The importance of the command-physician in trauma resuscitation

Objective: Definitive trauma team leadership, although difficult to measure, has been shown to improve trauma resuscitation performance. The purpose of this study was to evaluate the effect of an identified command-physician on resuscitation performance. In addition, the leadership capability of four physician combinations functioning as command-physician was studied. Design: Retrospective review. Methods: Videotapes of trauma resuscitations performed at a Level I trauma center over a 25-month period were reviewed. The presence of an identified command-physician was determined by multidisciplinary consensus. Resuscitation performance was measured by compliance with three objective criteria: primary survey, secondary survey, and definitive plan; and two subjective criteria: orderliness, and adherence to Advanced Trauma Life Support protocol. Performance was then analyzed (1) as a function of the presence or absence of a command-physician, and (2) between four identified physician combinations: AF (attending surgeon + trauma fellow); F (trauma fellow); ASR (attending surgeon + senior surgical resident); SR (senior surgical resident). Chi square and the Mann-Whitney U tests were applied. Results: A total of 425 trauma resuscitations were reviewed. A command-physician was identified (CPPOS) in 365 resuscitations (85.7%); no command-physician was identified (CPNEG) in 60 (14.3%). Compliance with completion of secondary survey (81.4%) and formulation of a definitive plan (89.6%) was significantly higher in the CPPOS group. Subjective scores for orderliness and adherence to Advanced Trauma Life Support protocol were significantly higher in the CPPOS group. In the CPPOS resuscitations, formulation of a definitive plan was lower in SR when compared with the other three physician combinations. Conclusions: An identified command-physician enhances trauma resuscitation performance. Completion of the primary and secondary survey is not affected by the physician combination. Prompt formulation of a definitive plan is facilitated by the active involvement of an attending traumatologist or a properly mentored trauma fellow.