Portable Vomit Simulator

I’ve just got back from another Critically Ill Airway (CIA) course at The Alfred, run by intensivist Chris Nickson of LITFL.  This packed two day course is designed for anaesthetic, emergency, intensive care and rural doctors and combines a multitude of hands-on task training with immersive simulation scenarios.  Great fun and highly recommended, although heavy demand means that there is a wait list for places!

For the first time, I brought along the ‘SALAD sim’ – this is the brainchild of Milwaukee anaesthetist Dr James DuCanto; we’ve used it at smaccCHICAGO and smaccDUB airway workshops and it’s nice to see the paradigm being adopted by many enthusiasts around the globe.

Suction-assisted laryngscopic decontamination (SALAD) is a task-training technique to cope with massive emesis (whether vomit or blood).  Instructions on how to make one have been well-described by the inventor, Dr DuCanto.  See a guide here from Airwaynautics.

In past few months I’ve been looking to refine my version for easier transport and obviate problems of large pumps and power supplies.  At the Critically Ill Airway course, several people asked me how to make one.  Here’s a quick guide to parts.

The Compact Vomiquin




I like this case as it has wheels and a handle, making it useful for lugging around the countryside.  It contains power supply, a bilge pump, on/off switch mounted in casing, reservoir for fluid and is large enough to carry airway head and assorted airway kit.


I’ve drilled a couple of holes in the case

(i) to accommodate a marine grade rocker on/off switch (with light)
(ii) a tank fitting to connect internal pump & hose to the airway head, via socket/collar quick connect fitting
(iii) a threaded cap port in lid to allow rapid filling of reservoir with case closed


Port in lid for rapid “hot refill” of reservoir even when in use & lid closed


I am using the Laerdal trauma head (kindly donated by Dr Andy Buck of ETMcourse.com). This head has a metal bar that can slide via the right cheek across the mouth (obviating bag-mask ventilation, supraglottic insertion and impeding laryngoscopy) and an inflatable tongue.

I’ve kitted mine out with a cheap USB-camera on a 2m long cable, which is placed via the left nares to allow video of the oropharynx via Quicktime recording on a Macbook.


USB camera placed in oropharynx with long cable to Macbook for video of rising tide


Jim DuCanto uses a separate reservoir for his ‘simulated airway contaminant’.  I found that having another container to carry took up too much space, so have made a reservoir within the Pelican case using a sheet of perspex (plywood is fine) cut to shape and then secured with waterproof sealant.  Initial experiments with Sikaflex were OK from a waterproofing perspective but failed under rough handling.  I’ve now fibreglassed the divider into place, which adds to both waterproofing and strength. So far no problems with leaks despite multiple plane trips.

Internal divider for reservoir, reinforced with fibreglass

Internal divider for reservoir, reinforced with fibreglass & contains Rule 360 bilge pump

Simulated emesis can be made simply with water and food colouring – green for vomit, red for GI bleed.  One can thicken it up using xantham gum powder, but to be honest I’ve found liquid vomit teaches the skill as much as using thickened versions.  Omitting the use of xantham also saves on tedious pre-mixing and is easier on the pump!


Barfume used by Sim Ninja in paramedic training (chunky vomit too)

To simulate the smell of vomit, one can either use white vinegar or add ‘Barfume’ (available online from the makers of ‘Liquid Ass’ faeces odour, this is s potent ‘simulated vomit’ odour which can be mixed in with the coloured water). Kudos to sim ninja Michael Borrowdale for this one!

Using barfume means props are small and easily packed, as opposed to having to carry around litres of white vinegar or source at destination!


Rather than use a large grey water pump and variable control rheostat to control the flow,  I’ve found that a simple Rule Bilge Pump (360-500) is more than able to cope with pumping simulated vomit/blood.  Flow rate is adjusted by an inline valve which can be turned from full on (impressive spurting out of mouth, nose, eyes) through to intermittent bursts, down to a steady trickle or just ‘off’.


Head connected to inline valve, which then connects rapidly to tank-fitting on case

The inline valve is connected to a simple threaded hose fitting placed in the oesophagus of the airway head and secured with a worm-screw clip.  The lungs can be left in situ, or removed and bronchi plugged with barb caps (saves on subsequent cleaning of the lungs).


With the head stored in the Pelican case, it’s important to be able to connect/disconnect easily.  I have used standard plumbing fittings from the local hardware store.

