Rural Critical Care Pearls

The work of a rural doctor includes not just primary care but also emergency medicine, palliative care, obstetrics, anaesthetics and some surgery. Often with no option to refer to specialist colleagues immediately to hand, rural doctors have to train to be a true ‘swiss army knife’ rather than a finely-honed scalpel. Casey Parker covered this nicely last year at smacc2013 in his ‘Macgyver Dilemma’ talk.

Readers of this blog, or anyone who was unfortunate enough to hear my profanity-laden talks at smaccGOLD, will know that I am a fan of the maxim “critical illness does not respect geography’.

My mission is to improve the quality of critical care in the bush – inspired mostly by colleagues like Minh le Cong in Queensland and Casey Parker in Broome. Dealing with critical care, whether polytrauma, sepsis or cardiac catastrophe can be stressful for the occasional operator – nevertheless, it is a core skill expected of rural clinicians and one which I am determined to make better. With no disrespect to my intensivist colleagues and their machines that go ‘ping’, it seems that most critical care comes down to doing the simple things well. The results from the ProCess trial reinforces this concept, as do easy to remember acronyms such as FAST HUGS.

The initial management of critical illness should not be feared by rural clinicians

Courses such as ATLS-EMST, APLS, RESP (REST) and ELS set a minimum standard, usually for credentialling purposes. But they do little to advance skills in managing critical patients. Thankfully FOAMed helps – the sharing of tacit knowledge amongst clinicians, as well as shortening the knowledge-translation gap.

For me, the past 2-3 years have been evolutionary & revolutionary – learning and applying techniques such as apnoeic diffusion oxygenation, tweaking ventilation strategies, exploring dogma around C collars, log rolls, sepsis and so on have reinvigorated my thirst for knowledge. I’ve also delved into areas such as human factors and the science of checklists, which I would never have expected. Difficult airway management and kit for the bush has become my passion.

So here are some (hopefully humorous) collection of tacit knowledge for the occasional operator – the rural clinician who deals with critical care infrequently but needs to sort out his or her patient and package them for retrieval. You can find more solid stuff over at or take the plunge and dive into the FOAMed community – blogs such as or via Twitter. There is also an excellent podcast on patient preparation over at from last year


The ABCs – Always Be Cool

Have a system to give structure to your resuscitation of the critically ill. The ABC approach works for most and is fairly uniform across the LS courses. You can extend the ABC paradigm all the way down to N as part of a transfer checklist

The cool kids are using C-ABC now (control of massive haemorrhage ie : circulation before airway) …or you may decide to get radical and use the ATACC mnemonic for trauma, MARCH

  • Massive haemorrhage
  • Airway
  • Respiration
  • Circulation
  • Head trauma & other serious injury

Systems and checklists are useful – particularly in a crisis. They are a ‘check done’ for experts, not a ‘how to’ for novices. Don’t get me started on checklists – if Minh hears. there might be another twitter war…

So – Airway, Breathing, Circulation. Or Arrive, Blame, Criticise. Or Always Be Cool. Your choice. One of my more cynical colleagues used to say “if you are stuck with a critical patient and have no idea what to do, wait ’til he/she arrests – then you’ll have an algorithm to follow”. This nihilistic approach kind of distills all of clinical medicine into one algorithm, but is NOT recommended!

Its easy to poke fun at ATLS-EMST. It provides a system for entry-level trauma management, but is slow to respond to change and doesn't cover trauma team management. I'd recommend ATLS-EMST initially, then graduate to ETMcourse or ATACC

Its easy to poke fun at ATLS-EMST. It provides a system for entry-level trauma management, but is slow to respond to change and doesn’t cover trauma team management. I’d recommend ATLS-EMST initially, then graduate to the ETMcourse or ATACC. Follow sites such as,,, for more discussions

Be aware of new developments and controversies – the concept of dogmalysis. Are cervical collars needed for all trauma victims? What about log rolls and the ATLS-mandated rectal exam? Click the links to read more from the excellent


You Are Never Alone

Australia is blessed with excellent Statewide retrieval services. Pick up the phone and speak to a colleague if you have concerns. Even if your patient doesn’t need retrieval, speak to a friendly ED consultant in ay of the major teaching hospitals.

Use adjuncts like a handsfree telephone so you can talk whilst still doing things (placing lines, drawing up drugs); better still, use a video link so that colleagues can assist you by seeing the patient as well as yourself.

I had a play around with GoogleGlass during smaccGOLD and there are plans afoot to run collaborative resus using this novel technology.

GoogleGlass - could revolutionise remote area resus

GoogleGlass – could revolutionise remote area resus…depending on the muppet wearing ‘em!

Of course, if you do ask for and receive expert advice, for heaven’s sake follow it! There’s nothing worse than a therapeutic vacuum…


Avoid Clinical Inertia or a Therapeutic Vacuum

I could wax lyrical about ‘anticipated clinical course’ for hours. But put simply, make sure that everything you do ‘value adds’ to patient care.

Similarly do not delay performing essential steps – nothing summons the ‘red mist’ more than a clinician who defers performing a simple procedure (like placing an arterial line or IDC) on the logic that ‘the retrieval team will do it for me’ (unless of course you are not competent to do the procedure – in which case, wait for someone who can!)

  • If you even think of intubating, you probably should set up for an RSI
  • No one ever regrets putting in a large IV; plenty regret putting in a small one
  • You’ll never regret putting in an extra cannula
  • Or an arterial line


Beware the Tangle Fairy

The monitoring cables & lines always seem to be totally tangled by the time the patient gets to ICU no matter how careful you are in ED. As well as ensuring two functioning (wide-bore) IVs, use minimum volume extension sets to run infusions and for small titrated doses. Plumb these to the head end, for easy access during transfer.


Secure All Tubes & Lines

This is obvious – I knot my ETT tubes (but make sure shears are to hand for removal); I am obsessive about securing IVs (I occasionally use a dab of use histacryl glue – and routinely use a mesentery on lines in at least two places to avoid accidental dislodgment)


Remember Mad-Eye Moody – practice Constant Vigilance!

Just when you think everything is under control & relax a bit, the Gods of EM will kick you in the teeth. Very hard. Usually on the ‘easy’ patient not the one you are worried about.

Act like the Mad-Eye Moody character (from Harry Potter) and practice ‘constant vigilance’ against the dark forces

I rarely get to meet the medical retrieval consultants (they are just a voice on the line) - but I reckon there's a couple who might look like this

I rarely get to meet the medical retrieval consultants (they are just a voice on the line) – but I reckon there’s a couple who might look like this


Trust Noone, Assume Nothing

Speaking of dark forces, whether handing over to retrieval or taking over care from a colleague, make sure that you have the history and examination findings firmly embedded in you mind. Don’t be afraid to ring ahead even when retrieval takes your patient away, and speak to the clinician at the receiving hospital


The patient is the one with the disease

That is of course a direct quote from the ‘House of God’. For the critically unwell patient, I think of it as :

“I can make a good pig out of a bad pig, but I can’t make a pig out of sausages”

Generally if the patient is awake, warm, pink and dry, they`re alright. Or you can use Clifford Reid’s 4W’s of sepsis

  • warm
  • wakeful
  • weeing
  • wactate


Look after Yourself & your Team

The enemy of success is HALT – being Hungry, Angry, Late or Tired. If you are going to be in a prolonged resus or retrieval, make sure you have an empty bladder and a full stomach. Don’t turn down the offer of a coffee.

Similarly if you are a rural doctor on for the interminable Fri-Sat-Sun shift and have had a big resus eeping you up all night, delay the morning ward round by a few hours and ensure the triage RN doesn’t call you for trivia – catch a few zzzzzz’s.


Learn from your Mistakes…or use FOAMed

Experience allows you to make good decisions. But experience is often gained by making bad decisions…be proactive and use FOAMed to tap into the collective wisdom of clinicians worldwide.

“Experience is what you get just after you needed it”

I believe that tapping into FOAMed helps make me a better clinician – simple things, like action cards in the ED, use of a crisis checklists, team training and use of sim, apnoeic diffusion oxygenation, difficult airway planning & kit, minimal volume resus, tranexamic acid and so on – these are all things that I’ve picked up through FOAMed, not annual refreshers or mandatory credentialling.

Similarly learn directly from the experts – make sure you are there to handover the patient to retrieval (yes, yes..I know – if a patient is sick enough to be retrieved then you’d think that a doctor would remain with them, but occasionally once stabilised the attending rural doctor will be called away to other patients).

I think it’s important for rural doctors to be involved in audit of difficult cases. Our local Health Service mandatory annual audit mostly consists of making sure appropriate paperwork has been completed for expected deaths in the nursing home – not audit of critical care & retrieval cases! Changing that culture is but one way to strive to improve, not just individual clinician care but a whole systems approach (right equipment, training etc). Again FOAMed delivers tangible benefits much quicker.

Any more pearls from the collective?

FOAMed & Homeopathy

FOAMed is powerful medicine. I recently tweeted on ‘what I love about FOAMed’ :

#1 : information is a commodity…yet everything is free. Share the love…

#2 : sense of community, common passion for improved patient care & advancing via education

#3 : adding finesse, refining practice based on shared tacit knowledge..

#4 : it’s asynchronous. I can keep updated in own time, podcasts/vodcasts/blogposts rather than in real time

This is all well and good – free open access medical education helps experienced clinicians share information..and is invaluable for me as a rural doctor. But how about our patients?

The more enlightened I am as a clinician, the better I can deliver effective remedies. Which makes the recent report from the NHMRC on Homeopathy even more interesting.

Put simply, there is no evidence for the homeopathy as an effective remedy, compared to placebo. This is explained more at the ‘how does homeopathy work?’ website or the ten:23 site

I believe that as clinicians we need to educate our patients about this. Similarly we need to encourage health insurers to stop funding these remedies from our premiums.

Point your patients to the report HERE

We have medicine and alternative medicine.

What works, we call medicine. The rest – alternative.

When alternative medicine works, we call it…medicine

It’s time to stop subsidising these unproven “therapies”.  Tim Minchin summaries this in his infamous ‘Storm’ beat poem & animated video :

If you want to have a bit of fun, write to your health insurer and ask them to stop subsidising homeopathy with your premiums. Ditto stroll into the local pharmacist and ask them why they are selling placebo.

Let’s not kid ourselves, homeopathy and indeed other “alternative medicine” is big business. Whilst some patients are sceptical of ‘Big Pharma’, it is worth reminding them that the Alternative Medicine industry is equally a business with ulterior motives – and in the case of homeopathy, is selling water to the gullible.

It behoves us to critically appraise claims (both established and alternative) and to seek to improve based on the available evidence.

That is the essence of FOAMed – to improve clinical practice through critical appraisal to apply effective treatments.



Are you a Good Samaritan?

I am sure everyone is familiar with the parable of the ‘Good Samaritan’. But consider this scenario :

It’s been a busy day. On the way home you notice a small knot of people gathered around a middle-aged person, prostrate on the pavement. The bystanders look uncertain of what to do.

Do you stop and help? 

Lay public are often uncertain what to do in an emergency - if you were nearby, wouldn't you want to help?

Lay public are often uncertain what to do in an emergency – if you were nearby, wouldn’t you want to help?

As clinicians we are trained in basic and advanced life support. Indeed for GPs, BLS is a mandatory component of triennial accreditation in Australia. Whilst there is as yet no legal duty to render assistance, I think there is a professional and ethical duty to assist, notwithstanding considerations of one’s own safety and training. Indeed Minh le Cong has blogged about some of the legal and professional obligations to render assistance over at the PHARM website. We know that early bystander BLS makes a difference, hence the successful campaigns to encourage lay public to ‘push hard, push fast’ (see videos at the bottom of this blogpost). But supposing this incident happened in the next street and was not witnessed by you. Wouldn’t it be great if there was a way to alert ‘good samaritan’ clinicians to such events?

Enter the GoodSAM App for smartphone

A group of smart clinicians are launching the GoodSAM app (SAM for Smartphone Activated Medics). The premise is simple – using the GPS-technology embedded in every smartphone and tablet, to create a network of credentialled BLS providers who can be activated to an incident and ‘crowdsource’ BLS before the arrival of statutory providers. If there is an out-of-hospital emergency, nearby registered GoodSAM responders are alerted via push notifications to smartphone. They can then elect to attend or not. The app is only active when turned on, so there is no onus to be ‘on call’ 24:7. Rather it plays to the inherent altruism in us all – after all, who would NOT assist if you were aware of an emergency in the immediate vicinity? The app is available as an ‘alerter’ and ‘responder’ version – only credentialled clinicians can activate as ‘responders’ – basically anyone with a BLS or clinical qualification can register (by showing proof of clinical registration or BLS/ALS credentialling)

GoodSAM app -

GoodSAM app –

But what’s the point? Aren’t the ambos supposed to do this?

Well yes – the last thing we want in the prehospital environment is a mob of “enthusiastic amateurs”. But the reality is that from activation to arrival of a paramedic response may take minutes – and if a cardiac arrest happened in a coffee shop next door, wouldn’t you feel guilty knowing that you had the skills to provide BLS but were unaware? If you are a paramedic, nurse or doctor it would be tragic to be sat next door, unaware of the crisis until you heard the sirens as paramedics arrive… There is a short (2 mins 30 secs) video from the developers of GoodSAM here as well as FAQs from their UK and International websites below:

Sneak Peek of GoodSAM at #smaccGOLD

"Neurosurgery for Everyone" from London HEMS Open Day

“Neurosurgery for Everyone” from London HEMS Open Day

I caught up with Dr Mark Wilson at the #smaccGOLD conference last month. Mark and I were in medical school together & podcasted last year on “Burr Holes in the Bush”. He has published a useful guide on “Emergency Burr Holes – How to Do It“. Mark ran a slimmed down version of his ‘neurosurgery for everyone’ on stage at #smaccGOLD (I was the muppet doing the Burr holes). It’d be good to entice him to smaccCHICAGO – who knows, #simwars might include some more hands-on skills next year… Whilst Mark spent his medical school elective with NASA, is part of the Centre for Altitude, Space & Extreme Environment Medicine (CASE), conducted research on everest (Xtreme Everest) and carved out a postgraduate career in neurosurgery and as a HEMS doctor, I became a rural doctor on Kangaroo Island. Quite how his career derailed so badly I can’t say, but nevertheless Mark was gracious enough to show off the GoodSam app both in his excellent smacctalks and over breakfast. I reckon it took less than 30 seconds to get up and running; register on the website, punch in your AHPRA details and download the GoodSAM app – wham, you are good to go. GPS technology will alert you if there is a GoodSAM alert and guide you to the location. You can opt in/out according to availability.

