14.1 High-Performance Team Roles

Why Team Dynamics Are a Tested PALS Domain

Pediatric Advanced Life Support is not only algorithms and milligrams per kilogram. Roughly 10% of the written blueprint and a large share of skills/megacode scoring evaluate how people work together under time pressure. A team that knows every epinephrine dose but cannot assign a compressor, clear for shock, or pass a weight-based order without confusion will fail the child—and often fail the course station.

Resuscitation environments are noisy, emotionally charged, and cognitively overloaded. Multiple tasks must happen in parallel: compressions, ventilation, pad placement, vascular access, medication preparation, rhythm interpretation, and documentation. Parallel work only works when roles are explicit. When roles are vague, people either collide on the same task (three people fighting for the airway while no one compresses) or freeze waiting for someone else to act.

AHA high-performance team concepts apply across BLS, ACLS, and PALS. PALS adds pediatric-specific load: weight-based dosing, length-based resuscitation aids, age-specific vitals, smaller airways, and family presence. The structure of the team remains the same—clear leader, clear roles, closed-loop communication (Section 14.2), and constructive intervention (Section 14.3)—but the content of orders is pediatric.

Assign roles early—before the next crisis deepens

As soon as a second rescuer arrives (and certainly when a full code team assembles), the person taking leadership should name roles out loud:

"I am team leader. You—chest. You—airway and bag. You—monitor and defibrillator. You—IO and meds. You—record and call time."

Early assignment beats late improvisation. In megacode testing, instructors watch whether leadership organizes the room within the first moments of recognition. On real units, the same habit compresses chaos into coordinated care.

The Team Leader: Direct, Do Not Do Everything

The team leader owns the overall resuscitation strategy. Primary duties include:

1. Assign and reassign roles based on skill, scope, and who is available.
2. Run the algorithm (respiratory failure, shock type, bradycardia, tachycardia, arrest pathway) out loud so the team shares one mental model.
3. Monitor CPR quality and intervention timing—rate, depth cues, pause length, when the next rhythm check is due, when epinephrine is next due.
4. Prioritize when resources are limited (airway first if failure is progressive; shock energy and early epinephrine when indicated; reversible causes).
5. Solicit input and summaries without surrendering clear decision authority.
6. Protect safety—clear for shock, confirm drug/dose/route before push, stop unsafe actions.

Critical leadership trap: task fixation

A common megacode failure is the leader who grabs the bag, starts the IO, and pushes meds while no one owns rhythm interpretation or timekeeping. Hands-on help is appropriate when the team is tiny (two rescuers must multitask), but as soon as enough people arrive, the leader should step back to the foot of the bed, maintain a macro view, and stop competing for tasks. Macro perspective preserves:

• Awareness of the full timeline (2-minute cycles, epi every 3–5 minutes)
• Recognition of shockable vs nonshockable pathways
• Detection of silent problems (leaning compressor, hyperventilation, wrong weight)
• Bandwidth to hear safety concerns from the team

Leadership is not dictatorship without listening

High-performance leadership is directive and respectful. The leader decides when conflicting options exist, but invites critical data: "What is the last BP?" "Is that sinus tach or SVT by history?" "Do we have a weight from the length-based tape?" Mutual respect means junior staff can raise concerns without ridicule—covered further under constructive intervention in Section 14.3.

Core Bedside Roles (Know Duties and Boundaries)

Exact titles vary by hospital, but PALS megacode and AHA team-dynamics teaching map cleanly onto these six functions. One person may hold two roles when the team is small; larger teams split them.

1. Compressor

• Delivers high-quality CPR: 100–120/min, depth ≥ one-third AP diameter, full recoil, minimal interruptions (Chapter 7).
• Uses age-correct technique (infant heel-of-hand or 2 thumb–encircling; child one or two hands).
• With two rescuers and no advanced airway, coordinates 15:2 compression–ventilation cycles for infants/children.
• Rotates about every 2 minutes (or sooner if fatigue shows)—fatigue destroys depth long before the compressor admits it.
• Does not leave the chest unattended for "just a quick look" beyond planned brief checks.

