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Difficulty: HardInterprofessional Teamwork and Conflict Resolution

A 28-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He has sustained a severe traumatic brain injury with clinical signs of increasing intracranial pressure and impending herniation. He also has a massive splenic laceration with active intra-abdominal hemorrhage, and his systolic blood pressure is trending downward despite aggressive fluid resuscitation.

The trauma surgery attending physician states that the patient must be taken immediately to the operating room for an exploratory laparotomy to control the intra-abdominal bleeding. The neurosurgery attending physician insists that the patient must first undergo an emergent decompressive craniectomy to prevent fatal brain herniation. Both physicians strongly defend their respective life-saving interventions, refusing to concede the priority of their procedure. The disagreement results in a tense standstill in the trauma bay as the patient's hemodynamic status continues to deteriorate.

Which of the following is the most appropriate next step to resolve this interprofessional conflict?

  1. A
    Consult the patient's next of kin to determine which life-saving surgical procedure they prefer to prioritize.
  2. B
    Proceed with the exploratory laparotomy first, as hemorrhagic shock is the most immediate cause of cardiovascular collapse.
  3. Escalate the decision immediately to the hospital's designated clinical leadership, such as the Chief Medical Officer or Trauma Director.Answer
  4. D
    Submit an urgent incident report regarding the conflict and wait for the risk management team to provide guidance.
  5. E
    Transfer the patient to a facility with specialized dual-operating room capabilities for simultaneous procedures.

Answer

The most appropriate action is to escalate the decision immediately to the hospital's designated clinical leadership, such as the Chief Medical Officer or Trauma Director.
In situations where attending-level physicians are at an intractable impasse regarding emergent, life-saving care, patient safety is immediately threatened by the delay. Standard peer-to-peer conflict resolution tools have already failed or are inappropriate for resolving a fundamental disagreement between two experts of equal standing in a time-critical emergency. The standard of care in systems-based practice dictates that the hospital's chain of command must be activated immediately. A designated clinical leader (such as the Chief Medical Officer, Chief of Staff, or Trauma Director) must step in as an objective arbiter to make an executive decision, ensuring that care proceeds without further detrimental delay.

Step-by-Step Solution

1
Identify the nature of the conflict and the level of the providers involved.
Two attending-level physicians are at a complete impasse regarding the prioritization of two equally emergent, life-saving procedures.
Recognizing the severity of the conflict is the first step in applying appropriate conflict resolution frameworks.
2
Evaluate standard conflict resolution tools.
Tools like the Two-Challenge Rule or DESC script are insufficient here, as both parties are fully aware of the clinical risks and possess equal hierarchical standing.
Peer-to-peer intractable conflicts in emergencies require a different approach than hierarchical safety challenges.
3
Determine the appropriate escalation pathway.
The chain of command must be activated to involve an objective third party with clinical authority.
When patient safety is compromised by an intractable interprofessional dispute, designated medical leadership must break the tie to prevent further delay in care.

Key Concept

Chain of Command Escalation in Interprofessional Conflict
Estimated Time:1m 30s
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Topics

Interprofessional Teamwork and Conflict Resolution

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