GoodSAM pushes alerts to your smartphone, then guides you via maps

GoodSAM pushes alerts to your smartphone, then guides you via maps

Impact Brain Apnoea

Of course the GoodSam app is not just confined to cardiac arrest; Mark spoke about the phenomenon of traumatic impact brain apnoea – put simply, if sufficient force is delivered to the skull, then apnoea will be induced for a period of time, during which critical hypoxia will cause irreversible damage. The delivery of basic measures, such as jaw thrust and assisted ventilation by a BLS-accredited GoodSam responder, can bridge this gap and help ensure more favourable outcomes for neurotrauma.

Where to get it?

The App can be downloaded from the App Store and is available for iOS platforms – an Android version is expected soon. I should stress that the App is in soft launch phase currently – I would expect that avid users of #FOAMed and #smacc aficionados would be early adopters, with more mainstream uptake in months to come. When browsing the App store, just search for “GoodSam” responder app – be sure to look under the ‘iPhone’ tab (iTunes App store tends to classify by apps available either for iPad or iPhone – it will work on either, but is optimised for iPhone)

 Screen Shot 2014-04-05 at 10.01.47 am

Other applications

Smartphone technology is changing the way we work as clinicians. Most users of #FOAMed resources are using their smartphone or tablet to pull up clinical guidelines, useful websites, videos, podcasts and so on on a daily basis. I use my iPad in theatre and ED most days, showing short videos to stimulate discussion, running sims, accessing clinical resources or just keeping up to date. But the embedded GPS-capabilities allow extra function – Many retrieval services are on board with regularly updated SOPs, drug doses and location of landing sites for their retrieval practitioners. The Scottish EMRS service is a good example. It is also gratifying to see the more enlightened retrieval services placing their SOPs online for dissemination – this is invaluable for us rural clinicians who wish to meet the same standard of care for our patients as delivered by dedicated critical care services. HEMS SOPs from London GSA-HEMS SOPs (see under Resources tab) I was speaking last week with David Hogg, a remote area doctor on the Isle of Arran in Scotland about the UK BASICS scheme – smartphone location and activation of BASICS responders offers significant advantages over bulky pagers or expensive vehicle-location systems. However such applications are limited by mobile reception – this is a real issue in rural areas.  See the NO BARS initiative from to improve the issue of limited mobile coverage. I think we will see more and more use of the embedded technology within our smartphones to deliver better patient care. GoodSAM is an interesting app – it would be wonderful to have good uptake of this by willing clinicians in both metro and rural areas, reducing time to BLS. Extension of the concept could allow much faster mobilisation of expertise in other scenarios, for example - smartphone location and activation of RSI-positive, equipped & trained RERN members to prehospital incidents (equivalent to BASICS UK) - smartphone activation of emergency responders for mass casualty or other incidents (bushfire, earthquake, tsunami etc) etc

My recommendation?

Download the GoodSAM responder app and have a talk to colleagues and lay public – they may wish to use the GoodSAM alert app for their friends & family. Through connectivity, we grow… GoodSAM website – International Contact via Twitter The developers seem very open to feedback. In Australia there is a slight hiccup, in that registration of doctors, nurses & paramedics requires supply of AHPRA registration – yet paramedics are not (yet) registered with AHPRA. Don’t worry – just register online and email GoodSAM who will authenticate by other means. As far as I know, registration is also available to other BLS providers eg: students, community first aiders etc on production of valid BLS credentialling. The potential to crowdsource BLS is huge. What a great idea!


I am not an employee nor a beneficiary of GoodSAM.  There are other similar crowdsourcing BLS apps available – the PulsePoint Foundation app is a similar concept, costing between $5K-$25K depending on population covered. As far as I am aware, GoodSAM is free and as such should appeal to users of #FOAMed ! Other apps exist to guide the lay public through the process of BLS eg: the AHA first aid & CPR smartphone app or this from Ambulance Victoria

Ambulance Victoria App for lay public - learn CPR

Ambulance Victoria App for lay public – learn CPR

GoodSAM does not teach you how to do CPR – it is an app to deliver trained responders to the scene, not to assist novices.

CPR videos for the Public

There is concerted effort by National bodies to educate the lay public in hands only CPR. I see GoodSAM as complementary to this, adding trained responders to lay responders. After all, BLS – even hands only – is what matters.

There is no point in pre-hospital ECMO for OOHCA if the brain is dead through lack of early CPR!

American Heart Association – Ken Jeong “Hands Only CPR”

UK  British Heart Foundation – Vinnie Jones “Hard & Fast”

..and of course the “Mini-Vinnie’ spoof

Australian Resus Council – ‘Hands Only CPR – It’s Not Aeroscience

…which is much more sensible than the infamous ‘Chopper Reid’ CPR demo

Canadian Heart & Stroke Foundation – ‘The Undeading’

(actually – not so sure about that last one; it implies that CPR produces brain dead zombies…perhaps I will stick with a DNR decision)

You gotta have love…

I was 14 when I nearly considered deliberate defenestration. It’s probably the closest I’ve ever been to suicide, but the memory of the angst that made me contemplate this action is still vivid.

The Headmaster had asked each of the 30 pupils in our class to give a talk. I cannot even remember the details now, but the prospect of standing in front of my peers caused me so much distress that jumping out of a fourth floor window seemed easier. Kind compassionate man that he was, he recognised my distress and engineered the situation such that I did not have to speak…hence I am still here.

Since then I have struggled with confidence … particularly confidence in public speaking. I have worked to overcome this, such that now I quite enjoy giving a talk on something which I am passionate about (trauma, airway, rural medicine). But talking on the big stage at smaccGOLD was a huge hurdle for me.

Spot the Imposter. From L to R : LeCong, Leeuwenburg, Greenland, Weingart, Levitan & Reid

Spot the Imposter. From L to R : LeCong, Leeuwenburg, Greenland, Weingart, Levitan & Reid

For those that don’t know, smaccGOLD was the second ‘social medic and critical care’ conference, following the debut in Sydney last year at smacc2013.

 “Innovation, education and creativity at the cutting edge and beyond the confines of convention. This conference was delivered by passionate patient focused, idea-nurturing visionaries” 

via Dr Bishan Rajapakse’s #smaccGOLD reflections

As Mike Cadogan said, if FOAMed was conceived (like many great ideas) in a Dublin bar at ICEM2012, then smacc2013 in Sydney marked FOAMed’s birth. I spoke at smacc2013 on my passion of rural prehospital care & was invited back to smaccGOLD. Thanks to the convenors, I was privileged to be invited to help teach in the pre-conference Airway Workshop, to enter into a debate with Minh le Cong and to deliver another presentation on rural resus room management.

Like all of the other presenters, I poured my heart and soul into preparation, yet with the spectre of my fears on public-speaking still present.

You can see narrated slideshows of the checklist debate and rural resus room management talks by right-clicking highlighted links, or download PDFs from these links

“Real airway experts use checklists – pro” slide set and “Rural Resus Room Feng Shui” slide set.

Preparation for speaking at smaccGOLD was one thing; being nominated to participate in #SimWars was another…all the stress of being on a stage, with the challenge of overcoming fear of public humiliation due to failure. I was pushed far out of my comfort zone – and this was a good thing.

The crowd

The Crowd : 1300+ attendees at smaccGOLD

SimWars fracas

Team leader – this resus is really “grillin’ my corn!

Many people have asked me what makes smacc special. From fears such as those of Scott Weingart at smacc2013 that it was going to be “just five guys in a bar talking about Twitter”, smacc has evolved into THE leading critical care conference and is a wonderful demonstration of the power of FOAMed & Social Media.

Those who engage in FOAMed share a passion for advancing their craft, for sharing ideas and for education – in short, they strive to make themselves and the care of their patients “better”.

At the same time, it is not uncommon for people to experience fears – fear of sharing thoughts and work in a free, open-access format; fear of criticism of our expertise by those operating in another arena, fear of difficulty. My passion for FOAMed was predominantly driven by fear. Fear that as an isolated rural clinician I would be at risk of being the weakest link in management of my patients and friends.

My obsession about difficult airway management and critical care was borne from a ‘lesson hard learned’ – and a commitment to overcome both my own fear and ensure that harm does not befall any patient through lack of training, equipment or expertise. FOAMed resources, harnessed through the power of social media, enable us to engage in asynchronous learning from experts worldwide – and there is no longer any reason nor excuse not to be aware of the latest medical developments relevant to my practice.

“Fear is what drives much behaviour.

But I think we are best when driven by love”

The most important lesson that I’ve learned in medicine is to love your patients (no, not in that way!). A colleague taught me the power of a handshake when I was an ED registrar – not just as a formal introduction to each patient, but also to emphasise the symbolic nature that I am genuinely here to help you.The handshake is an affectation that I have carried on into my work in primary care…and along the way I’ve added other tools – sitting at patient level, giving the patient time, not being afraid to have the difficult conversations, showing empathy and ensuring we use names, not bed numbers.

This isn’t just about the doctor-patient relationship; it is also about how we interact and look after each other – we operate in different systems, and it is too easy to criticise colleagues or different craft groups without understanding their circumstances or challenges. And love is what mades smaccGOLD such a good conference.  Sure there were inspiring speakers, great slide sets and some excellent hardcore critical care research. But there was also love – a shared passion for critical illness, a willingness to laugh and cry and play together, sessions on end-of-life care and bariatric medicine that challenged us to really think about our values as clinicians.

smaccGOLD was set modelled around a tribal theme – a main stage set that mimicked a tropical island (akin to an episode of ‘Lost’ or ‘Survivor’).  Delegates and speakers strove to break down the traditional silos between us, to consider aspects of critical care from different perspectives – and to unite in common love for critical care and celebration of the joy of discovery.

Tribal opening

smaccGOLD – breaking down the silos in critical care – we are but one tribe!


Ultimately we are all human – and the power of empathy, compassion and shared humanity is what binds us. Was it practice-changing? Yes! The rapid dissemination of ideas via FOAMed and the global community of enthusiasts dedicated to bringing “quality care, out there” is achieving its goal.

“smaccGOLD – grilled my corn!”

I simply cannot think of another critical care, emergency medicine or indeed any medical conference that came even remotely close.

Thank you to all – the organisers, those who helped me overcome my fears, those who shared their love of critical care & humanity – and everyone who made time to come up and say “G’day”.

One tribe – we are critical care!


More reviews can be found at :

ITeachEM (Rob Rogers) Friendship, Motivation, Altruism

Manu et Corde (Eve Purde) Lessons from smaccGOLD

RoloBot Rambles (Damian Roland) smaccGOLD – it hurts!

LifeInTheFastLane day 1 – 3 summaries

PreHospitalResearch – Lessons learned from smaccGOLD  “bye,bye dogma – hello best practice”

NomadicGP (Penny Wilson) Pure Gold

Rebel EM (Salim Rezaie) – social media & critical care

Injectable Orange (Jesse Spurr) – smacc : punk rock, paeds, palliation & people




One Tribe

Ugly Mug
Ugly Mug

Opening Ceremony

Opening Ceremony

Mark Wilson & GoogleGlass

Mark Wilson & GoogleGlass

Minh - a real airway expert

Minh – a real airway expert

John Vassilliadis' corn is grilled

John Vassilliadis’ corn is grilled

Ian Beardsell "does he have chronic pain?"

Ian Beardsell “does he have chronic pain?”

Cornered between Carley & Nickson "Is your swear box broken Tim?"

Cornered between Carley & Nickson “Is your swear box broken Tim?”

Rich Levitan in airway workshop, nasoendoscopy stream
Rich Levitan in airway workshop, nasoendoscopy stream

Neurosurgery for Everyone with mate Mark Wilson - Burr Hole demo

Neurosurgery for Everyone with mate Mark Wilson – Burr Hole demo


You're gonna do WHAT with that Cric-Key? Weingart plays fast n loose

You’re gonna do WHAT with that Cric-Key? Weingart plays fast n loose

Who's gonna be the mummy & who is the daddy? Karel Habig & Anthony Lewis arrive in same Jabba-the-Hutt costumes for #SimWars

Who’s gonna be the mummy & who is the daddy? Karel Habig & Anthony Lewis arrive in same costume for #SimWars

"Might as well shove it up your arse" from John Hinds in Cricoid debate

“Might as well shove it up your arse” from John Hinds in Cricoid debate

The laryngeal handshake - LeCong vs Chrimes

The laryngeal handshake – LeCong vs Chrimes

Rural Resus Room Mx

Rural Resus Room Mx

Carley goes wild

Carley goes wild

"Punk Rock, Top Gun & Emergency Medicine" - from Deniz Tek of Radio Birdman

“Punk Rock, Top Gun & Emergency Medicine” – from Deniz Tek of Radio Birdman


Should Real Airway Experts Use Checklists?

The smaccGOLD debate ‘should real airway experts use checklists‘ in March 2014 between RFDS powerhouse Dr Minh le Cong (against) and myself (in favour) started some nine months prior to the actual event, with an almost daily exchange of trash talk on the topic via the wonderful medium of Twitter.



Twitter trash talk between Minh & myself got heated on occasions. Not quite Bruce Lee vs Chuck Norrris, but close…


You can download a PDF of my argument PRO checklists here.

It’s no secret that I am a fan of checklists and cognitive aids – not just for ‘occasional intubators’ but across the board, even for those with significant expertise. Minh on the other hand was determined to argue the counterpoint and expose some of the flaws and fallacies surrounding checklist use.

