Why? How? What? Big Questions for Prehospital Simulation

At CareFlight another round of training many people is about to come up so it seemed like a good chance to ask Dr Sam Bendall for her first contribution. 

Sam is an Emergency Physician who is passionate about education, particularly all things simulation. She works half-time at Royal Prince Alfred Hospital in Sydney in the Emergency Department where she helped develop and teaches the RPA Trauma Team Training program, teaches on the CIN nurses programs and helped develop the ED Essentials program. 

At CareFlight she is a retrieval doc (the other half-time) and the Deputy Director of Education. The CareFlight Education Team are always up to interesting things – from training the Australian Defence Force medical on how to look after all things ballistic, medical, surgical and paediatric, to running the Pre-Hospital Trauma Course both in Sydney and other locations (Malaysia, anyone?), to running Trauma Care Workshops all over the country. Oh, and of course all those working with CareFlight too. 

Anyway, here’s Sam …


As a passionate advocate for simulation I look around and see this amazing tool appear in many guises, all under the same blanket term. It certainly seems to mean many things to many people depending on their previous experiences. In some ways it is the SWISS ARMY KNIFE   of kinesthetic education. The coolest knife has pliers and scissors. However, just like a Swiss army knife, it can be a harmful weapon (hence the name!), just plain useless (like when you want the one with pliers but you only have the single blade), or a bit uninspiring and encourage automatic behaviours – e.g. all Swiss army knives are red and you should have one.

This clearly rubbish version doesn't even have the magnifying glass.
This clearly rubbish version doesn’t even have the magnifying glass.

Simulation has almost become the learning apparatus du jour – everyone has to do it but some are not sure why or how to really make it work. A bit like having a Swiss army knife so you can be part of the Swiss army, but it lives in the drawer.

I will put a disclaimer in at this point. The following are my own opinions – the musings of a dedicated simulation-phile after several years of training in simulation and doing simulation exercises for anywhere from 2 – 150 people.

So what’s the point?

WHW copy                                            

I’m going to put a slightly different spin on it, with an emphasis on simulation for the pre-hospital environment. Simon Sinek, in his TED talk in 2009 titled “Start with Why” made a very powerful case for asking yourself WHY you want to do something… in this case, simulation, at the outset. The HOW and the WHAT will follow if you drill down onto the why and firmly establish WHY you want your participants to do simulation.

Simulation is a journey, for both the instructors and participants. Hopefully a journey towards some constructive learning, but one that will have many interesting twists and turns along the way. Being sure of WHY you are undertaking this part of the journey, gives you the freedom to explore the twists and turns of the journey without losing sight of the original intent. So my step 1 in building a simulation, is to ask yourself why? WHY are you doing this?

In our organisation, our WHY? is to create a mission-ready workforce.

Pre-hospital medicine throws out so many variables – communication, teamwork, environmental, situational awareness, medical challenges, geographical challenges and the list goes on.

In order to make our workforce mission ready, we need them to be critical thinkers, able to choose the right skill, equipment and approach for the right case at the right time.

Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?
Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?

We also need them to be aware of the variables they will need to deal with on real jobs so that they can manage them consciously. In order to do this we need to replicate as many of these variables as possible so they can address them in a training environment. We aim to send our participants out on jobs that feel just like the scenarios they have done in training. No pressure!

HOW? – choose your weapon

Weapon copy

The simulation menu is fairly extensive and limited only by your creativity and ability to structure it in a way that is true to the learning objectives and easy to follow for your participants. The key elements of creating a scenario, whether it be for 2 or 50 participants, is that they need to know the rules, boundaries, and premises for the scenario….. hmm sounds like parenthood!

So first decide on your structure. Is it an audience that is learning a concept for the first time and you need to do it for real, but slow it down? Well “pause and discuss” is your man. Do you need to see where your participants’ critical decision making is at and where the deficits lie? Immersive, relatively high fidelity simulation, with key variables built in, is the tool of choice.

Do you need to occupy 30 participants in a large scale simulation? – Create foci so the participants will need to form their own teams within the simulation. This will bring out all of the teamwork, communication and leadership points from the start.

Whatever weapon you choose, it needs to be appropriate to the audience, their experience and what you are trying to teach by doing the simulation exercise.

WHAT …the final frontier

Well this depends on what you are trying to deliver in your simulation. If, for example, your aim is to test and consolidate a new protocol, then the scale of your simulation can be quite limited. You may not need to bring in as many variables, or much fidelity. As long as the key prompts are there for the participants and they have the knowledge, skills and equipment to fulfill the protocol, then a limited scenario is fine.

