Things that Go Up Kids’ Noses – THRIVE and Paeds

Nasal prongs seem pretty popular for lots of things these days. So how about their use in kids. There’s a couple of papers out there on its use in the paralysed patient and Dr Andrew Weatherall is here to splice them together. 

Isn’t it supposed to be the kids who stuff things up their noses? Have we just seen them do it so often we started wondering about the possibilities ourselves?

Let’s assume not. It’s more a case of people finally getting around to testing things out on kids when they’ve been running with them in adults for quite some time. This time it is THRIVE and that ever so desirable feature of endless maintenance of oxygen saturations while we get around to the ensnorkelling we’ve planned.

In principle that makes plenty of sense. The normal kid is more likely to rapidly desaturate than the normal adult. Physiology is pretty insistent on that. Plus we know people find paediatric intubation tricky so dropping the stress by avoiding the slide of the plethysmograph tone down that digital scale is probably a worthy pursuit.

So how about we look at two papers examining just this issue – does THRIVE employed in the little people stop those saturations from … not thriving??

Fancy, nose-cramming air is what we’re dealing with really

Australian Angles

First up is this paper published by Humphreys et al, who work out of Brisbane. They did a small RCT on well kids with 24 in the control arm and 24 receiving 100% THRIVE. The kids fell between the ages of 0 and 10 years of age and are reported in the age groups 0-6 months, 6-24 months, 2-5 years and 6-10 years (with a total of 12 in each age range, meaning 6 in the controls and 6 in the THRIVE group within each age group – got it?)

The routine went something like *induction of anaesthesia* –> pre-oxygenation by doing that whole bag-mask ventilation bit –> the mask disappeared and THRIVE was added or nothing was added –> start the stopwatch.

You’ll note that, like the other paper we’ll mention, this is not about patients who are spontaneously ventilating. That’s a completely different thing.

In this group though the period of the saturations staying up was longer. Across the age groups the extension in apnoeic time was 86.8 seconds (0-6 months), 88.7 seconds (6-24 months), 129.5 seconds (2-5 yeas) and 169.2 seconds (6-10 years).

Right, lock it up. Everyone should have nasal prongs. All the time. It’d stop peanuts ending up there too.

Except there’s more pesky nuance in this paper. Like:

1. It’s not for pre-oxygenation

It’s worth noting that the preoxygenation here was all about face-mask ventilation with a good seal. They added THRIVE after that bit and started the clock. This is not entirely surprising because we know that nasal prongs compromise seals in adults and that’s only more likely with kids.

So if you were thinking that you should set up those nasal prongs from the before time zero, you need to think again. THRIVE for preoxygenation is not something tested here, and you shouldn’t assume it’d be better than good face-mask technique.

2. They didn’t test the duration that it worked for apnoea

All they said was it’s ‘more’. ‘Wait,’ you might say, ‘you mean they didn’t test the thing that was the point of study?’

Well not really because the cut-off was ‘twice the previously noted time to desaturation’. So they tested that they could reach the ‘double or nothing’ limit, but didn’t test the full extension. In the THRIVE groups the average saturation when they stopped the clock was 99.6%.

So I guess be reassured that it was likely to be really a heck of a lot of time.

3. Basic things were part of the procedure

For this study there was a lot of basics being done well. Throughout apnoeic oxygenation they weren’t doing things like airway instrumentation, suction, intubation or, I assume, anything much beyond chatting about the weekend and watching the clock. They did jaw thrust, a basic manoeuvre likely to optimise the impact of THRIVE. So maybe we should remember that all those things we are also interested in were not part of the picture.

And Now an Update from the Swiss

What if you didn’t make your cut-off ‘2 times the other cut-off we knew about’? How long could you go?

Well a Swiss crew with no interest in being neutral on the topic I guess have done a study comparing low flow nasal oxygen (0.2 L/kg/min) with THRIVE at either 100% or 30% FiO2 with 20 in each group. And they found … (wait for it…..) 100% THRIVE prolongs apnoea time.

OK there wasn’t much suspense there really.

Except again it was more subtle, and again cut-off matters. They had a cut-off to terminate on the basis of desaturation, but another at 10 minutes (as in ‘it’s 10 minutes and I’m bored let’s stop because those saturations are still great’) and the 3rd cut-off was if the transcutaneous CO2 hit 65 mmHg.

In the THRIVE 100% group no one desaturated, 4 hit 10 minutes and the other 16 had their nasal prongs ditched when they breached the CO2 target. This actually accords with the other paper where they also found that THRIVE doesn’t achieve ventilation and removal of CO2 in kids.

But at the end of this paper you still can’t say how long apnoea might be extended, at least when it comes to those saturations staying up.

Oh, and a couple of other points:

1. Pre-oxygenation was with face-mask ventilation. Again.

Again the nasal option had no role in the preoxygenation phase. They went with face-mask ventilation until the expired oxygen was 90% or above. Then they started the clock with the chosen nasal prong option going.

2. The other airway things done at the time were … none.

Yep. Once again this was just about the oxygen and the stopwatch. Nothing else was going on.

I mean this could be a visual metaphor for the need to appreciate their is still colour not just black and white when it comes to THRIVE or it could just be pretty, you choose. 

Let’s Think Clinically

So let’s imagine that we’ve actually got that paediatric patient in front of us. Maybe one who needs to get intubated before we get them out of wherever ‘in front of us’ is.

Let’s agree that maintaining oxygenation throughout is a good and noble goal. It’s not the only goal of course. We’d also like to make sure we make good choices around number of attempts, and for some patients (say the patient with intracranial pathology) we need to think about ventilation.

And we don’t have evidence that pre-oxygenation is aided by having THRIVE in place.

So assuming we’re going to do things standard to modern paediatric RSI like face-mask ventilation for a bit before we get going. There is at least a bit of  a question about whether THRIVE adds a huge amount.

What it undoubtedly adds is the confidence that saturations will stay up. That is something that lots of practitioners, particularly those not regularly intubating kids would find immensely reassuring.

There is a couple of caveats to keep in mind though.

There’s a risk to be aware of with THRIVE that those saturations staying interminably up might encourage tunnel vision on persisting with intubation when it’s not working out. It’s not too hard to imagine the scenario where the tube hasn’t passed straight down, but those saturations are OK so you persist a bit longer, and a bit longer, and now long enough that the airway is becoming traumatised and suddenly you’ve created a problem.

So this might be a cognitive challenge to have planned for in advance – how do you keep yourself to a limited number of attempts before re-evaluating and going to plan B (or C)? Do you make it a personal process or have others in the crew hold you to a maximum number of attempts or maximum duration of looking?

After all, THRIVE is going to get you to 10 minutes probably. But if you’re still conducting open negotiations with the glottic structures at 10 minutes, oxygenation is not the airway problem that should still be at the front of your mind. While you’re there, you might have to think about re-dosing anaesthetic agents too.

And the other key patient group is that one where intracranial pathology is an issue. Letting the CO2 rise for some patients is not a good plan because your TBI patient (as just one example) doesn’t need those cerebral vessels dilating and the intracranial pressure going up. For those patients, a step back to face-mask ventilation, or potentially placing a supraglottic airway,  to re-establish an ability to exchange CO2 is probably a better option.

So THRIVE might be great for some things. But whether it’s clinically better than an approach to the airway where really excellent pre-oxygenation is routine and good practices around face-mask ventilation are established seems like a line ball call.

I mean it’s still way better than a piece of Lego up the nose. But it remains an adjunct to the basic stuff, not a replacement.


OK. That first paper is this one:

Humphreys S, Lee-Archer P, Reyne G, et al. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomised controlled trial. BJA. 2017;118:232-8. 

