Trauma Is a Race Against Time — But Not Always the Way You Think

There is something about a busy trauma resuscitation that can make everyone move faster.

More people arrive.

More instructions are given.

Procedures start happening simultaneously.

Someone is asking for equipment. Someone else needs IV access. Bloods need to be collected. Observations are being called out. The monitor is making noise. Someone is documenting. Someone is trying to get a history.

And somewhere in the middle of all of this is a patient.

We often describe trauma as a race against time.

And, of course, sometimes it is.

But I think there is another part of trauma nursing that gets less attention:

Knowing what actually deserves your attention when everything feels urgent.

Because being busy isn't necessarily the same as being effective.

More people can make a resus more complex

It seems logical that having more experienced clinicians in a resus should make things easier.

And in many ways, it does.

More people mean more skills, more experience and more capacity to perform simultaneous tasks.

But more people can also create another problem.

More information.

Multiple clinicians may be giving instructions. Several procedures may be happening at the same time. Different people can start developing their own priorities.

Small teams naturally form within a larger resuscitation.

Someone is managing the airway.

Someone is dealing with circulation.

Someone is preparing equipment.

Someone is coordinating blood products.

Someone is documenting.

That division of labour is incredibly useful.

But it can also create tunnel vision.

A clinician can become very focused on completing their task without necessarily seeing how that task fits into the bigger clinical picture.

I've seen this particularly when a strong personality becomes focused on solving a particular problem.

For example, imagine a difficult IV access situation.

One clinician has made several attempts. They are determined to get the access.

It is a reasonable thing to want.

But while everyone watches the attempts, the rest of the team can gradually become focused on the same problem.

Suddenly, getting another IV becomes the most important thing happening in the room.

But is it?

What are we actually trying to solve?

Task focus isn't necessarily a bad thing

There is a tendency to talk about multitasking and cognitive load as though the answer is to constantly step back and look at the whole picture.

I don't think that's particularly helpful for a new nurse in a resus.

Task focus can actually be a strength.

If someone asks you to perform a task, listen carefully, understand what is required and do it well.

You don't need to try to run the entire resuscitation from your position at the bedside.

But there is an important difference between being task-focused and being task-blind.

You still need to understand where your task sits within the resuscitation.

Who is running the trauma?

Who are you working with?

What is your team's immediate problem?

And if somebody outside your immediate team asks you to do something else, where does that request sit in the clinical priority?

That last question can become particularly important when a resus gets busy.

You might be asked to obtain another IV.

Someone else might be asking for equipment.

Another clinician might need assistance with a procedure.

The answer isn't necessarily to refuse the request.

It is to prioritise it based on the patient.

What are we actually trying to solve?

One of the simplest questions I think we can ask ourselves in a busy trauma is:

What am I actually trying to solve?

Imagine you're working in a trauma where the patient may need a chest tube.

At the same time, somebody asks you to insert another small-gauge IV cannula.

Both tasks are reasonable.

Both might eventually be useful.

But they aren't necessarily equal in urgency.

The question becomes:

What is critical now?

And perhaps even more importantly:

What might become critical if we don't address it?

This is where returning to the basics can be surprisingly useful.

ABCDE isn't just an assessment sequence you learn as a student and then leave behind.

It can become a mental fallback when everything around you becomes noisy.

If the situation becomes confusing, go back to the patient.

Airway.

Breathing.

Circulation.

Disability.

Exposure.

What has changed?

What is the most immediate threat?

What could deteriorate next?

And what can safely wait?

Sometimes the most useful thing you can do in a busy resus is decide what you don't need to be doing right now.

The danger isn't always doing nothing

One of the interesting things about complex trauma is that everyone can be doing something useful while the team still misses something important.

That is what makes these situations difficult.

Nobody is necessarily standing around doing nothing.

People are working.

Equipment is being prepared.

Procedures are happening.

Documentation is occurring.

Instructions are being followed.

But the patient's clinical problem can become lost amongst the activity.

Imagine a patient with multiple fractures, obvious wounds and a significant head injury.

There are plenty of things demanding attention.

The room is busy.

People are doing what they have been asked to do.

And then the oxygen saturation begins to fall.

At first, it might simply become another number being reported.

Then it drops further.

Perhaps everyone is still focused on the obvious injuries.