A tank fitting is placed in a hole drilled at one end of the Pelican case and connected to the pump via flexible hose, secured with worm screw clip.  The inline valve (flow control) is then attached to the head and the whole assemblage can be attached to the tank fitting. Importantly neither head nor tank need to be rotated; the collar/cap fitting allows connection with a few turns only until tight.


I took advice from the local marine store and have used a 12V MotoBatt battery which can be recharged.  It’s secured in place with bungee and connected to a marine-grade rocker switch on the side of the Pelican case.  This means the vomit reservoir can be filled, the head connected and case closed – with pump turned on/off via the switch out of view.


Less than 100 Wh – check with airlines & CASA regarding specific carriage regulations

Having portable power means I don’t have to carry cables, worry about power supply at destination nor risk electrocution.

The MotoBatt battery is able to be carried in both ‘carry on’ and ‘checked’ baggage with airlines if is considered part of installed equipment, but do check beforehand as limits may apply based on Watt/Hours (typically less than 100 Wh).  Rules regarding carriage of batteries as ‘spare’ or not connected to equipment should be checked before travel.

The Australian Government Civil Aviation Safety Authority have a ‘dangerous goods’ app for iOS, or check out the information on batteries online, as well as with individual carriers.

I make a point to disconnect the battery from switch, protect terminal, cover switches (secure in off position) and discuss with airlines/border protection if any concerns. especially as am also carrying what appears to be a human head onto the aircraft…

Put it all together and you have a portable ‘vomiquin’.  

There’s space in the box for a couple of laryngoscopes (both DL and VL), spare suckers, bougies, ETTs, syringes, Barfume, food colouring, collapsible buckets and so on.

I have been trialling different suckers – the traditional Yankauer sucker vs open tubing vs the SSCOR Hi-D and ‘oral evacuation tool’ suckers.  Some fascinating preliminary results for flow rates of various options…

Sadly the current set up doesn’t have space for a suction unit – ideally this is available on site, but if not it will need to be carried in another bag.



So – that’s it.  How to make your own vomiquin using parts in most hardware store, and which can be easily packed up and transported (just empty the vomit reservoir using suction and dispose down sink). I can generally get this set up in under five minutes and pack away in same time (provided the suction works and a sink is handy!)

Was it a success at the Critically Ill Airway course?  Judge for yourself? I think Chris Nickson’s smile says it all…

Coming next on KIDocs :

– comparison of different suction devices (Yankaeur, Hi-D, S3, tubing)

– other techniques for dealing with massive emesis (intubation in head down position to avoid aspiration, intubation in left lateral, deliberate intubation of oesophague with 9.0 ETT to divert GP bleed etc)

Refinements on SALAD Sim

Along with many others, am playing around with various combinations of airway trainer, simulated vomit, pump and suction to develop a self-contained portable SALAD sim (SALAD – suction assisted laryngoscopic airway decontamination)

SALAD is of course the brainchild of James DuCanto, Milwaukee airway fanatic and well known to the FOAMed world. Instructions on the SALAD set up are here and training videos here

I’ve had the privilege of assisting Jim in airway workshops in Chicago and Dublin as part of the smacc conference series most recently assisted by UK anaesthetists Ben Shippey @rallydoc and Barbara Stanley (@theneurosim).  We’ve managed to train several hundred people in the nuances of airway decontamination, under both ‘static’ (simple deposit of simulated airway contaminant) and ‘dynamic’ tests (an ongoing tsunami of vomit which threatens to overwhelm the intubator unless master the art of continuous suction whilst intubating – not as easy as it sounds!)


SALAD sim shenanigans in Dublin


Barbara Stanley (@TheNeuroSim) ready to serve up some SALAD in Dublin


Even experienced airway operators feel the pressure under the SALAD Sim (smacc Chicago 2015)


The future challenge will be to create a SALAD sim set up that is both compact & self-contained

Present SALAD setups rely upon an open container of ‘simulated airway contaminant’ (a heinous mix of xanthem gum, white vinegar and food colouring) which is then pumped to the oropharynx using variously

  • a drill-powered inline siphon pump
  • a submersible bilge or pond pump
  • a dirty water sump pump


Flow rates can be adjusted by either use of inline valves or a variable rheostat speed-controller to reduce pump speed and hence flow of vomitus.

The contaminated airway is then suctioned out, using a medical grade suction device. I struggled with this in Dublin, as the two loan units rapidly became overwhelmed…I didn’t realise that the bags within suction cannister are designed as single use and the inlet valve soon became clogged.

In contrast Jim DuCanto’s units (from SSCOR) functioned brilliantly despite multiple rounds (200 litres each I reckon) of vomit passing through.