The second one out of Switzerland is this one:

Riva T, Pedersen TH, Seiler S, et al. Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) for oxygenation of children during apnoea: a prospective randomised controlled trial. BJA. 2018;120(3):592-99.

Did you want something on nasal prongs and seals? You could try this

Groombridge C, Chin CW, Hanrahan B, Holdgate A. Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. 2016;23:342-6. 

or this

Hayes-Bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med. 2016;68:174-80.

We’re always interested in other thoughts so feel free to drop a comment.

Just because you can …

With a couple of new papers landing that touch on the issue of how you provide and measure quality care around airway management, Dr Alan Garner returns to point at big animals that are bad at hiding.

Two new airway papers have come across my desk in the last couple of weeks and I now wish I had waited a bit longer before putting up the last post on first look intubation as a quality measure.

So where to start? Well how about a place where everything is apparently big? Yes, there’s a bit of work just out of Texas which sheds further light on that first look intubation story so that’s where we’ll land.

Chasing Quality

It sounds like they have used RSI for a while but undertook a quality improvement project to try and reduce their peri-intubation hypoxia rate.  The project involved introducing a bundle of interventions described in the paper as “patient positioning, apn[o]eic oxygenation, delayed sequence intubation, and goal-directed preoxygenation”.

The paper provides copies of the protocol for intubation pre- and post-bundle intervention in the on-line appendices so I might just go through them here to see what they did differently.

The first thing is there was an emphasis on positioning in the bundle, specifically head up a bit and ear-sternum positioning.  Lots of goodness here that I strongly support.

The second measure they mention was apnoeic oxygenation.  However looking at the pre- and post-bundle policies it is evident that they used it in both time periods.  In the before period it ran at 6L/min till the sedation was given then it was turned up to 15L/min.  In the post period however it was run at “MAX regulator flow” after the ketamine was administered.  I don’t know about the O2 regulators in Texas but to me this does not sound like they changed anything significant.  I will come back to apnoeic oxygenation later.

For pre-oxygenation in the pre- bundle period they used a NRB mask (with nasal prong O2 as above) in spontaneously ventilating patients (and arrested patients were excluded) but in the post- period the pre-oxygenation had to be by BVM with two handed technique to ensure a tight seal plus PEEP.  More goodness here that warms my heart.

Delayed sequence intubation in this study refers to administering 2mg/kg of ketamine then maximising preoxygenation for at least 3mins prior to administration of the muscle relaxant.  I don’t think this is necessary in all patients but this was the policy in the bundle.

The last thing they did was “goal-directed preoxygenation”.  This refers to having a SpO2 target >93% for at least 3 minutes during the pre-oxygenation phase after the ketamine had been administered.  If they could not achieve >93% the patient was managed with an LMA or BVM and transported.  I think this represents sensible patient selection in that it removes the high risk of desaturation patients from the process.  When you look at the results you need to keep this patient selection in mind. However I agree that in their system this is a reasonable approach to ensure patient safety for which the managers should be applauded.

Show Me The Money

Yes let’s get to that money shot:


I have been banging on about peri-intubation hypoxia being far more important than first look intubation rate for a while now and this data shows really clearly why.

There is no significant difference in this study in either first look or overall success rates pre and post the bundle but the hypoxia rate fell by a massive absolute 41%!  The 16% decrease in bradycardia emphasises just how much difference they made.  The managers of this system and their staff alike both need to be congratulated for this achievement as this is something that really matters.  And the first pass and overall success rates give no clue!

It really is time to drop first look as a quality measure and move on.  You could look at this paper and start wondering if it might even be worth dropping overall success rate too, which is an interesting thought.  Their policy favoured patient safety over procedural success rates by abandoning the attempt if the pre-oxygenation saturations could not be raised above 93%. It looks like it is working out well for the patients.

Oh, Back to Oxygenation

I promised I would come back to the apnoeic oxygenation issue.  I know the authors state that it was part of their bundle, but it was used in the pre- bundle period as well.  Hence there is no data here to support it’s use.

All three randomised controlled trials of apoeic oxygenation in the ED and ICU contexts (see the notes at the end) have now failed to find even a suggestion that it helps (check those notes at the end for links) and there are no prehospital RCTs.  My take is that it is time to move on from this one too and simply emphasise good pre-oxygenation and good process when the sats start to fall – or never rise in the first place like this group did so well.

Overall a big well done to the Williamson County EMS folks and thanks for sharing your journey with us.

Moving Right Along

The other paper comes out of London, where the ever-industrious HEMS group have published a retrospective review of their database over a 5 year period (from 2009-2014). They were looking for adult trauma patients they reached with an initial noninvasive systolic blood pressure of 90 mmHg or less (or where a definite reading wasn’t there, those with a central pulse only) and with a GCS of 13-15.

This gave them a total of 265 patients (out of a potential 9480 they attended). 118 of those underwent induction of anaesthesia out there beyond the hospital doors (though with exclusions in analysis they end up with 101 to look at) and the other 147 (that number dropped to 135 on the analysis) got to hospital without that happening.

Now the stated indications for anaesthesia listed are actual or impending airway compromise, ventilatory failure, unconsciousness, humanitarian need, patients unmanageable or severely agitated after head injury, and anticipated clinical course.

Now given that the inclusion criteria includes patients having a GCS of 13-15, it seems like both unconsciousness and those really impossible to handle after head injury are likely to be pretty small numbers in that 101. Even airway compromise, ventilatory failure and humanitarian need seem like they’d be not the commonest indications in that list that would apply to this patient group, though they’d account for some.

I guess it’s possible the patients were all initially GCS 13-15 on the team’s arrival but deteriorated en route, though I just can’t sift that out from the paper. Plus if that was the case it seems like you’d say that.

The Outcomes

In their 236 study patients, 21 died and 15 of those were in the ‘received an anaesthetic’ group. The unadjusted odds ratio for death was 3.73 (1.3-12.21; P = 0.01). When adjusted for age, injury mechanics, heart rate and hypovolaemia the odds ratio remained at 3.07 (1.03-9.14; p = 0.04).

Yikes, sort of.

What To Make of That? 

I guess we should make of it that … things you’d expect to happen, happen? Intubating hypotensive patients and then adding positive pressure ventilation in the prehospital setting is potentially risky for patients for a variety of known pharmacological and physiological reasons that the authors actually go into.

So the question is why embark on such a procedure where you know the dangers in detail? You’ve have to really believe in it to end up wiht 101 cases to follow up.

It feels like there’s an elephant in the room to try and address by name. I wonder if it has something to do with a practice I observed while working in the south-east of England 8 years ago. It relates to that last category “anticipated clinical course”.

Hovering elephant heads. They’re real.

The concept here is that if you figure the patient is going to be intubated later on in the hospital, you might as well get on and do it. Except the data here suggests that, much like you’d expect, you probably shouldn’t get on and channel your inner Nike marketing script.

Just because you can does not mean you should.  This paper really drives this home though it doesn’t really seem to come straight out and say it. It does pass the comment that “Emergency anaesthesia performed in-hospital for patients with cardiovascular compromise is often delayed until the patient is in theatre and the surgeon is ready to proceed.” Perhaps the problem isn’t using the phrase “anticipated clinical course”. It might be that you just have to remember that the anticipated course might best contain ‘risky things should probably happen in the safest spot’ in the script.

Compare and Contrast

The process of undertaking emergency anaesthesia because later the patient might require emergency anaesthesia is pretty much the complete opposite of the approach from the Williamson County EMS folks. They erred on the side of patient safety and withheld intubation if it was associated with unacceptable risk.

