Big Syringe, Little Syringe

Safety is paramount in anaesthesia, wherever it is being performed (in theatre, in ED or at the roadside). Many of the non-anaesthetists joke about the apparent simplicity of induction agents in an RSI, without appreciating the nuances.

RSI is easy!

inject the big syringe first – induction

then the little syringe – paralysis

By far the most commonly used induction agent in Australia is propofol, although in the ED and prehospital environment many of us prefer ketamine, for reasons as made clear in the infamous ‘propofol assassins’ rant from Cliff Reid.  Whilst somewhat tongue-in-cheek, it does make the point that a nuanced approach to induction agent is sensible, voiding the potentially catastrophic drop in blood pressure for critically unwell patients by avoiding agents and doses commonly used in theatre.  Similarly paralysis for RSI is traditionally performed with suxamethonium, although there is an increasing appreciation of the use of other agents such as rocuronium to maintain adequate paralysis throughout stages of difficult airway plans.

Drug safety

Like many other clinicians, I meticulusly draw my anaesthetic drugs in a standardised manner – big 20ml syringe for induction agent, 5ml syringe for midazolam, 2ml syringe for fentanyl, 5ml red-barelled syringe for neuromuscular blocker. These and all other syringes are labelled according to ISO standards as set out in ISO 26825:2008 – but I like to think that if the lights went out, I could still be sure that the big syringe was my induction agent….

There has been a lot of effort into safety in anaesthesia – probably the most important is the understanding and training of the impact of human factors in crisis management.  Checklists for both crisis management and routine (such as the WHO Surgery Safety Checklist) have their role, although all too often such tools become a mere tick-box exercise with lack of training or deviation subverting the aims of such aids.

In terms of drug labelling, there is still a long way to go.  The efforts of the international team at EZdrugID are worthy of praise – they are mounting a campaign to reduce avoidable drug error by exposing ‘lookalike’ drugs and campaigning for an international standard on such packaging. Check them out at the website or on Twitter via #EZdrugID.

Pancuronium or Suxamethonium? YOU CHOOSE
Pancuronium or Suxamethonium? YOU CHOOSE

So this week I was delighted to receive a set of sample ‘rainbow’ trays from UK company UVAMed.  These are a simple design – a plastic base tray which is colour coded, to which disposable plastic insert tray sets can be placed and disposed of after each case.

Screen Shot 2015-11-18 at 6.33.00 pm

I had a fiddle with them today in theatre – they are quite straightforward and the OCD in me liked the fact that ISO-labelled colour-coded syringes could be placed in a standardised layout in coloured trays. They use the AAGBI & RCoA standards.

It’s taken my standard anaesthetic tray from this


to this

Spot the deliberate mistakes! Midazolam in the induction compartment (yellow), propofol in the ‘miscellaneous’ section (grey). Placing wrong syringe in wrong compartment may increase error! Always check…

The trays are stackable – with a reusable (up to 100x) coloured tray into which a single-use palstic insret tray fits. There are three trays which can either be used individually, laid out on the anaesthetic trolley or stacked.

The Main Tray is for :

  • hypnotics
  • opioids
  • induction agents
  • muscle relaxants
  • anti-emetics
  • miscellanous (eg antibiotics, oxytocics etc)
  • reversal agents
  • induction agent

The Emergency Tray is for :

  • vasopressors
  • anticholinergics

The Local Tray

  • local anaesthetics
Main tray stacked on emergency and local trays – deliberate errors noted!

Sadly the greenie in me bemoans the wastage of plastic by use of such disposable trays.  I did kind of wonder if I could fashion my own standardised tray using an off-the-shelf product (such as a cutlery drawer divider, subsequently painted).  But a strength of the ‘rainbow’ tray is the modular design, the fact that it allows standardisation across an institution and hopefully goes some way to improving drug safety via avoidable error.

Of course, there is always the potential for INCREASED error, eg an antibiotic syringe, even correctly labelled, if placed in the wrong tray could inadvertently be given due to ‘cognitive forcing’ by the tray colour.  But I would imagine that if use was standardised across an institution and anaesthetists were diligent in both using the rainbow tray for standardised layout as well as the always present requirement to carefully check each drug before injecting, then inadvertent drug administration could be reduced.

The concept is similar to the colour-coded standard panels in the prehospital packs from Neann-RAPP in Australia; they can help locate agents in a crisis, but of course each syringe or ampoule still needs to be checked properly before administration.

Neann-RAPP prehospital packs demonstrated at #PAIC2015

As far as I am aware the Rainbow trays are not (yet) available in Australia. I would be interested to hear others thoughts on such colour-coding – and particularly if anyone is already doing similar with a ‘home made’ solution (there MUST be an off the shelf solution)


Currie M,Mackay PMagan Cet al.  The ‘wrong drug’ problem in anaesthesia: an analysis of 2000 incident reportsAnaesthesia and Intensive Care  199321596601.

Morris GPMorris RWAnaesthesia and fatigue: an analysis of the first 10 years of the Australian incident monitoring study 1987–97Anaesthesia and Intensive Care  2000283004

EZdrugID Campaign – access via

Propofol Assassins rant from Cliff Reid – click HERE to listen

Rainbow Trays – UVAMed


[NB: I received these trays as a free demo courtesy of UVAMed – I receive no financial benefit nor other reward for mentioning them on this blog!]

DAS 2015: Ditch the FastTrach?

It’s no secret that I am concerned with management of the difficult airway, especially as pertains to the rural/remote/austere context.  This may be either as a rural GP providing anaesthesia in the Operating Theatre, in the Emergency Department or at the roadside.  Whilst many of us learn and regularly upskill in anaesthesia via the comfortable environment of the OT (usually under the tutelage of a FANZCA), the reality is that rural practice is limited by lac of immediate backup and often a paucity of equipment.