“quality care, out there”

The debate takes place at smaccGOLD – a critical care conference open to intensivists, emergency physicians, rural clinicians, paramedics, nurses, students – indeed, anyone interested in the delivery of “quality care, out there”. With this maxim in mind, we are all looking for things that will make a difference during critical procedures – whether this be relatively new concepts like use of apnoeic diffusion oxygenation in RSI, developing robust airway equipment and algorithms for airway management…I believe that use of checklists in a crisis helps deliver quality care.

There are arguments for and against checklists in medicine sensu lato, not just airway management. This post is a summary of checklists relevant to their use wherever airways are managed (hence not just Operating Theatre, but also to ICU, ED and prehospital). Checklists aren’t just for routine – they should be used in crisis management – whether this is emergency RSI, dealing with unexpected hypoxia, a rare emergency such as MH or similar.

The main benefits for use of a checklist regardless of experience include:

  • Reduced task fixation & improve situational awareness
  • Reduced cognitive overload
  • Reduced stress
  • Defined team member roles
  • Improved team function
  • Improved team communication
  • Team understanding of potential complications and what they will be expected to do
  • Use can make crisis management & high-stakes procedures such as RSI smoother and quicker(when well practiced at using the checklist)

The argument is that in sick patients, unfamiliar environments, etc we are very prone to task fixation and loss of situational awareness.  The adrenaline rush pushes us to get on with it, when often time is not actually so critical that we can’t pause for 30-60 seconds and have a quick brief.

Minh however doggedly argues the opposite, pointing out that checklists per se do not bring about quality – it requires team buy in and awareness of their limitations. Using a checklist as a ‘tick and flick’ exercise, or inappropriate use of a checklist are all real caveats.


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So what actually IS a checklist?

Clinicians have been using checklists since medical school – we are all familiar with the usual deluge of mnemonics , acronyms, algorithms and assorted prompts. Newer formats such as The Vortex are being used increasingly in crisis management, not as a ‘recipe’ but as cognitive aids in a crisis.

Some scorn checklists and other cognitive aids as ‘a crutch for the novice’, ‘cookbook medicine’ or as nothing other than ‘cheat sheets for novices’. Perjorative terms, often used by experts. After all, the expert doesn’t need help…or do they?

Humans make mistakes, especially when tired, when distracted or interrupted…or in a crisis when under cognitive load. Moreover, the expert does not function as an individual – he or she is part of a team, and members may have varying levels of expertise. We know this from the extensive human factors work, championed in healthcare (and anaesthesia has lead the way) by people such as David Gaba or Martin Bromiley.

In the true sense of the word, a checklist is exactly that – a list against which a check (or tick) is placed, to confirm an action has been completed. However it is not just learners who benefit – the true power of a checklist is to establish routine and so allow cognitive offloading by experts in an emergency, as well as to strengthen team performance and establish shared mental models.

“effective CLs are more about helping reduce cognitive overload and error reduction, not purely about the manual procedure”

@HawkMoonHEMS Dr Brian Burns, FACEM & Retrieval Physician

One of the best forms of checklist is a two-person challenge-response format. This obviates the temptation to ‘skim’ items on a checklist and places responsibility for reading the items with the assistant, not the operator. I think that this sort of challenge-response checklist is the most useful in crisis management – but in order to be effective, must be embedded into routine practice and adopted by teams with institutional support.

“a check of what has been DONE by experts, not a HOW TO for novices”

Delving a little deeper, the literature describes FOUR main types of checklist (Winters et al, 2009) which differ in terms of number of operators and the extent to which information is verified :

  • static parallel : usually completed by a single operator and executed in the form of a series of ‘read-do’ tasks. The anaesthetic machine check is a good example, as is restocking of equipment
  • static sequential with verification : this involves a challenge-response, with one operator reading a series of items for verification of completion or normality by another. The central line checklist in ICU is such an example as is an RSI challenge-response checklist
  • static sequential with verification and confirmation : these are used more in team-based settings, with sets of tasks completed by different team members. A designated person reads the items (challenge) and each responsible party verifies the completion of a specific task. The WHO Surgical Checklist is such an example, with separate activities for scrub, surgical and anaesthetic teams
  • dynamic : these typically use a flowchart to guide complex decision-making. There may be multiple options to choose from and the team must decide optimal course – in essence, an algorithm. The UK’s Difficult Airway Society algorithms & Australian Resuscitation Council ACLS algorithms are such examples.

Of course it’s not just in medicine that we use a checklist – we write a shopping list before visiting the supermarket and most of us will perform some sort of mental checklist before leaving for work (have I got my car keys? My wallet? My sunglasses? Is today even a work day?). Humans use cognitive aids most days. Why would we abandon them at work?


That’s not to say that one needs a checklist for everything. For some reason, Minh seemed obsessed with the idea of using a checklist before intercourse. Whilst this is clearly a ‘tightly coupled’ procedure, I think Minh was missing the point. To paraphrase Weingart, sex – like resus – is one of those times when “slow is smooth, and smooth is good”.


Well then, what is a REAL airway expert?

Yeah, yeah – you want me to say that it’s an anaesthetist. Except of course it’s not – airways are also managed outside of the elective operating theatre setting by non-anaesthetists. Real airway doctors can be found in the Emergency Department, in the Intensive Care Unit, in the Pre-Hospital & Retrieval environment – as well as in the operating theatre. It goes without saying that even an experienced anaesthetist, with decades of training and experience in routine anaesthesia, may struggle when faced with a soiled airway at the roadside, with unfamiliar kit and a lack of trained assistance. Expertise in one area, even airway management in the OT, may not translate into another arena such as the ED.

"Smoke me a kipper, I'll be back by breakfast" - the idea of the expert as an individual 'ace' is obsolete

“Smoke me a kipper, I’ll be back by breakfast”
- the idea of the expert as an individual ‘ace’ is obsolete

So ‘real’ airway experts are drawn from the ranks of anaesthetists, emergency physicians, intensivists, & rural doctors. Heck, they may not be doctors – we have excellent intensive care paramedics working in various systems. Ambulance Victoria relies on MICA paramedics to deliver prehospital RSI; the South Australian medSTAR service has retrieval practitioners, drawn from ranks of doctors, nurses, paramedics. The skill set defines the job, not the initial qualification. And all are striving for mastery, whatever our heritage…

Medicine is truly an apprenticeship. We move through the classic stages of skills-acquisition as described by Dreyfus & Dreyfus (2005), each seeking to achieve mastery in our field.


Classic Model of Skills Acquisition (Dreyfus & Dreyfus, 2005) Not everyone transitions to expert stage; many are doomed to confuse competence with expertise

Classic Model of Skills Acquisition (Dreyfus & Dreyfus, 2005)
Not everyone transitions to expert stage; many are doomed to confuse proficiency with expertise; few reach true mastery.

The concept of “it takes 10,000 hours of training to be an expert” from Ericsson is often banded about – with the generalisation that it takes 10 years or so to accrue this experience. Sadly many do not reach the desired level – many repeat one year of experience ten times, rather than deliberately train and gain mastery. Moreover, for the ‘expert’ in emergency medicine or intensive care, airway management makes up just one component of practice. Does expertise in one area of medicine necessarily translate to expertise in procedures such as intubation? Even once ‘expert’ status is achieved, there is a real risk of ‘skill fade’ – a recent observational study of endotracheal intubation in a tertiary ED suggested that emergency physicians may only perform this skill as little as three times per week, due to requirements to supervise trainees and allow them to acquire skills (Fogg et al 2012).

“Half of all experts are below average”

Even within the ranks of anaesthetists, performance will follow a Gaussian distribution, with half ‘below average’ when compared to peers. Expertise in the calm ordered environment of the Operating Theatre may not translate to the chaotic environment of an emergency airway in unfamiliar settings.

Truly expertise is a relative concept.

Hang on, this is all getting a bit Zen isn’t it?

Well, possibly. The path to mastery is something we all strive for – but as time goes on, many clinicians become comfortable at the ‘competent-proficient’ stage. They are considered technically capable, they are able to make a (good)-living doing what they have trained to do. To strive for expertise and mastery requires a lot more effort for seemingly less reward.

The danger is that once you are at the ‘proficient’ stage, you may feel that there is no need for cognitive aids. You are on top of things at work, you manage things adroitly…and then you are thrown a curve ball. An unexpected crisis. Something you have read about, perhaps even drilled for, in the comfort of a sim lab or one of the many continuing-professional development courses…but sadly your proficiency in everyday practice does not translate into expertise in a crisis. How can it? True crises are relatively infrequent. How many have managed malignant hyperthermia? A true CICO requiring surgical airway? Intraoperative anaesthetic machine failure?

The anaesthetic error in the sad case of Elaine Bromiley is but one example of this. Here experts in their field were overwhelmed by the situation (CICO) and failed to make appropriate decisions despite having the requisite skills. If you aren’t familiar with this story, take time now to review the video :

[vimeo w=500&h=266]

"in aviation we know that 75% of error is caused by human factors. In healthcare, we don't know. Is it 75% as well? Is it 85%? Is it 55%? No one really knows ... I would argue that the actual statistic is irrelevant ... a large proportion of accidents will be caused by human factors, the lessons learned from other industries apply to healthcare"

Martin Bromiley, Airline Pilot & Human Factors Expert

There are many more examples of error leading to catastrophe in airway management, despite the presence of experts. Hence there has been a huge emphasis on training in human factors for crisis management in medicine – mostly lead by anaesthetists but seeping across into other clinical disciplines as the years go on. We can all learn from this.

Error in Medicine

We need to be very clear – error in medicine occurs despite the presence of experts & their expertise.

If you read nothing else, read McIlvaine (2006) on ‘Human error and its impact on anesthesiology’ – a gentle introduction to understanding how we err and use of tools to mitigate against the inevitable.

Catastrophe can occur because of a major error – failing to check the correct site for surgery; accidentally injecting a cytotoxic intrathecally; awareness under anaesthesia due to forgetting to replenish the vaporiser; failure to monitor ETCO2 in the ICU to confirm ongoing ETT placement.

Harm can happen because of equipment failure or because of a seemingly trivial mistake – forgetting to have suction available during RSI, or not having a syringe available to inflate ETT pilot cuff. Not having drugs available in a crisis. Assuming that assistant is familiar with contents of difficult airway trolley.

These are all anathema to experts – who would be so foolish as to perform RSI without suction? Without checking the ET cuff? With an assistant who is not equally ‘expert’? Yet in analysis of medical procedures, mistakes & omissions are noted in a similar percentage as in aviation – 75%. Thankfully humans are adaptable and able to compensate; for most cases (eg: RSI in the OT for an elective, fasted patient) no harm will occur. Similarly minor mistakes may not amount to much, given levels of redundancy. But for the trauma patient with critical hypoxaemia, shock, MILS limiting optimal positioning and in the presence of a soiled airway, such omissions are less-forgiving.

“It may take many minor “holes in the swiss cheese” to line up to cause catastrophe. If only 9/10 holes line up, the operator will end the day in blissful ignorance of the near disaster as if 0/10 errors occurred. It’s the final hole that gets you”

But hang on – surely the expert is immune to error? I’ve already alluded to the problems of ‘expert’ status – it’s a relative concept, subject to problems of skill fade, of poor translation between areas of expertise or in dealing with relatively infrequent events…and of variation within a cohort.

OK, perhaps checklists are OK for routine procedures

- but surely there is no time to use one in a crisis?

The literature is fairly robust on use of checklists for routine procedures – the anaesthetic machine check, the WHO surgical checklist, central line checklists etc. But what about in a crisis? Surely we can rely upon the expert to manage the situation? Sadly not. Human factors research shows that humans can only manage to retrieve seven +/- 2 pieces of information from our memory with relative accuracy. During a complex procedure, with additional elements of stress or fatigue, memory becomes increasingly unreliable. Worse still, as the number of tasks we simultaneously manage exceeds three, we show significant decline in the accuracy and speed of handling problems. Even worse still, under stress we show increased skill degradation. Listen to Cliff Reid and Scott Weingart talk about the impact of stress and the concept of stress inoculation.

A checklist can help compensate for this, allowing “cognitive offloading” and empowering others (the non-expert team member) to ensure that procedures are followed.

Minimising error is especially important in ‘tightly-coupled’ processes – technical procedures where omission of a single step can lead to failure. Airway management is one example – one cannot afford to be distracted during RSI by another task, as the patient will be at risk. Conversely interruption during a pre-anaesthetic consultation is less serious – and may even be welcomed.


Certain procedures – such as RSI – are ‘tightly-coupled’ with little margin for error

Rather than expect perfection in the human operators, we need to make sure there are effective systems in place – acknowledging that error is inevitable in any system. A comparison is usually made between medicine and other fields – most notably aviation and the nuclear industry. Characteristics of these industries is the requirement for high degrees of safety despite the technically complex nature of tasks. Similar concepts abound in the manufacturing industry, where efforts are made to minimise variability and defects in products – the ‘Sigma Six’ process aims to shift defects to six standard deviations from mean – or 3.4 errors/million (99.99966% error free).








I don’t know if achieving a 0.00033% error rate in medicine is achievable – but there is no doubt that conscientious clinicians will strive for perfection – whilst acknowledging that no system involving humans is perfect. Most importantly, even experts will make mistakes – and expertise in one situation does not translate to another. Put simply – an experienced and expert anaesthetist will encounter catastrophe relatively infrequently – hence their expertise in ‘routine’ airway management may not translate to the same in a crisis. How could it? It is difficult for to gain expertise in infrequent events.

Anaesthesia & Aviation – caution with analogy

Human factors experts talk about creating opening up of communication, of team training and use of cognitive aids to minimise error. One of my bugbears is that anaesthesia is often compared to aviation. True, pilots are highly skilled professionals and use checklists bin acknowledgment of the fact that mistakes can happen even when performing routine tasks due to inherent complexity (read about the origin of checklists in aviation here). I think most of us would hesitate to get onboard an aircraft if we knew that the pilot had omitted to use a pre-flight checklist and instead relied upon ‘experiential expertise’ as sole safety check.