This paper demonstrates that emergency anaesthesia in patients with a high GCS but haemodynamic instability is associated with higher mortality.  We should probably be glad the authors have made this so apparent, because this is probably as good as we’re going to get. We’re not going to get a randomised controlled trial to compare groups. No one is allowing that randomisation any time soon making this another example of needing to accept non-RCT research as the best we’ll get to inform our thinking.

Patients with hypovolaemia due to bleeding need haemorrhage control. The highest priority in patients with that sort of hypovolaemia would seem to be getting them to the point of haemorrhage control quicker. And delaying access to haemorrhage control (because the prehospital anaesthesia bit does add time in the prehospital setting) when the patient has a GCS of 13-15 doesn’t seem to prioritise patient safety enough. Patients probably need us to adjust our thinking on this one.

That seems like common sense. The retrospective look back tells us pretty conclusively it’s a worse option for patients. And now it’s up to us to look forwards to how we’ll view those indications for our next patients. And “anticipated clinical course” probably just doesn’t cut it.



That hovering elephant head was posted by James Hammond in a Creative Commons-like fashion on and is unchanged here.

How about all those things that got a mention above that you should really go and read for yourself?

Here’s that whole bundle of care paper out of Texas:

Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med. 2018;doi:10.116/j.annemergmed.2018.01.044 [Epub ahead of print]

Those RCTs of apnoeic oxygenation in critical care environments mentioned are these ones:

Caputo N, Azan B, Domingues R, et al. Emergency Department use of Apnoeic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med. 2017;24:1387-1394.

Semler MW, Janz DR, Lentz RJ, et al. Randomized Trial of Apnoeic Oxygenation during Endotracheal Intubation of the Critically Ill. Am J Respir Crit Care Care Med. 2016;193:273-80.  

Vourc’h M, Asfar P, Volteau C, et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomised clinical trial. Intensive Care Med. 2015;41:1538-48.

And that paper on the hypotensive, awake prehospital patients scoring an anaesthetic is this one:

Crewdson K, Rehn M, Brohi K, Lockey DJ. Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental? Acta Anaesthesiol. Scand. 2018;62:504-14.










The Deal with Seals

Greg Brown returns to look at an important thing relevant to first responders (and lots of other people really) – the sucking chest wound. 

We’ve all been there – sitting through some kind of “first aid” training and having some kind of “first aid trainer” speaking authoritatively on some kind of “first aid style” topic. If you are like me you’ve used your time productively over the years and perfected what my wife refers to as “screen-saver mode” – it’s that look on your face that tells the instructor that you are listening intently, often supplemented by the insertion of “knowing nods” or head-tilts, but in actual fact you are asking yourself “if I was able to collect all of my belly button lint over a 12 month period and spin it into yarn, I wonder if I could make enough to abseil off London Bridge?”

Don’t get me wrong – I reckon effective and accurate first aid training should be a mandatory part of having a car / bike / truck / bus licence. More appropriately trained people should mean faster recovery rates for most injured people (and less work for overstretched first responders).

It’s just that sometimes first aid trainers teach stuff based on ‘we reckon’ or ‘that’s how we’ve always done it’ rather than evidence or knowing it works in the real world. This post is about one of those things.

“What is a sucking chest wound?”

In the Army questions come in a few different shapes and sizes. A popular one is “there is only one obscure answer you should have guessed I wanted”. Trust me, the muzzle velocity of your primary weapon is 970 metres per second.

Another popular one is “the question that should be about one thing, but is actually to demonstrate a quite tangential point”.  Like,

“What is a sucking chest wound?”

For an army instructor the answer is not what you are thinking right now. It is “Nature’s way of telling you that your field craft sucks and everyone can see you and now you got shot”.

Let’s Go With the Medical One

We’re going to go with the alternative, more medical one. A sucking chest wound is defined as air entering the thorax via a communicating wound that entrains air into the space between the lungs and ribs more readily than the lungs can expand via inspiration through the trachea.

This is about pressure differentials – in order to inhale, the lungs must generate a relative negative pressure such that air can be sucked into them via the trachea. But if you make a big communicating hole in the trachea, that might become a pretty big highway for air to enter the space with the negative pressure.

The communicating hole does need to be pretty big. Depending upon which textbook you read, this hole needs to be a minimum of a half to three quarters the diameter of the trachea. Also, the patient needs to be undergoing relative negative pressure ventilation (or, in simple terms, breathing spontaneously). If they are being artificially ventilated (which requires positive pressure) then the pressure inside the lungs will be higher than the pressure on the outside of the body; the result is that air will be forced out of the intra-pleural space (or thorax) by the expanding lung (as opposed to being entrained into the thorax via the hole in the chest).

Are sucking chest wounds really that bad?

Well, yes. They suck in fact.

A sucking chest wound creates what is known as an open pneumothorax. Let’s consider the option where that hole does not seal on expiration. We’ll get onto the also very annoying sealing with a flap version in a bit.

In this slightly not so annoying case, the patient will have a ‘tidalling’ of air in and out of this communicating hole. The effect? Respiratory compromise, increased cardiovascular effort and reduced oxygen saturations. Patient satisfaction? No, not really. Death? Maybe – depends on what other injuries exist and the ability of the individual to compensate. See Arnaud et al (2016) for more details.

But if this communicating hole were to seal itself on expiration then you now have an open tension pneumothorax. Sounds bad; IS bad.

In such a case, each time the patient breathes in they will entrain air through the communicating hole in the chest wall (that whole “negative pressure” thing in action). But when they breathe out, instead of having that additional intra-pleural air tidal outwards, the flap will seal it in place; each time they breathe in, the volume of trapped air will increase and you’ll end up with the tension bit.

How much air is required? Well a randomised, prospective, unblinded laboratory animal (porcine) trial conducted by Kotora et al (2013) found that as little as 17.5mL/kg of air injected into the intra pleural space resulted in a life-threatening tension effect.

Actually, that’s a fair bit of air…for those of you who are lazy and don’t want to do the math, that’s 1400mL for an 80kg person. But remember, any tension pneumothorax (open or closed) is progressive – each time you breathe, more air is trapped; therefore, it doesn’t take long to reach crisis levels.

“But are they common enough for us to be worried about?”, I hear you asking. The short answer is yes – in fact, the long answer is also yes.

Kotora et al (2013) reviewed the statistics from the Joint Theater Trauma Registry regarding contemporary combat casualties with tension pneumothorax and found that they accounted for 3 – 4% of all casualties, but 5 – 7% as the cause of lethal injury.

“Yes, but I don’t live in a combat zone…”, I hear you say. I have two responses:

  1. Good for you; but also,
  2. According to Littlejohn (2017), thoracic injury accounts for 25% of all trauma mortality. And sure that stat is for all forms of thoracic injury and a sucking chest wound is but one of those but there’s a neat article by Shahani which sums up the incidence nicely and it turns out you should give this some thought.
The Table
We even saved you some time by grabbing the relevant image.

So, your field craft sucks – now what?

Now that we know that sucking chest wounds are both possible and bad, we should probably discuss treatment.

Some History

Back in the mid 1990’s, Army instructors were very big on rigging up a three-sided dressing. Unwrap a shell dressing, turn the rubbery-plastic wrapper into a sheet and tape three sides down with the open bit facing the feet to allow blood drainage.

And, in an astonishing turn of events, everyone I’ve met who tried this confirmed it didn’t really work that well.

In that Littlejohn paper they make reference to the fact that by the 2004 ATLS guidelines (which are not usually that quick moving), it was being written unblock and white that there was no evidence for or against the three-sided dressing option. It was done because it sounded good in theory, but the evidence wasn’t there.

Now to the New

Actually, not that new. Chest seals already existed.