Airway difficulty may be encountered unexpectedly in the OT, or be anticipated in the dynamic airway of a critically ill patient in the ED or prehospital environment

Back in 2012 I published on the availability of equipment to manage the difficult airway in rural Australia, driven by the publication of ANZCA PS56 “Guidelines on Equipment to Manage the Difficult Airway”.  As a result, recommendations could be made regarding airway equipment in an austere environment, especially on a budget – this might include standard direct laryngoscopy, videolaryngoscopy, both standard LMA and an intubating LMA as well as equipment to manage the emergency surgical airway. Similar setups are found in some prehospital services, with the FastTrach iLMA being the standard ‘go to’ device for rescue intubation attempts.

So I was interested to see the 2015 update on management of unanticipated difficult intubation in adults from the UK Difficult Airway Society (shout out to them by the way – interested airway enthusiasts can join DAS for a nominal fee and have their say in future guideline development).

So – what’s new in DAS 2015?

The 2015 Guideline can be accessed here. These guidelines are driven by published evidence where available; where evidence is lacking, is directed by expert opinion via DAS.  I think the paper is worth reading by ANY rural clinician, as well as those involved in airway management whether in prehospital, emergency department or operating theatre. Many of the topics discussed in FOAMed circles over the past few years are distilled into the DAS guidelines, finally.

Key features include :

  • planning for failed intubation in both routine intubation and RSI
  • extra emphasis on airway assessment including assessment of emergency surgical airway (ESA) or front-of-neck access (FONA)
  • preparation, positioning, pre-oxygenation, maintenance of oxygenation via apnoeic diffusion oxygenation/NODESAT and minimising repeated attempts causing trauma
  • importance of skills in both direct laryngoscopy and video-laryngoscopy for all anaesthetists
  • use of second-generation supraglottic airway devices (SAD) to maintain oxygenation & ventilation
  • importance of maintaining adequate muscle relaxation throughout difficult airway management, particularly to facilitate not only intubation attempts, but placement of SAD, face-mask ventilation and ESA/FONA.
  • emphasis on scalpel cricothyroidotomy as the preferred ESA/FONA technique over needle techniques.

It’s particularly gratifying to see mention of cognitive aids for crisis management such as The Vortex, the technique of apnoeic diffusion oxygenation (NODESAT), use of rocuronium to give rapid onset of intubation conditions and to maintain adequate relaxation during subsequent airway management, as well as use of the laryngeal handshake’ – all topics familiar to the FOAMed community.

“DAS make it explicit that adoption of guidelines and professional acceptance alone are insufficient – such techniques need to be practiced and understood by all members of the anaesthetic team”

On top of this, there is emphasis on the value of human factors, with this contributing to at least 40% of adverse outcomes identified in NAP4.  The new guidelines mention the impact of cognitive overload in a crisis, the need for structured communication tools such as PACE, the value of setting limits on intubation/SAD attempts, use of cognitive waypoints (“stop and think”), having a shared mental model and so on.  Again this is nothing new, but it is worth pause and consideration of how often we actually train together – many of the airway courses are aimed at the airway operator (typically a doctor) and it is actually quite rare for teams to train together for crisis, unless part of a high-functioning unit such as a retrieval service or forward-thinking ED or ICU.

“I would be interested to hear from rural doctors – how many of you have the chance to train together fro crisis management using ALL team members via in situ sim?”

DAS Airway Plans A-B-C-D

Full discussion is best left to the actual 2015 guideline published 10-11-15 in BJA.

Screen Shot 2015-11-15 at 12.48.18 pm
DAS 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults

In brief the guidelines include:

PLAN A : Facemask Ventilation & Laryngoscopy

  • Importance of head-up positioning and ramping are highlighted
  • Preoxygenation for all patients; apnoeic diffusion oxygenation for high-risk patients
  • Role for VL in addition to DL recognised, with statement that “all anaesthetists should be skilled in use of a videolaryngoscope”
  • Cricoid pressure is stated as ‘a standard component of RSI in the UK’ and should be applied correctly (*)
  • Maximum of three attempts, changing something between attempts (a fourth attempt by more experienced colleague is included as permissable’)

I won’t bore you all with the nuances of different VL devices, suffice it to say that DAS suggests their use be familiar to anaesthesia providers. In rural, we are often limited by available funds, making a compromise in cost and function. Many devices give excellent views of the glottic opening, which does not always translate into effective ETT delivery unless trained and practiced repeatedly.

“I think DAS missed a trick here – they mention cricoid pressure rather than taking the opportunity to describe it correctly as cricoid force”

Application of cricoid pressure is stated as ‘a standard component of RSI in the UK‘. The 2015 DAS guidelines acknowledge that cricoid needs to be applied properly to be effective and that is often inexpertly applied, thus making mask ventilation, direct laryngoscopy and SAD insertion more difficult. There is no mention of accepted modifications to RSI, including omission of cricoid, as practiced elsewhere in the world and accepted by certain airway providers as acceptable practice in airway management of the critically ill.

If fails, pre-agreed plan to move swiftly to:

PLAN B : Maintaining Oxygenation : Supraglottic Airway Device (SAD) Insertion

  • Limiting insertion to three attempts, changing size/device
  • Cricoid pressure should be removed during SAD placement
  • Maintenance of oxygenation & ventilation
  • Successful placement of a SAD creates a cognitive waypoint to “stop and think”
  • All anaesthetists should be trained to use and have immediate access to second generation SADs

Subsequent options at the ‘stop and think’ stage may include :

  • awakening the patient if possible
  • make a further attempt at intubation via LMA s a conduit
  • continue anaesthesia on SAD without placement of an endotracheal tube
  • proceed directly to surgical airway

I think this is terribly exciting. First up, the DAS Guidelines make it explicit that we should be using second-generation supraglottic devices. I have reviewed some of these previously eg: Supreme & iGel in A Love Supreme and AirQ in Desert Island Airways.

