Updated RERN Action Cards

I’ve been playing around with cognitive aids such as checklists and action cards for a couple of years (some are available via the RESOURCES section of this site or RURALDOCTORS.NET. Most of these were designed for handing off to nursing staff in the rural ED, partly to mitigate against the phenomenon of people disappearing off to the ‘big book of infusions’ to look up compatibilities during infrequent care of critical patients. I certainly have no problem with cognitive offloading and use of such aids in a crisis – pilots do it, and I think use of action cards is an under-utilised phenomenon in the emergency medicine.

These checklists and action cards were designed to be used both in printed format or electronically as PDFs (ipads are great for this). However working in the prehospital environment soon teaches that reliance on technology (particularly iPad or iPhone) is not without problems – mobile coverage is dismal in country (and can be at altitude)…and power failures, inadvertent water splashes or hard knocks can trash iShiny devices too easily. Recognising this, MedSTAR issue their staff with a “Vuey Tuey” – basically a 20 page clear pocket folder that fits easily in a flight suit pocket. It contains useful phone numbers, flight times to rural hospitals and other useful information.

This is the Vuey Tuey issued to MedSTAR doctors to carry in flight suit – it contains useful information for “on the job” and doesnt require batteries
Extra pages can be added and content modified to preference. So good, I decided to make my own for RERN…

I’ve snaffled a few of these “Vuey Tueys” from eBay (they’re also available from Army Surplus stores online). The 40 page one is not overly thick (about 1cm) and accommodates 80 sheets of paper. The aim was to create a series of action cards useful for rural doctors, particularly members of the South Australian Rural Emergency Responder Network (doctors who respond to prehospital incidents to back up local volunteer crews where no ICP available).

So here’s a series of RERN ACTION CARDS – designed with members of the South Australian rural doctor RERN team in mind  – but the content may be useful for any rural doctor who is looking for a quick pocket reference that can be easily adapted to local use.

The original was created in Pages on OSX, then converted to indivdiual PDFs and merged into one document. I am more than happy to share original files if anyone wants them to modify, or can download the entire PDF here.

One quirk of the “Vuey Tuey” is the page size – 95 x 135mm! So I generally print out two sheets onto A4 and trim up with a paper cutter.

Contents include:

  • principles of prehospital care
  • airway
  • breathing
  • circulation
  • crisis algorithms
  • drug doses

I am a big fan of making content available for all to share – and am happy to add extra sections or modify content if needed.

I should also emphasise that this content is NOT from MedSTAR, but a collation of various tips and FOAMed that I’ve found useful. Interestingly some retrieval services make their content available to share – I remain impressed with the efforts of SydneyHEMS, AucklandHEMS and UK-HEMS in this regard. Indeed, Karel Habig and colleagues gave some useful lectures at the 2014 Rural Medicine Australia conference – it’s refreshing to see such content from prehospital care creeping into rural arenas – and the PROTECTAustralia paradigm is very worthwhile.

Certainly with approx 2/3rds of trauma coming from rural areas, it makes sense to engage with rural clinicians and strive to drive “quality care, out there”. I am no expert, but seems to me that much of critical care is about doing the basics, well – and that whilst some rural doctors embrace the challenge of managing these patients, others are understandably nervous or feel under-prepared. I think this is where FOAMed, delivering asynchronous content, robust clinical governance and standardisation of protocols such as infusions etc can make a difference.

Anyhow, here are the cards. It’s work in progress. Enjoy!

RERN ACTION CARDS – click to download (NB RERN = Rural Emergency Responder Network)


They’re not accidents, are they?

It was back in 2001 that I read a piece in the British Medical Journal entitled “BMJ bans accidents” – hardly a new idea (it dates back to at least 1993) – yet we still hear reference to “road traffic accidents” (RTAs) or “motor vehicle accidents” (MVAs).

Words are important; I have been convinced of the BMJ argument for the past decade. I am not alone – others say “if you care, use the term crash“. The premise is simple – use of the term “accident” implies a sense that bad outcomes are due to fate and luck, rather than factors within our control. Indeed use of the term “accident” almost absolves anyone of culpability.

I am currently working in the prehospital environment. Like colleagues, I do not judge my patients – they are invariably critically unwell and my job is simple – to ensure they receive the best possible care with the minimum of delay, working within a well-governed organisation of trained clinical professionals.

However Christmas and New Year are fast approaching, and there is a sense of inevitability; namely that this holiday season will again be marred by tragedy on our roads, often due to drink- or drug-driving.