These chest seals (at that time the Bolin produced by H & H Medical, and the Asherman produced by Teleflex medical) included one-way valves to allow for the forced escape of trapped intrathoracic air and blood. basically they took the impromptu three-sided dressing and made it a ready-made device in the form of an occlusive dressing with an integral vent.

But did they work?

Yes and no.

On a perfectly healthy (albeit with a surgically created open pneumothorax) porcine model with cleaned, shaved, dry skin they sealed well and vented air adequately.

However, once the skin was contaminated (dry blood, dirt, hair etc) the Bolin sealed much better than the Asherman. And if there was active blood drainage too (such as in an open haemo-pneumothorax) then all bets were off. Both vents clogged with blood and ceased to work. Sure, you could manually peel the seal back and physically burp the chest but if you did so the Bolin became an un-vented seal and the Asherman was as good as finished (i.e. it wouldn’t reseal). But hey, at least you had sealed the communicating hole and in doing so stopped entraining air.

“Is this the best you can do?” you may be asking. Well to be honest, since the vents didn’t work for more than a breath or two most people decided that the vents were pointless. The outcome was that we all decided to forget about the vents and just seal the wound. That way, assuming that there was no perforation to the lung, this open tension pneumothorax (aka sucking chest wound) became a routine, run of the mill, plain old pneumothorax. And if there were signs of tensioning (e.g. increasing respiratory distress, hypotension, tachycardia….) one just needed to peel back the seal and manually burp the communicating hole thus relieving the pressure. Use a defib pad – those bad boys stick to anything! Problem solved….

Or how about a newer idea + research?

In 2012 the Committee on Tactical Combat Casualty Care (CoTCCC) started questioning the efficacy of contemporary practices regarding the placement of chest seals on sucking chest wounds. It had already been accepted that the current vented chest seals had ineffective vents, so practice had changed from using a chest seal with an ineffective vent to simple, “soldier proof” unvented seals and burping them as required. Surely there had to be a better way…?

Kotora et al (2013) decided to test three of the most readily available vented chest seals in their aforementioned randomised, prospective, un-blinded laboratory animal (porcine) trial: enter the Hyfin, Sentinal and SAM vented chest seals.

What they found was that all three were effective in sealing around the surgically inflicted wounds and in evacuating both air and blood. Thus, in 2013, CoTCCC changed their recommendations back to the use of vented chest seals.

But there were still some questions:

  1. Once life gets in its messy way, do they seal (or at least stick to skin)?
  2. Are all vent designs equal?

To answer question 1, Arnaud et al (2016) decided to evaluate the adhesiveness of the 5 most common chest seals used in the US military using porcine models. What they found was that the Russell, Fast Breathe, Hyfin and SAM all had similar adherence scores for peeling (> 90%) and detachment (< 25%) when tested at ambient temperatures and after storage in high temperature areas when compared to the Bolin. The researchers admitted, though, that further testing was required to assess the efficiency of the seals in the presence of an open tension haemo-pneumothorax.

In response to question 2, Kheirabadi et al (2017) tested the effectiveness of 5 common chest seals in the presence of an open tension haemo-pneumothorax (again, on porcine models). Essentially, there are two types of vent: (i) ones with one-way valves (like in the Bolin and Sam Chest Seals), and (ii) ones with laminar valves (like in the Russell and Hyfin Chest Seals). Their question was: do they both work the same?

What they found was that when the wound is oozing blood and air then seal design mattered. They found that the seals with one-way valves (specifically the SAM and Bolin) had unacceptably low success rates (25% and 0% respectively) because the build-up of blood either clogged the valve or detached the seal. By contrast, seals with laminar venting channels had much higher success rates – 100% for the Sentinel and Russell, and 67% for the Hyfin.

The Summary


  1. Sucking chest wounds are bad for your health.
  2. Sealing the wound is good.
  3. If the seal consistently allows for the outflow of accumulated air and blood, then that’s even better.

Therefore, now that we know all of this, one’s choice of chest seal is important. At CareFlight we use the Russell Chest Seal by Prometheus Medical (and no, we’re not paid to mention them we’re just sharing what we do). Why? Because it works – consistently. Both for us and in all the aforementioned trials.


The premise of this addition to the Collective is that you’re a first responder. That being the case, use an appropriate vented chest seal on a sucking chest wound.

However, you still need to recognise that the placement of the seal does not automatically qualify you for flowers and chocolates at each anniversary of the patient’s survival – you still need to monitor for and treat deterioration. Such deterioration is likely to include a tension pneumothorax for which the treatment is outside of the scope of most first responders (other than burping the wound).

If you are a more advanced provider then your treatments might include the performance of a needle thoracocentesis, or perhaps intubation with positive pressure ventilation and a thoracostomy (finger or tube).

In essence, know the signs and symptoms then master the treatments that are inside your scope of practice. (Or you could enrol in a course…such as CareFlight’s Pre-Hospital Trauma Course or even THREAT… OK that was pretty shameless.)

Meanwhile we’d love to hear:

  1. What chest seal do you use?
  2. Why?
  3. How does it go?

Or you could just tell us what other things you think suck.

Could be the leafy green thing. Could be a person maybe.


We’re not kidding about hearing back from you. Chip in. It only helps to hear other takes.

You could also consider sharing this around. Or even following along. The signup email thing is around here somewhere.

That image disparaging all things Kale (or kale) is off the Creative Commons-type site and comes via Charles Deluvio without any alterations.

Now, here are the articles for your own leisurely interrogation.

If you’re time poor and will only read one, make it this one by Littlejohn, L (2017). It’s “Treatment of Thoracic Trauma: Lessons from the Battlefield Adapted to all Austere Environments”. 

Another great one (albeit somewhat longer) is by Kheirabadi, B; Terrazas, I; Miranda, N; Voelker, A; Arnaud, F; Klemcke, H; Butler, F; and Dubick, A (2017). It’s “Do vented chest seals differ in efficacy? An experimental evaluation using a swine hemopneumothorax model”.

An oldie but a goodie is this one by Kotora, J; Henao, J; Littlejohn, L; and Kircher, S (2013). It’s “Vented chest seals for prevention of tension pneumothorax in a communicating pneumothorax”.

To round it out, take a squiz at Arnaud, F; Maudlin-Jeronimo, E; Higgins, A; Kheirabadi, B; McCarron, R; Kennedy, D; and Housler, G (2016) titled “Adherence evaluation of vented chest seals in a swine skin model”.

Cobras and the First Look

Dr Alan Garner has been here before, asking whether we’re asking the wrong questions when we try to measure quality advanced airway care. Here’s a fresh bit of research that adds to the discussion.

Unintended consequences would hardly be a new thing in medicine or in any other endeavour.  Here is one of my favourite examples taken from Wikipedia (look we all go there from time to time):

“The British government, concerned about the number of venomous cobra snakes in Delhi, offered a bounty for every dead cobra. This was a successful strategy as large numbers of snakes were killed for the reward, but eventually enterprising people began to breed cobras for the income. When the government became aware of this, they scrapped the reward program, causing the cobra breeders to set the now-worthless snakes free. As a result, the wild cobra population further increased. The apparent solution for the problem made the situation even worse, becoming known as the Cobra effect.”

Check this link for some more cracking examples.

Avid or maybe even occasional readers who chanced to come back at exactly the right moment might recognise that I have previously expressed my doubts about reporting the first look intubation rate as a quality measure for intubation.  Have a look here for the previous post.

Now where might you go to find a basket of cobras these days? Well I have just spotted a new paper published in Prehospital Emergency Care which fits the bill.  You can find the full text here. I guess we’d better start picking up the snakes.

It’s probably a friendly one, right?