2. Airway / ventilation

• Opens and maintains the airway; suctions as needed; provides bag-mask ventilation with visible chest rise only.
• Avoids excessive rate and volume (hyperventilation worsens venous return and cerebral blood flow).
• Prepares for advanced airway when indicated; confirms placement with clinical findings and waveform capnography when available.
• With advanced airway, ventilates about 1 breath every 2–3 seconds (≈20–30/min) with continuous compressions (Chapter 4 / 7).

3. Monitor / defibrillator operator

• Applies pads correctly for size/age; selects pediatric attenuator or pediatric pads when indicated.
• Watches rhythm continuously; announces clear rhythm labels at check times ("asystole," "VF," "sinus tach," "SVT").
• Charges to the ordered energy (2 J/kg first shock, then 4 J/kg, not exceeding 10 J/kg or adult maximum—Chapter 8).
• Ensures everyone is clear before shock; resumes CPR immediately after defibrillation.
• Pre-charges near the end of a 2-minute cycle when a shockable rhythm is anticipated to shorten peri-shock pause.

4. Vascular access / medications

• Establishes IV or IO access promptly; IO is appropriate when IV is delayed in arrest or critical shock (Chapter 13).
• Uses length-based tape / known weight for dosing—never guess adult doses for small children.
• Draws and labels meds; administers only after closed-loop confirmation.
• Core doses burned into memory: epinephrine arrest 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL) IV/IO every 3–5 minutes; adenosine 0.1 mg/kg then 0.2 mg/kg for SVT when indicated; fluids 10–20 mL/kg isotonic boluses with reassessment by shock type.
• Flushes after meds so the drug reaches central circulation.

5. Recorder / timer

• Documents rhythm checks, shocks, drugs, doses, routes, and times.
• Prompts the team: "Two minutes—ready for rhythm check," "Epinephrine due," "Last shock was 2 J/kg—next is 4 J/kg if still shockable."
• Prevents the common silent failure of "we forgot the second epi" during a long code.

6. Additional / flexible roles when staff allows

• Family liaison / support—explains events, manages presence at bedside per protocol.
• Runner / equipment—brings airway cart, second defibrillator, blood products, PICU team.
• Procedure specialist—difficult airway backup, ultrasound, chest tube for tension pneumothorax.

Role clarity prevents chaos—clinical picture

A 9-month-old becomes unresponsive in the ED. Without roles: three people shout for epinephrine while compressions are shallow and pads are not on. With roles: compressor starts high-quality CPR within 10 seconds; airway bags with oxygen; monitor pads on and rhythm identified as asystole; access/meds establishes IO and prepares 0.01 mg/kg epi; recorder clocks the first dose and the 2-minute mark; leader states "nonshockable pathway—CPR, epi early, search H's and T's" and keeps the room synchronized.

Knowing limitations and mutual respect

Every member must know professional and skill limitations. If assigned intubation without competency, say so immediately so the task is reassigned—do not attempt a dangerous first try while the child desaturates. Mutual respect means experienced clinicians coach without humiliation and less-experienced staff speak up about safety (wrong dose drawn, leaning on the chest, unclear order).

Megacode: team performance, not a solo exam

The PALS megacode evaluates whether the group executes assessment (PAT, Evaluate–Identify–Intervene), correct algorithms, high-quality CPR, and team dynamics. A technically skilled compressor cannot "carry" a station if communication fails, roles collide, or the leader never prioritizes. Conversely, strong dynamics can salvage imperfect individual technique by catching errors early.

Bottom line for 14.1: Assign leader, compressor, airway, monitor/defibrillator, access/meds, and recorder early; keep the leader in a directing, macro role; practice mutual respect and limitation disclosure; remember that PALS skills testing grades the team system, not isolated heroics.