What would be the best Christmas gift for colleagues and myself this year? That we did not have to respond to roadside primaries, nor for community members to experience personal tragedy.

With this in mind, I’d recommend the following video – a montage of road safety videos from the TAC in Victoria, Australia (ironically, this stands for Transport Accident Commission)

It is sobering stuff. I remember hearing trauma surgeon Karim Brohi talk at the Australian Trauma Society conference in Melbourne, 2006 – he commented that “it’s better to be the fence at the top of the cliff, ratehr than the ambulance at the bottom”. In trauma medicine we tend to get very excited about the sexy things – prehospital REBOA, clamshell thoracotomy, helicopters etc and debate is always heated on chestnuts such as subclavian vs IO access, fluid resuscitation, skill mix of retrieval teams etc.

There is no doubt that the downstream consequences of trauma are horrific.

Instead I wonder if the greatest gains in trauma medicine remain with the unsexy – with primary prevention (um, that’s the GPs) and with rehabilitation (thats rehab physicians, physiotherapists and other allied health). we don’t often consider the contributions from primary care and rehabilitation in trauma care – perhaps we should.

Prevention is indeed better than cure. Please, this Christmas – don’t drink or drug-drive.


Airway Classics – A Love Supreme?

Many people are eagerly awaiting the release of the new Difficult Airway Society UK (DAS UK) guidelines, in the wake of their recent Annual Scientific Meeting.

Some recommendations are available HERE and include :

  • acceptance of gentle mask ventilation during RSI
  • use of videolaryngoscopy as an option in initial intubation plan
  • apnoeic diffusion oxygenation
  • didactic technique and training for emergency surgical airway

One other recommendation caught my eye – namely to use second generation LMAs

Now the Classic LMA (cLMA) was the brainchild of Archie Brain; it is a wonderful device and has been in commercial use since 1987. It is easy to use and affords the ability to ventilate – although does not protect the airway. Some critics would argue that the LMA has deskilled a generation of anaesthetists, who may use the cLMA for routine cases rather than bag-mask or intubate. I disagree – it is just another tool in the armamentarium.


LMA Classic - cLMA
LMA Classic – cLMA


However I made a decision a few years ago to switch to the Supreme LMA – a lovely second generation LMA that is a step up form the ‘initial’ second generation LMA (the ProSeal). The Supreme combines an integral bite block with a gastric drainage channel in the tip, unlike the ProSeal.

Supreme LMA - sLMA Note gastric drainage channel at tip of cuff
Supreme LMA – sLMA
Note gastric drainage channel at tip of the LMA bowl (R)

But there is a problem – once in place, it is almost impossible to pass an ETT tube through the Supreme.

Many people will be familiar with the Intubating LMA (iLMA) – the brand most use ins the FastTrach. It’s not a bad device – it allows blind intubation rates of up to 90%, using the LMA as a rescue ventilation device and then as conduit for an ETT.

FastTrach Intubating LMA - iLMA
FastTrach Intubating LMA – iLMA

The large handle on the device is designed to facilitate manoevuring of the iLMA in the oropharynx, ideally allowing the bowl of the LMA to align with the glottic opening and hence allow blind passage of an ETT. There is a great paper from the originator of these maneouvres, Chandy Verghese. A description is available HERE – anyone using the FastTrach should be able to perform the “Chandy Manouevre(s)

I like the FastTrach – it is a good ‘go to’ device for rural and remote doctors as allows both rescue ventilation and possible intubation – no pissing around with fancy fibreoptics or calling for help – none is available in the bush! However there are some problems – it’s expensive and it doesn’t have a gastric drainage channel. Furthermore, one can get into a world of hurt if attempting to remove the iLMA over the ETT per instructions. This might include stripping off the pilot cuff of the ETT or ‘losing the airway’…one should read the infamous ‘exploding scrotum‘ case for a masterclass in airway catastrophe.

So problems with the FastTrach are not uncommon in inexperienced hands – precisely the time when you least want to have an additional problem after failed intubation. My advice? Once in, leave both iLMA and ETT in situ until the patient is either awake or you are somewhere with backup!

Furthermore, the FastTrach has a somewhat hyperacute angle, meaning that even if you have a basic fibreoptic device (such as a malleable FO stylet), this cannot be used to turn blind intubation into fibreoptic intubation via the iLMA conduit.