The standard argument is that ‘pilots use checklists’ and so should we

Some argue that in a crisis there is not time to use a checklist – the landing of US Flight 1549 on the Hudson River by Captain Cheslea ‘Sully’ Sullenberger after an unprecedented complete engine failure due to birdstrike immediately after takeoff is a case in point. Nevertheless, the pilots used their checklists even though they KNEW there was insufficient time to complete it – falling back on routine allowed them to rapidly confirm crucial procedures performed and come up with a novel solution to the problem. This is expertise – high-level problem solving in a crisis – and it relies upon the routine use of procedures such as checklists to help cognitively offload and so allow such improvisation.

“standardise until you absolutely have to improvise”

Dr Kevin Fong in “How to Avoid Mistakes in Surgery” – BBC Horizon

Of course anaesthesia is nothing like aviation. For a start, aircraft are designed to fly. And it’s not the norm for an aircraft to be on fire and hurtling towards the ground, whilst the Chief Engineer attempts to repair holes in the fuel pump – which is the analogy of a patient in haemorrhagic shock, needing an RSI for theatre as the surgeons attempt to ‘find the bleeding, stop the bleeding’.

There is a classic article written by Grant Hutchinson in 1998, originally published in ‘Today’s Anaesthetist’ and reproduced via this link. It is well-worth a read if you had any doubts about comparisons between aviation & anaesthesia.

As time moves on, lessons learned from aviation are being supplanted by those learned from the human factors industry and within anaesthesia itself. Training in “crisis resource management” has been practiced since 1990 (Gaba, 2010) – and it is not always appropriate to seek answers from the aviation field, when healthcare differs fundamentally.

If you really want to piss off a surgeon, remind them :

anaesthetists fly the plane …

…whilst surgeons serve the drinks & do the in-flight entertainment


Not that lessons from aviation are all bad – emphasis on human factors and team training is generally considered a good thing in clinical education via crisis simulation. But of course the clinical team is NOTHING like the highly-trained team on an aircraft or in a nuclear power plant. Rather the ‘team’ in an airway crisis in the ED is often comprised of disparate individuals who may have unknown skills mix and have probably never trained before (the exception of course being small rural EDs and of course highly-trained prehospital teams who ‘train hard, fight easy’). These are best considered as ‘flash teams’ – and it is obvious that although ostensibly a ‘team’ the rate of error in achieving a highly technical task amongst a ‘flash team’ is higher than in a team that has trained together.

Tannenbaum et al. describe the concept of “flash teams”

One of the ways to help mitigate against the vagaries of performance within a ‘flash team’ is to incorporate protocols that allow teams to form quickly – rapid identification of role clarity, use of a ‘shared mental model’ (the C-ABC approach). Checklists during critical procedures such as RSI can be considered as ‘join-in-progress’ protocols that allow individuals to function as a team – independent of the operator’s expertise.

Thus error is seen as inevitable in any system and may occur independently of expertise. Changes in systems, in addition to individual expertise, is the way forward to minimise error and reduce patient harm, particularly in technical & tightly-coupled processes. Cognitive aids (such as The Vortex) and use of checklists for critical procedures (surgery, RSI) have much to offer – even to experts.

Checklists in Medicine

Unless you have been living under a rock, it is highly likely that you have at least heard about Atul Gawande and his book ‘The Checklist Manifesto’. With any luck you will have read this and his other books – ‘Complications’ and ‘Better’. Gawande writes eloquently on the path to expertise, the need to see improvements in quality and the problems that clinicians face when things do not go wrong. He articulates clearly the difficulties of tightly-coupled processes in clinical practice, along with the inherent instability in dynamic systems such as the human body and disease.

The three books read as a series : ‘Complications‘ (published 2002) describes the problems we face in medicine and difficulties to achieve excellence. ‘Better‘ (published 2007) describes the qualities for success in medicine – diligence, doing the ‘right thing’ and ingenuity’. ‘The Checklist Manifesto‘ (published 2009) describes the importance of pre-planning and how simple interventions at an organisational level may help overcome predictable error.

Gawande’s work has lead to the widespread implementation of the WHO Surgical Checklist, reported to reduce surgical error (such as wrong-site surgery or retained instruments) by as much as 30% – see for more details.


There have been criticisms of the WHO Checklist – there are reports in the UK’s NHS of the checklist being introduced ‘top down’ with no local change champion, resulting in lack of institutional ‘buy in’ from team members. I have certainly witnessed the checklist completed as an aside AFTER induction – or the checklist being performed by part of the team (typically scrub & scout nurse) without the participation of either surgeon or members of the anaesthetic team. Moreover they can fail – as discussed by active twitter-contributer Dr Helgi Johanssen (@traumagasdoc) in this podcast.


WHO Checklist MUST take place without interruption, involve all team members and take place before the procedure – not aside as ‘additional paperwork’

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The WHO Surgical Checklist – widely adopted – is designed to be adapted to local circumstances – this is the Aus/NZ version


There have been other successes in checklist implementation – Provonost describes reductions in complications from central line insertion by introduction of a simple checklist to reduce central-line associated infection.

A recent (this week) paper in the NEJM describes NO improvement in outcomes when comparing checklist use before/after implementation (Urbach et al “Implementation of surgical checklists in Ontario, Canada” N Engl J Med 2014 370 : 1029-38). However, an accompanying editorial points out that the checklist was NOT USED in many cases, and cites other examples where checklist implementation takes time – it is probably that benefits will be proven with a longer period of study and ensuring that the checklist is used (Leape, L. 2014 The Checklist Conundrum NEJM 2014). As Gawande says “the checklist won’t work if you don’t use it”

The question is as to whether use of checklists is really needed by experts dealing with complex, non-routine events such as airway crisis management. 


The smaccGOLD debate :

‘Real Airway Experts Use Checklists’


Given the proven value of checklists in routine and yet tightly-coupled procedures such as surgery and central line insertion, should their use become standard in airway management, even by experts?

Arguments in Favour

Expertise is a hard area to define. Whilst the assumption that Fellowship or Board Certification in Anaesthesia means that one is an ‘expert’, even anaesthesia is a broad church. The wise anaesthetist knows that he/she may have strengths as well as weaknesses – and whilst airway management is a core skill, during times of cognitive overload even the most seasoned veteran may struggle. Moreover, the management of an airway procedure (let’s say RSI) or of a crisis (let’s say intra-operative hypotension) requires more than just the individual’s skills – success or failure requires a complex interplay of expertise, coupled with teamwork and equipment. Even the best airway doctor can fail if his/her assistant is unable to assist or if a vital piece of equipment is lacking. These are not theoretical concerns. In one study, anaesthetists were reported to make mistakes in nearly 50 % of mistakes even during a ‘core skills’ such as RSI – thankfully suck mistakes are small and usually compensated for by redundancy in systems and the fact that error (eg: failing to check suction available) may be undetected in a routine RSI that goes well.

First up, who is an expert? Monash anaesthetist Nicholas Chrimes suggested via Twitter that we consider this to be “anyone qualified to independently perform advanced airway management, regardless of specialty” – this including anaesthetists, intensivists, emergency physicians, pre-hospitalists and paramedics – even those country doctors. At 3am in an ED, the only available ‘expert’ for a crisis is going to be one of the ED/ICU/anaes registrars…not the anaesthetic consultant. Ditto in a small rural town, the country doctor or paramedic will be the designated ‘expert’.

(i) being expert is not enough

Regardless of the ‘label’, assuming the operator is qualified to independently practice, I argue that expert status is insufficient. Understanding dual-process decision-making shows us that experts tend to practice via so-called “system I” – experience and intuition, whereas novices tend to use more “system II” – rule-based heuristics. This can lead to the phenomenon of ‘strong but wrong’  decisions…countered by introducing cognitive checkpoints – such as checklists.

Experts tend to operate in routine, borne by years of experience. I interviewed Dr Helgi Johannsen (@traumagasdoc) for a podcast on wrong-site surgery (an example where use of the WHO checklist failed) and this naturally lead to a discussion of checklists in crisis management and high-stakes procedures such as RSI. Helgi made it clear that he does NOT use a checklist – as he operates in a theatre environment with ‘one set way’. Even if moving into a different environment (such as the ED) for an RSI, Helgi admits he would bring his ODP (a trained theatre assistant) with him from the OT to that environment.

Yet not all of us have that luxury. Moving from a routine, practiced over years of experience, to an unfamiliar environment, with new personnel, probable changes in equipment and a dynamic situation (invariably a crisis – hence the need for expertise) places extra demands, such as stress & cognitive overload, unclear authority gradients, complex human factors interplay. As cognitive demand increases, performance decreases with concomitant loss of situational awareness, task-fixation etc – the perfect storm for error. Add in the common strains of working in a medical environment (often being hungry, angry, late or tired) and error is almost inevitable. That’s just part of being human…

Checklists can help – not as a recipe or cookbook for novices, but as an adjunct to the expert to ensure key stages or information have not been omitted. They function as a check of what has been done, not a ‘how to do it’.

Being expert is NOT enough! Using a checklist is an additional line of defence against latent error.

(ii) a “team of experts” is not an “expert team”

Even assuming our expert is in tip-top form, able to superhumanly overcome the demands of cognitive load under stress (perhaps through stress-inoculation training)…he or she is only as good as the team around them.

Checklists help to democratise knowledge and establish a shared mental model of what is going on. The pre-RSI checklist is a good example – taking 60 seconds to run through the checklist during preoxygenation not only ensures that all equipment and planning is in place, it also sets the scene for crisis management in case of difficulty. Again, checklists are there to help the team ‘check done’ not tell the expert ‘how to do’.

(iii) checklists are for crises as well as routine

Books, journal articles and lay media have popularised the value of checklists for routine procedures – the WHO Safe Surgery Checklist from Gawande and colleagues as well as the central-line checklist from Provonost are the usual cited examples. Critics will tell you that checklists are fine for routine – but not for crisis management.

This is, of course hocum. Since the 1990s, anaesthetists have been implementing training in crisis resource management, leading to development of crisis algorithms & checklists. More recently the NAP4 study from the UK suggested implementation of checklists into practice. Aids such as Borshoff’s Anaesthetic Crisis Manual and crisis cards such as those for malignant hyperthermia, local anaesthetic systemic toxicity, CICO, anaphylaxis etc are enthusiastically adopted in theatre by anaesthetists. Is there evidence? Well, like aviation, anaesthesia is prepared to implement safety measures borne through accumulated wisdom – lessons learned through tragic human loss. Anaesthetists accept the use of such cognitive aids in crisis management, despite ‘expert’ status. Is anyone going to do a randomised-controlled trial of checklist use vs non-use in a crisis? Probably not. Should we use them? Probably yes.

Critics also state that use of a checklist in a crisis will cause delay and that sometimes you ‘just have to act’. Indeed. But if you break this down, it should be clear by now that routine use of a checklist helps establish a team with shared mental model and ability to flatten authority gradients…and if a crisis evolves, all the necessary steps have been considered and are in place. Moreover, during a crisis the impact of stress and cognitive overload can lead to ‘strong but wrong’ decisions by experts using ‘system I’ decision-making – having a reader run through checklist can act as a cognitive waypoint, ensuring alternative options have been considered and acting as an adjunct to the expert.

Critics often point to examples from aviation – either QF32 or US Airways Flight 1549. In the former, QF32 (an Airbus A-380) was on climb-out from Singapore to Sydney, then suffered an “uncontained turbine failure” causes multiple other failures. Using their own human instincts and decisions allowed the crew to override the numerous automated error messages. Does this mean that ‘expertise’ wins out over checklists? Not at all – having a routine – whetehr this be SOPs or checklists – allowed the QF32 team to make decisions even under pressure. In aviation parlance, they were able to aviate-navigate-communicate. Ditto in the case of Capt Sully Sullenberger and crew – loss of both engines after a birdstrike from New York to Charlotte, NC allowed only 208 seconds from crisis to landing – in this case on the Hudson River. There is no checklist for loss of both engines on climb-out – nor was there time to execute the checklists for power loss at higher altitude – nevertheless, the First Officer commenced a checklist and the use of routine allowed the pilot and team to function.

large_hudson river us airways flight splash landing

As Sullenberger says :

“My pulse shot up. My blood pressure shot up. My perceptual field narrowed because of the stress. And I had to really actively compartmentalize and focus and force that distraction away, and just concentrate on the task at hand. So I forced calm on my myself and then I imposed order on the situation”

This illustrates the impact of stress on performance – moving into the zone of raised HR and impairment of cognitive skills, with risk of loss of situational awareness and task saturation. Compartmentalising the problem allowed a solution – in this case, I believe regular use of checklists (as well as team training and crisis management) allowed the expert pilot to realise standard options are exhausted and to improvise.

Regular training, standardisation and checklists to ensure task completion allow us to develop both individual and team cognitive resilience. 

There is published evidence that use of a checklist for out-of-theatre RSI both reduces error and takes no longer than non-use (“Checklist for emergency induction of anaesthesia in critical care” Babolhavaeji, F. et al, Anaesthesia 2013 68 655-661)

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(iv) There is evidence for beneficial use of checklists

This leads on from the above. Critics say that there is no evidence for checklists and that as such they should not be adopted. Most of the work comes from simulation…but as mentioned previously, there is no reason NOT to extrapolate from simulation, given the known problems of under-reporting of error in healthcare and the relative infrequency of crisis during training and subsequent professional career.

Stiegler et al (2012) highlight cognitive errors in as many as 50% of simulated anaesthetic crises – a sobering fact. Moving on from demonstrating error alone in simulated crisis management, Arriaga et al (2013) demonstrate an almost 75% reduction in error rate during simulated surgical crises when comparing management with checklists (6%) vs without (23%). 97% of clinicians involved in this trial expressed a preference for checklist use.