Let’s Start with the Headlines

This paper is a look at a ground paramedic system in a small US city (Spokane in Washington State) where the paramedics have used muscle relaxants for more than 20 years i.e. you would have to consider this a mature system.  It appears to be a well supervised system and paramedics have a minimum number of intubations they must successfully perform each three-year certification cycle in addition to a well-structured training regime.

Superficially the system appears to be working well.  They had a 95% success rate and 82% first look success.  Although 95% overall success rate is below par compared with other systems world-wide, all patients not successfully intubated were successfully managed with a supra-glottic device.  That should be OK, right? That probably means the primary focus is on managing the airway to achieve the goal that really counts – oxygenation. And that first look rate of 82% seems quite respectable compared with reports from other systems.  So not a star system but safe enough if these were the only quality measures you were looking at.

Let’s Get Our Hands Right Amongst the Snakes

The thing is the paper also reports physiological data captured by the patient monitor during the peri-intubation period and this tells a very different story.  Much of the data is not that surprising.  Desaturations were more common when patients were being intubated for respiratory pathology and were also related to the highest SpO2 achieved at the end of pre-oxygenation.

How about we look at some oximetry data highlights?

  • Oximetry data was available in 110 cases. Peri-intubation desaturation occurred in 47 cases (43%) and in 32 (68% of the desaturations) it was severe (<80%).
  • The median nadir was 71% and median duration was 2 minutes. Among cases with any desaturation, the time in the unhappy valley was at least 2 minutes in 46% of cases with first-attempt success and in 100% of cases requiring multiple attempts.
  • Although the frequency of desaturation was significantly higher in cases requiring multiple laryngoscopic attempts versus a single attempt (70% vs. 37%; p = 0.01), 70% of all desaturations occurred on first attempt intubation success. Only 11% of desaturations were reflected in the EMS patient care report.

Heart rate changes

  • 13% became bradycardic, 7% profoundly. The median SpO2 nadir during bradycardic episodes was 30% with median duration of nearly 5.5 mins.
  • Sixty percent of bradycardia events occurred on first-attempt intubation success.

Yes in the multiple attempt cases the desaturations were worse than cases requiring a single attempt.  But given the very high rate of desaturation events in this study is reporting the first pass success rate providing any meaningful quality data?  Is there subtle pressure placed on the paramedics in this system to achieve first pass intubation at the potential expense of desaturation events, by the very fact that first pass rate is being reported?

We can’t be sure and I’ll put my hand up and say “yes, I’m inferring a little bit from what we can see in the paper”.  But clearly the overall success and first pass success rates provide no real indication of process safety in this particular EMS system.  It is only in reporting of clinically meaningful quality data like desaturation that we see the real safety performance.

Who Else Thinks This?

To quote the paper itself “What may be obscured by this focus on the risks associated with multiple intubation attempts is the large absolute number of physiologic derangements occurring on first-attempt success. In our study, 70% of all desaturations, 60% of bradycardia episodes, 63% of hypotension episodes, and one of the two cardiac arrests occurred on first-attempt success.”  That’s really the nub of it and it’s excellent work by the authors to make sure that’s right up there in the discussion.

The authors conclude that first attempt success “is not a reliable indicator of patient safety.”  The authors specifically note that prolonged duration of first pass attempts is a contributor to the desaturation rate and that prolonged attempts might be “a consequence of lack of awareness of the passage of time during an intubation attempt, or lack of awareness of the occurrence of desaturation”.

But is the very fact of reporting first pass success rate a subtle psychological contributor too?  The authors clearly agree with me here when they comment “prolonged desaturations on first attempt success could be an unintended consequence of the focus on first-attempt success itself and the common use of first-attempt success as a primary measure of intubation quality.”

Maybe it’s an example of the Cobra effect.

The Take Home Bit

Prospectively it is right to set yourself up to get the ETT in the right place on the first attempt and with minimal complications.  However once the intubation attempt commences the emphasis needs to shift to prevention of complications by reacting to physiological changes as they occur.

We want to encourage this.  I want my teams obsessed with preventing complications, not first pass success.  Why are we reporting a process measure as a quality indicator when it might well be having the perverse effect of encouraging those very complications we were trying to remove?  The system I work in here in NSW requires us to report first pass success.  I remain hesitant to do this as I don’t want to signal to my teams that this is actually something that matters.  I would much rather them be proud of the 0% desaturation rate that we have for intubation over the last 9 months – that is really impressive.



That paper is this one:

Walker RG, White LJ, Whitmore GN, et al. Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation. Prehosp Emerg Care. 2018;

And the link to that first post covering similar ground is right about here.

The image of the cobra came via Creative Commons off flickr and is unchanged from the post by Luca Boldrini.





The Social Resuscitation

There are parts of the resuscitation with no algorithm. No protocol. How do we improve that part? What are the social resuscitation skills we need to work on? We’re very pleased to have Dr Ruth Parsell chip in with some thoughts. Ruth is a current ACEM Registrar working on the CareFlight Rapid Response Helicopter in Sydney. She joined the NSW Ambulance Service in 1998 and has worked in prehospital and hospital settings in varying roles since that time. 

The “social” resuscitation is a term I’ve been using for quite some time now. I apply it in dire situations. In both adults and children. But this is about the paediatric resuscitation and, specifically, cases where the prognosis is highly likely to be tragic. It is in these cases that I utilize this term because we are clearly treating more than just the patient when we resuscitate. I use the term because when I treat the child I am treating their family and all of the social connections that are linked to such a brief, precious life.

Experience We Don’t Always Want to Gain

The sad reality is that every paediatric resuscitation we do offers an opportunity to improve more than just our clinical skills. We all wish we didn’t see these cases but if they continue to occur then we will continue to do our best to serve the needs of both the patients and their families. What if we were able to improve the way we serve them? Which part of the resuscitation we call “futile” is the opposite of futile?

The best way to do both would be to have the “miracle” recovery. The “against all odds”, the “everything was against them”… the full recovery of a child who has had a terrible insult. The drowning, the fall, the pedestrian, the horse riding accident… all the terrible insults we see and all those mechanisms of injury that can potentially cause an early cardiac arrest or a moribund child.

Instantly we think of our algorithms, our protocols, our list of reversible causes and the sequence of steps we might take when we arrive at the scene. We hear the age, we think about weights, sizes, drug calculations. None of this should ever change and I’m not suggesting it should.

But what about when we hit that turning point?

It may have been an inkling early on. The thought that the mechanism is just too great, the injury just too severe, a poor response to even the most efficiently and expertly performed algorithm. It’s a moment where, sometimes even without verbalizing, the whole team is aware of the magnitude of the odds against this little one.

The Pause

What if in these cases we took a moment? Just a brief moment. When it comes to adult resuscitations I find we seem to automatically provide explanations to the family even while we are working. To explain that his heart is not beating and that we are working very hard to restart it; with a breathing tube, trying to stop the bleeding and with powerful medicines.

Perhaps it feels automatic because we just see more of those cases. We get to drill those algorithms more so there is a window that gives us space to look around.

So how do we provide this window in those paediatric prehospital jobs?

What if it was just a kiss before the transport? What if the family could have a little more from us? What if we suggested getting their daughter’s favourite teddy or blanket from the house? Just to fill their arms for the trip to hospital, to stop Mum’s hands from relentlessly wringing or something to give her tears a soft landing when they fall.

What do the books say?

The evidence for family presence during resuscitation has evolved over many years. Factors examined include the resuscitation team performance, stress levels amongst staff, clinical outcomes and psychological outcomes for family members. The evidence in paediatrics, including in some randomized control trials, demonstrates that there are improved measures of coping and positive emotional outcomes among families (1). These outcomes are achieved without impeding team performance.

