Sedating Kids in Strange Spots

This post is based on a talk prepared by Dr Andrew Weatherall for the South African Society of Anesthesiologists Congress for 2017 held in Johannesburg. As invited faculty 

I think when they first offered this the plan was to do sedation in the dental chair. Which I’ve never done. And this is for a refresher course.

So we changed the topic to sedating kids in strange places. Which I have done.

But they’re strange places so by definition they should seem weird to you which means you probably haven’t done it before in which case it’s not a refresher course topic at all. Just like it’s hard to have a refresher course on swimming with sharks in bathtubs, it’s hard to have a refresher course on undertaking sedation in places people don’t do sedation.

So I guess I’ve screwed this up every which way.

Nothing for it but to sedate someone though. So let’s start with a 18 month old who has a hand injury. We’re going to sedate him to get things fixed up rather than waiting for a free operating theatre.

At the start of any sedation we need to ask some questions of ourselves. And I like to start with the Cluedo questions. The ones about “Who?” or “Where?” or “How” that help us make the choices to get this sedation done.


What are we talking about?

It’s pretty vital up front to understand what we’re describing. We need to understand what we mean when we talk about sedation.

Well as good a place as any to start is with the ANZCA documents on this (this is my low rent version of international colour for this one). ANZCA include a couple of key points:

  1. There is an implication that you’ll be using pharmacological support to improve tolerance of uncomfortable or painful procedures.
  2. They try and separate out some levels of sedation.

That latter one can be a little problematic but they do talk about conscious sedation, where the individual will produce a purposeful response with minimal stimulation, and deep sedation where there will only be that purposeful response with painful stimulation.

To be just this side of general anaesthesia however you do need to have some sort of response. Plus you need to consider if what you’re really talking about is analgo-sedation because you’re expecting some pain to be dished about.


The “Who?” is important in planning for a bunch of reasons. Is it you or someone else actually delivering the sedation? What’s their level of experience or expertise? What’s their clinical background? The background of the practitioner is highly likely to influence the choices they make, particularly when it comes to pharmacology.

The “Who?” also covers the patient at question because the needs of an 18 month old are not the same as those of a 12 year old, and aren’t the same as the needs of a 40 year old.

Lastly, the “Who?” question applies to the proceduralist. If you’re giving sedation to get a job done, then the needs of the proceduralist to get things done have to be taken into account.


Well, we’re talking about strange places, right? So that definitely matters for this scenario, but it matters for every sedation scenario. It will influence what you feel comfortable offering, and what help is available. It will also heavily influence where they get looked after when it’s done and might influence how quickly you want them back to their entirely normal state.

Wait, this is the strange places post so I should probably mention something….

Today’s patient is in a bathtub. He’s had his hand stuck down the drain for 2 hours with people trying to get it out. It’s 22:00. It’s about 6 degrees Celsius outside. Your proceduralist is the rescue volunteer with the jackhammer who is going to have to work through concrete to reach the bath and dismantle it. 

Ready then?


Well I think in this case we already know that. For other sedations though it’s worth making an assessment of when it has to be done? Does it really have to be now or can it wait a little if you have concerns with sedation. Will the timing matter for available care afterwards?

What about that fasting question? All if it helps at all there is very limited evidence that fasting intervals influence things like aspiration rate. The Pediatric Sedation Research Consortium looked at 139142 patient records in 2016. They found a total of 10 aspirations and 75 major complications. 8 of the aspirations were in kids fully fasted (though that was from 82546 records whereas the non-fasted made up 25401 cases with details). Both rates were < 1 in 10000.

Another look at 12 years of nitrous oxide procedural sedation in kids not necessarily fasted revealed 1058 cases with 0 major complications (and I think quite astonishingly only 11 cases of nausea and vomiting).

So I probably would still make an effort to fast most times, I’d also be pretty relaxed if clinical need indicated we were in a “right now thanks” scenario.


This isn’t a moment for an existential pause. It’s the key question about our goals of this sedation. Personally I find it useful to think about the ins and outs of it. Roadside Pictures Hamburgers

What are the sensory inputs we’re going to inflict on the patient and what is the level of cerebral output we’re aiming to see?

In radiology you might just need a little stillness. The inputs might be almost nothing, or just a little noise. That’s clearly different to a burns dressing, or a quick pull on a fracture.

Remember our little punter? This kid is stressed after 2 hours of messing about and there are 10 weird people in bright orange in the bathroom with him. They’re using noisy tools. His hand is sore. He is way past his bed time. The extrication is thought to be a 2 hour job.