The ideal device is characterised by reliable first-time placement, high seal pressure, integral bite block, separation of respiratory and gastrointestinal tracts and compatibility with fibreoptic devices. The latter is important when considering a ‘staged airway approach eg: placement of SAD in the field by trained EMS providers, allowing rapid intubation in the ED via FO using same SAD as a conduit.

“One could also consider the need for an integral bite block and lack of need for an inflatable cuff to be recommendations for a rescue SAD device”

The DAS algorithms previously advocated use of an intubating LMA to facilitate blind intubation as a rescue technique.  Many theatres, emergency department sand even retrieval services have relied upon the FastTrach device.  Whilst it has reportedly better blind intubation success than alternatives (eg: the Cook Gas Air-Q II device), I find the FastTrach to be bulky, expensive, fiddly to use unless specifically-trained. It also lacks a gastric drainage port – and whilst the device can be removed to leave an ETT in situ, this is a high-risk procedure which can result in inadvertent loss of the airway (for example, see the Gordon Ewing case).

In the past I have been a fan of the Air-Q device, mainly because it obviates the need for cuff inflation, has integral gastric drainage and is a great conduit for fibreoptic intubation, either by stylet or flexible scope. DAS acknowledge the many types of SADs on the market and make specific reference to the iGel, Proseal and Supreme LMAs as being supported in practice by large-scale longitudinal studies, literature reviews or meta-analyses.

“Is the FastTrach iLMA redundant under DAS 2015?”

One can argue the toss between iGel, Supreme and AirQ devices, but one thing seems clear from the 2015 DAS Guidelines – there is NO ROLE for blind intubation through an iLMA. Instead PLAN B necessitates use of a second generation SAD and pause to consider options as above (ie: awaken, place ETT, continue on SAD or perform ESA).

Most places where I have worked have kept the FastTrach as the accepted go to device, including in theatre, ED and in retrieval.  I was always puzzled by the inclusion of a single size 4 FastTrach in the intubation pack of South Australia’s retrieval service – logic would dictate that a variety of sizes be carried, rather than rely on a single device. The lack of gastric drainage also irked me!

“Is there an excuse NOT to intubate using fibreoptic device via SAD as a conduit?”

But now the way forward is clear and appears supported by DAS 2015 – use a SAD for Plan B, and one which allows fibreoptic placement of an ETT over blind techniques which are “not recommended”.  Logically this could be achieved via carrying a variety of second generation SADs as both rescue devices and as conduits for fibreoptic intubation – to my mind this could be via either the iGel, the Supreme or the AirQ…but of course now requires consideration of training and skills maintenance with a fibreoptic device.  Whilst their availability is taken as a given in DAS, the reality is that very few rural doctors, EDs or even some prehospital providers will have access to what was traditionally expensive equipment.  Of course there are low-cost solutions, such as the use of the Levitan intubating stylet or the AmbuAscope.

I think that these devices will see renewed interest and form part of a robust airway plan for use in rural and austere environments.  Whilst AFOI techniques are hard to learn and maintain for occasional intubators, the placement of an ETT via SAD as conduit using eg: the Ambu Ascope is releatively straightforward and affordable even for cash-strapped rural hospitals.

For me the equation seems simple : second generation SAD + fibreoptic = robust safety

Here’s a video of my mate Geoff Healy at SydneyHEMS demonstrating the AmbuAscope for both awake fibreoptic intubation and via the iGel SAD as a robust technique in a mature and innovative prehospital service.  These scopes are affordable and fairly straightforward to use when combined with the SAD as conduit technique. I think every rural hospital and ED should consider it to allow staged airway management in case of difficulty.

Thus I think it may be time to retire the FastTrach for blind intubation and switch to use of a SAD-fibreoptic combo.  But promise me one thing – don’t throw out the Parker tip ETTs that come packed with the FastTrach – they are great for avoiding hangup on the right arytenoid!

PLAN C : Facemask ventilation (FMV)

If effective ventilation has not been established after three SAD insertion attempts, then Plan C should be enacted.  By this stage Plans A & B have failed and the only remaining options are to awaken the patient with full reversal of neuromuscular blockade or to continue and perform an emergency surgical airway with ongoing paralysis.

Plan D : Emergency front-of-neck access (FONA)

In the past, various techniques for ‘needle’ vs ‘knife’ have been advocated. Most of us in Australia are familiar with the excellent work by Andy Heard and colleagues in WA, describing needle, knife and open techniques for cricothyroidotomy (see links at youtube channel here). Even in the post NAP4 era, it was not uncommon debate to hear experienced anaesthetists express a preference for needle cricothyroidotomy and a relaiance on the surgeon to perform a surgical airway with scalpel.

DAS 2015 make it clear that the scalpel technique is an expected skill of all anaesthetists, which must be learned and have regular training to avoid skill fade.

The laryngeal handshake is a technique I have been teaching on various airway courses & workshops, as well as on the ETMcourse, after being shown by Levitan on a cadaver course. It is simple to teach and reliable. Thus it is pleasing to see DAS 2015 make explicit this technique of identification of the cricothyroid membrane and subsequent entry.

DAS 2015 offer two options for FONA :

  • identifiable anatomy – stab, twist, bougie, tube
  • if unsuccessful or no identifiable anatomy – scalpel, finger, bougie, tube

To be fair, DAS 2015 does mention cannula techniques as options, but maintains that surgical cricothyroidotomy s both faster and more reliable – and again, emphasises that the scalpel technique is an expected skill of all anaesthetists, which must be learned and have regular training to avoid skill fade.

As an added extra, mention is made of the use of ultrasound as part of airway evaluation, with recommendation that training in it’s use is recommended for anaesthetists. I have certainly found it useful for identification of the trachea and cricothyroid membrane in difficult anatomy where time permits.


So, a quick rattle through the DAS 2015 guidelines for management on unanticipated difficult intubation (for both routine and rapid sequence intubation) in adults.