There are many barriers to family presence in the pre-hospital arena. These scenes can be highly distressing, emotions are raw and the procedures required are time critical. Transport logistics can be a huge barrier too. It is rarely practical for a family member to travel with a child to hospital when they are critically unwell or in cardiac arrest. The confined environment of the back of an ambulance is usually congested and the potential unpredictability of a relative may compromise staff safety. The evidence regarding family presence is also more difficult to obtain.

However, there is some evidence regarding family presence during pre-hospital CPR in the adult literature and this also confirms positive results on psychological variables in family members without interfering with medical efforts, either clinically or with regards to health carer stress.(2)

When I have used the term “social” resuscitation in the past, I used it primarily in the dire situations I mentioned previously. Traumatic cardiac arrest in children fits this description, with a less than 5% neurologically intact survival rate (3).

I use this term in cases where I feel the resuscitation efforts are more a resuscitation for a family than the  patient. I use it in the context of transporting to an appropriate place, where I feel that the optimal ongoing social supports for family members can be best met. Somewhere where others can assist with tissues, quiet rooms and hushed explanations. Somewhere where others can understand the welled up look that we give them when we enter the bay.

Now I think that the social resuscitation needs to start earlier. A more conscious and deliberate effort. Maybe not every time. Not when you can feel yourself buckling under the cognitive load. Not when your emotions are so close to the surface you can’t get the words out. Not when the scene is like a powder keg and you might just be putting people at risk.


But in those paediatrics cases we need to make a conscious effort to find a window, even where the algorithm is crowding us a little more. That might be the part of the resuscitation that isn’t futile for those left behind.

Try the explanation. Try the kiss. Wait for that teddy. Just try it and let’s see if it improves our social resuscitations. It might even just improve things for all of us.



Notes and References:

  1. ANZCOR Guideline 10.6 Family Presence During Resuscitation, August 2016. 
  2. Jabre et al. Family Presence During Cardiopulmonary Resuscitation. NEJM. 2013;368:1008-18.
  3. Fallat et al. American Academy of Pediatrics. Policy Statement: Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest. Pediatrics. 2014;133.  

That image is shared unchanged from the post by Gabrielle Diwald at under Creative Commons.


A Quick Look Back at 2017

Well everyone else is doing the “look back, look forward” thing, so why not us as well?

It’s that time of year. You know, the one where we just want a few more days to kick back and relax or enjoy a southern hemisphere summer. What better way to look busy than a review of the posts that got the hits in 2017? Ssshhh. There may well be better ways but this is what we’re going with.

First up, music for the ears

Podcasts. People do them and people listen to them. Clever people do them regularly. We are not that clever it seems. We did finally get around to putting up a couple this year though and the most recent one was very comfortably the most popular podcast we’ve done. OK, it’s a field of four but it’s not nothing.

The podcast features Dr Blair Munford. Blair has been in the retrieval and prehospital field since the mid ’80s. He has stories. Lots of stories. This story is his though and in it you get to hear a little about what it’s like on the day you’re getting picked up by the helicopter. So maybe have a listen. Lots of people obviously thought it was worth it.

The Not Very Final Countdown

We’re not packing up or anything so it’s nothing like a final countdown, but is there a theme amongst the posts that people seem to click on the most? Well let’s see. Here are the 10 top written posts through 2017:

10. This is how he does it

Coming in at number 10 is a post from a new contributor, Dr Shane Trevithick. This one is a great example of someone describing where experience has led them when they’re looking after a patient for retrieval.

9. Tactics for hostile places – Tactical Medicine still going strong

The series on tactical medicine dates from 2016 but still gets plenty of interest. The third instalment just keeps clocking up the hits (and provides an easy link to chapters 1 and 2). People just want to know about phases of care I guess. If you like that you might also find this conference update worth your time too.

8. An old classic – little kid RSI

A couple in the year’s top 10 were all about kids which is a pretty pleasing thing. The care of kids isn’t just about shrinking stuff from adults and there’s plenty to gain from being kid friendly. This post went over the reasons that the approach to RSI in kids has changed and what we should be trying to focus on.


7. Necessity and the mother of invention

As much as we like kits sometimes you have to be flexible. This post on how to use what you have when you just have no choice is designed for when you’re stuck in one of those moments that will make you thank your gods for your real equipment when you’re back on a real job. Tourniquets? Check. Pelvic binding? Check.

6. Holding the line

Could there be a practical theme emerging here? This post covers a simple thing that you can really use – a way to keep that IV line in no matter what the world tries to pull it out.

5. Sucking and blowing and the pleural space

Did you feel like this list didn’t have enough physiology in it? Alan Garner’s post covering pressures and the pleural space is a really interesting revisit of something we all ‘know’ from way back when.

4. Kids and drips

This practical post on putting cannulas in little people certainly grabbed some interest. Maybe it will help out next time you’re facing a procedure that can cause pain at both ends of the needle.

3. More physiology when you pick a person up

This post comes from 2016 as well but it just keeps people coming up. A topic not covered that much elsewhere, but the physiology of a patient being winched is certainly relevant to lots of people in the  rescue space.

We’ll level with you the rescuee here is apparently a mannequin so the physiology would be pretty forgiving but you get the idea.

2. In a bind

What is it about pelvic binders that gets people coming back for more. Our long running series on pelvic binders got a boost with number 5 which covered a case where the binder really probably didn’t help. You could drop by and end up down the rabbit hole of the other 4 posts with those links at the start of it.

1. Back to basics

And the top spot for 2017 goes to one of those great posts that covers things we often think of as basic but which might just make the biggest difference to patients – “basic” airways and adjuncts. Maybe you’d like to drop by this edition of those things we wish we’d known way back when we started.


So that’s the list. And the theme is pretty clear. People like practical things. And physiology. And things about kids. And things that touch on the literature. And … actually people probably just like all things prehospital and retrieval. Better get back to it.



The image from was posted just like this by Neil Thomas.

Maths and Choppers from Norway to New South Wales

There are a bunch of ways to figure out where to put your resources. Dr Alan Garner found a guy who can crunch the big numbers to look at it a little differently. 

What’s the answer for optimal locations? First ask what is the question.

We have just had a new study published in BMC Emergency Medicine on modelling techniques to determine optimal base locations for helicopter emergency medical services (HEMS).  There is always more to say than can be covered in a publication so I thought I might have a look at some of those issues here.

First up is a big thank you to my co-author Pieter van den Berg from the Rotterdam School of Management in the Netherlands.  Pieter is the real brain behind the study and the mathematician behind the advanced modelling techniques we utilised.  Pieter has looked at HEMS base location optimisation previously in Norway and has done some modelling for Russel McDonald’s service Ornge in Ontario, Canada as well.  Without him the study would not have been possible.

So what did we do and why?

As already noted Pieter had recently done a similar exercise in Norway where the government has a requirement that 90% of the population should be accessible by physician staffed ambulances within 45mins.  Pieter and his co-authors were able to demonstrate that the network of 12 HEMS bases easily accomplishes this – indeed it could be done with just four optimally positioned bases.  They also modelled adding and moving bases to determine if the coverage percentage could be optimised with some small adjustments.

As it happens New South Wales (NSW) and Norway have very similar population densities and both are developed, first world jurisdictions.  Hence this previous study seemed a good place to start for a similar exercise in NSW.  Both jurisdictions also have geographical challenges; Norway is long and thin with population concentrated at the southern end whereas NSW has almost all the population of the state along the eastern coastal fringe with high concentration along the Newcastle – Sydney – Wollongong axis.