Our goals are to achieve a comfortable light snooze that might have to deal with variable pain input.


Finally we get to it. And you might figure we’ll dive straight into drugs. Nope. This is a super short chat so I’m more interested in an approach that will work, while assuming that clever people checking this out have an armamentarium of things they are good with.

So I think when we get to the “how?” it’s easiest to remember we need to offer some REST.






Let’s work through them.

1. Rapport

In most sedations establishing a good rapport with the patient is vital. Sedation isn’t like general anaesthesia and there is the potential for recall and moments of discomfort. Establishing trust is therefore a big help, because if there is one of those moments it’s a lot more ideal if the relationship you’ve established means they’ll trust you when you try to provide reassurance. The same goes for if you’ve got a carer around.

So there are plenty of ways to work on that beyond this scope, but slowing down to take this step pays off.


Lorenzoclick clown
Look I wouldn’t try this approach personally, but whatever works for you…

2. Environment

As much as possible setting up an environment to support the sedation is ideal. Simple things like choosing a specific spot where you can, reducing noise in the area (bugger, jackhammer), ensuring easy access to the patient and controlling the numbers of people in the space can make it a much calmer experience all round. If the environment is good, really you should need less pharmacology. The environment is also a key element of …

3. Safety

Sedation is actually pretty safe overall. Biber et al have published stats showing a 4.8% adverse event rate in 12030 patients. For the really concerning ones they only observed airway obstruction in 1% of those sedations and laryngospasm in 0.6%. 1.2% of patients needed some bag-mask ventilation. Unsurprisingly issues were highest in the 0-5 age range.

Obviously we need to be actively focussed on safety though. And I’d start with your eyes, ears and hands. Personally I think delivering good sedation can be much more taxing than giving a general anaesthetic. To keep them consistently at a state of sedation, which can be a lot more dynamic than anaesthesia, requires a continuing close quarters assessment of where they are right now and what the inputs are about to be.

So being able to reach out and touch or gently stimulate the patient matters. Close observation of respiratory patterns matter. This doesn’t suggest we should abandon monitoring. We should have at a minimum pulse oximetry, a means of measuring pulse rate and BP and I’d argue that in hospital or static settings capnography is a must.

Every sedation also requires a plan for how to manage airway complications, support breathing well and manage any circulatory issues, rare as they all might be.

Safety requires a team too. The ANZCA documents suggest that beyond yourself you need at least one person available to assist you at the drop of a hat. Or a clatter of the safety helmet I guess.

Which brings me to the last point, don’t forget PPE. That’s not just for you either. Your patient might need it.

4. Therapy

We finally got there. This really comes down to two big groups:

  • Non-pharmacological, which should absolutely not be considered as a lesser item. If you have some good distraction and redirection techniques they can get you a long way there.
  • Pharmacological.

When it comes to agents this isn’t really the space to argue for one over the other. I would say that if you’re sedating in a new spot or new situation, I wouldn’t try out that cool drug someone told you about for the first time.

Each agent has its pros and cons. Propofol is great for sedation when used right but can sting a little and respiratory depression can be an issue. Ketamine has a lot to recommend it but I have seen nasty dysphoria and that shouldn’t be dismissed. Dexmedetomidine has some strengths but there’s no doubt patients are sleepy for longer afterwards. Nitrous oxide clearly works but you do need a way of delivering it and you might not want it for too long in a tight space. Opioids obviously are superb for analgesia but require caution, particularly if used as an additive to another agent.

Again the key thing is to choose agents whose characteristics feel familiar to you and use them to manage the goals you came up with in the “why?” bit.

Is it just sedation you need. If it’s painful, how painful? Is that pain likely to be consistent or variable in nature? Does the time to wake matter? Would regional options help with those inputs?

Now choose the agent that lets you get things there.

Because a strange spot for sedation is really just a different office to do your work.


Here’s your patient. You can only just see some of the elements here, but the patient is covered up in blankets. They have earmuffs on. They have oxygen going and a cannula in place. After some midazolam, fentanyl and ketamine in we managed to sneak in digital nerve blocks. From that point on we really didn’t much of the ongoing infusion to have the patient snoozing but rousable to touch. The one obvious flaw here? We didn’t control the environment quite well enough to know the family had sent in a news reporter to get a shot. 

And one hour in, with the patient relaxed we figured we might as well try a gentle pull on that hand. And it slid right out. Pity about the bath. 