What does this mean for rural clinicians or those practicing in an austere environment?  Perhaps no change from what many of us have been advocating for several years, namely

  • be prepared for unexpected difficult airway management
  • understand the importantce of human factors in crisis management and train accordingly
  • use an agreed plan, articulated to team members regularly practiced with in situ sim
  • be competent in both direct and videolaryngoscopy techniques
  • minimise repeated attempts at intubation and SAD insertion; make FIRST attempt the BEST attempt using appropriate positioning (head up, ramping) and use apnoeic diffusion oxygenation in high-risk patients
  • use a second generation supraglottic airway device
  • maintenance of oxygenation and ventilation via SAD is a cognitive way point for the team to ‘stop and think’ before proceeding further
  • blind intubation through an iLMA is no longer recommended; rather, place a SAD with integral gastric drainage and use as a conduit to intubate using a fibreoptic device
  • maintenance of paralysis is essential to optimise intubation, SAD insertion, face-mask ventilation and ESA/FONA
  • use of a scalpel to perform surgical cricothyroidotomy is an essential skill for anaesthetists and should be practiced regularly

A lot of this is covered in the ‘Airways on a Budget’ talk for rural doctors from a few years back

There are plenty of other pearls in the 2015 Guidelines – have a browse and think how you will implement in your practice. We’ll be discussing some of this in the forthcoming Critically Ill Airway (CIA) course hosted by Chris Nickson at The Alfred in December.  I will be one of the Faculty for what promises to be an interesting mix of task-trainign and hands on in situ simulation.

Game on…



Chrimes N & Fritz P The Vortex Approach Access here

Frerk et al (2015) Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults British Journal of Anaesthesia doi 10.1093/bja/aev371

Leeuwenburg T (2015) Airway management of the critically ill patient: accepted modifications ot traditional rapid sequence induction & intubation Critical Care Horizons 1 Access here

Leeuwenburg T (2012) Access to difficult airway equipment & training for rural GP-anaesthetists in Australia Rural & Remote Health Access here

Sydney HEMS Fibreoptic Intubation using iGel and AmbuAscope – trainign video Access here

Weingart S. & Levitan R. (2011) Preoxygenation and prevention of desaturation during emergency airway management Annals of Emergency Medicine Access here

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What Makes a Good Conference?

It was a few years ago that I blogged about the death of the medical conference. I had been to a fairly hum drum rural medicine conference and felt significantly underwhelmed with both the quality of presenters, the educational programme and the lack of vision for the future.  Read about the experience here.

Since then I’ve only bothered to attend the smacc conference series…and it’s hard not to make the inevitable comparison between smacc and the other medical conferences. The smacc model of short, engaging speakers and a flat hierarchy (speakers and attendees are drawn from anyone involved in critical care (students, nurses, doctors, paramedics)  and from many different tribes (prehospital, rural GP, emergency, anaesthesia, ICU, social work etc) – all united by passion for keeping ahead of the latest developments in care for the critical patient. Tellingly the first release tickets for smaccDUB were sold out within a few hours of registration opening – a first for any medical conference I reckon!

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In 2015 I dipped my toes back into the world of other medical conferences – sure, there was smaccCHICAGO at which I infamously spoke…but also chance to both give talks and run workshops at GP15, PAIC2015 and RMA15

So – four conferences in as many months. I reckon this has given some insight into what works, and what doesn’t. So here are my suggestions. Read along with the previous blog post on the need for presentation skills for medical presenters

(i) pick a bonza venue

I am not a fan of those ‘conferences in exotic locations‘ (it’d be nice, but the reality is that this can be exclusive). Better that the conference is held in a dedicated facility with excellent transport options and nearby accommodation and dining. All of the major cities have conference centres – use them!

More importantly, make sure the venue is appropriate and doesn’t involve too much time walking. GP15 was noticeable for having the sessions held some distance from the exhibition hall, requiring a mass move of people between floors and buildings. Not cool!

(ii) make the programme available well in advance and make it easy to navigate

People are paying a LOT of money to attend and won’t commit unless they know what they are up for. It’s a nightmare to organise a conference…but in my mind there’s no excuse not to have confirmed speakers and sessions sorted 6 months or more prior.  Having speakers confirmed and grouped into themed sessions punctuated by keynotes and plenaries makes sense. Certainly do not launch registration until speakers are confirmed and a session timetable is available – most of us want to know what we are stumping up for before committing the moolah!

Many conferences seem to use apps nowadays. I am a bit of a tech geek and love apps…but to be honest I’ve been significantly underwhelmed with all the conference apps used this year.  It may seem a god idea to have links to social media, networking contacts, QR code readers and the programme available online – but many are poorly designed and hard to navigate.

Easy to navigate - one page view of all events and speakers
Easy to navigate – one page view of all events and speakers

Give me a simple pamphlet that is easy to navigate. Make sure the format is like a standard timetable, allowing people to easily see what sessions are on when and where, for each day. Again smacc does this well, as did PAIC2015. GP15 was so-so and RMA15 was a spectacular fail in this regard.

(iii) run good pre-conference or post-conference workshops

Everyone likes to tack on some quality CPD. Most conferences I went to ran workshops before or after the conference main. GP15 was perplexing in that whilst there were some workshops prior, there were also ‘active learning modules’ and workshops of several hours duration plonked right in the middle of the conference, meaning that those registered for an ALM couldn’t attend the conference proper. Keep the learning modules separate to the conference sessions where possible.

Most of us enjoy hands on workshops – but preferably delivered by clinicians drawn from own craft group.  CPR skills are mandated for all GPs and were offered at GP15 – but I reckon it would be really cool to have GPs teaching GPs to do this, rather than outsourcing to a first aid provider. Ditto sessions on sonography, retrieval, opiate dependence etc etc – better to be delivered by credible clinicians from the craft group, rater than partialists (specialists) – they may be experts in their specialty, but they are NOT experts in the arena in which audience practices.

