團隊資源管理挽救不穩定骨盆骨折合併休克：以溝通困難的外籍移工為例

Team Resource Management to Resuscitate Unstable Pelvic Fracture with Shock in an Incommunicable Foreign Labor

團隊資源管理目的是提升醫療團隊成員間的溝通及合作能力以減少醫療疏失。外籍移工的語言障礙導致病史獲得不足及不完整的理學檢查。在半身麻醉時，麻醉護理師注意到臀部瘀青，提醒手術醫師，及時進行一系列緊急處置。跡近錯失的致命性骨盆不稳定性骨折併低血容性休克才得以成功挽回。

Team Resource Management is the way to promote communication and cooperation among members of medical team and thus to decrease medical errors. Language barrier caused troublesome medical history taking and inadequate physical examination in a foreign labor. Anesthesia nursing staff reminded the operator of the gluteal bruises she noticed during spinal anesthesia, which led to a series of emergent management subsequently. A near miss possibly fatal unstable pelvic fracture with hypovolemic shock was successfully resuscitated finally.