And all it needed was a bit of REST. Maybe that’s not so strange after all.


It is very cool that you dropped by here. Remember that if you like the stuff we have on the site you can sign in for an email update when a new post goes up. Have a look around, it’s here somewhere.

Of course none of the posts are meant to be the final word. We’d love to learn from anyone if you have the time to leave a comment. No pressure though.

Yep I’ve had previous clearance to use this case in public.

The image of the job is as it appeared in the local paper, The Illawarra Mercury.

The other images are both from flickr in the Creative Commons area and are unchanged. The clown was posted by lorenzoclick and the sign came from Roadside Pictures.

Now, reading things:

Here are those ANZCA Guidelines.

Here are those fasting type things:

Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room. Anesthesiol. 2016;124:80-8.

Pasarón R et al. Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients. Pediatr Surg Int. 2015;31:173-80. 

Here’s that adverse events one I looked at (though in GI endoscopy work):

Biber JL, et al. Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia – Outside the Operating Room  for Esophagogastroduodenoscopy and Colonoscopy in Children. Pediatr Crit Care Med. 2015;16:e251-e259.

Now here’s some more general reading of things that might have some interest:

Mahmoud MA, Mason KP. A forecast of relevant pediatric sedation trends. Curr Opin Anesthesiol. 2016;29(suppl 1):S56-S67.

Alletag MJ, et al. Ketamine, propofol, and ketofol use for pediatric sedation. Pediatr Emerg Care 2012;28:1391-5.

Phelps JR, et al. High-dose dexmedetomidine for noninvasive pediatric procedural sedation and discharge readiness. Pediatr Anesth. 2015;25:877-882.

And here’s a couple of things I’ve had a chance to contribute to:

Marland S, et al. Ketamine: Use in Anesthesia. CNS Neurosci and Therapeutics. 2013;19:381-9.

Weatherall AD, Venclovas R. Experience with a propofol-ketamine mixture for sedation during paediatric orthopaedic surgery. Pediatr Anesth. 2010;20:1009-16. 

Now have you scrolled all the way down here? Then I have a bit of a treat. In the presentation version I had a multi-exposure shot of Danny McCaskill in action in his film Cascadia. You could watch it by clicking here and reflect on safety. Or maybe just watch it because it’s amazing.


Kids Prehospital Care Here and There

This is the written version of a talk by Dr Andrew Weatherall for the South African Society of Anesthesiologists Congress 2017, just held in Johannesburg. It’s probably just about the shiny things. 

You probably figure that a talk on prehospital paediatric medicine in Sydney should be about shiny pictures of that thing we call the coat hanger. Or maybe actions shots of this character …

Morning BIF.

And of course there are a lot of cool things we can do in prehospital paediatric care. Maybe the best thing to do is to start with a story. It’s a story of a kid we’ll call B.

Lazy Mornings

One of the odd features of Sydney is that on its edges there are some areas that are essentially rural. They’d take an hour or so to drive to from the CBD, but are probably only 10-15 minutes flight from the base.

One day, a Monday I think, on one of the properties out that way there’s a Dad watching cartoons with a couple of his kids. They want to keep hanging out and he has a bit of work to do moving some earth so he heads out, kids parked firmly on the couch and closes the door behind him.

In the truck he starts to manoeuvre to turn it around. Back. Forward. Back with a glance at a side mirror and he sees legs. They look like the legs of his 4-year-old and they are sticking out from under the wheels.

I imagine the seconds it took to reach her felt like a long time. I imagine the wait for help to arrive felt a lot longer.

Things That Aren’t Common

The weird thing about being an Aussie talking about trauma in South Africa is that I am not talking about something that is common to us. Most of the audience would laugh at our numbers. The NSW Institute of Trauma and Injury Management published some stats from the 2015 annual review and across the whole of NSW there were 3970 major trauma patients. The busiest adult trauma centre would see a bit north of 600. Across the state the kids’ hospitals would see less than 200 severely injured kids between the three of them.

So I should pack up and stop talking I guess?

Well I guess the thing we could reflect on is that if you can’t rely on exposure to numbers to get everybody better and produce better outcomes there are other things you can focus on. You can start with the system to make the response bring the hospital to the patient quicker. It’s over an hours drive back once anyone gets there.

That day the NGO I spend time with was called about B and was airborne in minutes to get to her. This ability to get in the air quickly came from a trial to look at ways of getting care to patients quicker where every second that could be cut down was thrown in the bin.