Whilst it’s easy to establish workshops on the obvious clinical topics, I have greatly enjoyed workshops on other areas relevant to my practice – these might include clinician self-care (avoidance of burnout), creative writing, presentation skills and so on.  Workshops on social media and FOAMed are becoming increasingly common – as are those centred on heutagogy and metacognition for adult learning.

Resilience is also a hot topic currently – whether developing cognitive resilience for clinicians in high stakes arenas (prehospital, emergency care) or resilience for a professional lifetime of grind (saying no to inappropriate requests, avoiding burnout etc).  Tackling topics which are common memes but often ignored in traditional education can offer a more nuanced approach to achieving mastery in the discipline.

Sim is creeping into medical education more and more – it’s possible to deliver high quality sim sessions across a variety of clinical arenas for large groups…and also to offer workshops in how to run sim sessions and debrief properly. I’ll mention events such as SonoWars, SimWars & FernoSim a little later….

(iv) have a good mix of plenaries, breakouts, workshops and concurrents

It’s easiest to frontload each day with a keynote or two – but keep them short, no more than 30 minutes.  Then break into concurrent sessions for rest of morning.  Rinse and repeat in afternoon, although may wish to close each day with another keynote or plenary session. I think of it as :

<opening session keynote/plenary – everyone present>

<concurrents – break into groups>


<concurrents – break into groups>

<everyone present for forum/keynote session>

Inviting expert panel discussion and audience participation works a treat for contentious topics and increase engagement. There are some REALLY interesting software packages out there to make audience participation easier eg: live polling – I’ve been playing with GLISSER and CROWD MICS to allow audience polls during a presentation or use of own smartphone as audience mic, respectively.

(v) have a varied academic programme

I loved the smacc2013 idea of submitting abstracts as a ‘pecha kucha’ competition in the months prior…this increased the hype and engagement of participants, and allowed the BEST talks to be selected to be delivered as a 15 min presentation…whilst also building up a resource of rich PK talks for use as an asynchronous web resource.  For those of you who haven’t seen the PK format, it’s very simple – 20 slides, each of 20 seconds duration – or thereabouts – total talk time is 6 mins 40 secs (400 seconds) and ensures a short, punchy delivery for maximum impact.

So – invite abstracts early, and filter the best for presentation.  I was perplexed at GP15 and RMA15 as the academic programme seemed to mix & match talks inconsistently…where possible ensure themed sessions are grouped.

(vi) insist on short, punchy presentations and ensure conference speakers prepare properly

It’s no secret that I am not a fan of ‘death by powerpoint’.  I was in a fit of rage to hear experienced professors of emedicine apologise for ‘this is a busy slide’ or ‘some of you may not be able to see this at the back’ – saying this implies that you really don’t care about the audience

So, some rules

  • ensure all presentations are kept short (20 mins, plus 5-10 mins questions)
  • get presenters to submit slides 1 month prior to the conference. Exert editorial control over slides that are busy
  • ensure presenters use the appropriate slide dimensions (4:3 or 16:9)
  • make sure the presenters are briefed to KEEP TO TIME and TALK LIKE TED
  • follow the rules on creating a killer slide set – large good quality pictures, few words, zero bulletpoints
  • remember the 10-20-30 rule : 10 slides, over 20 minutes with minimum 30 point font

Many speakers get hung up on trying to deliver their thesis or research paper as a powerpoint slideset. Forget that. Speakers are there to educate and entertain.  The audience will remember only three things (at most) from your presentation. What REALLY matters is to tell a story and to engage the audience in order to make them care! My mate Gracie Leo talks about presentations that have PURPOSE, PASSION and are PRACTICED

There’s often concern about story-telling vs hard-hitting science for presentation format and delivery. I think a blend can be achieved easily enough – but you HAVE to engage in order to educate.  If you accept that the purpose of speaking at a conference is to impart information about your area of expertise, then surely it’s important to look at effective methods of delivering that knowledge? A powerpoint version of your acadeic paper won’t cut it!

Have a read of this post from Simon Carley of StEmlyns

If in any doubt, read the advice in this blogpost on presenting at medical conferences. Please!

(vii) Encourage dissemination of conference content as FOAMed

In the spirit of FOAMed, encourage speakers to make resources available for the audience – this can be in the form of ‘flipped classroom’ content for workshops, and as show notes for short talks (I usually include a QR code or link to a DropBox link containing all relevant references, copy of slides and additional materials such as videos or links at the beginning and end of my talks).

Many people are unaware that both Powerpoint and Keynote allow speakers to quickly and easily generate a narrated slideshow video of their presentation. This is GREAT as it means you can make your talk available for people to watch again and again – and savvy speakers will use social media to allow the ‘reach’ of their talk to be vastly increased by releasing the narrated slideshow video at same time as they deliver their talk – I’ve given talks to a room of 50 people…whilst over 500 have downloaded the talk in the same hour.

Hot tip – get all speakers to agree to make their slideset available as FOAMed.

Encourage speakers to create a video file of their talk by recording a narrated slideshow in Powerpoint/Keynote, saving this as a video file and then uploading to Vimeo, YouTube or DropBox for sharing

Sure, conference organisers can video talks as they are delivered and upload them, but this is expensive, labour intensive and files can be large to download. Such videos are often also hidden behind paywalls or secure logins.  Beter to make them available as FOAMed. Encouraging speakers to make their talks and their content available as FOAMed both before, during and after the conference accelerates the interaction and leads to greater participation….which is what a good conference is all about

(viii) Make sure the tech stuff is rock solid

Needless to say every conference nowadays needs blisteringly quick wireless internet access and the login details should be available to all attendees.

Many conferences now have their own hashtag – this should be used pre-conference to publicise and preferably be short and easily memorable (#smaccDUB, #PAIC2016 etc).  Along with a Twitter hashtag comes the need for a twitter account and the possibility of twitter moderation – thus a keynote delivered at the conference can generate questions and comments from a worldwide audience.  Having a twitter moderator can be useful to sift and sort questions and put to the speaker in the alloted time.

