Teaching leadership and teamwork
An earlier version of this article was published in Ski Patrol Magazine Spring 2006

Trained rescuers are accustomed to working in teams when they respond to accidents, and when everyone at the scene is experienced they usually work together smoothly and efficiently. But what happens when you're responding with new rescuers, or working with strangers? Even if other people at a scene have emergency care training, they will probably have different procedures, and you can't count on them understanding cues that your team-mates would pick up automatically. Worse, misunderstandings can lead to conflicts of leadership, which would not be reassuring to the patients. To prepare for those situations, you need to think about how to organize and direct an accident response, or (if someone else has taken that responsibility) how to help ensure efficient teamwork. Although all rescuers are trained to do a scene size-up as they approach an incident, team leaders take this process several steps further. After checking for hazards, the number of victims, and their status, they:

•  Analyze the problems;

•  Set priorities;

•  Divide the problems into tasks that they assign to helpers;

•  Translate each task into a logical sequence of clear instructions.

Setting Priorities

If an incident involves one patient, the first rescuer to arrive will secure the scene, perform an assessment, and (if possible) call for help and equipment. If several patients are involved, the one with injuries that could cause death or disability has priority for treatment and transport   In a multiple casualty incident (MCI), however (where there are more patients than the patrollers can quickly assess and transport), the team leader will have to do immediate triage, i.e., determine which individuals have the severest injuries that threaten disability or death. Such patients will have priority when it comes to care and transport.

One difficult but necessary decision a leader faces during an MCI is to sort out patients who have no signs of life; e.g., those who have no pulse and do not start breathing when their airway is opened. No matter how much help arrives on scene, if there are more patients than rescuers it's important for the team leader to direct rescuers to patients who need immediate care, i.e., those with abnormal but perceptible vital signs. Following such a course of action is more likely to save lives; patients whose vital signs are normal and stable can wait for care.

Giving instructions to team members

When a skilled team leader directs a rescue, it usually goes so smoothly and quickly that that it seems rehearsed. Such leaders seem to keep track of everything that is happening, and almost never have to raise their voices. But if we watch more closely, we can usually identify some techniques and traits that make these leaders effective.

Courtesy : Good leaders treat team members with respect, even when they make mistakes. They address people by name, and phrase instructions as requests rather than orders, e.g. "John, would you take another set of vitals for me?' When addressing strangers, they use respectful forms of address such as "sir."   They are equally respectful when they address patients, and ensure that team members meet the same standards of courtesy.

Clarity : Good leaders give clear, complete, and unambiguous instructions. For example, instructions for moving a patient should include details such as when, how far, and in which direction; and the reference for the direction should be independent of team members' orientation, e.g. "two feet to the patient's right," not "two feet to the right."  

Brevity : Good leaders do not waste words. They think before they speak and tell team members exactly what they need to know to perform the task. Inexperienced leaders often think aloud, and make several rambling attempts to describe what they want the team to do before they succeed in expressing their intent. In the worst case, a leader's indecision or obscure direction can generate arguments that stall the response and shake patients' confidence in their rescuers. .

Logic : Good leaders anticipate the sequence in which tasks need to be performed, depending on priorities and the mechanics of the techniques the team uses. For example, in cold weather an inadequately clothed patient needs to be protected against hypothermia as soon as it is practical; and for a complex technique such as backboarding or traction splinting, all the equipment needs to be laid out and the patient positioned before the team begins the technique.

Delegation : Good leaders give each team member specific jobs, and make sure that they do their jobs properly. With an inexperienced team that lacks strong leadership, jobs seem to migrate around the team, with much duplication of effort and some tasks forgotten. Good leaders also select rescuers for tasks based on their talents and experience. Some choices are obvious, such as picking big and strong people for heavy lifting. Others are more subtle, such as picking a parent who has good empathy with children as patient leader for an injured child.    

  Letter to JEMS on article, Transformational leadership

The article on transformational leadership in the April issue was long overdue, and the techniques described in it would benefit several organizations with which I have been involved. Coincidentally, I just published an article on a related topic, leadership and teamwork in accident response, in Ski Patrol Magazine , the journal of the National Ski Patrol ( www.nsp.org ). One important point is made in both articles: a good leader trains, mentors, and encourages other people to become leaders. The implied converse is that a bad leader suppresses and discourages leadership tendencies in others as potential threats to his or her authority. Unfortunately I have seen far more examples of the latter than of the former in my career as a health & safety educator and program developer.

One factor that strongly affects leadership style is the size of an organization. Anthropologists have observed again and again that the rule of 150 applies not only to primitive tribes but to any organization. This seems to be the maximum number of people that anyone can know well enough to remain familiar with their capabilities, regularly exchange ideas, and work with productively. So villages and other social groups tend to split off new villages when their population exceeds this number. Otherwise they fragment into conflicting factions, or develop a bureaucracy that imposes decisions from the top down.

Fortunately, few ski patrols have more than 150 active members, and since they are all volunteers, they need to encourage and mentor new leaders in order to share the burden of administration and keep the patrol functioning. Some innovative organizations, however, make a deliberate decision to split off new groups as they expand, to keep the number of people in each group below 150. W.T. Gore & Associates is a classic example. By this strategy, they have avoided the need for an administrative hierarchy and kept everyone actively involved in decision-making. But it is a much greater challenge to introduce transformational leadership to an organization that has already grown far beyond the critical number, and compensated by developing a rigid, top-heavy bureaucracy.

Steve Donelan

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