The perpetual question we are asking is “what can we bring to the accident scene that will make things better?”


Change the Scene

Let’s imagine a different version for a minute. Let’s imagine in the perpetual construction site that seems to be outside most hospitals, this happened out the front door of where you work. What would you offer this kid?

My expectation is you’d rapidly assess for exsanguinating haemorrhage. You’d work as quickly as possible to ensure A, B and C are adequately sorted and you’d get analgesia on board. You’d image, transfuse if you need to, consider tranexamic acid and splint any fractures.

If oxygenation and ventilation means anaesthesia, intubation and ventilation (maybe even chest decompression) you’ll do that. You’ll assess and reassess as things evolve, operate where it’s really needed and keep making new plans to cope with a dynamic situation.

So here’s a question to consider – which one of these should we forget about while the patient travels by road for an hour to reach the front door of the hospital? If you’re the anaesthetist up in theatres who will meet them later, which ones do you not want to have been looked at early?

We can take almost anything we want to the scene. Helicopters carry stuff. So we take with us all the equipment for advanced airway management, a small ventilator and oxygen in our backpack. We can decompress chests. We can splint. We can ultrasound, tourniquet, pack wounds with haemostatic agents, give tranexamic acid and transfuse. We have to get there of course.

And on this day the team did. They were confronted with a child looking more than a bit pale and cool peripherally. Her HR was 140 and above with a brachial pulse palpable. Her GCS was 9/15. Her injuries were apparently below the umbilicus but looked like they included a fractured pelvis and right femur. She had been eviscerated and had a large skin flap extending from the front of the abdomen all the way around her back. She was still under the truck.

Over the next 50 minutes or so, the team obtained intraosseous then intravenous access. They performed a controlled rapid sequence intubation. They splinted fractures and covered up defects. They delivered warmed red cells. They got her to the hospital. She was fairly stable through the emergency department and then the operating theatres. She made it to PICU.

She made it home.

Cool story, huh? But also really irrelevant if you’re talking at a conference in a different health setting, right?

Another Change of Scene

What if this happened in Cape Town? Which team would turn up then. The dispatchers are likely not to have medical background. An activation of advanced teams will happen some time after the sent team gets there. The team that first arrives will have paramedics with variable levels of training. They might not be able to give a range of stronger analgesic agents. They will have more limited options for airway management. They are likely not to feel as comfortable with cannulation in kids as in adults.

The kid gets what they get.

The thing is, I could be describing the same back in Sydney. I gave you a story from the system on a good day. We know a system like that is there but we don’t really offer it. Most days our kids will get teams that finds kids really challenging (because they are of course).

Getting the Team There

How do I know this? Well we looked.

A while back CareFlight was running a randomised trial to try and activate advanced teams to patients on the basis of the initial information that gets called in using a strict protocol. The trial applied to adults but we were asked to offer it to kids as well.

The crew (doctor/paramedic/pilot/aircrew) next to the helicopter had access to the screens and took it in turns to match the high acuity calls to tasking criteria and even to call back for more info if required. A decision to get in the air, cross-checked with central coordination for kids) had to be made within about 5 minutes of the start of the call.

For a while the systems (crew watching and central coordination watching) operated alongside each other. So we had a look at how that worked out. Over a period of time where the Sydney area had 44 severely injured kids, on that initial info the advanced care crew picked up 20 of them. The central guys looking noticed 3.

The numbers are obviously small (not much trauma, remember) but when the crew were watching and going to jobs it also made differences to the system. As they always brought kids back to the kids’ trauma centre, the time to get there averaged 92 minutes. When they were not available (on another job or offline) that time became 296 minutes. That’s for a few reasons but in no small part to some of those patients getting taken to other hospitals and waiting for transfer.

So there’s one thing you can do for your more trained up teams without much infrastructure required to get the right team there.

And I hope someone picks it up because in Sydney they abandoned it. At the end of the trial the screens went.

Another Look

So we had another look to see if the system had picked up the slack. We looked at the time when the advanced crew had the screens and the time after that. These were longer time periods (34 months in the first epoch and 54 months after which equated to 71 severely injured kids before and 126 after).

In the first 34 months the collaborative system picked up 62% of those severely injured kids and the average time to hospital was 69 minutes. In that latter period, with centralised looking alone, 31% of kids were triaged to advanced care, the version of care the system says it wants. The time to reach the kids’ hospital averaged 97 minutes.

