CRASH-3 Discussion

Thank you to Dr. Ben Porter for this summary:

The CRASH-3 trial was published in October 2019 and along with collaboration from Prof. Toni Belli (co-investigator on the CRASH-3 trial) we discussed its relevance and applicability to Sydney HEMS operations at our recent education day.

The paper had been widely circulated amongst staff through internal communications as well as being widely circulated through social media and FOAMed sources prior to the education day.

A brief discussion about the study aims, recruitment and methodology started the discussion with a general consensus that that study was well conducted, pragmatic and the results were likely to be reliable given the large recruitment population and study size. Discussion was had over the number of patients recruited from middle income countries where trauma systems that are organised differently to ours as it was felt that the standard of care may differ from that in Australia limiting the applicability of the results.

Discussion then moved onto the results, with focus on the meaningfulness of the subgroup analyses given the overall headline result of no benefit between treatment groups (TXA vs Placebo). There were mixed feelings about the best way to interpret the subgroup analyses (as has also been shown by the wide ranging reviews on many of the FOAMed websites). Some groups feeling that due to the large numbers in each subgroup that there could be some meaningful results extracted, and that the width of some of the confidence intervals suggest there may be potential for some benefit, with low risk of adverse events. Others felt that use of sub-group analysis to guide changes in practice was not best practice and felt like further work needed to be done before changing Sydney HEMS protocols. It was questioned as to why the authors had not published the all-cause mortality data, given this was the primary outcome in the clinical trials registry,  which several audience members said would have made them more comfortable looking at the sub-group data. (Further discussion with the authors following the education day has suggested this data may be made available during 2020.)

The overall felling of the group was that even if there was the possibility of benefit to giving TXA in traumatic brain injury the results were difficult to generalise to the Australian population given the large number of patient’s recruited from countries with significantly different healthcare arrangements to our own. If further data is realised containing the all cause mortality and the sub-groups by country of recruitment, then this would be more likely to lead to a change in our practice for a some specific sub-groups sustaining traumatic brain injury.

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Education Day 11 December 2019


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CGD 27 December 2019

CGD 27th Nov

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Education Day 13 November 2019


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How to secure an IVC cannula


In the retrieval setting, IV access is crucial. Oil/blood/dirt all create difficulties for adhesives. This method is an effective way to reduce the chances of cannula displacement.

Materials needed: 1 x gauze.

Step 1: Secure the cannula with normal adhesive dressing if possible

Step 2:  Start unrolling the crepe bandage from under the IVC, (1 roll)

Step 3:  Roll again over the IVC , and roll distally over the pump set line (3 rolls)

Step 4: Create a loop with the pump set distally and return the line towards IVC

Step 5: Roll proximally ensuring access port is visible (2 rolls)

Step 6:  Create a further loop proximally and return line distally, roll crepe (2 rolls)… secure end of crepe with tape

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Clinical Governance Day – Wed 30th Oct


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Education Day 16 October 2019


Summary from Dr. Ben Porter (Consultant Anaesthetist working with Sydney HEMS) – thanks Ben!

Clinical Education Day Summary – 16th October 2019

Thank you to all those involved in both the presentations and in the background helping to make todays education day a success.


SALAD Simulator

The Suction Assisted Laryngoscopy and Airway Decontamination simulator was in action again to give some fidelity to the management of severe airway soiling during induction/intubation. The simulator provides realistic catastrophic soiling of the airway and helps our crews rehearse management of passive regurgitation to minimise aspiration and hypoxia. Key learning points from today’s session included the importance of having two suction units available, noting that the portable suction unit, whilst very effective, only has a small canister capacity and a backup should always be available (usually in the form of the helicopter or road vehicle main suction unit).

Secondly, the importance of turning the patient lateral to allow passive drainage of the secretions/blood/gastric contents by gravity and maintaining this position for intubation if necessary. Time was spent practicing intubation of the manikin in the lateral position with both direct and video laryngoscopy.

Finally, use of suction assisted laryngoscopy, where one suction device is held parallel to, and in the same hand, as the laryngoscope to provide continuous suction thus allowing the working hand to be free for a second suction, or for instrumentation of the airway.



We were arrested by a very emotive and personal talk from Justin McLean about the HEMS helicopter crash sustained by his organisation in the US in 2015. The focus of the talk was around the recovery phases following the incident and how the organisation and individual staff responded over the days, months and years after. The need for a robust strategic plan in the event of an incident was covered, and in particular; that this is reviewed regularly, accessible to all levels of staff and provides for the immediate and longer term.

Specific reference was made to communication, both within the organisation and to the wider public. In the current internet climate of rapidly available social media and news streams, it is crucial that the organisation publicly acknowledges any significant incident within minutes, particularly where the incident may have been witnessed by media groups or occurred in a very public place.

Huge thanks to Justin for sharing these difficult issues and for allowing us a very small insight into some of the incomprehensible difficulties faced by the team after such a catastrophic event.


Geriatric Retrieval, ICU Outcomes and Case Discussion

The decision to admit an elderly patient to an ICU presents challenges that differ from younger patients. There is frequently a greater burden of comorbidities, complexities with advance care planning and increasing awareness of the significance of morbidity following ICU admission. The separation of patients likely to obtain benefit from an ICU admission from those that will not can present great challenges to critical care clinicians, however this does not mean it shouldn’t be considered in the context of retrieval medicine. Exactly how these decisions should be made when tasked to retrieve a patient remains unclear, however at least historically appears to be an infrequent occurrence within our service.

In NSW the Guardianship Act 1987 governs the process of making medical decisions for patients lacking capacity and is important knowledge for any health professional. Advance Care Directives are legally binding, but can only withhold consent to particular treatments, not compel a medical professional to perform a particular treatment. Establishing whether an Advance Care Directive exists remains an important part of the assessment of a critically-ill patient and should be considered in the context of retrieval taskings.


Retrieval Team Complex Decision Making

A 90 minute debate was had on the motion “There is little role for the retrieval team in making treatment limitation decisions”. This was an informative discussion with both sides represented well and some really good thoughts vocalised by the team. At the end there was a unanimous vote against the motion supporting the believe that the GSA HEMS retrieval teams should be delivering critical care expertise to the patient in any location and thus should deliver all that this encompasses. This includes complex discussions about ceilings of care and palliation where this is appropriate.

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