In Emergency Medicine, the ABCDE approach is our sacred algorithm — airway, breathing, circulation, disability, exposure.
It’s simple, universal, and lifesaving.

But once the basics are underway, something more is required.

Leadership.

Not checklist-following.
Not shouting across a crowded resus bay.
Not standing back with arms crossed.

Real leadership: calm orchestration, clear decision-making under pressure, and holding the cognitive thread when others can’t.

This article explores what happens beyond ABCDE — and how you, as the ED leader, can turn a chaotic resus room into a controlled theatre of precision.

Chaos or Command: Two Minutes That Define Everything

20:32, Friday night:
The red phone rings — trauma pre-alert.
Patient: 30-year-old male cyclist hit by a van at 40 mph. Hypotensive, GCS 9, pelvis suspected unstable.
Team on standby: 2 ED doctors, anaesthetist, trauma surgeon, 3 ED nurses, 1 radiographer.

The patient is wheeled in.

Voices overlap.

“BP first!”
“No, airway first!”
“Has anyone exposed him properly?”
“Where’s the pelvic binder?”
“Who’s calling CT?”

No clear leadership. No assignments. No shared mental model.

The first two minutes drift into chaos. Precious seconds lost.

How Great Resus Leaders Change the Game

1. Establish Silence Before Action

The best consultants say little — until it matters most.

Example:
As the patient enters, the ED consultant raises a hand.

“Everyone stop. Silence. Assignments first.”

Then:

• “Anaesthetics — airway lead. Confirm GCS and airway protection now.”

• “Surgical registrar — prepare for immediate chest or pelvic intervention.”

• “Nurse 1 — two IV lines, bloods, gas. Nurse 2 — major haemorrhage protocol.”

• “Radiographer — stand by; no X-rays until airway secured.”

Result:
Noise drops. Priorities reset. Cognitive bandwidth restored.

2. Pre-Empt the Next Three Steps

While junior staff tunnel-vision on vitals and lines, leaders watch the patient’s trajectory.

Example:
A 72-year-old woman arrives with massive haematemesis. Initially normotensive but confused.

The leader:

• Orders O-negative blood before systolic pressure collapses.

• Pre-books an urgent OGD before ICU even asks.

• Sets up for RSI before the GCS falls below 8.

Result:
No surprises. No panicked escalation. Just calm execution.

Key: Leadership is anticipatory, not reactive.

3. Close the Loop Every Time

In a noisy environment, open-ended requests fail.

Instead of:
“Can someone get fluids up?”

Say:
“John, please give 500ml Hartmann’s now. Confirm once running.”

Then confirm.

Example:
In a blunt abdominal trauma, an open request to "get blood" leads to two nurses doing the same task, while IV lines are delayed.
Closed-loop communication prevents duplication, delay, and error.

4. Maintain the Cognitive Thread

When complex cases unfold, teams spiral into task overload.

Your job: hold the story.

Example:
A 25-year-old collapses playing football.
Initial checks — normal ECG, normal obs.
Junior staff reassure.
Consultant quietly asks:

• "Family history of sudden death?"

• "Previous syncopal episodes?"

Answer: Brother died at 27.
Consultant triggers an urgent cardiology review.
Echo shows hypertrophic cardiomyopathy. Life saved.

Holding the narrative finds what task completion alone misses.

5. Debrief the Team — Not Just the Patient

Once the patient leaves, a strong team finishes the case with reflection, not just paperwork.

Example:
Post-cardiac arrest, the ED consultant gathers the team for a 5-minute huddle.

• "What went well?"

• "Where were the sticking points?"

• "Anything we can improve for the next call?"

Junior nurse hesitantly mentions that no one confirmed ventilation after intubation.
Learning locked in.
Next arrest, it's the first thing they do — and a misplaced tube is caught early.

Result:
Safer patients. Stronger team.

Key Takeaway Messages

✅ ABCDE is essential — but leadership is the multiplier.
✅ Great leaders create clarity, calm, and cohesion under pressure.
✅ Establish clear roles, anticipate the next steps, and close communication loops.
✅ Maintain the clinical thread even when others focus only on tasks.
✅ Debrief every team, every time — that’s how you build resilience.

Final Word

In the resus room, your team doesn’t need a hero.
They don’t need noise.
They don’t need hierarchy.

They need a leader who sees the whole picture, speaks with precision, and brings control to chaos.

Beyond ABCDE — that’s your role.