You can imagine that this is something I find … disappointing.

But you might also be thinking “If you are suggesting I try and change a whole system then you are an extremely crazy person affected by anaesthetic gases that have rotted your brain because that will involve meetings, and talking to people who do politics and some of those people will expect me to wear ties and that is not why I got into anaesthesia”.

And that is fair.

But a much as I’d love us to do things about systems there’s something we could all focus on right now to try and make a difference.

If the system is mostly going to send the “not pointy end” part of the system, then we should also look at the care most of the kids will receive.

The Big Story

Every talk on prehospital stuff by a doctor can end up being mostly about the really sharp edge. But in NSW less than 1 in 5 kids ever see the advanced care team. So the biggest bang for our buck is in making sure all the kids get access to prehospital clinicians who feel confident working with kids and give them what they need on indication, not influenced by age alone.

When we focus on the pointy end the chances for gains are pretty marginal. Let’s look at intubation for example. Advanced EMS practitioners in Switzerland have published on their efforts and the highly trained and experienced professionals mostly get the tube in without incident but almost 1 in 5 kids had the wrong-sized tube and the majority were placed too far down the airway. Bringing up the whole of the prehospital provider group to a level above Swiss advanced EMS is probably a pretty big effort.

Particularly when you look at stats like those from Prekker et al looking at a big EMS system in Washington where intubation was an option. A paeds response happens for them in 1 in 2198 callouts (there were 299 in total in 6 years spread across all the practitioners). Their first pass success was 66% (though they did eventually get there in 97%) and 10% of the patients needing intubation needed 3 or more attempts.

And I can’t tell you what the oxygenation was like through that and really oxygenation is the name of the game.

The simple truth is kids get a raw deal at the pointy end. Everyone finds them tougher. Bankole et al compared kids receiving high level EMS care around New Jersey with a severe traumatic brain injury and compared them to the adults being looked after by the same really well trained first responders.

20% of kids with a GCS under 8 had no attempt at airway intervention. Of those intubated 69.2% had complications and 29% (vs 2.27% in adults) had a failed intubation. Even cannulas were placed in only 65.7% vs 85.9%.

It starts making you think that if those of us in prehospital medicine looked harder at the thing we want to achieve, oxygenation, rather than interventions that sometimes can do that but have big potential complications we might be able to change things for a bigger population of kids.


Although there are problems drawing on battleground experience in civilian trauma care, particularly in kids, there is a quite interesting paper from Sokol et al. looking at the Camp Bastion experience with 766 kids with traumatic injuries. 20% of them needing some sort of intervention and circulation measures (particularly stopping bleeding) was the most effective. Simple airway manoeuvres were done not often enough and interventions for breathing (like chest decompression) were a lesser order issue than circulation issues.

So perhaps what we should focus are things we could train more people in and more prehospital providers of all experiences could deliver:

  • Recognising the sick kid.
  • Stopping haemorrhage effectively.
  • Assessing A and B and delivering effective bag-mask ventilation.
  • Cannulation and appropriate fluid use.

Recently we’ve done some focus group work at The Children’s Hospital at Westmead with clinicians who do paediatric airway management and one of the strong themes emerging as we write up is that all of them rate airway assessment and bag-mask ventilation as the most vital skill they want to be good at and they’d like to pass on.

There are all sorts of interesting hints here. Hansen et al conducted an exploratory study in 2016 to look at how well paramedics recognised and treated in croup. After whittling through records their small study looked at 14 patients with a primary upper airway issue. 8 of the patients had “stridor” or “croup” explicitly noted in the tasking or information noted by the responding paramedics. 6 had trigger words like “barky cough” or something pretty convincing. All of them received salbutamol, not the nebulised adrenaline or other treatments on offer.

But Some Things are Easy, Right?

Analgesia though, that might be an easier target because relieving pain in kid sis a no brainer.

Well, no.

Samuel et al. published a systematic review of evidence looking at analgesia provided by prehospital providers for kids in 2015. In it they describe a review of 55642 patients where 26% of the kids had trauma and another 16.1% of kids had a primary complaint with significant pain.

0.3% of the kids were given any analgesia.

There were other studies included reporting rates of analgesia administration for fractures of 2.1-3.2% (and at  least one with 0% in the under 5s with fractures).

What is going on?

Well sometimes there might be limitations in what the paramedics have available (e.g. opioids or not, ketamine etc). One physician system showed 92% getting given strong analgesia in these sorts of patient groups.