“If I were having an operation & experienced this intraoperative emergency, I would want the checklist to be used” 

One of the key recommendations from the UK’s NAP4 study was for use of an intubation checklist to be used alongside capnography in all remote site emergency airway management situations involving critically ill patients, as they have been shown to significantly reduce complication rates (Wijesuriya & Brand, 2014). Learning from NAP4, the recent introduction of a package of RSI checklist in all out-of-theatre intubations in a UK NHS trust lead to improved confidence in managing such situations and has been enthusiastically adopted locally, with suggestions to implement across other institutions.

There is recent evidence for a 50% reduction in the risk of desaturation for children undergoing RSI in a paediatric emergency department. That is impressive. Here’s the checklist user by Kerrey et al in the USA to reduce error in paediatric RSI :

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In Australia, the Royal North Shore Hospital ED published an important piece of work highlighting the performance of ED RSI in their institution. It makes for sobering reading, highlighting problems of skill fade, infrequent use of a bougie and complications in 29%. Kudos to the authors for publishing and more importantly, for using this audit to drive change in their institution and elsewhere. Fogg and colleagues have established an updated RSI checklist and are calling for other to join the audit of ED RSI via

Implementing change in medicine takes time. Yet high-performance teams such retrieval services are also enthusiastic early adopters of checklists – they understand the impact of human factors on crisis management, and even despite regular training will adopt cognitive aids and check tools into daily routine because of perceived benefits. And you think you are too cool or too good to need a checklist et these guys do? Come on!

Even Minh agrees – he is on the record talking at SMACC 2013 about “Airway Clean Kills(slideset available here).  Intubation offers you many ways to kill your patient.  Checklists can help avoid some of them as usually Minh espouses…


Slide from “Airway Clean Kills” by Dr Minh Le Cong, SMACC2013

Anaesthetist Dr Mark Knights, whose team in Wales, UK demonstrated less error and no delay in use of an RSI checklist, puts this well :

We do a lot of things in medicine that are costly and the evidence of benefit is marginal.  A lot of the more recent improvements in critical care are about doing the simple things well (ie care bundles for ventilation, central venous catheters, etc.) We do know that poorly conducted airway management causes significant morbidity and mortality and that there is particular risk of this in ED/ICU.  (NAP4).  Using a checklist is simple, free and should  improve the standard of intubations (we have shown that it does in simulations).  To quote Atul Gawande “Better is possible.  It does not take genius. It takes diligence

Arguments Against Checklists

We have covered (and debunked) some of these above. Anaesthesia has been embracing lessons of crisis resource management for almost 25 years, with development of guidelines, algorithms, crisis action cards and checklists as a result. Whilst the weight of evidence for checklists has been demonstrated in routine procedures (elective surgery, central line insertion), there is emerging evidence that checklist use not only reduces error, but also does not cause delay in a crisis. Indeed, regular use may enhance performance in a crisis.

Much of this work has come from simulation – necessary given the problems of error reporting and relative infrequency of crises – but savvy experts who understand the limitations of crisis management even by experts are adopting checklists into their practice, guided by evidence from audit and the emerging evidence of benefit.

Of course checklists are not a panacea for all ill. Merely having a checklist won’t ward off disaster. Neither is a crisis the ideal time to implement a checklist – they need practice, buy-in from team members and regular rehearsal. They need to kept simple and only used for high-risk, tightly-coupled procedures where omission of steps can lead to disaster. Checklist fatigue is a real danger, as is the ‘tick and flick’ mentality of filling in boxes or ‘just another piece of paper’.

Ideal checklists should be kept as a laminated sheet for reference, not for filling in. The items are read as a challenge-response to enable the expert and team to avoid cognitive error in a crisis.

Design is key – a poorly designed or inappropriate checklist is worse than useless. They need to be relevant, simple and adapted to local use.

Have a look at some of the examples below and see if they fulfil the criteria.


Introducing The Vortex

The Vortex is a cognitive tool that we demonstrated in the Airway Workshop. I’ve seen it used effectively on the ETMcourse and seeing it in use by experts and novices alike is one of those ‘lightbulb’ moments of clarity. It neatly simplifies previously complex airway management algorithms into a “high stakes cognitive aid” – simple enough to be recalled in a crisis and flexible enough to be used in any context.

If you missed the workshop, check out The Vortex via There is a neat video demonstrating the ‘read aloud’ manner of a sensible and well-designed checklist in a crisis.


@NicholasChrimes “#Vortex is a checklist. Prompts the enactment of training in crisis”


@NicholasChrimes “#Vortex - It’s a novel checklist, for broad strategies not exhaustive, designed for real time crisis Mx”



Nick was kind enough to email me some ‘ammo’ in the argument PRO checklists – particularly poignant as he knows how much Minh loves The Vortex approach (as do I) :

“the Vortex is essentially an innovative graphic representation of a simple checklist for 4 airway techniques & 5 categories of optimisation manoeuvre. The graphic representation allows it to also convey additional elements of urgency (in the funnel) & safety (in the green zone) as well as facilitating use by the whole team”

So – it’s a checklist & cognitive aid – one which Minh endorses. Game – Set – Match.


Here are more examples of checklists used by airway experts :














From Bangor, Wales (authors of study demonstrating use of checklist did not delay intubation and reduced error rates in out-of-theatre airway management). Click to read their presentation via slideshare.

RNSH Checklist

Checklist from from the Royal North Shore Hospital ED via - see also commentary from Cliff Reid at


The above checklist is from George Douros of Austin Health (Victoria, Australia) and is discussed over in an article at It’s simple and well laid out.

Another RSI checklist

This example is from Yen Chow in Thunder Bay (Ontario, Canada). He’s a co-author on Minh’s excellent site and posts on PHARM about the benefits of checklists here. Check it out.

Click link below to download

Remembering that a true checklist is a “check of what has been done” not a “how to do it read-do”, I use the above in my ED and prehospital bag – works really well as a challenge-response checklist in the final minute before intubation and has the added bonus of a ‘kit dump’ to help layout kit – especially useful if enlisting helpers who may be unfamiliar with the kit.

 This has been modified from similar checklist mats used by retrieval services in Australia and the UK. This and a smaller ‘checklist action card’ is available for download and adaptation from the anaesthesia resources section of the site, along with an ED/Theatre Crisis Checklists pdf for iPad.


The above modification of an RSI kit dump and checklist is courtesy of Dr John Hinds from Eire – the essential item is in bottom right corner, concerning cricoid pressure….

Obs RSI checklist


Scott Weingart has weighed in on checklists – his version is above and can be downloaded here. I think one has to weigh up the pros of being all inclusive vs ease-of use.

With this in mind, I reckon the BEST checklists are those that are simple, easy to follow and limited to just key items. They should read as checks, not ‘to do’, although the latter blurs the line between checklists proper and cognitive aids or more complex crisis algorithms.


The above ‘checklist for checklists‘ is from – an excellent site which discusses checklist design and implementation.

Of course, checklists are not a panacea for all – they are but one extra layer of defence against error. Checklist implementation requires appropriate leadership, training and organisational change and must take place against a background of embracing human factors into a safety culture. This is discussed more in the book ‘Beyond the Checklist‘. In case you were dead set against checklists – don’t worry, the patients will be doing it for you – here is a checklist for patients to assess the teamwork & safety of their clinicians!

Beyond the CL

As EM IM Doc states in the “Ch…ch…ch…check it out; ED RSI Checklists” blog post – to create a practical checklist, consider the following:

  • Design each item to address a specific, actionable, critical safety step
  • Make it short and easily understandable
  • Utilize natural breaks in work-flow
  • Build it in to your process and delegate a team member
  • Review, Revise and Refine

The last word (for now) should go to Atul Gawande – writing in the Incidental Economist “When Checklists Work & When They Don’t“, he comments on checklists and their naysayers, saying “there is one thing we know for sure: if you don’t use it, it doesn’t work

 In Summary – Real Airway Experts use Checklists


Theatre checklists


Recommended Books

“An astronauts guide to life on earth” Chris Hadfield 2013 Macmillan

“Better – a surgeon’s notes on performance” Atul Gawande 2008 Profile Books

“Beyond the Checklist – what else healthcare can learn from aviation teamwork & safety” Suzanne Gordon, Patrick Mendenhall & Bonnie Blair O’Connor 2013 Cornell University Press

“Complications – a surgeon’s notes on an imperfect science” Atul Gawande 2002 Profile Books

“Crew resource management” barbara Kanki, Robert Helmreich & Jose Anca 2010 Academic Press

“The Checklist Manifesto – how to get things right” Atul Gawande 2010 Profile Books

“On Combat – the psychology & physiology of deadly conflict in war and in peace” Dave Grossman  2004 Warrior Science Publications

“Patient Safety” Charles Vincent 2010 BMJ Books

“Patient safety in emergency medicine” Pat Croskerry, Karen Cosby, Stephen Schenkel & Robert Wears 2009 Lippincott, Williams & Wilkins

Recommended Sites



CRISIS CHECKLISTS – via Brigham & Women’s Hospital projectcheck


EMERGENCY MANUALS – great list of refs at







In favour of checklists :

Arriaga A., Bader A., Wong J., Lipsitz S., Berry W., Ziewacz J., Hepner D., Boorman D., Pozner C., Smink D. & Gawande A. (2013) Simulation-based trial of surgical-crisis checklists The New England Journal of Medicine 2013 368 (3) : 246

Augoustides J., Atkins J. & Kofke W. (2013) Much ado about checklists: who says I need them and who moved my cheese 2013 Anesthesia & Analgesia 2013 117 (5) 1037

Babolhavaeji F., Rees I., Maloney D., Walker J. & Knights M. (2013) Checklist for emergency induction of anaesthesia in critical care Anaesthesia June 2013

Bates D. & Gawande A. (2000) Error in medicine: what have we learned? Annals Int Med (2000) 132 9 : 763

Braude D. (2008) Checklists : simple but overlooked solution to airway complexities Emergency Medicine News 2008 30 (5) 16

Dieckmann P. & Rall M. (2005) Safety culture and crisis resource management in airway management: General principles to enhance patient safety in critical airway situations Bailliere’s Best Practice in Clinical Anesthesiology 2005 19 (4) 539

Fogg T., Annesley N., Hitos K. & Vassiliadis J. (2012) Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia EMJ 2012 24 617

Gaba D. (2010) Crisis resource management and teamwork training in anaesthesia British Journal of Anaesthesia 2010 105 (1) 3

Gaba D. (2013) Perioperative cognitive aids in anesthesia: what, who, how and why bother? Anesthesia & Analgesia 2013 117 (5) 1033

Goldhaber-Fiebert S. & Howard S. (2013) Implementing emergency manuals: can cognitive aids help translate best practice for patient care during acute events? 2013 Anesthesia & Analgesia 117 (5) 1149

Hales B., Terblanche M., Fowler R & Sibbald W. (2008) Development of medical checklists for improved quality of patient care Int J Quality in Health Care 2008 20 (1) 22

Hoffman L. (2013) Crisis checklists improve management of rarely occurring events Critical Care Alert 1st Sept 2013

Huang L., Kim R. & Berry W. (2013) Creating a culture of safety by using checklists AORN 97 (3) 365

Hunter D. & Finney S. (2012) Follow surgical checklists and take time out, especially in a crisis BMJ 2012 344 1136 d8194

Keane M. & Marshall S. (2010) Implementation of the World Health Organisation surgical checklist : implications for anaesthetists Anaesthesia & Intensive Care 2010 38 (2)

Kerrey, B.Y. et al (2013) Improving the safety of Rapid Sequence Intubation in a Pediatric Emergency Department. Abstract presented at American Academy of Pediatrics Conference, Orlando Oct 26-29 2013 Accessed 9 March 2014 via

Leape L. (2014) The Checklist Conundrum NEJM 2014 370 11 1064

Lichitor, L. (2012) Pilots use checklists. Why don’t anaesthesiologists do the same? - [accessed 2 Feb 2014]

Low D., Reed M., Geiduschek J. & Martin L. (2013) Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project Pediatric Anesthesia 2013 571

Mackenzie R., French J., Lewis S. & Steel A. (2009) A pre-hospital emergency anaesthesia pre-procedure checklist SJTREM 2009 17 (supp 3) O26

Marshall S. (2013) The use of cognitive aids during emergencies in anaesthesia: a review of the literature Anesth Analg 2013 117 : 1162

McIlvaine W. (2006) Human error and its impact on anesthesiology Seminars in Anaesthesia, Perioperative Medicine & Pain 2006 25 : 172

Myburgh J., Chapman M., Szekely S. & Osborne G. (2005) Crisis management during anaesthesia: sepsis  Qual Saf Health Care 2005 14 e22

Mulroy M. (2013) Emergency manuals: the time has come Newsletter of the Anesthesia Patient Safety Foundation 2013 28 (1) 1

O’Leary, F., McGarvey K., Christoff A., Major J., Lockie F., Chayen G., Vassiliadis J. & Wharton S. (In Press) Identifying incidnets of suboptimal care during paediatric emergencies – an observational study utilising in situ and simulation centre scenarios Resuscitation (2013)

Pace G. &  Carmignani L. (2012) Checklists: are really necessary in the routinely clinical practice? Int. J. Surgery 10 (2012) : 169

Rall M. & Dieckmann P. (2005) Safety culture and crisis resource management in airway management: general principles to enhance patient safety in critical airway situations Clinical Anesthesiology 2005 19 (4) 539

Runciman W., Morris R., Watterson L., Williamson J. & Paix A. (2005) Crisis management during anaesthesia: cardiac arrest Qual Saf Health Care 2005 14 e4

Schmutz J. & Manser T. (2013) Do team processes really have an effect on clinical performance? A systematic literature review British Journal of Anaesthesia 2013 110 (4) 529

Sibbald M., de Bruin A.B.H. & van Merrienboer J.G. (2013) Checklists improve experts’ diagnostic decisions Medical Education 2013 47 301

Siriwardena A., Shaw D., Togher F., Davy, Z., Spaight A. & Dewey M. (2014) The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England Implementation Science 2014 9 : 17