Symplur is the de facto medical conference analytics site for social media impact – check out their metrics (but make sure you register the conference hashtag with Symplur to generate the data – it’s free)

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Symplur – to analyse healthcare conference social media impact via Twitter

Many of us use Macs over PCs. Insisting that speakers only use Powerpoint pre-2007 is ridiculous…a conference should be able to deal with most presentation formats and have options to hotswap between Mac/PC, as well as afford sound and video via HDMI, VGA and other connectors.

I think it’s high time we all abandoned the lectern or podium and allowed speakers to roam the stage or amongst the audience. A headset (or lapel) mike can achieve this and allows a much more relaxed presentation style. Insist on this.

(ix) intermix the conference programme with some fun

I am not talking about clowns and jugglers (although this could be fun). Nor the Gotterdamerung of marching bands and firedancers in the opening ceremony.  But one of the joys of smacc has been the introduction of some novel yet educationally-sound fun.  And to entertain is to educate.

I’ve mentioned the PK talks as a vehicle to generate abstracts and select the best for presentation, whilst also building up a knowledge base for free dissemination. That’s easily reproducible. But having tongue-in-cheek debates or even cage fights between opposing views can be a stimulating way to educate and entertain.

Ferno Sim – Shark bite, boat fire, spear guns, & DCI challenge!

Some of the BEST medical education I have ever seen has come form the SonoWars and SimWars series at smacc, and the FernoSim at PAIC2015. These are big ticket items – competing teams performing in front of a large audience on the main stage, either undertaking various challenges (performing an eFAST on a mechanical bull in SonoWars) or engaging in gnarly sim and hot debrief (SimWars).

Teams for around the world competed in FernoSIM – this year’s event in Adelaide involved a traumatic amputation from sharkbite, a speak-gun injury, decompression illness and crowd control…all onboard two small dive vessels off the coast of Australia…one of which caught on fire!  Doing this well requires skillful compere skills and a rapid changeover of teams/equipment to maintain audience enthusiasm.  Debriefing in front of a large crowd also has to be done sensitively – the Pendleton Rules shit sandwich won’t wash!

(x) have a great social programme

Some people like a formal black tie/frock Gala dinner – others like a less formal drinks n nibbles. Social media allows attendees to attend not only the planned conference events, but also to generate their own – the #EMSWolfPack movement kicked off in Chicago and saw many prehospital paramedics crowdsource ther own social events in parallel with the other fine events. RMA15 and smaccUS both had fun runs and other social events – smaccYAK (a kayak tour on nearby rivers licked off in Chicago and we will be doing the same on the River Liffey in Dublin June 2016)

smaccYAK in Chicago Kirsten Kingma - paramedic & medical student, South Africa Mark Wilson - neurosurgeon & HEMS doc, UK Colin Dibble - EM Physician, NSW Oz
smaccYAK in Chicago
Kirsten Kingma – Paramedic & Medical Student, South Africa
Mark Wilson – Neurosurgeon & HEMS doc, UK
Colin Dibble – Emergency Physician, NSW Oz

Similarly sit down gala dinners are fine – but don’t exactly encourage interaction and intermingling. Some events cater well with small food tents offering nibbles and drinks, with a live band playing and opportunities for attendees to dance, mingle, mosh or chillax, depending on space and available seating.  Much better than 12 strangers sitting at a table!

What else? We’ve had FOAMeoke (karenoke amongst the FOAMed mob), bar meets, sight-seeing (inc visits to concomitant U2 concerts, cocktails atop Sears tower, baseball games)…but not confined to smacc – the rural docs conferences do this sort of stuff really well with parallel medical students programme, creche for kids, family activities and so on.

Finally – remember the goal of the conference – to inspire, to educate – changing the format from the usual tired old format of lectern-seats-hour-long powerpoints will encourage interaction and true innovation. Try it.

Interested in others thoughts on what makes a good conference….

Emoji in Medicine

Doctors are getting younger – at least that’s what it seems to old dinosaurs like me.  On my occasional forays into the Hospital system, it’s not uncommon to receive messages from junior colleagues via text…and I’ve even seen textspeak slip into some of my student’s written clerkings.

Which makes me wonder – has anyone seen a referral note or discharge summary written entirely in emoji?

The gauntlet was thrown down via Twitter…and already two (hypothetical) cases have been submitted.

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Can you translate them or do better?

The Cutting Edge

Thanks to Kenu Dilega Parker for photography

I’ve just had the incredible good fortune to spend a few days between GP15 and PAIC2015 as a speaker and facilitator at RescueExperienceOz events in Victoria and Tasmania.

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The one day Rescue Experience workshops are provided free of charge around the world by Holmatro – the makers of rescue tools.  I don’t know anything about hydraulics or cutting equipment, but has previously browsed the rather excellent ‘Vehicle Extrication Techniques’ book from extrication guru Ian Dunbar (@dunbarian).  You can get the book as either hardcover or as an interactive app (both OSX and Android versions available). It’s useful for clinicians to have an idea of vehicle extrication at the roadside!

“Excellence – Innovation – Education”

So it was a pleasure to meet the legendary Ian Dunbar (aka “Dumpy”). A former firefighter with Cheshire Fire Brigade in the UK, Ian now has the enviable title of ‘rescue consultant’ with Holmatro and gets to travel the world – not selling tools, but advising on technical aspects of road crash rescue.  He also plays a mean guitar and has a keen interest in all aspects of road crash rescue – not least trauma management.
Also helping were SA-born firefighter Joff van Ek and SES guru Kris Parker – they a part of the team at Extrication Matters and both struck me as incredibly knowledgable and engaging folk – a sort of FOAMed for SES/fire services!


“Road crash rescue – safer, quicker, easier”

I was struck by the similar ethos between these vehicle extrication expert and my trauma gurus – both governed by the maxim of bringing cutting edge techniques to the roadside in whatever form.