There may be a fear of drug errors because there is work suggesting issues with drug dosing in kids in more than 30% of prehospital cases.

However Rahman et al have also done work exploring the perceptions of paramedics in providing analgesia to kids and showed very high levels of reported discomfort with providing and assessing analgesia in kids. More alarmingly 25% of respondents indicated that kids needed less analgesia because of immature nervous systems.

These are not small chips either. Schreier et al looked at PTSD symptoms after just mild to moderate trauma (things like isolated fractures) in kids. At 18 months (in an admittedly small study) 38% of the kids they looked at had at least mild symptoms.

PTSD in kids expresses itself as poor attendance at school, missed marks in education and social disengagement.

While < 4% of kids are getting analgesia for obviously painful things, there are things we can tackle that don’t need a rapid sequence intubation and a snorkel.

What is the cost?

So the cost to patients will undoubtedly be big if we are sending teams who don’t feel comfortable in kids, but is the cost of addressing it prohibitive.

I reckon not. Here’s one example.

CareFlight, that little charity I mentioned, has started to treat education of first responders as a way of providing service to the community. By taking simulation education and courses mobile to rural and remote first responders maybe we can make the first person who turns up to the injured just that little more comfortable that there are things they can do.

Uluru 3.JPG
The MediSim crew in action next to a big red rock.

Since 2011 they’ve reached almost every state in Australia and trained more than 3000 people. Participants don’t pay.

In the Western Cape there is an EFAR program that would be worth checking out that is seeking to enhance the response of first-aid responders.

But if you’re an anaesthetist or other critical care provider, then there would have to be ways for you to link up with local prehospital services and offer to help paramedics gain skills and experience.

Everyone in the room (or reading this) can probably provide analgesia. Everyone has seen a sick kid. Everyone knows how to splint and work on stopping bleeding. In particular I am full of a room of people who have exquisite skills in things we think of as basic, like bag-mask ventilation, but could be the difference between a patient being oxygenated on the drive in, or obstructed the whole way.

The Wish List

If you’re the anaesthetist waiting in that operating theatre when an injured kid is on the way, what’s on your wish list?

Mine would include the patient being identified and getting to me as quickly as possible. I’d hope the team that reaches the patient can recognise if they’re sick and keep reassessing well. I’d hope they felt confident managing the airway and could optimise oxygenation as much as their skills allowed. I’d love it if they turned up with some form of intravascular access and some analgesia on board.

The priorities to start making that happen for more patients is actually not about BIF with the noisy rotors. The priorities are the same if you’re looking at an old bridge across a harbour. Or some mountain near the sea.

Damien du Toit Table Mountain

Or a downtown area closer to the sky.

Paul Saad Jo'burg.jpg


I cannot express the depth of my gratitude to the patient and family who have granted permission for the use of their story as part of education in this area.

Thanks also to the clinicians involved in the case, Dr Rob Bartolacci and Ben Southers, super paramedic, for background on their case and the shot from the sky that day.

A huge thanks also to the brilliant Jo Park-Ross, Flight Paramedic from AMS in Cape Town and Ross Hoffmeyr, an anaesthetist also working in this area down in Cape Town for helping me understand more about the local system and checking my work.

A shout out too to Colin Brown and Greg Brown (no relation) at CareFlight for the stuff about the MediSim program.

As part of the invited faculty the organising committee covered travel, accommodation and registration for the conference.

The images of BIF and Sydney are from my personal collection. Other images are from the Creative Commons area of flickr and are unmodified here. Paul Saad posted the shot of Johannesburg and the shot of Cape Town is by  Damien du Toit.

Right, now the things to read…

Here are the trauma stats in NSW for 2015:

NSW ITIM Trauma Stats 2015

Here is the Head Injury Retrieval Trial:

Garner AA, et al. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe traumatic brain injury compared with management by paramedics. Emerg Med. J. 2015;32:869-75.

Here are the tasking studies:

Garner AA, et al. Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew-case identification rates and effect on the Sydney paediatric trauma system. Scand J Trauma Resusc Emerg Med. 2012;18:20:82.

Garner AA, et al. Physician staffed helicopter emergency medical service case identification – a before and after study in children. Scand J Trauma Resusc Emerg Med. 2016;24:92.

The Swiss study:

Schmidt AR, et al. Ease and difficulty of prehospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis. Scand J Trauma Resusc Emerg Med. 2016;24:22.