Stiegler, M.P., Neelankavil J.P., Canales C. & Dhillon A. (2012) Cognitive errors detected in anaesthesiology: a literature review and pilot study British Journal of Anaesthesia 2012 108 (2): 229–35

Thomassen, O., Espeland A., Softeland E., Lossius H., Heltne J. & Brattebo G. (2011) Implementation of checklists in healthcare; learning from high-reliability organisations SJTREM 2011 19 53

Tobin, J., Grabinsky A., McCunn M., Pittet, J-F., Smith C., Murray M. & Varon A. (2013) A checklist for trauma and emergency anaesthesia Anesth Analg 117 (5) : 1178

Walker I., Reshamwalla S. & Wilson I. (2012) Surgical safety checklists: do they improve outcomes? British Journal Anaesthesia 2012 109 (1) 47

Weingart S. (2012) Podcast 92 – EMCrit intubation checklist [accessed 2 Feb 2014]

Winters B., Gurses A., Lehmann H., Sexton B., Rampersad C. & Provonost P. (2009) Clinical review: checklists – translating evidence into practice. Critical Care 2009 12 : 210

Wijesuriya J. & Brand, J. (2014) Improving the safety of remote site emergency airway management – Accessed 9th March 2014 via

Wittenberg M.D., Vaughan D.J.A. & Lucas D.N. (2013)  A novel airway checklist for obstetric general anaesthesia International journal of obstetric anesthesia 2013 22 (3) 264


Caveats re: checklists

Bosk C.L., Dixon-Woods, M., Goeschel C.A. & Provonost P. (2009) Reality check for checklists. Lancet 2009 374 444

Carthey J., Walker S., Deelchand V., Vincent C. & Griffiths W. (2011) Breaking the rules BMJ Sept 2011 343 621

Ko H., Turner T. & Finnigan M. (2011) Systematic review of safety checklists for use by medical care teams in acute hospital settings – limited evidence of effectiveness BioMedCentral - Health Sciences Research 2011 11 : 211

Maxfield D., Grenny J., Lavandero R. & Groah L. (2005) The silent treatment: why safety tools and checklists aren’t enough to save lives [accessed 3 Feb 2014]

Sparks E., Wehbe-Janek H., Johnson R, Smythe W. & Papaconstantinou H. (2013) Surgical safety checklist compliance: a job done poorly J Am Coll Surg 2013 1

Urbach et al (2014) “Implementation of surgical checklists in Ontario, Canada” N Engl J Med 2014 370 : 1029-38

Waehle H., Haugen A., Softeland E. & Hjalmhult E. (2012) Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room BioMedCentral - Nursing 2012 11 : 16


General reading on error, distraction & crisis resource management :

Campbell G., Arfanis K. & Smith A. (2012) Distraction and interruption in anaesthetic practice British Journal of Anaesthesia 2012 109 (5) 707

Heard G (2005) Errors in anaesthesia – a human factors perspective Australian Anaesthesia 2005

Kahneman D. & Klein G. (2009) Conditions for intuitive expertise : a failure to disagree American Psychologist 2009 64 (6) 515

Marshall S (2010) Simulation-based education for building clinical teams J Emerg Trauma Shock 2010 3 (4) 360

Tannenbaum S., Mathieu J., Salas E. & Cohen D. (2012) Teams are changing : a research and practice evolving fast enough Industrial & Organisational Psychology 5 2




Abbreviated flight checklist

IVF checklist



Dr T is embarking on an intense 6 month programme of training prior to the debate with Dr le Cong

Dr T is embarking on an intense 6 month programme of training prior to the debate with Dr le Cong



Screen Shot 2013-12-25 at 2.27.34 pm




I KNEW IT ! Minh demonstrates the KIdocs version of kit dump - and RSI challenge-response checklist

I KNEW IT ! Minh demonstrates the KIdocs version of kit dump – and RSI challenge-response checklist



One of the criticisms of checklists is that there is “no evidence that they work”. As I keep suggesting to Minh, try jumping out of an aircraft without a parachute. There’s never been a randomised controlled trial on the effectiveness of parachutes.

Astute readers will be aware that absence of evidence doesn’t equate to evidence of absence, as the authors of this classic BMJ paper state :

“Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute”

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 More General Papers


Why Use Emergency Manuals: Evidence From Medicine

Babcock W. Resuscitation during Anesthesia. Anesth Analg 1924;3:208-13
Berkenstadt H, Ben-Menachem E, Dach R, Ezri T, Ziv A, Rubin O, Keidan I. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the Israeli board of anesthesiologists. Anesth Analg 2012;115(5):1122-6
Gaba DM. Human error in dynamic medical domains. In:  Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc, 1995:197-224
Gaba DM. Human error in anesthesia mishaps. Int  Anesthesiol Clin 1989;27(3):137

Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg 2009;250:1029-34    

Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth 1998;45:130-2    

Lipman SS, Daniels KI, Carvalho B, Arafeh J, Harney K, Puck A, Cohen SE, Druzin M. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol 2010;203:179.e1-5

Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation 2006;68:101-8    

Smith KK, Gilcreast D, Pierce K. Evaluation of staff’s retention of ACLS and BLS skills. Resuscitation 2008;78:59-65   

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth 2012;108(2):229-35
Steigler MP, Ruskin KJ. Decision-making and safety in anesthesiology. Curr Opin Anaesthesiology 2012;25:724-9

Why use Emergency Manuals: Evidence from high-stakes industries, psychology, and human factors


Accident report: Loss of thrust in both engines after encountering a flock of birds and subsequent ditching on the Hudson River. National Transportation Safety Board. 2010

Psychology and Human Factors

Committee on Quality of Healthcare in America. To Err Is Human: Building A Safer Health System. Vol. 6. Kohn LT, Corrigan J, Donaldson MS, eds.Washington, D.C.: National Academy Press, 2000
Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol 2009;64(6):515
Klein G. Naturalistic decision making. Hum Factors 2008;50(3):456-60
Orasanu J, Connolly T. The reinvention of decision making. In: Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision Making in Action: Models and Methods. Norwood, NJ: Ablex Publishing Co, 1993:3-20
Tversky A, Kahneman D. Judgement under uncertainty: heuristics and biases. Science 1974;85(41257):1124-31


Driskell JE, Salas E, Johnston J. Does stress lead to a loss of team perspective? Group Dynamics: Theory, Research, and Practice1999;3:291

Checklists and Cognitive Aids From Non-Emergency Settings in Medicine

Abbett SK, Yokoe DS, Lipsitz SR, Bader AM, Berry WR, Tamplin EM, Gawande AA. Proposed Checklist of Hospital Interventions to Decrease the Incidence of Healthcare-associated Clostridium Difficile Infection. Infection Control and Hospital Epidemiology. 2009;30(11):1062-9
Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32(10):2014-20

Birkmeyer JD. Strategies for improving surgical quality–checklists and beyond. N Engl J Med 2010;363:1963-5

Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. Br J Anaesth 2009;103(4):570-5
Dellinger RP, Vincent JL. The surviving sepsis campaign sepsis change bundles and clinical practice. Crit Care 2005;9(6):653-4

Gawande A. The checklist manifesto: how to get things right. 1st ed. New York: Metropolitan Books    

de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37    

Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care 2006;21(3):231-5
Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008;20(1): 22-30

Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9    

Mills PD, DeRosier JM, Neily J, McKnight SD, Weeks WB, Bagian JP. A cognitive aid for cardiac arrest: you can’t use it if you don’t know about it. Jt Comm J Qual Saf 2004;30(9):488-96

Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700    

Nelson KL, Shilkofski NA, Haggerty JA, Saliski M, Hunt EA. The use of cognitive AIDS during simulated pediatric cardiopulmonary arrests. Simul Healthc 2008;3(3):138-45
Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality of Care in US Hospitals. Health Affairs. 2010; 29(9): 1593-1599
Spector, J. M., Agrawal, P., Kodkany, B., Lipsitz, S., Lashoher, A., Dziekan, G., … & Gawande, A. (2012). Improving quality of care for maternal and newborn health: prospective pilot study of the WHO Safe Childbirth Checklist Program. PLoS One7(5), e35151

van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 2012;255:44-9

Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz, S. R., & Gawande, A. A. (2010). Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Annals of surgery251(5), 97

Checklists, Cognitive Aids, and Manuals in Operating Room Emergencies

Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal Of Medicine 2013;368:246-53
Augoustides, John G. T. MD, FASE, FAHA; Atkins, Joshua MD, PhD; Kofke, W. Andrew MD, MBA, FCCM. Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?. Anesth Analg. 2013 November.

Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simulation in Healthcare. 2012 Feb; 7: 1-9.

Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesiology. New York: Churchill Livingstone; 1994    

Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg 2006;103:551-6    

Goldhaber-Fiebert SN, Howard SK. Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events?. Anesth Analg. 2013 Oct [E-pub ahead of print]
McEvoy MD, Smalley JC, Field LC, Furse CM, Rieke H. Use of cognitive aids significantly increases retention of skill for management of cardiac arrest. Abstract. American Society of Anesthesiologists Annual Meeting 2010
Moitra VK, Gabrielli A, Maccioli GA, O’Connor MF. Anesthesia advanced circulatory life support. Can J Anesth 2012; 59: 586-603
Mulroy, Michael. Emergency Manuals: The Time Has Come. Anesthesia Patient Safety Foundation; June 2013.
Neal JM, Hsiung RL, Mulroy MF, Halpern BB, Dragnich AD, Slee AE. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med 2012;37(1):8-15
Neily J, DeRosier JM, Mills PD, Bishop MJ, Weeks WB, Bagian JT. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Saf 2007;33(8):502-11
Podraza Stiegler, Marjorie and Sara Goldhaber-Fiebert. “Cognitive Errors and Cognitive Aids in Anesthesiology”. Patient Safety Newsletter. 77-5 May 2013: 10-12

Runciman WB, Webb RK, Klepper ID, Lee R, Williamson JA, Barker L. The Australian Incident Monitoring Study. Crisis management–validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:579-92    

Runciman WB, Merry AF. Crises in clinical care: an approach to management. Qual Saf Health Care 2005;14:156-63
Tobin, J. M., et al. A Checklist for Trauma and Emergency Anesthesia. Anesthesia and analgesia. 2013.
Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213:212-7 e10

Clinical Guidelines for Emergencies

Crew Resource Management, Team Training and Simulation-Based Training

Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual 2007;22(3):214
Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007;33(6):317-25
Gaba DM, Howard SK, Fish KJ Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience.Simulation & Gaming 2001;32(2):175-93
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents.Aviat Space Environ Med 1992;63(9):763­-70
Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises.J Clin Anesth 1995;7:675-87
McGaghie WC, Draycott TJ, Dunn WF, Lopez CM, Stefanidis D. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011;(6):S42-7
Moorthy K, Vincent C, Darzi A. Simulation based training. BMJ 2005;330:493-4


Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective Surgical Safety Checklist Implementation. Journal of the American College of Surgeons. 2011; 212: 873-879
Heath C, Heath D. Switch: How To Change Things When Change Is Hard. New York: Random House, Inc., 2010

Designing Checklists and Cognitive Aids

Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, Gawande AA. Perspectives in quality: designing the WHO Surgical Safety Checklist. International Journal for Quality in Health Care. 2010;22(5):365-370


Levitan Airway Workshop

So as a pre-smaccGOLD prelude, I was able to join the Levitan Airway course held in Sydney at the Royal North Shore simulation lab run by John Vassilliadis and team. I’ve been to this sim centre before, for both the Effective Management of Anaesthetic Crises course and as adjunct to the Rural Doctors NSW conference. For those who haven’t, it’s a top notch facility on the North Shore.

The RNSH Team have run four Levitan courses  so far, with more planned. Levitan also runs these courses in the States.


Scott Weingart was right – Rich Levitan is an engaging speaker and manages to convey important airway messages in a mix of didactic lectures, group discussions and practical hands on.  For those who don’t know, he’s the author of the ‘Airway Cam‘ book

I’d read Levitan’s book before, and to be honest despite being engaged in an anaesthetic training programme at the time, it wasn’t until reading this book that the subtleties of intubation ‘gelled’ for me.

More than anything, I was humbled to learn that Levitan now works as a rural doc himself, downsizing from the GSW-laded high-adrenaline of Philadelphia ED to a small community hospital of 25 beds in North Hampshire. More importantly, he speaks authoritatively and with great use of body language and anecdote to convey messages on airway management.

I was literally grinning from ear-to-ear after the first fourm as all the pearls from FOAMed airway management were distilled into bite-sized chunks for digestion. It was also great to see 100% hands up in response to the question “who uses NODESAT in their practice” – I’ve sat in anaesthetic “refresher” courses in the past two years, where this concept has been unheard of – by Faculty! Truly FOAMed is changing the way we practice…

Synopsis & Content

Day One was mostly lectures, with some minimal hands-on work in a nasoendoscopy session. Rather than fibreoptic, we use CMOS ‘chip on a stick’ tools (great lumens, less visual distortion) to perform nasoendoscopy either on ourselves or colleagues. Amazingly we were able to achieve this without topicalisation for the most part.

Feel the burn - Dr Anand Senthi (@DrSenthi) navigates my turbinates

Feel the burn – Dr Anand Senthi (@DrSenthi) navigates my turbinates

Dr Fran Lockie (the original model for Mr Hurt mannikin) "volunteers"

Dr Fran Lockie (the original model for Mr Hurt mannikin) “volunteers”

Rich Levitan helps Dr Senthi self-scope  "left a it, right a bit - hang on, wait - is that semen in your piriform fossa?"

Rich Levitan helps Dr Senthi self-scope “left a bit…now right a bit…hang on, wait – is that semen in your piriform fossa?”

Clear cords, relief...

Clear cords, relief…

The rest of the day was spent discussing airway pearls – difficult cases, the use of DL vs VL, the mantra of OOPS (Oxygen On, Pull mandible forward, Sit patient up), using high-flow nasal cannulae to deliver oxygen as apnoeic diffusion oxygenation (NODESAT), ramping or elevation of the head the patient into an ear-to-sternum and breaking airway management down into parts – with epiglottoscopy as the key.