What we need is a device combining the benefits of a second generation LMA (eg Supreme) with an intubating LMA. Enter the second generation iLMA, the AirQ-II

I first heard of these in 2011 from James duCanto in the States. They’ve also had some coverage from Scott Weingart over at EM-Crit in the past. It’s basically a second generation iLMA which is :

  • cheap
  • useful as a rescue ventilation device ie 2nd generation LMA
  • able to be used as an intubating LMA for blind intubation
  • less acute curvature of the tube will allow passage of both flexible and malleable stylet fibreoptics, for visual intubation
  • integral bite block and gastric drainage channel
The AirQ-II iLMA with separate orogastric tube
The AirQ-II iLMA with separate orogastric tube


An elevation bar helps direct ETT tip from bowl of LMA into trachea. The orgastric tube is passed down separate channel adjacent and under the bowl of LMA, into the oesophagus
An elevation bar directs ETT tip from bowl of LMA into trachea. The orogastric tube (left) is passed down separate channel adjacent and behind the bowl of LMA, into the oesophagus

I’ve replaced the FastTrachs with Air-Q IIs in both my RERN prehospital pack and also on our hospital difficult airway trolley. Indeed, for the finance-limited environment of a small rural hospital, the combination of the AIrQ-II along with a fibreoptic device such as a Levitan FPS scope offers a fairly robust option for difficult intubation – drop in an AirQ-II, then wither blindly intubate or use the malleable fibreoptic stylet to pass the tube under direct vision. Then leave the ETT-LMA in site and pop down an orogastric (difficult to do with the FastTrach). James DuCanto writes well on this with a simple guide and Weingart explains how to mould a malleable stylet to conform to the AirQ anatomy.

If you don’t need an intubating LMA, then follow the guidance of DAS2015 and go with a second generation supraglottic device – like the Supreme.

But if you want to allow maximum flexibility including integral intubating-LMA capability, it’s hard to beat the Cook Gas AirQ-II – especially of trying to put together an affordable yet robust difficult airway kit for rural/remote.


RAGE podcast – great FOAMed

I just have to give a shout out to the RAGE PODCAST this week. If you have been living under a rock, the RAGE podcast is a semi-regular “resuscitationists awesome guide to everything” featuring top quality FOAMed contributers who are credible in their field.

“Do not go gentle into that good night

Rage, rage against the dying of the light

Dylan Thomas

This months session is entitle neuroRAGE and deals with all things to do with neurosurgical emergencies. It features Mark Wilson who speaks authentically on experiences as a HEMS physician, neurosurgeon and with some significant anaesthetic experience. I managed to talk with Mark on “Burr holes in the bush” a couple of years ago and since then the idea of prehospital Burr holes has been enthusiastically mooted elsewhere. Is this something that a prehospital service clinician needs to be able to do? Is an extradural the ‘tension pneumothorax of the skull?

Mark gives good talks (if you saw him at smaccGOLD and were impressed, the good news is that he’s back at smaccUS). He’s also prepared to share – he gave a great talk at medSTAR clinical governance day earlier this month and was a major contributor to Sydney HEMS themed neurotrauma session earlier this year – content from the latter is available online. He also runs the AcuteBrain website and is a coninventor of the GoodSAMApp


Also on RAGE, Cliff Reid also gives a lovely description of being on the end of both an LP and in the K-hole, reinforcing the need for concomitant benzos and (where possible) a calm, low stimulus environment to avoid emergence phenomena.

I’ve certainly noticed similar tales of spiral ‘helter skelter’ sensations amongst my dissociated patients…to me this emphasises the need to be familiar with ketamine for both induction, dissociation and analgesia – something all trainees should endeavour to gain experience with in their anaesthetic placements or in ED.

Here’s a video of the potential nasty dissociative effects of ketamine – I love the drug, but consider adding some benzo if appropriate

Anyhow – trust me on this – LISTEN TO THE neuroRAGE podcast. It’s a good one!