The thing by Prekker et al.:

Prekker ME, et al. Pediatric intubation by paramedics in a large Emergency Medical Services System: Process, Challenges and Outcomes. Ann Emerg Med. 2016;67:20-29.e4

And the first responder TBI comparison:

Bankole S, et al. First responder performance in pediatric trauma: A comparison with an adult cohort. Pediatr Crit Care Med. 2011;12:e166-e170.

Here’s the battlefield stuff:

Sokol KK, et al. Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs. J Trauma Acute Care Surg. 2015;79:983-9.

The thing on assessment and treatment of upper airway obstruction by paramedics, which is exploratory but interesting is here:

Hansen M, et al. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Children’s Safety Initiative – Emergency Medical Services. Amer J Emerg Med. 2016;34:599-601.

Now here’s that analgesia review that is a sobering read:

Samuel N, et al. Prehospital pain management of injured children: a systematic review of current evidence. Amer J Emerg Med. 2015;33:451-54.

Here’s the thing about comfort level of paramedics in providing analgesia to kids:

Rahman A, et al. Emergency medical services provider comfort with prehospital analgesia administration to children. Prehosp Disaster Med. 2015;30:66-71.

Plus that little PTSD study:

Schreier H, et al. Posttraumatic Stress Symptoms in Children after Mild to Moderate Pediatric Trauma: A Longitudinal Examination of Symptom Prevalence, Correlates, and Parent-Child Symptom Reporting. J Trauma. 2005;58:353-63.

If you wanted to get a little more info on that mobile simulation training CareFlight do here’s a link.

MacGyver Medicine

So you’re out there somewhere and you really want to do a thing you think might help but you don’t have your standard kit. Can you adopt the lessons of Richard Dean Anderson and improvise? Mel Brown has you covered. 

Okay, so I am guessing from the title of this post you have a good idea of my age….I am talking about the original MacGyver, not the new one. And for those of you that are too young to know who I am talking about…..MacGyver could improvise everything he ever needed from anything that was “just” lying around. I once saw him create an explosive device with little more than a pepper shaker and some foil wrapping off some chewing gum.

It is wonderful that we live in a world where most of the time we have access to all we need (and more), including our medical equipment. But what happens when you don’t have what you need (or don’t have enough of what you need) to treat your patient?

So in line with our series on “I wish I knew then what I know now” we are going to look at MacGyvering (improvising) arterial tourniquets and pelvic binders – two devices that we are all very familiar with (or if you’re not you can be if you go …

These easily reproducible techniques are certainly something I wish I knew about when I first started nursing…..and no, it wasn’t when Florence was around (although I am pretty sure she trained one of my lecturers).

Continuing with the History Theme

Did you know that arterial tourniquets have been around for a while now? In fact, the first combat commander to advocate the use of tourniquets was Alexander the Great – he based his decisions on the works of the medical researches at Cos.

However it wasn’t until 1718 that Louis Petit, a French Surgeon, developed a “screw device” that could be placed over blood vessels to stop flow. From the French verb “tourner” (to turn), he named the device “tourniquet.”

Elegant, non?

Improvised Arterial Tourniquets

One of the most important things to remember with any arterial tourniquet is that indirect pressure MUST be applied whilst the tourniquet is being applied. This will at least minimise if not stop the bleeding whilst the tourniquet is being applied…

Improvised tourniquets need to be at least 5cm wide to ensure adequate arterial occlusion can be achieved. Have you ever wondered why a shark attack victim that has had an improvised tourniquet applied to their bitten leg (usually via a surfboard leg rope) soon begins bleeding again after the bleeding was originally stopped? Well the theory goes that the initial narrow occlusion of the artery was enough to completely occlude the artery but as the pressure proximal to the point of occlusion builds up behind the narrow improvised tourniquet the arterial pressure is able to beat the tourniquet and the patient begins bleeding again. You need something applied over a wide area to get the job done.

So, what should we use? Firstly you need to find a windlass device that is thick enough and tough enough to withstand the pressure applied to it as you twist it to tighten the tourniquet (which can be up to 300mmHg of pressure). Some things (and only some, there would be more) that are readily available include:

  • A thick solid stick (not always ideal)
  • An indicator lever (probably not out of your own car)
  • A screwdriver
  • A tyre lever
  • A set of pliers

As for the tourniquet itself, what should be used? Some materials used with good effect include (but again are not limited to):

  • Triangular bandages (make sure these are the cotton ones and not the cheap paper ones)
  • Seatbelts (once again probably not out of your own car)
  • Canvas belts
  • Shirt sleeve (preferably with non-stretchy material)
  • Neck ties (not sure how many of these are around these days).

