Big Room Reports

A couple of months ago, I took a patient to one of the local Level I trauma centers.  I put the patient into their assigned room, told the receiving nurse about the patient’s abdominal pain of three years, or something, and was headed back out to the ambulance.  At the same time, a crew from another local EMS agency rushed in after an emergency transport.  Their patient was immobilized, with IV bags and other accoutrements of trauma care piled on the patient’s legs.  The trauma team was all fired up, ready to go and awaiting their arrival.  I slowed out of a mixture of jealousy and curiosity to hear their report.

“Hi.  This is Evelyn.  She is allergic to, um, penicillin…”

I’m out.  I no longer cared.  Neither did the trauma team.  From their point of view, they knew that they would be starting from scratch.  With a report like that, the paramedic didn’t give the impression that he knew what was going on.  That’s how fast you can lose your authority and their attention.  The trauma team in a ‘big room’ wants to hear from an expert on that specific patient, briefly, and get to work.  They truly want to know what happened to the patient, what injuries occurred, and what was done about it.  But that feeling is contrasted with the need to get to work applying their prodigious skills immediately.  If the reporting medic doesn’t give the impression of expertise, the team isn’t able to trust anything they say.

Big room reports take training and practice to do well.  It is a critical prehospital skill that is absolutely integral to our job.  I’m in no way perfect, and I have screwed up a lot of big room reports, but I think I have learned what the hospitals in my system are looking for.  Big room reports are weird; you’re used to giving a report to a nurse with (maybe) a doctor, but now you’re giving a report to ten or fifteen people.

This can be a scary place, both for the patient and for you. (Scripps Mercy Hospital trauma bay, San Diego CA)
Courtesy: Walleigh via Wikimedia Commons, with permission.

Overall, any big room report should be loud and clear.  That is for several reasons.  First, it gives the impression of confidence.  You want to give the impression (whether it is true or not) that you have a handle on this patient.  You know all there is to know and you are here to give the trauma team a head start.  You’re the closest thing that they have to an expert regarding what happened to this patient; they want to listen to you if you give them the chance.  Second, everyone involved on the team needs to hear your findings.  EMS is important, and prehospital findings affect care decisions.  Let everyone in the room hear you, but do it without bellowing as though you’re at a Metallica concert.  Finally, you need to be clear with your language.  Communication does not occur with mumbling or vernacular terms that not everybody understands.

I divide big room verbal reports into three types.  Each has different requirements.

Emergency trauma reports to a trauma team have five parts:

• Title: This is the one-sentence description of the overall patient.  Include the age and mechanism.  A title is what your answer would be if a coworker asked what the last call was when you were too rushed to answer fully; something like “Thirty year old male, gunshot wound to the face.”
• Findings: Run through a brief list of pertinent findings on your secondary exam.  Include very pertinent negative findings, but make it short.  There is no need to point out each abrasion.  Don’t forget to include a description of vehicular damage and any pertinent bystander reports, such as reported seizures, loss of consciousness, and that kind of thing.
• Vital signs: Give the team your most recent set of vitals, plus a quick description of any changes.
• Non-obvious treatment you’ve provided: There is no need to tell the trauma team that the patient is immobilized. They can see that.  They can’t see that you give the patient 300 micrograms of Fentanyl.  Make sure to tell them.

When that is done, I ask for any questions and let them get to work.  I love seeing that process.  It looks like hyenas on a fresh zebra kill.  Really skilled and educated hyenas, but still.  I wander over to the charting nurse to make sure that s/he got all of the information and to give him/her specifics about IV sizes and such.  The charting nurse cares more about scene gossip than the surgeon does.  Make sure admissions gets any demographic information that you have – knowing who the patient is seems unimportant to us, but is critical for the hospital and the patient’s care.

