Effective crisis management depends on strong leadership, transparent communication, and collaborative teamwork. However, challenges arise when these essential elements are missing.
The Case
When the internal emergency alarm sounded in the recovery area, three other anesthesiologists, the pharmacist, and I rushed over to help, arriving simultaneously. We found a patient none of us recognized; he wasn’t even a surgical patient but was recovering from a colonoscopy. His gastroenterologist had already returned to the GI suite and was busy performing another procedure.
The patient, a 55-year-old man, was in distress—flushed, sweating heavily, with a severe headache. His blood pressure measured 260/160 and pulse was 140. He had just arrived after undergoing a colonoscopy for intermittent abdominal pain. CT the week before had revealed a small colonic mass and colon biopsies had been taken. One test for metanephrines had been done weeks before but had been negative.
Multiple anesthesiologists assumed command and began issuing orders to the pharmacist and PACU RNs without coordination. Requests included prepare a nitroglycerin infusion, switch to a nitroprusside infusion, obtain phentolamine from the pharmacy, give a betablocker — no wait don’t give a betablocker, gather arterial line equipment, and perform an EKG. No one was paying attention to what anyone else was doing. The pharmacist and nurses made every effort to respond promptly to these orders.
Finally, after about 5 minutes, the frustrated pharmacist yelled, “Who is in charge?”
That stopped us all in our tracks. We picked one of us who then brought order out of chaos. The patient was stabilized using nitroprusside and phentolamine. Work up ultimately showed a silent extra-adrenal pheochromcytoma which apparently had been excited into revealing itself by the colonoscopic manipulation and biopsy. He underwent surgical removal and did well. For a good review of the anesthetic management of pheochromocytoma see:
Perioperative Care of Pheochromocytoma
How Did We Fail as a Team?
In this instance, despite being a highly trained group of physicians with lots of training in crisis management, we failed as a team.
A good model for team management in a crisis is TeamSTEPPS, an evidence-based framework to optimize team performance. TeamSTEPPS emphasize leadership, communication and teamwork. Utilizing TeamSTEPPS, where did we go wrong?
Crisis Management: Always Identify the Leader
In the OR or perioperative setting, the anesthesiologist responsible for the patient usually leads resuscitation. If unavailable, the next anesthesiologist present takes over. In other non-ER hospital emergencies, leadership typically goes to the internist in charge of the code or stroke team.
Our problem was that this patient didn’t fit into any of those categories. Four anesthesiologists arrived at the same time and with the same lack of information about the patient or the situation. Rather than stop and organize, we all assumed leadership and jumped in enthusiastically.
Prioritize Steps in the Plan
Since we were all shouting orders and performing tasks based on our own individual plan, no one was looking at the big picture. Crisis management requires setting priorities. No one was prioritizing where to start and what to do next.
Communicate the Plan
We certainly weren’t doing a good job sharing our thoughts or our plan with the others.
Encourage Team Members to Assist One Another
We were more involved in our own plan, than thinking about coordinating efforts and assisting each other. Things turned around when our pharmacist had the courage to speak up and ask for clarity on who was in charge. At that point, everyone started functioning together as a team.
Manage and Allocate Resources
Key resources included one pharmacist and two nurses, who could not keep up with the conflicting and unprioritized orders being given. The anesthesiologists themselves were duplicating efforts on certain tasks. Critical time was lost.
Facilitate Information Sharing
As one of us reviewed the patient’s medical history, bits of information were revealed. However, those clues circulated inconsistently within the group. Again, no one had the big picture.
Model Effective Teamwork
We were definitely not modeling effective teamwork. Crisis management depends on collaborative teamwork. Without it patient care suffers.
Key Takeaways
- Effective crisis management requires strong leadership, clear communication, and teamwork.
- In an emergency, anesthesiologists failed to establish a command structure, leading to chaos and confusion.
- The incident highlighted key failures in crisis management, including lack of prioritization, poor communication, and disorganized resource allocation.
- TeamSTEPPS, an evidence-based framework, emphasizes the importance of identifying a leader and coordinating efforts during a crisis.
- Establishing protocols and adhering to them is crucial for effective crisis management; every team member must know their role.
It’s important to establish protocol for dealing with emergencies and then follow that protocol. Our team of highly qualified providers, each trained in crisis management, did not adhere to our established protocol during an uncommon and exceptional incident. The event took us by surprise. It can happen to anyone. Each of us when faced with emergency must not be afraid to step back and make sure everyone knows who is leading the charge. And if they don’t know, fix it.