One of the issues with improvised tourniquets is the narrowing of the tourniquet at the windlass point. This can pinch the patient’s skin and make an already painful intervention more painful. The narrowing of the tourniquet material can also lead to greater damage to the underlying skin, muscles and nerves. Having said that I am not sure the alternative of death due to blood loss is ideal either.

I think many of us have spoken about how we could improvise an arterial tourniquet….but how do we actually do it? Let’s use the triangular bandage as our improvised tourniquet to discuss this in detail.

  • Ideally you want two triangular bandages – lay the first one along the arm or leg.

TQ 1

  • Wrap the second triangular bandage over the first and around the arm or leg and tie a knot or two.


  • Place the improvised windlass rod on top of the knot and tie two more knots to secure that windlass (note: if you can’t tie knots, tie lots).

TQ 3

  • Turn the windlass until the bleeding stops and then turn once more. Secure the windlass in place with the first triangular bandage.

TQ nongaffer

If you forgot the first triangular bandage you can use gaffer tape (or equivalent) to secure the windlass in place.

TQ Gaffer

It is important to still write “T” and the time of application somewhere obvious (maybe on the patient’s forehead would catch the eye) as you would for any arterial tourniquet. Obviously improvising is not ideal when compared to commercially available products. However, they are life saving for your patient when you don’t have the equipment that you need available.

Improvised Pelvic Binding

Improvised pelvic binding has been widely used throughout Australia by our Ambulance services for a very long time – I think most people would be familiar with pelvic sheeting. There’s some nuance around when pelvic binding may or may not be useful (just check out the posts here, here, here and here) but what do you do if you’ve made an assessment it is worth trying and you’re without your fancy gear?

Well we all go driving or hiking with sheets in our car boot (that’d be a trunk for our North American friends) or backpacks, right? I don’t think so, and I know I certainly don’t. So what do we commonly have on us that we could use? A jacket works well as an improvised pelvic binder. Let’s have a look at what this looks like:

  • Prepare the jacket for use. Use the arms as a width guide and fold it up like so.

Pelvic 1.jpeg

  • Place the jacket under the smalls of the knees where there is a natural hollow.

Pelvic 2

  • Preferably with two operators seesaw the jacket up to the correct position over the greater trochanters.

Pelvic 3

  • Bring the arms of the jacket together and tie a knot.

Pelvic 4

  • Twist those sleeves until the required pressure is achieved.

Pelvic 5

  • Secure that knot (gaffer tape works again, or zip ties or equivalent).

Pelvic 6

  • You’re done. And maybe cold, but done.

Once again it is obvious that improvising is not ideal when compared to commercially available pelvic binders. However they are life saving for your patient when you don’t have the equipment that you need available. All interventions, whether improvised or not, must be continually checked for effectiveness – especially if your patient is moved.


It is important that as clinicians we understand how to use the commercially made equipment we have available to us. However, it is just as important that we know how to improvise life saving interventions as there will be a time when we won’t have our equipment (or enough of it) to treat our patients. This is a predicament that I certainly don’t want to find myself in. So let’s share what we know as shared knowledge is power. Or share what MacGyver knows because that is also power.


A bit more reading:

Those posts on arterial tourniquets and bleeding are here.

Pelvic fractures? Look here, here, here and here.

Feel like doing the sort of reading that means your improvisation is actually not just making stuff up in your head quickly?

Try these:

Kragh JF, Wallum BS, Aden JK, et al. Which improvised tourniquet windlasses work well and which ones won’t? Wilderness and Environmental Medicine, 2015. 

Nunn T, Cosker TDA, Bose D et al. Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries. Injury International Journal of the Care of the Injured. 2007;38:125-8.

Ofori-BoaduL, Osei-Ampofo M, Forson PK, et al. Practical Pearl. African Journal of Emergency Medicine. 2013;3:88-9.

Stewart SK, Duchesne JC, Khan MA. Improvised tourniquets: obsolete or obligatory? J Trauma Acute Care Surg. 2014;78:178-83.

Shackleford SA, Butler FA, Kragh JF, et al. Optimising the use of limb tourniquets in tactical combat casualty care: TCCC Guidelines Change 14-02. Journal of Special Operations Medicine. 2015;15:17-31.