Trauma arrest reports are much shorter in my system:

• Title
• Time of arrest: The trauma team’s treatment decisions depend on the duration of arrest and mechanism.  Give them either the exact time that you recognized loss of pulses or the exact duration of pulselessness.  (It is important to glance at your watch when you note the patient has arrested.)  For example, “She lost pulses 4 minutes ago” or “She arrested at 7:03…”

That’s it.  Let the staff get on it.  Hang out and answer their questions as they give them to you, but a trauma arrest only needs the mechanism and time of arrest.  Wander over to the charting nurse and admissions clerk to help them out, as with any big room report.

Medical big room reports are more extensive and less structured.  They are both tougher because they are more complex, as well as easier because they are closer to a normal handoff report.  I teach new paramedics about the ‘fish hook theory.’  Your report should perform the same job that a fish hook does.  Sink it into the receiving team’s cheeks.  Pull the line exactly to what you want the receiving staff to know about.  Don’t be afraid to tell them exactly what you think is going on, or what you’re worried about.  Diagnose, at least in a preliminary way: “I think she is having a lower GI bleed.”  It’s fine.

Make sure to include the same points that you would include in a normal hand-off report: complaint, onset, provoking/ameliorating factors, quality, radiation, severity, time, associated complaints, pertinent medical history, secondary exam findings, and vital signs.  All the stuff that will go into your written report’s narrative.   A big room report in this case is the same verbal report that you would normally give.  The only difference is to use the report like the fish hook.  Drag the listeners right to MI, or lower GI bleed, or stroke, or whatever.  Rearrange the order of your information to facilitate the fish hook.

“Sixty-five year old female, normally lives alone with normal mentation.  Found this morning with profound facial droop, left-sided weakness, and aphasia.  I am worried she is having a stroke.  She has a history of…”  After reading that, do you have an idea of what is wrong with this patient?  Lay it out for the receiving team so they end up with the same worries and differentials that you have.

Three final points: 

First, give the shortest report that you can, making sure it contains all of the necessary information, and then… Shut.  The.  Hell.  Up.  There is no need to make these reports especially long.  In many cases, the more critical the patient the shorter my verbal handoff report is.  Work needs to be done and work doesn’t involve listening to me.  

Second, this is how big room reports work in my system.  Your ED physicians, specialists, and surgeons may have other expectations.  Ask them what they would like to hear.  

Third, these reports are what the trauma team needs to get to work.  I hang out, wash my hands, talk to the charting nurse, and those kinds of things in order to make myself available for any questions that come up.  A lot of times, I find, only the critical information in my report is heard the first time around.  Specifics are missed, or aren’t important initially.  When the team cares about the specifics, I am there to fill them in.

So how does all this work out?

“Hi everyone.  I have a thirty-year old female, ejected from a highway-speed rollover.  She’s been conscious the whole time I’ve been with her.  She has the big lac that you can see to her left arm, plus crepitus to her left midaxillary chest wall.  Her breath sounds are clear, though.  She has no cervical pain and is moving all four extremities.  Blood pressure one-ten over sixty, pulse one-twenty, respiratory rate twenty-four.  Any questions?”

“Everyone here that needs to be here?  Good.  Seventeen-year old male, gunshot wound to the face.  He initially had a GCS of eight, but is now unresponsive.  The wound to his left temple is the only one I’ve found.  One-ninety over one-ten, heart rate sixty, respiratory rate of six before I intubated him.  Any questions?”

“Evening.  Mid-twenties male, GSW to the anterior chest.  Lost pulses enroute [look at watch] three minutes ago.  Get ‘im…”

“Hi everyone.  Edith is seventy-seven, found lying on her right side after not being heard from for three days, covered in urine and feces.  She is complaining of a headache, but is perseverating and altered to everything but her name.  It looks like she spent three days on the floor, with deep carpet impressions all on her right side.  Everything is tender, wherever I touch her.  I can’t find any specific deformity, bruising, or crepitus except for generalized tenderness in the secondary, though.  There was a strong smell of ammonia in her house, like from her urine.  Blood pressure seventy-six over fifty, pulse irregular at about one-ten, respiratory rate of eighteen with clear breath sounds and sats in the low nineties on the non-rebreather.  A-Fib on the monitor with a little ventricular ectopy.  Anything else I can tell you?”