We were interested in population coverage but we also wanted to look at response times as this also is a key performance indicator for EMS systems.  It is certainly reported as a key indicator by NSW Ambulance.  Response times were not modelled in the Norwegian system so we were interested in seeing how the optimum base locations varied depending on the question that was asked, particularly in a jurisdiction such as NSW where the population is so concentrated to a non-central part of the state.

If you look at the study you will note from Figure 1 the existing arrangements in NSW. You’ll be shocked to know these arrangements weren’t planned in advance with the aid of a Dutch maths guru. These things happen organically. Nevertheless it provides a reasonable balance of response times and coverage although the gap on the north coast is immediately evident.

Figure 1If you start with a clean slate and optimally position bases for either population coverage or average response time, both models place bases to cover that part of the coast (see Figure 2).  Hardly surprising.  When we modelled to optimise the existing base structure by adding or moving one or two bases, the mid north coast was either first or second location chosen by either model too.

Figure 2

This seems an obvious outcome from even a glance at the population distribution and current coverage in Figure 1.  What is surprising is that the 2012 review of the HEMS system in NSW (not publically released) which utilised the same census data in demand modelling did not come to the same conclusion when two previous reviews in the 1990s and 2000s had recommended just such a change.  Certainly the Reform plan for helicopter services which was released the following year did not make any changes or additions to base locations leaving this significant gap still uncovered.

Wagga Wagga was the other location identified for a HEMS base in the 2004 review.  Interestingly it is favoured as the first relocated base when the existing structure is optimised for average response time by moving Canberra to this location.  But a Wagga Wagga base also was not mentioned in the reform plan.

What about the green fields?

When the green field modelling was done it is clear that the current NSW system mostly closely resembles the model optimised for average response time, rather than coverage.  The Wollongong base really justifies its location on this basis as it contributes to a better overall average response time.  Its population coverage falls entirely within the overlapping circles of the Sydney and Canberra bases so it makes no contribution here, at least if a 45min response time is used as the standard.

There was another aspect that interested us compared with Norway.  In Norway all aircraft have the same capability and this is also true for the recently tendered services in NSW.  The unusual feature in NSW though (unique to Australia although common in Europe in particular) is a dedicated urban prehospital service operating from a base near to the demographic centre of the largest population density – Sydney.  The performance characteristics of this service have been well described (by us, because I’m talking about the CareFlight service which I think does serve a useful function) previously and when it was operating with its own dispatch system was the fastest service of its kind in the world to our knowledge.

Like the Wollongong service it operates entirely within the population coverage circles of other bases, but it makes an enormous contribution to average response time.  When this rapid response urban service is added to the network of large multirole helicopters in NSW the average response time across the entire state falls by more than 3.5mins because that service is able to access more than 70% of the state population within its catchment zone, and significantly faster than the multirole machines.

This modelling only takes into account the response time benefit of the specialisation afforded by such as service.  We have previously been able to demonstrate that the service is also much faster in almost every other aspect of care delivering patients to the major trauma services in Sydney only a few minutes slower than the road paramedic system but with much higher rates of intervention and ultimately passage through the ED to CT scan faster than either the road paramedic or multirole retrieval systems in NSW.  At least this was the case when it had its own specialised dispatch system but that is a story we have discussed previously too.

There are recurrent themes here.  The Rapid Response Helicopter service adds significantly to the response capability in NSW whether you model it using advanced mathematical techniques or whether look at the actual response data compared with the alternative models of care.  Indeed the real data is much stronger than the modelling.  It seems that at least in large population centres in Australia there is a role for European style HEMS in parallel with the more traditional multirole Australian HEMS models that service the great distances of rural and remote Australia.  Different options can work alongside one another to strengthen the whole system and better deliver stuff that is good for patients – timely responses when they really need them. The capability differences however need to be reflected in dispatch systems that maximise the benefits which come with specialisation rather than a one size fits all tasking model that takes no account of those significant differences.

Every version of the numbers I look at tell the same story.


Notes and References:

While this post covers a few ways of looking at a tricky sort of problem, there are lots of clever people out there with insights into how these things work. If you have ideas or examples from your own area, drop into the comments and help people learn.

Now, the paper that’s just been published is this one:

Garner AA, van den Berg PL. Locating helicopter emergency medical service bases to optimise population coverage versus average response times. BMC Emerg Med. 2017;17:31. 

The paper on optimal base locations in Norway is this one:

Røislien J, van den Berg PL, Lindner T, et al. Exploring optimal air ambulance base locations in Norway using advanced mathematical modelling. Injury Prevention. 2017;23:10-15.

And if you like any of the posts on here, then maybe share them around. Or sign up for an update when new posts hit with the email sign on thing.


Tactical Update – A Report from TacT17

OK it’s a few weeks back, but here’s Greg Brown with the lowdown on a conference about tactical matters. 

Conferences: a formal meeting of people with a shared interest, typically one that takes place over several days; the means by which professionals from around the globe congregate with a view to learning from each other. Sometimes also referred to as junkets, jollies, paid holidays and tax write-offs.

But in all honesty, oftentimes the only way one can be afforded the chance to be surrounded by like-minded professionals with a view to learning from the experience of others, benchmarking your intellectual property against that of other organisations operating in the same “space” and refining your knowledge thanks to the latest in international research is to travel to the other side of the world and attend a conference. So, as one of the few non-government providers of tactical medicine training in Australia, that’s precisely what we did.

In mid-October 2017 two of CareFlight Education’s staff travelled to sunny (well, we assume there was sun above the pouring rain) Sundsvall, Sweden, to attend the inaugural Tactical Trauma conference.  If you are on Twitter, you can search for it using #TacT17. If you are not on Twitter, then join Twitter and search for it using #TacT17….

This post provides a summary of what we found, what we liked, what we didn’t like and some takeaway points.

The words are cool probably, but maybe put a shirt on when you hold Death back buddy.

The Peeps

This was truly an international event. Presenters came from across Europe (with a strong Scandinavian presence, as expected), North America, the Middle East and even Australia. Participants included both hospital and pre-hospital doctors, nurses, paramedics, police medics, retrieval (road and air) clinicians and military folk.

The Stuff to Chew On

As the name “Tactical Trauma” suggests, the conference was focussed on the medical management of trauma with a tactical twist. It should be noted that discussions regarding any tactical imperatives were limited by the realities of operational security. For obvious reasons, nobody wished to describe their unit’s tactics in great detail.  They were enough to paint the scene though.

Therefore, if you were looking to learn how to become the next big thing in SWAT team medicine then this conference probably wasn’t for you – and there certainly were no skill sessions on how to kick in doors, breach a terrorist stronghold or fast rope from a helicopter (although these might be popular sessions next time).

Rather, focus was placed on the provision of “good medicine in bad places”. There were sessions by military doctors discussing what worked (and what didn’t) on recent deployments (including topics such as blast injuries, penetrating chest injuries and rates of injuries in dynamic events), the usefulness (or otherwise) of helicopter emergency medical services in hostile mass casualty events, comparisons of contemporary haemostatic agents versus conventional bandages in wound packing, the perils of acute traumatic coagulopathy, discussions on vascular access options, and the progress over the years in the application of clinical management strategies. It is also worth noting that since this is in fact 2017 no medical conference would be complete without at least one presentation on POCUS (that’s Point Of Care UltraSound – and yes, it is very useful) and one on REBOA (or Resuscitative Endovascular Balloon Occlusion of the Aorta – and no, there is not enough evidence to definitively support it); these were dutifully attended to.

Case studies are always useful; in this instance we were treated to reviews by the Finnish and Norwegians of their tactical emergency medical support systems, the Israelis and their medical response to contemporary domestic contingencies and both the French and Swedish on their responses to recent mass casualty events. There were also a few “closed door” sessions for police medics regarding recent mass casualty events in the USA.