I was particularly interested in Ian’s involvement with ATACC – the “anaesthesia trauma and critical care” course is one which I’ve long championed (see blog post here).

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Unlike ATLS-EMST, the ATACC course offers immersive simulation from prehospital to tertiary centre.. It is also a multidisciplinary course, with doctors, paramedics and fire/rescue participants.

“Extrication practice should not happen in isolation – it requires multi-agency training and inter-agency understanding”

Ian told me how he attended ATACC as a rescue operative over a decade ago – and became passionate about learning clinical skills as well as road crash rescue – a sensible decision, given that fire/rescue services are often first on scene and may have to deal with a critically ill patient with minimal training. Of course, even if paramedic & retrieval services are on scene, it is essential for all agencies to understand each other’s operational priorities and capabilities. As well as being an instructor on ATACC, Ian (and fellow ATACC Faculty) have championed the institution of BTACC  a one day course designed to give first responders the necessary skills to deal with such patients, in addition to their usual role as vehicle rescue operators.

Teaching vehicle rescue workers the MARCH approach
Clinical & Extrication priorities need a shared plan

Details of BTACC, RTACC and ATACC are available by clocking the respective links.  Sadly there is nothing like this available in Australasia of which I am aware, although the Sydney-HEMS induction course comes pretty close by all accounts.

Needless to say I think this is definitely something that could (and indeed should) be brought ‘down under’ – an ATACC course in Oz would certainly fill a niche – but perhaps more useful would be a suite of courses including BTACC…

The rescue operators whom we taught were mostly drawn from ranks of the State Emergency Service (SES) as well as Country and Metro Fire services – and all seemed to enjoy the mix of practical hands on demos and inspirational lectures we delivered.

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Of course it’s not just courses that make a robust system – my paper with John Hall on establishing a national Australia-wide rural responder network was published this week in Emergency Medicine Australasia and has attracted some positive feedback – but wouldn’t it be awesome to tap into the available workforce of other emergency agencies to help deliver support when it’s needed?

Perhaps the BEST bang for buck will be to support the freely available GoodSAMapp.  This is not specific for trauma – in fact, it’s better for delivery of crowdsourced basic life support (airway opening and CPR) by trained personnel such as SES, fire, surf life saving as well as off duty clinicians.

I would be so proud if attendees at ResExOz15 and colleagues in SES, fire and surf lifesaving would download both the GoodSAM ‘responder’ and ‘alerter’ apps  and register as a GoodSAM responder

Once done, encourage friends and family to download the ‘alerter’ app.


Thanks to Kenu Dilega Parker for photographs – see more of her excellent work here


Out with the Old – In with the New

It’s been three years since I last went to a national conference aimed at primary care clinicians in Australia. Workshops aside, I was so disappointed with the content and general lack of engagement with attendees at RMA2012 that I vowed never to return and even blogged about the experience in “is the medical conference dead?

Please – no more turgid medical conferences with shitty powerpoints

My negative experience in late 2012 meant that I was ambivalent about attending smacc2013 in Sydney – but curiosity got the better of me.  Suffice it to say, the smacc experience was a revelation as well as a revolution.  Short talks from experienced clinicians.  Story telling interspersed with science.  Innovative ideas.  And the whole edifice built upon relationships engendered through the FOAMed community using social media. Since then I’ve spoken at smaccGOLD and smaccUS – although I’ve opted to have a break and not to speak at smaccDUB next year. On the way my presentation skills have improved – but I still have a lot to learn.  You can see some of the smacc talks here.

This week I am in Melbourne at the GP15 conference. I was pleased to see that GP15 has a fairly active social media engagement, with many attendees (particularly those from the GPs Down Under Facebook group) tweeting about their experience. But one common theme stood out – apart from the workshops, the vast majority of the conference presentations were abysmal.

I should qualify that – the speakers were clearly highly-educated researchers and passionate about their work…but the delivery SUCKED. With a few exceptions, most talks were characterised by dense slides packed full of text, complicated diagrams and a complete failure to engage with the audience.

Be very clear, if you get up and say “I am sorry but this is a busy slide” you are actually saying “I don’t give a **** about my audience”

Ditto if the presenter over runs time, cannot control the AV equipment or reads the words on the slide aloud…word…by word….

As a result, audiences were bored and many of us frustrated with the experience.

I appreciate that very few of us have any training in presentation – and some clinicians are naturally gifted orators.  Sadly many (I am one) have to work at it. But it’s worth investing the effort – otherwise perhaps you shouldn’t be presenting!

The New?

I would really like there to be clear instructions to future presenters at such conferences – as well as to offer workshops in different topics – presentation skills, use of social media and clinician self care being some obvious ones.

Of course some of the problems with a turgid conference aren’t on the presenters – the organisers need to be clear about WHO the audience is.  They also need to ensure that content is themed into appropriate streams (as I found out at GP15, there’s no point talking on rural emergencies in the middle of a session on diabetic eye disease!).  A diligent organiser would also ensure that speakers understood the basics of presentation and vetted their slides prior.

It’s a year to the next GP16 Conference in Perth.  Plenty of time to implement some preventative medicine. In the meanwhile, here’s a quick run down of do’s and don’ts…

Know your audience

It’s old advice, but I am not sure people pay enough attention to this.  Consider carefully:

  • What are they like? Imagine them on a personal level. Are they old clinicians, weary from life at the frontline? Are they new doctors thirsty for knowledge? What experience do they bring to the room?
  • Why are they here? What do they think they’re going to get out of this presentation? Why did they come to hear you? Are they willing participants or mandatory attendees?
  • What keeps them up at night? Everyone has a fear, a pain point, a thorn in the side. Let your audience know you empathize—and offer a solution.
  • How can you solve their problem?What’s in it for the audience? How are you going to make their lives better?
  • What do you want them to do? Answer the question “so what?”—and make sure there’s clear action for your audience to take
  • How can you best reach them? People vary in how they receive information. This can include the set up of the room to the availability  of materials after the presentation. Give the audience what they want, how they want it.
  • How might they resist? What will keep them from adopting your message and carrying out your call to action?

