22 July 2022

Put health before the hierarchy and CUSS

Comment Public Health

Sometimes the senior person in the room makes a mistake. How do you tell them?


“Cat 2 trauma call!”

At 11.45pm, upon finishing handover to the night staff, this is the last thing you want to hear.

Arriving in resus, I saw the triage nurse transfer an intoxicated young man into the resus bay in a wheelchair. Max* had self-presented after falling from a first-floor deck approximately 10 hours earlier.

It’s widely known in the emergency community that drunk people frequently escape harm from trauma by employing the tactic of going limp on impact. In fact, after the fall, Max had continued to drink. His main concern was the pain in his ankle and foot.

By this time, I had been at work for 12 hours. It had been a long shift accompanied by the increasingly prevalent bureaucratic challenges of ramping and access block. Gestalt born from 20 years as a doctor, 10 of them as an emergency specialist, told me that he had avoided any major damage. I was rapidly losing interest.

“Should we put him on a trauma mat?”

Paul* was an experienced emergency nurse and had seen more trauma than most.

“Nah, look at him, he’s been walking around for 10 hours. He’ll be fine,” replied my midnight brain.

Paul raised one eyebrow but did not reply.

Max was able to transfer himself onto the resus bed and Paul applied a soft collar to remind us that his C spine was not yet cleared. He rapidly applied monitoring equipment and documented the first set of vitals which were normal.

From the end of the bed, his primary survey was intact. As the resident doctor watched on, I moved closer, chatting to Max about the events that had culminated in his ED visit today. I palpated his cervical spine and found no tenderness. I ranged his neck without pain.

“Clinically cleared,” I said.

“Even though he’s intoxicated?”

“Yeah, he’s had a good trial of life,” I casually replied, though in the back of my mind, Paul’s questioning prickled my conscience.

At this point, my friend and consultant colleague arrived in resus. She was the on-call clinician for the night and I apprised her of the situation.

“Ummmmm, maybe we should scan his head and neck,” she suggested gently, “given his level of intoxication. Especially since the CT scanner will be down later tonight.”

More bureaucratic challenges relating to staffing shortfalls.

“You’re so conservative.” I flushed red. “Paul, perhaps we need that trauma mat after all.”

I was a little embarrassed. I knew she was right. As had Paul been before her.

It was so unlike me. Often to the nurses’ chagrin, I always strongly advocate for trauma patients to be cared for in a trauma bay, with a thorough head-to-toe assessment. My experience was that things get missed otherwise.

Many health care professionals are now aware of the 2005 Elaine Bromiley case. During the induction for a routine ENT procedure, anaesthetic and surgical staff became so fixated on securing an endotracheal tube, they failed to identify the rapidly progressing hypoxia that was eventually fatal. The nursing staff attempted to intervene without success.

It has been shown that health care staff can be reluctant to voice patient safety concerns up the hierarchy. The gradient may relate to seniority within a craft group (intern vs consultant) or between different professions (nurse vs doctor).

Emergencypedia outlines some useful steps that can be used to voice your concern to a colleague, regardless of their relative position in the organisation.

I suspect I’m not alone in noticing that contemporary junior staff do not revere us seasoned consultants as we did our bosses in yesteryear; however, I encourage any junior staff to CUSS me if they have concerns!

  • C – CONCERN – “Do you think this patient should be on a trauma mat?”
  • U – UNSURE – “I’m not sure we can clear his neck while he is so intoxicated”
  • S – SAFETY – “I’m worried the patient might suffer a spinal cord injury if we don’t immobilise his spine”
  • S – STOP – “Dr Boulton! Before we do anything else, we need to apply spinal precautions immediately to this patient to prevent any further injury!”

The PACE model is another well-recognised structure that can be used to speak up for safety when a health care professional sees an action or behaviour they consider inappropriate or unsafe.

  • Probe – gain attention or raise a concern
  • Alert – repeat your concern, raise your volume
  • Challenge – formally state your concerns and challenge the individual’s decision
  • Emergency – get eye contact and potentially take over the task

Before I left the department, I wandered around to CT where Max was traversing the donut of truth. I spoke to Paul and apologised for trivialising his concerns. I applauded his attempts at graded assertiveness and encouraged him to use more and go further next time.

Obviously, my fatigue had impacted my decision making, but thankfully the patient had not suffered. ED is nothing if not a team sport.

Max was fine, by the way.

*not either of their real names

Dr Bethany Boulton is an emergency physician working on the Sunshine Coast and a founding member of WRaPEM (Wellness Resilience and Performance in Emergency Medicine), dedicated to bringing the non-technical skills of medicine to the fore.