Prehospital Basic Airway and Oxygenation

Cliff Reid, Karel Habig, and Geoff Healy discuss the approach to patients with hypoxia and obstructed airways, prior to rapid sequence induction. This is all about effective basic airway management.

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Penetrating Trauma

Cliff Reid, Karel Habig, and Geoff Healy discuss the approach to patients with penetrating injury.

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The Prehospital Primary Survey

In this podcast, Cliff Reid, Karel Habig, and Geoff Healy discuss how to do a prehospital primary survey

Ware S, Reid C, Burns BJ, Habig K. Helicopter emergency medical service registrars do not comprehensively document primary surveys. European Journal of Emergency Medicine. 2012 Jul;:1.


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Lessons from the Airway Registry – CGD 15 June 2016

At our Clinical Governance Day on 15 June 2016, Dr. Clare Hayes-Bradley presented cases and lessons learned from our April Airway Registry. Thank you to her for the presentation and the pearls below which shed light on our airway practice.


Common things are common. All prehospital care teams need to plan (& ideally team train with simulation) for the following:

  1. Tissued IV/IO sometimes only apparent when RSI drugs don’t work. This reinforces the need for two working IV/IO access prior to RSI
  2. Laryngoscope light failure during laryngoscopy. Everyone needs to be aware of where to put their hands on a second blade and handle in case this occurs: Dropdown Airway (DEA) Kit, pediatric airway kit in the Red Primary Pack (short handle)
  3. Cuff leak? You pass the ETT between the cords and start to ventilate. A reassuring ETCO2 trace begins and the chest rises but there’s the noise of a cuff leak. Cuff rupture on intubation is a common problem necessitating ETT exchange over bougie, but there are other causes:
  • Tracheal ETT with cuff deflated (cuff rupture or pilot balloon failure)
  • Pharyngeal cuff (ETT too shallow)

Repeat laryngoscopy may reveal a pharyngeally sitting cuff. Take note of ETT depth at insertion and continue to reassess.


From the wall of the Esky


Does Hand ventilating save time? And Implications for cardiac output.

Severely injured and shocked patients are frequently moved by our service by road or air. It can be tempting to think that hand ventilating with the BVM is going to ‘save time’ to get the patient to definitive haemorrhage control, but there are many down sides. Unintentional overventilation is common in severe injury and can result in raising intrathoracic pressure from positive pressure breaths, further lowering venous return and worsening shocked state. The time taken to instigate mechanical ventilation may help care by lowering mean IMG_2503.JPGintrathoracic pressure; allowing the ETCO2 to reflect the cardiac output response to resuscitation, and free hands for putting on harnesses/loading patient/providing other care, etc. Particularly with the added times of preparing the helicopter and spinning up for takeoff, then cooling down after landing, helicopter transport often takes much longer than you think. In general, mechanical ventilation wins over hand ventilation for prehospital trauma care.





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CGD 29th June 2016


Next week’s CGD begins with a pearl-packed Mortality & Morbidity session and is followed by the always revealing Airway Registry.

In the 2nd half of the day, Chris Partyka is returning with part two of the oustanding Sonography Training Oriented to Retrieval Medicine (STORM2) course. This is a fantastic opportunity to hone your ultrasound skills with real-time feedback from the pros and to log some proctored scans to add to your CPD portfolio or just increase your confidence.

STORM2 will include a refresher session on Basic Echocardiography in Life Support (BELS) and a 3-station workshop with volunteer patients. If you haven’t previously attended the STORM course, do not fret, you are still encouraged to attend.

To get the most out of the session, we suggest that you take a quick look at the following pre-reading with a focus on the echo section of the STORM course manual + the basic echo views.

Sonography Training Oriented to Retrieval Medicine Manual(sm)


For the enthusiasts, check out the links below as well.

STORM Course training page

Virtual Transthoracic Echocardiography (Toronto General Hospital)

Echocardiography in ICU (Stanford University)

We will conclude the day with a BBQ in the hangar. As usual all NSW Health staff are welcome to attend, a sign in is required. See here for directions:



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Clinical Governance Day – 15 June 2016

CGD 15 June draft agenda.png

     We have an outstanding CGD planned for Wednesday, the 15th of June. The morning starts with a clinical pearl-filled recounting of April’s Airway Registry as well as a thought-provoking Mass Casualty / Mass Injury session. After some coffee, we will host this year’s first exposure to the concepts and logistics of tactical medicine with a multi-modal extravaganza – a Skype presentation from a US trauma surgeon / SWAT physician, two talks by our own paramedics about real experience with tactical incidents and training, capped off by hands on workshops courtesy of expert local ambos and Defence medics.

