Having to tell a patient bad news, or informing a family that their loved one has died, is a difficult and unsettling task under any circumstances. But in the case of a traumatic injury, there are factors that make it even more challenging:
- Traumatic injury affects people of all ages and unlike other illnesses, many victims are young and/or healthy.
- Physicians do not typically have a prior relationship with the patient or family.
- The trauma response team may themselves experience a high level of stress and emotional distress during some trauma resuscitations.
- Physicians are asked to communicate news often, which leads to possibly incomplete, evolving and often complicated information being passed on to anxious family members.
- There is a high emotional impact on families; responses may include shock, anger and even violence as they consider the far reaching consequences on their lives.
- Mass casualties, such as multi-car accidents, add complexity for physicians trying to communicate with multiple families while preserving patient privacy and dignity.
Creating a new curriculm
Clinical training in trauma is centered on teaching procedures and skills that save lives, with little attention given to the communication skills that are so desperately needed in this area of medicine.
A Picker-Gold Challenge grant from the Arnold P Gold Foundation allowed us to bridge this gap by designing a Graduate Medical Education curriculum addressing communication skills during trauma.
This curriculum was created at Rutgers New Jersey Medical School – University Hospital in Newark — an urban Level 1 Trauma center that has the unique strength of being an academic center where multiple faculty have expertise in both trauma and palliative/end of life care. This project was undertaken by an inter-departmental collaboration between palliative care physician champions Dr. Sangeeta Lamba (Department of Emergency Medicine), Dr. Anne Mosenthal (Chair of Surgery) and Dr. Leslie Tyrie (Division of Trauma).
The first step of this group was to develop the ABCDE mnemonic, which was then refined based on feedback from families of patients who experienced traumatic death and from faculty whose practice involves trauma resuscitation. This mnemonic assists recall of the key steps for effective communication in trauma since the ABCDE framework is quite familiar to trainees who use it for other resuscitation skills training.
A great response to online learning and simulation
Next, we used a hybrid online and simulation format to teach and assess communication skills for surgery and emergency medicine residents. After learning basic steps through an online video, residents resuscitated a simulated patient in the trauma bay and then practiced delivering news of death or injury to the simulated family. Residents also took part in self-reflection and were given feedback from the simulated patient and family.
Not only were the surgery and emergency medicine residents fully engaged, a majority of them requested that such training become a routine practice in residency training. Trainees enjoyed the simulated setting that allowed for practice and improvement, and they valued the feedback from the standardized patients and their peers.
The curriculum has generated a great deal of interest with successful poster and oral presentations for annual meetings for the American College of Surgeons, American College of Emergency Physicians and the American Academy of Hospice and Palliative Medicine. The materials and tools, including an ABCDE pocket card, simulated cases, and assessment forms are available free to medical educators everywhere via the peer reviewed MedED portal site.
Dr. Sangeeta Lamba is a Professor of Emergency Medicine and the Associate Dean of Education at Rutgers New Jersey Medical School, Newark, New Jersey. Through her roles in the Improving Palliative care in Emergency Medicine (IPAL-EM) project of the Center to Advance Palliative Care and as Chair of the Palliative Medicine Section for the American College of Emergency Physicians she is addressing issues regarding palliative and end of life care in the emergency department.