But finally, as most of us already appreciate, being outstanding at your trade is only part of the job; the ability to communicate effectively with your team members whilst managing your own stress levels are also vital in providing optimal patient care. As such, sessions on crew resource management skills, the cognitive revolution, tips for centring one’s self prior to and during a job, and how to get the rollout of good ideas actually rolling were welcome additions to the program.

Things We Liked

  • Firstly, whilst it is obvious that military experiences inform civilian practices, we appreciated the fact that this conference was focussed on civilian (not military) practice. Other conferences of the type claim to do this yet the majority of the auditorium is filled with uniforms of various militaries.
  • Secondly, sessions were kept at a length that were short enough to retain audience attention but long enough to cover the required level of detail for the given topic. If a topic was not floating your boat, a new topic would commence in 20 minutes.
  • Thirdly, at no point did we hear “you must do it this way – if not, you are wrong”. The overall feel of the conference was that no single entity had all the answers but that through collaboration we can all improve. Participants were encouraged to seek out presenters (who were all easy to find) and undertake collaboration.
  • Finally, the focus was on “good medicine in bad places” and not cool Velcro patches, the latest fashion in tactical gear (which would obviously only come in black and be stamped with a label consisting only of numbers) and the liberal application of mutual back-slapping.

Things That Were Not the Business For Us

  • Despite the fact that the conference was aimed at civilian practice, the majority of presenters referred to TCCC (Tactical Combat Casualty Care) and not TECC (Tactical Emergency Casualty Care). It is possible that the presenters were using the term TCCC out of habit, but when one considers that the latest review of TCCC by the Committee has lead to their terms coming closer into line with that of TECC (and not vice versa), it is time that the world started embracing the correct terminology.
  • Having a single track makes it hard to keep everybody interested, and at times we felt sorry for certain members in the room. These folks included frontline police officers who have a secondary role of medical response – whilst the clinicians were riveted by the maps of clotting cascades and stories of roadside REBOA, the Police Medics just wanted to know (a) how best to plug the hole, and (b) how fast to drive.

[Note: we got the impression that the conference convenors were victims of their own success – we are not sure they realised just how popular it might be when they originally floated the idea on social media. We are confident that this issue will be alleviated next time.]

The Takeaways

If you had to sum up the content of a jam-packed two-day conference in just a handful of points then these would be them [note: these are more paraphrases than quotes]:

  • “Learn from the experiences of others. Recognise that no single agency has all the answers, so work with and not against each other.” Matt Libby, flight paramedic with Boston Med Flight, USA
  • “In resuscitation, the most effective therapies are those that can be applied quickly. Time is blood.” Dr Richard Dutton, trauma anaesthetist, USA
  • “You can possess all the best haemorrhage control devices in the world, but if you are not using them properly then they are worthless. Training is key.” Dr Mark Forrest, medical director of ATACC, UK
  • “Battlefield medicine is like plumbing: if it’s blocked, clear it; if it’s leaking, plug it.” Gary Grossman, CSAR paramedic, Israel
  • “In a high risk or major incident, it makes sense to have all rescue agencies working together under a common SOP that has been tested prior.” Dr Stephen Sollid, medical director and retrievalist, Norway
  • “REBOA has a place in pre-hospital care; we are just not quite sure what that place is. Blood will still be lost from backflow.” Dr Tal Hörer, vascular surgeon, Sweden
  • “Medics in the hot zone should focus on not getting themselves killed and not endangering the mission. Cross training is vital.” Dr (LTCOL) Ishay Ostfeld, IDF and cardiothoracic surgeon, Israel
  • “In a critical patient, performance of life saving interventions should take precedence over applying rigid protocols around immobilisation.” Dr Thomas Dolven, intensivist and retrievalist, Norway
  • “People only improve if they actually want to. You cannot force improvement.” Michael Lauria, former USAF PJ and current medical student, USA
  • “When it comes to vascular access, there should not be different hospital standards and prehospital standards. There should just be standards.” Dr Knut Taxbro, anaesthetist and retrievalist, Sweden.

The Recommendation

So I guess the big question that remains for everyone is “was 50+ hours of travel from Australia to central Sweden for a 17 hour conference really worth it?” Given that we were able to assess the content of our training against that which other like-minded organisations from around the world provide in an open and non-threatening forum, tweak our content in line with the latest evidence, build contacts with groups and individuals that have the same struggles as we do in Australia, and provide some guidance to participants who were looking to develop their own tactical medicine training – the answer is obvious.

Look it’s hard to respect an animal mascot that doesn’t spend most of its time sleeping like a koala but good effort I guess.

Wait, I almost forgot the really vital lessons

These things:

  • The Swedish love speed cameras. I mean, seriously, they are everywhere!
  • Reindeer is actually quite tasty.
  • Moose is a bit, well, meh….
  • When it comes to rivalries, Norway is to Sweden what New Zealand is to Australia.
  • The Australian TV shows “Prisoner” and “Flying Doctors” are compulsory viewing for Swedes.
  • And 50+ hours of travel by air is in fact a very long way – but it beats driving.



Hey, are you interested in this stuff?

Well you could choose to read our previous posts about TECC here, here, or here. If you do you’ll find heaps of references and further reading on all things tactical.

CareFlight does have courses on that sort of stuff (it’s one of the bits you can find here) so you might find a bit of interest in that or, [looks shy, kicks dirt] y’know, do whatever. If you were interested (but no pressure) it runs pretty regularly (like in 2018 it’s happening on 12 February, 26 May, 20 August and 24 November).

Meanwhile if you like the stuff on the site you could always share it around. Or even sign up to get the emails whenever things hit.



Podcast #4 – Another Side

Straight back with another podcast and with the same guest, Dr Blair Munford. 

This time Blair has a very different type of story to share.

Please have a listen and consider sharing. Or if you like the site consider signing up to get emails when posts hit.

Anyway, here’s the various ways to get the podcast.

Right click and choose save as to download the podcast. (That’s control-click if you’re on a trusty Mac.)

Of course you could just find the podcast over at iTunes here.

Or the rss feed is here.


There’s a chance that something about Blair’s story might make you want to help someone, somehow. If that’s the case either drop a message in the comments or email at and we’ll follow up.

In this episode all the music is by Broke for Free and available via Creative Commons at the Free Music Archive.

The image is by Justin Luebke and was uncovered at


Podcast #3 – Introducing Blair

Finally, we decided to record someone. Dr Andrew Weatherall with a new contributor, Dr Blair Munford. 

So we always meant to include the occasional podcast. Finally it might happen. This episode features Dr Blair Munford, whose career in prehospital and retrieval medicine started back in the mid-80s when flight suits probably required shoulder pads and big hair. Blair should be dropping by pretty regularly but this is an introduction with a reflection on a bit of history and a few tales of a life in retrieval (all de-identified and with clearance previously provided).

Anyway, it’s a long history (if you want to get some sense of it if you drop by CareFlight’s publications page you can see him way back at the start, around the time he was kicking off with descriptions of the CareFlight stretcher bridge in 1990).

Les Chatfield
Actual line up of potential multi-patient retrieval transport vehicles when Blair started.

Anyway, here’s the various ways to get the podcast.

Right click and choose save as to download the podcast. (That’s control-click if you’re on a trusty Mac.)

Of course you could just find the podcast over at iTunes here.

Or the rss feed is here.


Intro and outro music is here under Creative Commons via the Free Music Archive. The intro is from ‘Only Instrumental’ by Broke for Free. The outro is ‘Lewd’ by Just Plain Ant.

The image was via flickr Creative Commons and posted by Les Chatfield (and is unaltered here).