BUT…. and there is a BIG but in this one. Be realistic in developing your scenario. If you are testing an ALS protocol, doing a bog standard ALS protocol with a patient in a bed may tick your box. BUT ….. in 20 years of medicine I think I have been to less than 10 arrests in ward beds and way more than 30 in other places – the toilet, the CT scanner, theatre, the foyer of the hospital, the waiting room, the beach etc. etc. You get the picture. So I would argue here that a bog standard ALS type scripted scenario has its place, but should be followed up by the application of the protocol where it is likely to happen and bring in the teamwork and communication aspects that we know actually make ALS protocols work in real life.

At CareFlight we educate using a “crawl, walk, run” paradigm.

  • First you crawl – i.e. you learn the skill or concept in isolation.
  • Then you walk – using relatively low fidelity simulation with limited learning outcomes, you learn to apply that skill appropriately.
  • Then you RUN. In our “RUN” scenarios, we introduce many more variables that replicate the environment they will have to operate in. We increase the fidelity and prompt the participants to evaluate the situation, decide whether that skill or concept is appropriate, apply it if it is or find an alternative if it is not. This layering approach helps to consolidate skills and knowledge and develops critical decision-making processes in a way that is directly applicable to the job we do.

When you get to the RUN scenario you are trying to bring out multiple learning points across many categories, for example:

  • Teamwork and communication (CRM)
  • Leadership skills (CRM)
  • Graded assertiveness and conflict resolution (CRM)
  • Scene safety and situational awareness (CRM, environmental and logistics)
  • Management of a multitrauma patient in an isolated environment (medical)
  • Packaging and preparation for transport (logistics, medical)
  • How to carry a patient out of the bush safely (logistics, medical)
  • Planning for contingencies e.g. weather etc. (logistics)

Then the scenario has to be much higher fidelity and be crafted in a way that replicates those key learning objectives – CRM, medical, environmental and logistic. You need to recreate the key environmental elements that will impact on the participants’ decision-making, bring in the key teamwork elements, replicate the equipment or types of equipment they will use and think about the team structures they will be given. Even simple tweaks to the scenario such as limiting access to the patient’s head, can improve the problem solving and CRM elements of the scenario so the devil is very much in the detail here. AND SO IS THE FUN …

Why yes that is a mobile rollover simulator that some clever people built ...
Why yes that is a mobile rollover simulator that some clever people built …

A Short Video About Bleeding Airways

Managing the airway in prehospital and retrieval medicine is a challenge and has inspired many a discussion in many a setting. And anyone working in the area would appreciate the additional challenge when there’s lots of blood getting in the way.  As a result everyone has tips and and tricks to try and manage things.

This is by no means the first time people have come up with an approach (or shared an approach) but in the spirit of wide-ranging discussion, here’s a suggestion from Dr Alan Garner recorded for posterity in video.

It runs for about 10 minutes and you’ll note that at the end there’s an update as the approach evolved.

All thoughts, feedback and experience very welcome.

Keeping Things Calm: Remote Retrieval of the Psychiatric Patient

Jodie Mills, RN works with CareFlight’s Top End Medical Retrieval Service, flying out of Darwin across vast stretches of the Northern Territory. She grew up in the Royal Melbourne Hospital ICU before moving to Darwin 8 years ago where she completed midwifery studies.  She joined CareFlight 4 years ago and slightly pities all those who don’t get to fly in the top end. 


When asked to contribute to a blog and write about psychiatric aeromedical retrieval all I heard was my colleagues’ collective signs of “not another psych job!!”

The thing is, I’ve developed a bit of an interest in these patients after closely looking at the psychiatric retrievals in NT for the last 3 years. This specialised patient group presents a huge challenge to both the flight crew and our remote colleagues when presenting acutely unwell in our communities.

By the Numbers

I recently presented at the ASA/FNA/ASAM Aeromedical Retrieval Conference in Brisbane. I thought maybe we had a few psychiatric patients but I quickly realised after my presentation that the number of psychiatric retrievals we undertake in the top end is well above average i.e. its extremely high (15% of our total missions).

From Feb 2012 to the 20th October 2014 we retrieved 651 psychiatric patients, averaging 22-24 per month  – it’s an almost daily occurrence. Demographically the patient population remains consistent with approx. 90% of patients Indigenous Australians, with male to female ratio if 1.45:1. The mean age is 31, however our youngest was 12, our oldest being 74 years.

We have only intubated 3% of this population which has led to expedited admission to the singular psychiatric facility at Royal Darwin Hospital (RDH). The inpatient psychiatric ward at RDH has a catchment area of 700,000 square kilometres.

It’s Not Just a Local Thing

Mental illness throughout the world is on the increase with the WHO (2014) predicting mental illness to be second only to cardiovascular disease for burden of disease by 2030. The stigma associated with mental health issues remains the greatest obstacle to such patients accessing appropriate care. This stigma may be even more pronounced in remote Indigenous communities. Drug induced psychosis, predominantly cannabis (397 patients), followed by suicidal ideation/ hanging (224) were the most common diagnosis with the remaining patients having bipolar, mania or behavioural disturbances.

