Undertaking a decompressive crainectomy is perhaps one of the most challenging decisions we face within critical care, we don't know if we should do the operation, and even if we think we should we don't know when, or even how. Perhaps more importantly we don't do the operation, the neurosurgeons do, but we frequently put them in the position of doing the operation when we are at our wits end, or they do the operation without asking us when we still feel we have space to play. How can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches? Evidence based medicine isn't going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either. An important component will be the future structure of clinical training, our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts. Training should involve exposure to collegiate decision making and consensus building but this will be difficult to achieve within our current nationally co-ordinated training schemes.