Eventually, the cause is identified as a tension pneumothorax.

The problem wasn't a lack of activity.

It was that the activity had started to compete with clinical thinking.

The obvious problems had become the important problems.

The scribe isn't just the person writing things down

This is one reason I think the scribe role in trauma is more important than it sometimes appears.

The scribe is often given to a junior nurse.

And understandably, it can feel like a documentation role.

Record the times.

Record the medications.

Record the procedures.

Record the observations.

Keep up with what everyone is doing.

But the scribe can potentially have another role.

Eyes and ears over the whole resuscitation.

Because they aren't necessarily tied to one procedure, they may be in a position to notice things happening across the room.

Has someone noticed that the blood pressure is continuing to fall?

Was the ultrasound performed?

Has anyone ordered blood products?

Has the oxygen saturation continued to drop?

Is everyone so focused on the airway that something else has been missed?

The scribe shouldn't be expected to diagnose every problem or take responsibility for the entire patient.

That's not the point.

The point is that documentation doesn't have to mean switching your brain off from the patient.

In fact, good scribing can involve listening to what is happening, understanding the sequence of events and noticing when something doesn't quite fit.

The quiet nurse can be incredibly valuable

I've also come to appreciate that the person who contributes most to a resus isn't necessarily the loudest person in the room.

Some nurses are naturally vocal.

Others are quieter.

Neither is inherently better.

A quieter nurse who can absorb a large amount of information, recognise a developing problem and then speak up at the right moment can be incredibly valuable.

The skill isn't simply speaking up.

It is knowing when something needs to be said.

And when it does, communication doesn't have to create another source of tension in an already busy room.

Sometimes the most effective intervention is calm, factual and specific.

Imagine an airway doctor is intubating and you notice the oxygen saturation has fallen to 85%.

You could simply say:

“The sats are dropping.”

Or you could say:

“Sats have dropped to 85. Do you want to go back to oxygenating, or do you need the difficult airway trolley?”

The second statement doesn't challenge the clinician.

It doesn't imply they've missed something.

It doesn't create panic.

It provides information and offers a decision.

Even if the options are obvious, sometimes putting those options into the room at exactly the right moment is incredibly useful.

Speaking up doesn't have to mean taking over

I think this is an important distinction for new nurses.

You don't need to become the person running the trauma.

You don't need to have the answer.

You don't even need to be completely certain that something is wrong before you raise a concern.

But you do need to recognise when something doesn't fit.

And there are different ways of doing that.

Sometimes it is simply:

“The blood pressure has dropped again.”

Sometimes:

“We've been trying to get IV access for several minutes. Do we need to prioritise something else?”

Sometimes:

“The sats are 85. Do you want to reoxygenate or prepare for a difficult airway?”

The communication is factual.

It is focused.

And importantly, it is directed towards the person who can act on the information.

That last part matters.

If you're working within a small team, communicate with the person leading that team.

If you're assisting with the airway, communicate directly with the airway clinician.

If you've noticed something that needs the attention of the trauma team leader, tell them.

You don't necessarily need to broadcast everything to everyone.

Focused communication can actually reduce noise.

So what makes a good trauma nurse?

I don't think it is simply speed.

It isn't necessarily knowing the answer to every question.

And it certainly isn't being the loudest person in the room.

A good trauma nurse understands their role within the team.

They can focus on a task without losing sight of the patient.

They can recognise when another request needs to take priority.

They can step back mentally when something doesn't make sense.

They can use ABCDE as a fallback when the resus becomes noisy.

And they can speak up without adding more noise.

Sometimes that might mean asking a question.

Sometimes it might mean pointing out a change.

Sometimes it might mean offering two possible options.

And sometimes it might simply mean saying:

“Something doesn't fit here.”

The best trauma teams I've worked in aren't necessarily the quietest teams.

They can be incredibly busy.

People are moving quickly, procedures are happening and there can be a lot of conversation.

But underneath that activity, there is a shared understanding of what matters.

Everyone doesn't need to watch everything.

Everyone doesn't need to know everything.

But someone needs to keep asking:

What are we actually trying to solve?

And when something important doesn't fit, someone needs to be comfortable enough to say so.

That's not about being the loudest person in the room.

It's about being the person who noticed.

Further Reading: The first time I froze

The Hidden Curriculum

The Knowledge We Carry

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