I can almost hear some of the speakers at GP15 whine “But that sounds like a marketing pitch – I was there to tell everyone about my research data“. You know what? I don’t care about your research.  And if I don’t care, the presentation is doomed.  The star of the presentation is the AUDIENCE – the speaker is merely there to facilitate their knowledge, feeding into existing experience and offering a solution to a problem that they can connect with.

To put it bluntly, if you cannot deliver your message in a three sentence “elevator pitch”, then you shouldn’t be speaking.  Which leads nicely on to…

Presentation is about story…

My mate Ross Fisher at P3 Presentations explains this well.  Start with a piece of paper. Tell a story.  Make sure your talk will engage the audience at an emotional level – make them WANT to listen.


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 Ross blogs under P3 Presentations – Ross’ site is a wealth of resources and thoroughly recommended.

P3 (presentation) is the product of  story (p1) x supportive media (p2) x delivery (p3)
Nancy Duarte builds upon this, emphasising the need for the content fo a presentation to resonate with the audience
  • Connect with your audience empathetically
  • Craft ideas that get repeated
  • Rely on story structures inherent in great communication
  • Create captivating content
  • Inspire enthusiasm and support for your vision

Of course a good presentation needs a beginning, a middle and an end – that goes without saying.  But PLEASE resist the temptation to use a standard powerpoint template and the curse of bulletpoints.

If you have any doubt, read this on burning your powerpoints.  As Gracie Leo (below) speaking is all about PURPOSE – PASSION – PRACTICE.

Creating a killer slide set

Actually, you don’t NEED to use slides. Some of the best presentations might be someone speaking – or a video…or as demonstrated by Paul Grinzi at GP15, modelling behaviours and facilitating discussion)

If you DO need to use slides, then make them elegant.  Big pictures, large text. Focus on the ONE message you want to get across. Text alone means 10% recall at one week – pictures increase this to 60%. Do the math.

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There are some great image banks out there to mine for pictures – I use Google Images and select ‘filter’ to ‘large’ – also worth looking online at free stock image libraries such as MorgueFile, Getty  Images etc. I am sure I don’t have to tell anyone not to use clip art! Some links are at the bottom under Resources.

I am a HUGE fan of Gracie Leo (a medical student who delivered a powerful talk on creating powerful presentations at smaccGOLD).  See her work here (includes free handout and podcast)


Remember that people will only remember a maximum of THREE things from your talk.  Do them a favour – tell them up front why your message matters to them – then tell the audience a story about how they can achieve this.

Lastly – remember the 10-20-30 rule (like all rules, it can be broken): 10 slides, over 20 minutes with a minimum of 30 point font.

Once you have completed your slide deck, practice. Then practice some more.  Then practice again.

Technical Considerations

I was amazed to see speakers arrive at a conference session late, then fumble with the AV kit.

Preparation to give a talk starts from the moment you receive conformation of a speaker slot.  In general, a good presentation will require approximately one hour preparation for every minute of speaking.  I reckon some of the smacc talkers put in more (although some of the natural talents would have basked it out a few hours before – looking at YOU Mark Wilson!)

First up, find out how long is allocated to your talk.  Do NOT exceed this.

Secondly, find out the format of the display – will the conference prefer 4:3 or 16:9 format? This matters, as otherwise your sides will not be congruent with the other speakers.

Thirdly, scout the room well in advance – think about the size.  The lighting.  Will your slides project best on a black or white background? Can you adjust lighting?

Next, introduce yourself to the tech guys – they will usually want you to upload your presentation to a conference file so it can be accessed by AV tech.  A quick word on Mac vs Pc here – a good conference facility will cope with either – sadly many conference facilities seem to think that only Powerpoint exists.  Don’t sweat it – just explain that you will be using a Mac and ensure you ave appropriate adaptors (if needed) for video and audio. HDMI is your friend, although some venues will still have VGA adaptors. The tech guy is the most important person – make friends with them as they will troubleshoot any issues. A lot of this can be sussed out via email beforehand.

I carry a small organiser bag with spare laser pointer, adaptors, HDMI and other cables etc if travelling to an interstate or overseas conference – it ensures no surprises.

It’s worth having a backup on the Cloud and USB stick – just in case.

Some presentations will require internet access.  Make sure it works!  I was shown a platform called Glisser last night (thanks Andy Buck of ETMcourse for putting me onto this) – allows interactivity with audience by online polling instantaneously, with results embedded into your presentation, Powerful stuff!


The Glisser platform takes audience interactivity to a new level – needs WiFi though!

Putting it all together

Obviously practice makes perfect.  I would recommend giving our talk out loud at least 3-5 times. Check that the timing doesn’t overrun and that the ‘flow’ of the talk appears natural.

In fact, be sure that the content IS organic – don;t fall into the trap of reading a script, supported by slides.  If you are telling a story, from the heart, then the content will change slightly each time, but the flow and supporting media will be congruent.

Next, think about your body language – are you a nervous pacer? An arm waver? Do you need to red slides aloud?

I am a fan of abandoning the podium and using a roving mic – this allows me to engage with the audience (eye contact helps) and wander around…

But ultimately do whatever you are comfortable with. Walt Disney had it right – a good presentation is about entertainment, with the audience as the focus, not the speaker!

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Suggested resources

The SMACC talks –

Presentation Zen –

P3 Presentations (Ross Fisher @ffolliet) –

Grace Leo on Powerful Presentations –

Teresa Chan from Academic Life in EM –

Nancy Duarte TEDx on presentations

Image Banks – MorgueFile, Corbis Images, iStockphoto, Getty Images – and more

Alternatives to PowerPoint – Mac Keynote and Glisser are my preferred platforms. Prezi makes me reach for the ondansetron wafers.

Finally, read this on simplicity in presentation style – it changed the way I present!

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