Leaders must ensure their team is well informed, well practiced, and able to perform as expected
  • TTLs should establish their expectations from the beginning
    • Leaders must set high standards and enforce them
    • Recognize that when it comes to standards, as a leader, it’s not what you preach, it’s what you tolerate. If substandard performance is accepted and no one is held accountable, poor performance becomes the new standard
  • Great leadership is contagious: once team members know what great leadership is (Extreme Ownership) and embrace it, this mindset permeates into the entire team’s culture at every level
    • The goal is to have every team member deeply invested in the overall task and feel personally accountable for the outcome
    • Everyone team member needs to be a leader at some level
    • With a mentality of Extreme Ownership team members will:
      • Accept accountability and take charge of their tasks (i.e. their own training, equipment, communication, etc.)
      • Be more willing to own their failures, and
      • Be more willing to speak up, confess they don’t understand something, or share their own ideas with the leader
    • Efficiency and effectiveness increase exponentially, and a high-performance, winning team is the result

Believe

Leaders must understand the overall goal of resuscitation and how each individual task will further that goal in order to lead effectively

  • A TTL must understand the priorities and rationales for tasks they’ve prioritized for their team as well as communicating the “WHY” to their team
    • The team should understand both WHAT they must do and WHY (how their task contributes to the patient’s overall care)
    • Your team, who you’ve delegated specific important tasks to, will never have as clear an understanding of the overall resuscitation as you
    • It is critical that TTLs communicate a general overview to their team – a useful tool for this is intermittently summarizing
  • Conversely, team members should assert themselves to identify any ambiguity and ask questions up the chain of command until they feel aligned with the team’s overall goal

Check the Ego

Extreme Ownership mandates that a leader set ego aside, accept responsibility for failures, attack weaknesses, and consistently work to build a more effective team. You must be humble and admit your mistakes. We must realize that we have only a narrow set of answers, and that we can learn from any possible source. You must always strive to improve.

  • Practicing humility allows a leader to consistently work on challenges and weaknesses—this is the only way to build an effective team
  • If the ego is overactive, you may ignore constructive criticism and advice
  • Ego can prevent a leader from conducting an honest, realistic assessment of their team’s performance
extreme ownership

Members of Operation PRESENCE-Mali conduct a night time forward aeromedical evacuation exercise in the vicinity of Gao on August 15, 2019.
Photo: Corporal Richard Lessard, Task Force-Mali. Canadian Forces Combat Camera. TM03-2019-0006-001

The Laws of Combat: Leadership in the Trauma Bay

Cover and Move

Trauma teams must “cover” or support each other selflessly.

  • The TTL must direct elements within the team to complete tasks while maintaining support for one another, not hindering or impeding each other
  • Teamwork: every member working collectively and supporting each other to forward overall patient care
    • Smaller task-based teams (e.g. access, airway, procedural, etc.) can develop tunnel vision on their immediate task, losing situational awareness
    • While team members should seek out situational awareness once their task is completed, it falls on the TTL to continually maintain perspective and remind members that they are part of a greater team
  • Hospital-wide: Departments and groups within the Trauma team must break down silos, depend on each other, and understand who depends on them. If they operate independently, they can inadvertently work against each other, damaging overall outcomes
    • In practice, avoid blaming other departments. Avoid thinking “they aren’t my problem, they don’t work for me, and they should just do their job.”
    • You’re united to help the patient. Form relationships and working groups to help other departments do their job more effectively so they can help you accomplish your goals, and together you can win.

Simple

Plans must be simple enough to be communicated easily and understood by the entire team; focused and explicit directives are ideal.

  • Plans and priorities must be communicated simply, clearly, and concisely
    • Complicated plans lead to complications: members misunderstand and inevitably things go wrong
    • It doesn’t matter how well a leader feels they have presented the plan. If your team doesn’t understand, you have failed
  • Everyone must understand the overarching objective, their own role, and what to do in the event of likely contingencies (a simple plan is easier to adapt when things go wrong)
    • It’s not enough for the team member to understand their own role; they also must understand how their role relates to the overall plan. Otherwise, they won’t be able to adjust in moments of chaos (or their actions may hinder others)
    • The plan should allow room for delegation and improvisation. A rigid plan will not be able to adapt as priorities shift.
  • The TTL directs, facilitates, and supervises the planning process (discussion and input by all relevant team members) while maintaining an overall picture and not getting burdened by details
    • Leaders must encourage open communication that allows team members to ask clarifying questions when they do not understand any aspect of the overall care or their task

Prioritize and Execute

TTLs must prioritize problems, make decisions about how to solve them, and execute. This requires situational awareness, proper contingency planning, and clear communication up and down the chain-of-command.