At the ASA conference I asked my aeromedical peers “How do you transport your psychiatric patients?” the answer was “we don’t, they go by road”. I quickly realised then that CareFlight and other retrieval services working in truly remote areas provide a unique service.

The small window view of a big country.
The small window view of a big country.

The Perfect Storm

We all know too well the challenges involved in the aeromedical transport of compliant patients who are unwell. However if we add delusions, hallucinations, physical aggression a tendency to physical violence and homicidal thoughts into the mix we have a potential aviation disaster on our hands. These are the just some of the symptoms the majority of our psychiatric patients display when referred to CareFlight. We then face the task of transporting such patients in a small aircraft where we will place seatbelts and wrist and ankle restraints on them, we will sit approximately 50cm away from them and the tell them they cannot smoke, they cannot go to the bathroom, they cannot eat or drink. I can’t imagine how stressful this must be for a patient that is already thought disordered.

What We Do

The biggest challenge for the aeromedical clinician is assessing the need and amount of sedation that will be required for safe retrieval of the acute psychiatric patient. If we have learnt anything it is definitely that “one-size DOES NOT fit all” when it comes to choosing sedative combinations to safely retrieve acute psychiatric patients. However we have found that pre-flight sedation with an atypical antipsychotic (olanzapine) and a sedative (diazepam) is of the utmost importance. As we become better skilled at treating psychiatric patients we have increased the pre-sedation (Olanzapine & Diazepam up to 20mg oral) which seems to be decreasing inflight sedation requirements. This enables the psychiatric patient to be admitted to the appropriate ward in a timely manner.

Top Tips for What to Do:

  1. Start sedation early:

As mentioned above, premedication prior to retrieval is vitally important. In most cases an antipsychotic (Olanzapine 10mg) and a benzodiazepine (Diazepam 10mg) is the premedication of choice. However, acute psychiatric patients presenting with drug induced psychosis (be it first or subsequent presentations) routinely require up to 20mg- 30mg of both Olanzapine and Diazepam orally. The first dose of sedation is given prior to the crew departing Darwin and then half an hour prior to the crews landing at the communities/ regional hospitals. This administration is overseen by the Medical Retrieval consultant (MRC) on duty. If the patient is not responding to the Olanzapine and Diazepam, the likelihood of requiring in-flight sedation is increased as is the probability of intubation for transport.

  1. In-Flight sedation:

We find in flight we tend to use midazolam, propofol and ketamine. The drug of choice is directly related to the flight doctor’s area of expertise. The ED Registrars tend to use midazolam and ketamine, whereas the ICU and Anaesthetic registrars head for the propofol and midazolam.

On arrival at the referral centre the patients are assessed for the need for further sedation prior to flight.

  1. Pre-Flight Sedation: Midazolam 2-5mg IV
  2. In-flight Sedation:
    • Propofol Infusion 0.2-0.5mg/kg/hr and titrate as required
    • Ketamine Infusion 0.5-1mg/kg/hr and titrate as required

A Richmond Agitation Sedation Scale (RASS) of -3 (Moderate) to -4 (Deep) or a Ramsey Sedation score of 5 indicates the level of sedation required for safe transport.

The ability to discontinue the sedative and allow the patient to wake prior to admission at the receiving centre is extremely important. If the flight crew are able to deliver an acute psychiatric patient to the receiving centre awake and ready for assessment this expedites the patients’ admission to the in-patient facility from the emergency department or, optimally allows for direct entry into the inpatient facility at the receiving centre.

Richmond Agitation Sedation Scale:                                                                               

Richmond copy

Ramsey Sedation Scale:

Ramsey copy

  1. Managing the environment:

Managing the stressors of flight is extremely important when retrieving an acute psychiatric patient. Using ear plugs, blankets to keep patients warm, positioning for comfort when heavily sedated, limiting cabin conversation and ensuring physical restraint are fastened appropriately ensures the acute psychiatric patient does not experience any extraneous stressors throughout their flight.

  1. Local law enforcement:

On occasion the local law enforcement will be involved with the acute psychiatric retrieval. The resource poor environment of the community clinic necessitates the presence of police to help control patients as documented under the section 9.

  1. Coordination:

The coordinating Medical Retrieval Consultant will liaise with the Consultant Psychiatrist on call at the hospital, alerting them to the impending admission.   The Consultant Psychiatrist then coordinates  with their in-patient team to ensure timely assessment of the patient if they are to be admitted through the emergency department.


Although the collective groan when another psychiatric retrieval arises resonates through the base we remain steadfast in our support to our rural and remote colleagues and we will continue to play a vital role in maintaining safety of the community, the families and the patients who are all touched by mental illness in the top end of the NT.