More than anything though, Levitan emphasised the impact of stress on performance in a crisis, the need for simplified airway crises algorithms (needless to say, The Vortex got a plus) as well as enabling team-buy in via use of checklists EVEN IN A CRISIS. There are even rumours of involving a psychologist on future courses…

RSI, parachuting and difficult airway kit

I’ve always considered RSI as a procedure needing total commitment. I’ll talk a little more about this at smaccGOLD (in the RSI checklist debate) – but essentially it’s a tightly-coupled potentially high-risk procedure. A bit like BASE jumping.

Levitan tells an anecdote of the EM & Anaes doc approach. Anaesthesia has a low tolerance of risk – whereas EM may have to embrace it. Picture the scene – an anaesthetist and an EM doc decide to go sky-diving. The anaesthetist turns to his Em colleague and says “Hey mate – you ED docs are risk takers – why don;t you use my OLD parachute? It’s not that reliable…in fact, I’ve replaced it with this brand new one which is far better“. Do you think the ED doc would take that risk? …and yet when anaesthesia turns around to ED and says “We’re getting rid of our old airway kit, do you guys want it?” the ED docs say “Hell yes!

We really shouldn’t accept a lesser standard of care. Whether in ED, prehospital or rural. My bugbear is making sure that rural docs have the right kit and skill set to deal with the difficult airway or trauma RSI – but they need the kit.

Day Two was a day in the cadaver lab; I don’t know how he gets through customs, but Levitan imported 18 half cadavers (heads and thorax, no abdomen/pelvis or limbs) prepared in such a way that tissue elasticity is preserved and can be intubated in a variety of ways using varied kit. There really is no better way than repeated practice at laryngoscopy. This was mostly a re-hash of established routine, with emphasis on

  • determination of eye dominance for intubation
  • focussing on larygnoscope grip, proper positioning of self and patient to ensure maximal mechanical advantage with minimal effort
  • breaking intubation down into stages – epiglottisoscopy, identification of interarytenoid notch, then maximising view of the laryngeal inlet

I am not a huge fan of stylets, preferring the bougie held in a ‘Kiwi grip’ as taught to be by Paul Baker of the ANZCA Difficult Airway SIG. But I was glad to practice the ‘straight-to-cuff’ technique of stylet, approaching laryngeal inlet from below without interruption to visual axis. Manouevres were practiced that I’ve learned through experience or FOAMed (not through formal anaesthetic teaching), such as rotating stylet right to enter trachea without impingement on the tracheal rings and my all-time favourite ‘the flip-flop’ manoeuvre as illustrated below (from GSA-HEMS, natch) for advancing ETT on bougie.

Flip-Flop manoeuvre to avoid R arytenoid hangup when railroading ETT over bougie, via GSA-HEMS

Flip-Flop manoeuvre to avoid R arytenoid hangup when railroading ETT over bougie, via GSA-HEMS

Further cadaver work included placement of a variety of LMAs, although disappointingly not the Air-Q II ‘Cook Gas’ (I’ve got these second-generation iLMAs on Kangaroo Island). I reckon the Air-Q II holds the advantages of an iLMA with bite block, gastric drainage port and allows wither blind or fibreoptic intubation – the latter with either malleable stylet or a flexible scope. There’s none of that faffing around with the FastTrach that causes problems (thin the infamous Gordon Ewings case) and has become my ‘go to’ device for maintenance of ventilation in a difficult airway.

A short session on videolaryngoscopes followed, including use of the AP-Advance, C-Mac (although disappointingly not the pocket C-Mac) KingVision and McGrath devices, as well as practice with fibreoptic and CMOS-type flexible scopes.

No airway workshop is complete without practice of a surgical airway. I’m in the rather unusual position of having done five now (one in ICU, two in ED two prehospital) – and from the initial muppet show that was my first (needle-over-wire, truly traumatic) I have reflected and refined this, now preferring a scalpel-finger/bougie-tube technique. But even on this, I was able to refine skills – Levitan teaches the ‘laryngeal handshake’ approach. I found that shutting my eyes and performing this manoeuvre allowed rapid identification of the cricothyroid membrane on all of the 18 cadaver specimens. Moreover, focussing on position (hand resting on sternum to perform scalpel incisions) was a useful pearl. Of course the surgical airway is a primarily tactile procedure, and the chance to identify and feel the CTM on 18 specimens is an opportunity rarely afforded. using the laryngeal handshake works – with 100% success in rapid (2-3 seconds) identification of the CTM on the cadavers supplied.

It was also great to see the Cric-Knife & CricKey. I’d heard about this via Minh le Cong at and it’s been covered recently by Weingart (click here). It was lovely to get hands on with this very simple device. The integral tracheal hook that slides off immediately after CTM puncture was simplicity itself. The actual ET tube itself (CricKey) has features of a bougie – and helps give tactile feedback that operator is in the trachea not a false passage. Good to see Levitan realises the inherent benefits of a bougie over a stylet (TFIC – there was a bit of good-natured “bougie-bashing” over the course, reflecting differences in North America vs Australian practice).

Only one criticism – the actual ET tube is deformable and can potentially kink (thanks Jon Gatward for pointing this out). Unless this is fixed I may just stick with a size 6.0 ET if I ever have to do a sixth “crike”. But I am so tempted to get a couple of these – both for my CICO kit in ED/theatre, but also to demo on EMST-ATLS where the ridiculous scalpel/invert use handle technique is still considered ‘the ATLS way’


Rich Levitan with AirwayCam on head, CricKey at the ready…




As always, an airway course like this attracted similar enthusiasts – the usual mix of intensivists, retrievalists, anaesthetists and the odd rural doctor. A chance to meet old mates and make some new friends. I think I’ve persuaded a few more people to come visit Kangaroo Island…but whether we get Levitan there is another story!

I’d recommend this course for the experienced airway operator, looking to incorporate some finesse and FOAMed goodness to his or her practice.

Any suggestions for the future? Perhaps less of the (fascinating and entertaining) didactic lectures…a bit more of the interactive case discussions or small group work. And a summary session at the end to ‘close’ the course and thanks all those who participated cleaning scopes, helping out with nasoendoscopy etc – John’s team (inc stalwarts like Toby Fogg and Jon Gatward) plus the sim centre staff and numerous airway equipment reps ensured that attendees always had hands full of airway gadgets. But these are minor criticisms.

The bottomline is that you CAN improve your practice, even by making very small changes – the so called “aggregation of marginal gains”.

If you are serious about airway management, particularly in an emergency setting and looking for some finesse to your practice or how you yourself teach others, then this course is worthwhile.


Guerilla Sim taking off….

Like many other FOAMites, I am frantically putting finishing touches to my talks for smaccGOLD, the forthcoming critical care conference up in the Gold Coast.

Meanwhile the daily grind of work continues. I remain fascinated with the power of FOAMed to narrow the knowledge translation gap and bring clinical concepts with tangible benefits to the bedside for improved patient care. Along with the dissemination and discussion of ideas via FOAMed, like others I am interested in how best to practically apply knowledge learned. FOAMed has encouraged me not just to keep up with the literature relative to my field, but also to consider concepts such as clinical decision making and some of the barriers to practical implementation of knowledge.

Decision-making in a crisis is something I am passionate about. Simulation training and exploring human factors would seem to have a lot to offer to reduce clinical error, improve patient care and streamline systems – yet it is not something which is common in my arena of rural medicine.

All too often, rural clinicians (doctors, nurses and volunteer paramedics) engage in CPD updates that are either metrocentric, or infrequent. For us rural doctors, the usual round of alphabet-soup LS courses (ATLS, APLS, ALSO, REST.RESP etc) do not address human factors in clinical performance – despite the wealth of evidence of the importance in avoiding error. Similarly the rural nurses with whom I work are mandated to perform annual ALS updates and online moodle-based learning – which may tick boxes but doesn’t necessarily translate into clinical effectiveness. Moreover due to the contractual basis of rural doctors in SA (we are mostly VMOs, under fee-for-service), there is no allowance for team-training.

I must admit that I didn’t used to think about this. Instead I plodded along, accruing my usual CPD points each triennium and yet remained frustrated that that it was hard to ‘make things happen’ in a rural resus. At the same time I teach and direct on ATLS-EMST, and although this course has value in teaching ‘one safe way’ of managing trauma, it does not address teamwork and human factors which are pivotal to success.

Now that can change.

Perhaps the best way of truly understanding crisis management and patient safety is that outlined by Andrew Petronosiak, currently in Toronto. He describes a ‘Triple Threat’ approach integrating :

  • mental model theory for team and task processes,
  • training for stressful situations
  • and metacognition & error theory

all of which lead towards a more comprehensive training paradigm than traditional methods.

Why does this matter? CRM isn’t part of the usual training we get at medical school or postgraduate training, nor on the various LS courses (EMAC & the ETMcourse being notable exceptions). If you ever had any doubts about the value of CRM, watch this powerful pecha kucha entry from @TamaraHills for the smaccGOLD conference. Then tell me you think CRM doesn’t matter…



“Simulation – training hard in order to fight easy”

iSimulate is an affordable simulation setup, comprising two iPads and a medical equipment bag, plus assorted monitoring. It allows one iPad to be controlled by a facilitator, controlling the student iPad housed within the equipment bag in a realistic looking package. One can control HR, RR, BP, SpO2, ETCO2, temperature…throw in various rhythms, trend parameters over time, set up and store scenarios, pace, defibrillate. It even has a CTG package.

It is being used by retrieval services such as medSTAR, GSA-HEMS and Auckland HEMS. Many city hospitals use it for training. Even the Govt has got on board with sim, offering education via the NHET-Sim programYet the REAL power of iSimulate (or indeed any other product) is to deliver in situ training using own team, own equipment in so-called high-rep, low fidelity simulation. Jon Gatward gave an excellent talk on the concept of guerilla sim at the smacc2013 talk, which I highly recommend – especially if anyone has doubts about the value of sim training.



Of course sim forms part of the core of crisis resource management – and also opens up the door to the concept of stress inoculation, used in the military and other high-performance units – with obvious implications for emergency medicine. Listen to Weingart and Reid chat about this via the EMCrit blog


Screen Shot 2014-03-02 at 4.05.52 pm


We tried a few sim scenarios as part of the 2013 rural masterclass – mostly aimed at rural doctors who are keen on rural resus and critical care, as well as members of the RERN squad. These seemed to go down well, with scenarios including intubation of an obese, septic patient, dealing with catastrophic haemorrhage, a nightmarish CICO scenario and a perimortem C-section testing the participants.

Yet sadly uptake of simulation from the local hospital has been lacklustre – the reasons for this are not clear, but from what I can gather caveats include :

(i) sim training doesn’t work as well as traditional methods

Uh, no – plenty of evidence showing benefit to sim compared to didactic training. Gatwards’ talk and slideset takes you through that.

(ii) sim training is expensive

Uh, no – whilst many sim trainers are just CRAZY expensive (think the Laerdal models), packages such as iSimulate are relatively cheap. A sim centre costs a few million to set up and tends to be located in a tertiary hospital or medical school; running costs are around $150K per year. iSimulate is less than a twentieth of that cost and has one additional advantage…

(iii) training needs are already met by annual ALS updates

Uh, no – there’s a wealth of evidence that skills fade relatively quickly. Rather than have annual updates which ‘tick the box’, evidence shows it is far better to offer more frequent repetition of sim and preferably embed into routine. If there is a spare few minutes on shift, clinicians are far better served by running a quick sim on site, using own team and equipment than an annual session held in a sim centre or LS course, using different kit.

(iv) sessions need to be specially prepared and debriefed as part of an educational package

Well, maybe. The national NHET-Sim online training gives some structure to those who wish to facilitate sim sessions. There is no doubt that a poorly structured sim and inadequate debrief will not help learning needs. But  my approach is that any sim is better than none. Even a few minutes spent conducting a simulated scenario will throw up interesting information – we’ve discovered that:

  • some beds won’t fit through doors (infamously the bed from labour ward to theatre!),
  • knowledge ‘taught’ cannot be applied (we found that some staff don’t know the location of difficult airway trolley or PPH kit – not a fault of individuals, but an inevitable result of traditional training)
  • expectations of team members will vary (typically the romantic notion that ‘the doctor’ will fix all problems in a crisis rather than understand the limitations of loss of situational awareness, cognitive overload and all the other lessons from human factors)

Debrief is critical. We now try and avoid the Pendleton ‘shit sandwich’ – I tend to use the +/delta model now – and it was gratifying to see Andy Buck and Amit Maini use same on their excellent ETMcourse…which in itself ran lo-fi, high-rep sim as a key part of their trauma training course to highlight importance of teamwork.

(v) must train using the same kit ie: if using Phillips defib, then must use this model to train

Uh, no. One has to distinguish between a task-trained and a sim-trainer. Task trainers are fine for training with one piece of kit eg: the defib, a particualrl infusion pump etc. But this is best done in a small group or in-servce session. Sim trainers allow clinicians to do so much more – to explore complex decision-making in dynamic environments, to run and re-run scenarios with debriefing. To explore impact of human factors on performance and clinical outcomes. Since using sim, initially on an EMAC course and now more routinely in own practice, I have been amazed at how much valuable learning takes place. Far more than one gets from didactic sessions, in-services or mandatory updates.

(vi) annual updates in a sim centre or lead by tertiary hospital specialists are best

Uh, no – all too often such sessions tend to focus on the practice in those institutions. Personally I am fed up to back teeth of going to courses or listening to specialists who tell me that we must have a massive transfusion protocol (uh, we have three units of O neg then it’s on to retrieval +/- walking blood bank), call ENT and a senior anaesthetist for difficult airway (uh, no, we’re on a bloody island with rural GPAs as frontline) or to get a CT head on every PFO (uh, nearest CT scanner is 250km away on the mainland).