  • Maintain Situational Awareness
    • This is essential to correctly identify priorities
    • Maintain awareness of the overall resuscitation and its goals
      • Avoid becoming bogged down in the details of individual tasks and procedures; see “decentralized command” below
  • Contingency Planning (staying a step ahead of real time problems) is an effective way to help prioritization and execution under pressure
    • Anticipate likely challenges and map out effective responses before they happen
    • If your team has been briefed and understands what actions to take for likely contingencies, they can rapidly execute when those problems arise
      • This is further discussed below in “decentralized command”
  • Prioritization is key because even the most competent leaders can be overwhelmed trying to manage multiple problems simultaneously
    • When facing a problem, taking the first step can often be the most difficult
    • Identify the most immediate priority, then:
      1. Relax
      2. Evaluate / Observe
      3. Make a call
  • Correct prioritization in the Trauma bay involves the following steps:
    • Identify life-threats / highest priority problems
    • Relay priorities to your team; clearly state the highest priority
    • Establish a solution, asking team members for input when possible
    • Execute the solution, re-direct efforts as required until the highest-priority issue is solved
    • Repeat
  • Priorities can rapidly shift with the patient’s clinical condition
    • When this happens, TTLs must communicate this clearly to their team and how this affects ongoing care
  • Teams must be careful to avoid tunnel vision on a single issue
    • Tunnel vision limits a team’s ability to rapidly recognize when priorities shift
    • It is the TTL’s responsibility to maintain situational awareness
    • If the situation and resources allow, multiple priorities can be tackled simultaneously
  • Decisiveness amid Uncertainty: Leaders must be comfortable making decisions quickly, even without 100% of the facts (aka “analysis paralysis”)
    • A leader should look on past experiences, gather input from the team, and consider the possible outcomes to make these decisions

Decentralized Command

Once the TTL has established clarity about what the overall goal and priorities are and WHY, the TTL should push preparation, decision-making, and execution down the chain-of-command (delegate tasks).

  • Often, the Trauma team is broken into smaller, task-based teams (e.g. airway, procedural, etc.) with a junior leader (or sometimes a single member). Again, these members must understand the case priorities and how their task fits into overall patient care
    • These junior leaders must be empowered to make decisions regarding their assigned tasks as they will have more awareness than the TTL of what is necessary to effectively and efficiently accomplish the task
    • Smaller, task-based team leaders must relay what they plan to do, pass critical information, and consult with the TTL for decisions outside of their authority
      • While the TTL should clarify the limits of decisions by junior leaders, each smaller team should feel empowered to recommend decisions outside their authority up the chain-of-command
  • Situational awareness of the entire resuscitation and individual tasks must be pushed both up and down the chain of command by all team members
    • It is the TTL’s responsibility to maintain situational awareness, set priorities, delegate tasks, ensure their team understands the plan and is working effectively together
    • It is the team member’s responsibility to communicate all necessary information to the TTL, pushing for urgency and decisions when necessary, and asking for clarity/guidance when needed
extreme ownership

Canadian Armed Forces members deployed as part of Operation IMPACT prepare for small arms training at Camp Taji, Iraq on September 26, 2019.
Photo: Corporal Ryan Moulton, OP IMPACT JTF-I Image Tech. Canadian Forces Combat Camera. KW11-2019-0061-08

Summary

  • Leaders are responsible for everything that affects the success of their team; TTLs should anticipate, mitigate, or eliminate any barriers to patient care
  • Your team’s actions reflect your leadership, whether effective or ineffective
  • A TTL must clearly understand the priorities of the resuscitation and communicate to their team both what they must do and why
  • TTLs must ensure that their entire Trauma team is working synergistically towards the best patient outcome by delegation of tasks and maintaining situational awareness
  • Practicing humility and maintaining a growth mindset allows consistent improvement
  • Plans should be simple, formed from the open input of the entire Trauma team, and understood by the entire team
  • In order to get things done in the Trauma bay, a TTL must prioritize and execute while maintaining situational awareness, planning for contingencies, and being decisive despite uncertainty
  • Decentralized command (delegation of tasks) allows a Trauma team to complete life-saving interventions while allowing the TTL to think ahead and maintain situational awareness

For other topics related to Military Medicine, please see our posts on Damage Control ResuscitationTCCC and Recent UpdatesProlonged Field Care, Blast Injuries, Inhalation Injuries, Abdominal stab wounds, and Resuscitative Thoracotomy.

 

References

Willink, J., & Babin, L. (2017). Extreme ownership: how U.S. Navy SEALs lead and win. Second edition. New York: St. Martin’s Press.

Richard Hoang

Richard Hoang

Dr. Richard Hoang is a 5th year Emergency Medicine Resident at the University of Ottawa with a variety of academic interests including military medicine, trauma, simulation, and FOAMed.