It’s gonna be smaccTASTIC! #smaccUS

After months of planning from the smaccTEAM, the programme for smaccUS is now released and available on the smacc website
The program looks HOT – some old favourites and some new allsorts. The genius that is Mark Wilson will be cohosting a fabulous “it’s a Knockout” neurotrauma session….and there are many concurrent sessions and “cage matches” on topical issues.
Plus there’s an excellent round of pre-conference workshops and a chaotic but entertaining social calendar; I am already looking forward to catching up with old friends and making new ones – all united by a common interest in critical illness, from a variety of perspectives (intensivist, emergency, rural, prehospital, medical, nursing, paramedic, social worker etc)
Chicago is a great venue and the first time smacc has ventured overseas. If you missed macc2013 in Sydney and smaccGOLD in 2014 and are wondering what makes this conference different, check out the commentaries at :
…or the smaccVIDEOS from intensivecarenetwork & affiliated sites :
I am delighted to be sandwiched in a session with EM giant Joe Lex, Scandanavian powerhouse from ScanCrit Thomas Dolven and my old mate from BroomeDocs, Casey Parker – all under the watchful eye of Minh le Cong.
Screen Shot 2014-10-29 at 1.54.16 pm
Needless to say I have started preparation on my talk already; I owe inspiration to Penny Wilson (@nomadicGP) for the kernel of an idea which may take fruit at #smaccUS. One should always aim to deliver a memorable talk, so I am learning from the example of an unforgettable talk as made infamous by Prof Brindley
Prepare for your corn to be grilled…

Keeping it all together…

Like most clinicians, my time spent in anaesthesia drilled me in the importance of performing routine pre-anaesthetic machine checks, of keeping the workspace tidy and paying meticulous attention to detail. ‘

These lessons translate well into other areas of practice – at the start of every on call period in emergency, I check the resus trolley and store boxes to ensure we have the right kit available. In recent times I’ve begun to think more and more about resus room ‘feng shui’ – the concept of making sure that the components of the room are ordered correctly, eg :

  • resus & airway trolley on the intubator’s right side so as not to impede visual axis during intubation
  • all monitoring/O2/suction cables & tubes running from single point, allowing almost complete 360 degree access
  • orientation of bed so that clinicians can see monitors, clocks, whiteboard, equipment etc
  • colour-coding of equipment so as to group kit together for those unfamiliar with set up or in a crisis
  • clear signage to essentials such as defib, difficult airway trolley, paediatric kit etc

Working with MedSTAR retrieval builds on this and I get to indulge by obsessive compulsive disorder (it’s called OCD, but aficionados know that it should be called CDO – you…have…to get…letters…in…right order).

Every day starts off with a full kit check (using a challenge-response checklist), then kit tagged and labelled – anything with a broken seal gets a full re-check. Packs are colour coded to aid recall in a crisis (it’s easy to ask a firefighter to get the ‘small red pack sitting in the big blue pack’ rather than tell ‘em to get the arterial line kit). MedSTAR uses an RSI kit dump plastic bag that doubles as a clinical waste repository, with an integral challenge-response checklist.

One of the two-person team (typically doctor-nurse or doctor-paramedic) carries a drug pouch with Schedule 8 drugs (fentanyl, ketamine etc). The team always carry pagers, GRN radio and an iPhone (the latter contains checklists for daily kit checks, contact numbers and SOPs).

In recent times an iPad Mini has become available as an option – although no good as a communication device (unless use FaceTime or Skype!), it is easier to use for performing checklists and reading SOP PDFs. It also allows for addition of useful clinical apps such as Matt & Mike’s excellent Bedside Ultrasound iBook and pre-loading with FOAMed content (podcasts, vodcasts etc). The problem though had been where to carry it – the iPad mini JUST fits into a pocket on the flight suit. Stuffing it into a pack means you’re never likely to use it – it’ll be stored in the back of ambulance, tied down in flight or otherwise inaccessible.

How am I gonna keep my shit together on a cramped helicopter?
How am I gonna keep my shit together on a cramped helicopter?

Despite initial scepticism, I have been using Twitter for the past 18 months to connect with #FOAMed enthusiasts – it’s a great tool for signposting and sharing information from likeminded people around the world, some of whom I have met, some not. Retrieval clinician Natasha Burley (@skimightythings) put out a tweet of the GridIt system in use with Careflight, Queensland a few weeks ago…a sensible idea so good that I had to try it!

So for the past few shifts I have been experimenting with the GridIt system. This is basically a neoprene sleeve and folder for phones, phablets, tablets and PCs, with a series of interlocking bands forming a grid into which chargers, connectors etc can be placed. It’s marketed to power users who carry lots of kit. I find it quite useful for giving presentations as I can make sure I’ve got my projector controller, VGA/HDMI adaptors, power cords, audio cable and other sundries available when giving a talk off home ground.

The Grid It system from cocoon
The Grid It system from cocoon


 The question is as to whether it would ‘value add’ for the retrieval setting. I managed to snaffle an iPad Mini GridIt pouch (had to hunt for the MedSTAR red version on eBay) and experiment with it during a typical shift.