Moreover, one of the problems of training in a sim centre or with a ‘sim roadshow’ is that the equipment doesn’t reflect that of the local hospital. In situ training reveals local system errors and local threats – location and use of key equipment being recurrent themes.

(vii) sim sessions take too long to organise

Uh, no. Anytime, anyplace, anyone, anywhere are the maxims of high rep, lo-fi ‘guerilla’ or mobile sim. Clearly the best simulator known to humankind is the brain – and we should engage it whenever possible

For example, every shift the resus trolley is checked. Ratehr than this be a mindless rote exercise of ticking off items in their respective drawers, this ten minute exercise can be turned into a practical and more importantly beneficial training tool. Pull out a piece of equipment (like a 1mg vial of adrenaline) – then ask some questions, preferably scenario-based. “Suppose a patient came into resus this shift and was septic. How would we assess them? What equipment might we need? The MO wants to set up an inotrope infusion – want options do we have? If we only have adrenaline available, how are we going to set up an infusion? How can we determine the dose and rate? Where’s the syringe driver set? Is it compatible with the retrieval service?”

Takes perhaps 15 minutes and embeds some valuable knowledge that may be useful in a crisis.



“Guerilla Sim – Anywhere, Anytime, Anyone”


I am convinced that the best way forward to improve perfromance in rural hospitals will be to integrate sim training into the ethos of daily work. I am using ‘guerilla sim’ with this years PRCC students, so far with good results (in a crisis they have been able to set up IV fluids, apply monitoring and even begin the COAT & review approach at a relatively early stage in their career). But other than a once year visit from the mobile sim lab and the usual mandatory ALS update, such training is not embraced locally. This is a shame – with the evidence showing that ‘how you train is how you fight’, it suggests that health units that do NOT engage in regular sim training are those prepared to be mediocre, not exceptional.

I do hope that Country Health SA will consider embedding sim into country hospitals – current training tends to rely on only once a year annual updates or travel to a sim centre/course. The untapped potential of sim will be to deliver in situ training using own team and equipment as part of regular education. For a relatively cheap cost, packages like iSimulate could be used in every rural hospital. Western Australia Health does this. It’s about time SA did – but will need to come ‘top down’ from the clinical lead for rural emergency and anaesthesia, rather than individual health units choosing their own adventure.



Clinical Human Factors Group – from Martin Bromiley of ‘just a routine operation’ - from John Vassiliaidis and colleagues, mobile and telehealth sim resources online

Guerilla Sim – talk & slideset from smacc2013

MobileSim - from Jon Gatward & Co at Royal Prince Alfred ICU

NHET-Sim – a national project to train educators and technicians to deliver sim

Simulation Training in Emergency Medicine ( – Jo Deverill & colleagues on Sunshine Coast

Sim & Choppers – from HEMs doc and Sim Fellow Andrew Petrosoniak

If you have any doubt about the power of sim, see how GSA-HEMS incorporate into their training “how we train is how we fight” :



See also their ‘smacc2013′ simwars entry – again, featuring use of iSimulate, checklists, team training etc


Guerilla Sim



Change, change, change…

March 6th 2014 is Change Day in Australia.  Change Day  is a movement promoted by individuals working within the health system. It is all about each of us Making a Pledge to do one thing (or many things) to improve the health and wellbeing of others. What pledge can you make to improve patient, client and consumer health outcomes?

I’ve got to thanks Tessa Davies of the excellent paediatric emergency medicine site Don’tForgetTheBubbles for putting me on to this – change is something that I have struggled with – not so much to get used to (the alternative to evolution is, after all, extinction!). Rather I have struggled with making change happen…

Some things seem blindingly obvious as amenable to change in my (albeit small) pond. I am interested in the translation of new concepts that will make a difference in patient care, particularly in my interest of emergency medicine and airway management – indeed the focus of much of my blog posts is around this. There are some GREAT ideas out there via the FOAMed community, many of which have immediate practical application to the world of rural medicine.

My dream has been to incorporate that into my local institution – and to spread the paradigm wider amongst the SA country hospital community and further afield. Sadly effecting change has not been an easy process.

These are by and large simple ideas – what many FOAMed people would consider ‘no shitters’ :

…sadly this has been harder to action that I would have anticipated. Lack of clear leadership within Country Health SA and local resistance to ‘crazy shit on twitter’ has not helped my enthusiasm, but I will keep plugging away.

So my motto for change has been to slow down, relax and to ‘smile and wave’ – to change the things I can change, and not to worry about the things I cannot.

“Seven days in the week – ‘someday’ and ‘one day’ aren’t them.

Live your dreams, embrace change in life”

More inspiring change pledges were made from my mate Casey Parker up in Broome – my spies (well, rural generalist about Oz Jamie Doube who spent a few weeks locuming up there) tell me that as a locum he was unable to commence a case until plans A-B-C-D had been verbalised. Sensible policy, particularly when locum docs are around. Casey has made a brilliant pledge for ChangeDay – read his piece on The 7 Laws of Diagnostics.

Meanwhile – what is YOUR pledge?


Rural Team Entry for SimWars

The most awesome conference ever, smaccGOLD is fast approaching.

I was privileged to attend smacc2013 in Sydney last year and present at one of the sessions. It was truly humbling to be at such a friendly conference, with like-minded people – and although badged as a ‘critical care’ conference, there were attendees from ED, rural medicine, nursing, paramedicine, primary care, prehospital as well as the expected anaesthetists & intensivists. So I’m looking forward to helping out in the pre-conference Airway Workshop, and joining the big stage to debate Minh le Cong on “real airway doctors don’t use checklists“. I would encourage other rural doctors, nurses – indeed ANYONE with an interest in critical care (especially as to how it is applied outside of the ICU – in ED, in the bush, at the roadside) to come along to smaccGOLD.

This year a few of the rural clinicians have decided to put themselves in “harms way” – to submit a team for the SimWars competition. We are up against some stiff competition – reigning champions, the St Emlyn’s crew lead by Prof Simon Carley – as well as a host of other strong candidates. Our team has the added disadvantage of the team members never having worked together before – let alone trained. Casey is up in ED in Broome; on the other side of the continent, Minh is with RFDS in Far North Queensland and Tamara is in ED on the Sunshine Coast…meanwhile I am down on an island off the coast of South Australia.

This is a true resuscitation ‘flash team’ – although highly trained individuals (well, with perhaps the odd exception), we are going to be expected to perform as a team…despite never having worked together. A bit like the night shift gathering of ICU reg, ED reg and assorted junior RMOs at the bedside or a crash call.  Andy Buck of the ETMcourse writes more about this at

So…here’s our entry.



If you want to see us perform, come along to smaccGOLD – this will be but one of many educational events interspersed with fantastic speakers (my old mate Mark Wilson from London is coming over – a HEMS doc AND neurosurgeon, plus ex-GP. So he is well-placed to advise on ‘burr holes in the bush‘).

It’s gonna be epic…



This week MICA paramedic Rob Simpson put up contents of his prehospital kit for all to see – nice set up, with impressive slide out drawers for kit and even a gas-piston life to make shouldering a backpack that little bit easier.

Seeing Rob’s colour-coded drug vials made me re-visit the contents of my own RERN kit (rural emergency responder network) and do a little labelling & re-ordering of near expired stock.

I’ve posted a video on “what’s in your emergency bag” previously, although my own bag has undergone some revisions since then. Many doctors (particularly rural doctors) ask me about what kit to carry in their car. There are commercially available kits (such as GPKit) but to be honest I think the best kit remains a mobile phone, gloves and simple airway adjuncts such as Guedel’s and bag-mask valve (preferably with PEEP valve).

As a RERN member my role is to support (not replace) existing ambulance officers in rural SA – many of whom are volunteers trained to Cert IV level and supported in turn by career paramedics, intensive care paramedics and extended care paramedics. They are the experts in prehospital care – not passing-by doctors or ‘enthusiastic amateurs‘. Indeed one of my bugbears is the notion that having any old doctor on scene value adds to care – to my mind, the prehospital environment is VERY different to the ED or consulting room, and most doctors have little to add unless they have undertaken specific training in this field. Karel Habig talks about this in the most recent RAGE podcast (No 2) and is worth a listen.

Thus my role is to perform a very limited set of interventions – IV or other drug administration when ICP/ECP not available, facilitating extrication through judicious use of ketamine, needle-finger-tube thoracocentesis through to (very rarely) pre-hospital RSI. So what kit have we got?


Boots – Eye Protection – Hard wearing trousers with reflective strips & knee-pads – Jacket with reflective stripes and ‘Doctor’ ID. Interestingly no gloves or hat…


Most RERN members respond in their own vehicles or arrange to be met by the local ambulance crew en route to a scene. Some locations keep their RERN kit at the local hospital. Due to the geography of my location (KI is 150 x 50km) I keep my kit with me and respond by pager or mobile phone activation. At this stage we do not have a GPS-enabled solution, although I have been looking with interest at the mobile phone-GPS solution being used by BASICS doctors in Scotland.


RERN doctors are supplied with two bags – a green ‘oxygen and basic airway’ bag and a red ‘circulation, IV access & drugs & advanced airway’ bag. We don’t carry a defib or monitor – the Phillips MRX is the standard on SA Ambulances and we would be dependent on the volunteer crews having this to hand. Ditto adjuncts like extra oxygen, IV fluids, dressing, suction etc.

The bags are supplied by SA Ambulance and restocked through RERN. The bags are made by NEANN and are of excellent quality – waterproof, removable ‘boot’ on bottom and with sturdy zips and carry handles.


Green Bag – OXYGEN – BASIC AIRWAY – ADJUNCTS (collars, splints)

This contains oxygen, BMV, oro and nasopharyngeal airways, sphygmanometer, stethoscope, glucometer, Abbotcaths, 3-in-1 masks, nebulisers etc.




I’ve customised mine to a degree, adding a CT-6 femoral traction splint and a Prometheus pelvic binder to the side-pockets, as well as an assortment of Air-Q II intubating LMAs.

OXYGEN CYLINDER runs the lengt of the green bag/backpack

OXYGEN CYLINDER runs the lengt of the green bag/backpack


IDE POCKETS hold cervical collar, pelvic binder, CT-6 femoral traction device and AirQ II intubating LMAs

IDE POCKETS hold cervical collar, pelvic binder, CT-6 femoral traction device and AirQ II intubating LMAs



The red bag contains more serious kit :

Circulation, Drugs & Advanced Airway

Circulation, Drugs & Advanced Airway


Side pockets hold :

(i) formulary, pens, gloves (always carry a Sharpie)

(ii) local anaesthetic and suture kit

(iii) combines, dressings, bandages

(iv) Tranexamic acid, OLAES/Israeli bandages, combat-application tourniquet, RapidRhino




Main compartment has skin staples, local anaesthetic and more sutures in the zipper top lid (useful to control scalp lacs etc), with individual bags within for ADVANCED AIRWAY and IV ACCESS/MEDICATIONS.

Snuck alongside are some extras – two 500ml bags of N/saline, giving sets and an EZ-IO drill. The latter was a bit of a push to get 0 the local hospital stocks the Bone Injection Gun (a useless piece of kit, no tactile feedback, errors made with deployment even after training) and I was able to badger RERN to supply needles for the EZ-IO if I supplied the gun. used it four times in past 6 months, so reckon it’s worth it. There’s also a pre-packed Guedel’s oropharyngeal airway set.




The yellow IV access / medication module is quite neat, with vial holders, enough room to stash IVs, a mucosal-atomisation device for IN drug delivery plus assorted ventolin inhalers, GTN spray, penthrox inhaler as well as minimal volume extension lines, more tape, a couple more Sharpie pens and as much ketamine as I can cadge.



Drugs include : ketamine, morphine, fentanyl, tramadol, midazolam (5mg per ml and 5mg/5ml), naloxone, adrenaline, atropine, amiodarone, metoprolol, frusemide, metoclopramide, tropisetron, promethazine, chlorpromazine, hydrocortisone, benzylpenicillin, cefazolin.

I tend to stash a couple of vials of propofol, some ephedrine & metaraminol and of course GTN spray, salbutamol and Methoxyflurane (Penthrox) inhalers along with the IVs. Hidden amongst this lot are some 3ml syringes and ‘snot rocket’ mucosal-atomisation devices.

Needless to stay these are kept locked and a written record of S8s maintained.

I will probably ditch the metoclopramide and chlorpromazine soon, and get some droperidol instead.

After talking to Robbie recently, I reckon some wafers of both ondansetron and olanzapine might be useful…

RSI drugs (specifically, induction and neuromuscular blocking drugs) are kept refrigerated.


The grey advanced airway bag contains Mac & Miller blades, classic LMAs, emergency surgical airway kit (scalpel, bougie, size 6.0 ETT). I’ve added a pocket bougie as well as the supplied Frova oxygenating bougie and rapi-fit connectors (O2 or BMV), as well as the medSTAR kit dump and challenge-response checklist.


I am not afraid to use cognitive aids in a crisis; the side pockets of the bag contains ‘action cards’ for mixing inotrope infusions, RSI drugs and paediatric calculations.

Note the kit dump (yellow) and Introes "pocket bougie"

Note the kit dump (yellow) and Introes “pocket bougie”

I also carry the KingVision VL and both channelled and non-channelled blades. Of all the VLs I’ve tried, this works best in sunlight (less glare than the McGrath) BUT I should be clear that VLs do not cope well with blood/vomit (the sensor chip is easily contaminated) and DL remains the core skill. I carry mine as a back up, the logic being that may be useful if performing RSI in back of (stationary) ambulance rather than at the roadside. I also carry the AirQ-II iLMA in a side-pocket of the green bag – these are less bulky than the FastTrach iLMA, less fiddly to deal with (less parts) and allow gastric drainage unlike the FastTrach.

KingVision VL - but DL remains the core skill!

KingVision VL – but DL remains the core skill!


So that’s my kit. My wish list remains for :

- pelvic binders to be carried by SA ambulance crews

- GPS-smartphone to enable location & targetted activation of RERN members

- consider prehospital CPAP device

- common kit between services with recycling of near-expiry stock

- interagency training