This CGD is not intended to prepare our medical teams to don body armor and kick down doors. Wednesday is designed to give us a better appreciation of the complexities of law enforcement operations, how we might be called upon to care for patients extracted from a tactical incident, and what valuable skills/mindset can translate to our primary missions.

See the links below for more information and some background reading of this unique body of knowledge.

All NSW Health staff are welcome to attend, a sign in is required. See here for directions:


Pre-CGD Preparation:

Committee for Tactical Emergency Casualty Care (Resources/Guidelines)

EMS Operational Considerations for Active Shooter / MCI Response

European Society of Emergency Medicine‘s excellent Mass Incident link list

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HEMS Team Induction Training

As we go into Winter here in Sydney we are gearing up for the August HEMS Team Induction Training. The following piece provides an overview of the philosophy and content of the training, which was originally written for a NSW Ambulance publication:

The Greater Sydney Area Helicopter Emergency Medical Service has helicopter bases at Sydney, Wollongong and Orange and provides a paramedic-doctor team to accident scenes, remote area rescue, and for the interhospital transport of critically ill and injured patients. Our doctors also work closely with NSW Ambulance flight nurses during long range fixed wing retrieval missions.

Every six months, new doctors are trained alongside new and existing critical care paramedics in a course that has become a world leader in its class, attracting participants from all over the planet.

The purpose of the first week of training, called the HEMS Team Induction Course, is to get critical care doctors and intensive care paramedics ready for the prehospital & retrieval medicine environment. This week consists of 60 hours of workshops, simulations, skill stations, and assessments, culminating in a 90 minute multi-station exam. 12 hour days are punctuated by additional practice, study, exercise (running around the airport), and unhealthy quantities of coffee.

In February there were 37 participants on the course, consisting of not just our own NSW Ambulance doctors and paramedics, but also doctors sent from Lismore, Canberra, the Royal Flying Doctors at Dubbo, CareFlight NSW Ltd, the Australian Defence Force, and overseas prehospital specialists. We trained individuals from Australia, Britain, Ireland, the USA, Norway, Poland, and Hungary.

The course is unique in several aspects. Firstly, the focus is on team performance, not individual success. Physican-paramedic teams are trained together and tested together, strengthening the teamwork and cooperation within the team and keeping the focus always on the patient. This generates a healthy competitiveness between teams, all striving for the best exam score!

Another key component is cross training. Physicians are taught logistic and scene management skills which traditionally are the responsibility of the paramedic. Paramedics are taught all the life, limb, and sight-saving surgical techniques in an animal lab that are the doctors’ responsibility to perform. Although paramedics do not directly perform these procedures on patients, this greater understanding of each others’ roles results in more effective team coordination and mutual support, with the aim of smoother, faster missions.

Simulation is the key to performance improvement. We strive to put clinicians ‘in the zone’ so that it feels as real as possible. One way to do this is to use human actors rather than the unrealistic manikins that can’t scream or become agitated and combative.

Everyone reading this knows that prehospital care can be really tough for a number of reasons. To prepare our teams for the more acute pressures of the job, we include stress exposure training as an increasing component of the simulations throughout the week, culminating in a fairly extreme ‘stress inoculation’ station as part of the end of week exam. A strong element throughout the course is human factors training, which includes imparting the tools required to minimise the effects of stress on performance. Many of these lessons have been learned in sporting and military domains, and translate well into prehospital practice.

The opportunity to run this training every six months provides us with a ‘training laboratory’, in which we continue to improve the quality and effectiveness of the training based on participant feedback and team performance. A massive and complex logistic exercise, we welcome qualified NSW Ambulance staff to act as helpers to act in simulations and to provide other hands-on support. Anyone interested in helping with the HEMS Team Induction Course in August 2016 or February 2017 should contact Paul Kernick via the NSW Ambulance intranet.

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