Dan Martin with GridIT
Retrieval Nurse Dan Martin with the Grid IT in our storeroom

I was pleasantly surprised. The neoprene pouch is easy to carry and non-slip despite the recent hot weather (temperatures in the 30s). The iPad Mini fits snugly in the pouch and is further protected by a fold over sleeve. Having the iPad Mini available at all times (rather like the President of the United States ‘football’ of nuclear access codes) meant that I was more inclined to actually USE the device for kit checks and SOPs, as well as afford the potential for mini-tutes on ultrasound and listening to podcasts from my FOAMed mates (eagerly awaiting Mark Wilson & co with neuro edition of RAGE podcast). Listening to content or refreshing knowledge is always possible on the outward leg of a mission, whether by road, rotary or fixed wing.

IPad Mini sits snugly in neoprene puch with GridIt on one side. A neoprene sleeve is folded over the entire assemblage, covering the syringes & iShiny from accidental knocks
IPad Mini sits snugly in neoprene puch with GridIt on one side. A neoprene sleeve is folded over the entire assemblage, covering the syringes & iShiny from accidental knocks

We carry our S8s on our person already, but the syringes and caps are kept in our kit, making it impossible to draw up drugs en route unless remember to get the large major drug/IV pack out before travel. By keeping a few syringes, saline and red caps plus vial access cannulae in the pouch, I found that could mix up basics (ketamine, fentanyl) at anytime using the kit on my person. Once pre-drawn, syringes were kept protected by the neoprene sleeve and readily available.

Grid it with predrawns

I did wonder how we would go in transit WITH a patient, especially in the crowded space of a helicopter. The photos probably don’t do it justice (lots of vibration!) but I found I could secure the GridIt system to the stretcher using the velcro cuffs – or just stuff the darn thing into a pocket if I was worried.

Depending on the aircraft and configuration with stretcher, I found could secure to either the side of the stretcher so that iPad and drugs were within easy reach (basically between legs if sitting side on to stretcher)…or secure to the head end where we already stash bag-valve-mask in a pouch.

The ability to reverse the neoprene sleeve and loop around the stretcher rail then secure with velcro worked well – but for added security one could easily add a carabiner.

On the outward bound (no patient) I used the GridIt to secure syringes and secured the entire package to stretcher rail by looping the neoprene sleeve around rail and velcroing. One could add a loop for carabiner easily.
On the return leg – iPad and drugs secured to stretcher side for easy access in flight
Hanging the iPad Mini and predrawn syringes off the head end of stretcher (head elevated in this picture) – means both FOAMed and DRUGS available immediately!

We already have a system of securing pre-drawn syringes (for bolus dosing) on a hoop system on our ventilator. Many missions don’t require a ventilator, just standard monitoring, so the options have usually been to stuff syringes into a pocket on flight suit.

Adding an iPad to the mix means pockets get full or tend to either stash in a pack bag (inaccessible) or just leave the thing behind… a shame as having an iPad available could value add to missions, I feel.

Combining the iPad Mini and syringes in one system seemed to work well. I am interested in other options available out there!

Spotted in the UK and tweeted by my mate Dr Alan Grayson (of the StEmlyns blog crew) - not sure this will catch on; nor is there space for iPad!
Spotted in the UK and tweeted out to the world by my mate Dr Alan Grayson (of the StEmlyns blog crew) – not sure this bandolier approach will catch on; nor is there space for an iPad!

And what else should we put on the ipad Mini?

The next question will be which apps and FOAMed content should be included on a tablet. MedSTAR has it’s own proprietary app for checklists and SOPs. My preference would be to add :

[ I am a big fan of the UK HEMS SOPs available online - http://www.uk-hems.co.uk/ukhemssops.html and the Sydney HEMS clinical governance and sim resources in particular - http://sydneyHEMS.com ]

Who knows? Perhaps in the future my mate Mark Wilson’s GoodSAMapp could be added to not just individual clinicians smartphones, but also to institutional devices – as it allows tracking of location and ‘push’ alerts integrated with comms CAD; potentially very useful in a MAJAX situation

GoodSAM app for smartphone (iOS and Android, Windows etc) - not just for first responder BLS, but also to track and push info to institutional members via central ambulance dispatch
GoodSAM app for smartphone (iOS and Android, Windows etc) – not just for first responder BLS, but also to track and push info to institutional members via central ambulance dispatch


Hey! If you are a Paramedic, Nurse, Doctor or Registered First Aider who can hold open an airway or do BLS, please take time to register with GoodSAMapp for Android or iOSIt’s FREE