The SSCOR Medical Grade Suction Pump performs brilliantly - but this, submersible pump & head consume a lot of space!

The SSCOR Suction Pump performs brilliantly – but suction, submersible pump & head consume a lot of space!

Problem is, lugging around suction pumps, submersible pumps and the containers for vomit is quite bulky.

The purist in me wants to design a closed system, namely

  • bladder which can be removed, filled with vomit and then emptied at end of session
  • both submersible pump and suction pumps small enough to sit within Pelican case and be self-contained
  • suctioned contents to be automatically returned to the bladder, for further pumping to airway head
  • controls for pumps to be available on outside of case, once closed
  • variable controller built in

So the challenge will be to create something that can be carried in a Pelican case (Storm IM2500, on wheels).

It might look something like this:

Screen Shot 2016-07-10 at 1.24.28 PM


I’d envisage the whole unit being self-contained, the “simulated airway contaminant” (vomit) being cycled from bladder to oropharynx and back via the two pumps.

Bladder needs to be removable for filling/emptying at start/finish of session and able to tolerate periods where inflow < outflow (suction out < pump in to oropharynx).

Ideally the whole unit should function with lid of Pelican case closed, with control switches for pumps accessible on outside.  Marine rocker switches are ideal, as would a variable control rheostat panel control, flush with case.

Marine rocker switch

Marine rocker switch

A simple mains socket could be mounted in the Pelican case, such that the SALAD Pelican case can be plugged into mains power.

Really interested to hear from anyone with ideas on how to make this happen…preferably on a budget!


Building Community Resilience with Careflight

Rural trauma – a high-speed vehicle roll over, a farming accident with a chainsaw, a gas BBQ explosion at the family picnic.  These are all scenarios that may affect individuals & families…and the rural community.  Occasionally a multi-agency event such as a bushfire, extreme weather event or other natural disaster will cause traumatic injuries and impact on not just local community but also on State resources.

Whilst it is true that each State has well-developed retrieval services, whether land, fixed or rotary-wing, the reality is that the help they can offer is usually distant to rural folk; response times are measured in hours, not in minutes or seconds.

For all practical purposes these services might as well be on the moon in the face of truly urgent care (catastrophic haemorrhage, impact brain apnoea, compromised airway, delivery of effective analgesia etc).

The first link in the trauma chain of survival is invariably the first responder – he or she may be a rural volunteer in a service such as ambulance, fire, SES , coastguard…or may respond as part of their job role (eg: Parks officer, tour guide)…or may be a lay member of the public who comes across an incident and is thrust into the maw of trauma care.

This impromtu response what Christina Hernon defined as the ‘immediate responder’ in her excellent talk on ‘the disaster gap’ at smaccDUB.

The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better.

Screen Shot 2016-07-01 at 5.14.44 PM

Of course many organisations insist on their members having an advanced first aid qualification; whilst these are useful, their proscribed content often lags behind current trauma care delivery. First responders are the initial link in the ‘trauma chain’ and there is no reason not to equip them with appropriate skills, knowledge and equipment – regardless of agency!

Whilst most interagency training is focussed on ‘mass incident’ exercises as a learning exercise, the reality is that these rarely, if ever, happen. Most of the work is in the usual business – a vehicle rollover or crash, an injured bushwalker, a farm accident, a patient needing medical care but unable to use the stairs, requiring SES and Ambulance teams etc – and yet do we ever train as a team for such circumstances?

Careflight MediSim – Delivering Necessary Trauma Education

This week we were privileged to have a visit from the Careflight MediSim team, to deliver the Trauma Care Workshop on Kangaroo Island, SA.

Launched in 2011, this innovative program from the Careflight organisation (mostly charity funded) delivers a world class trauma education system designed for rural first responders.


MediSim training 2011-2015

Despite the session having to be rescheduled, willing first responders from Parks, CFS and SA Ambulance were able to come together for an interactive day of lectures, task-training and sim sessions under the credible instruction of the approachable MediSim facilitators.
Screen Shot 2016-07-01 at 6.08.50 PM

I’ve been banging on about the need for effective interagency training in rural communities for some time now.  My involvement in trauma nowadays is mostly limited to involvement via the SA RERN system (a doctor responding only when needed by volunteer ambulance officers, with the goal of value-adding by performing certain interventions), in the hospital when oncall for emergency or anaesthesia and of course in trauma education through ETMcourse and EMST etc.

Whilst RERN, SAAS and of course RFDS and SAAS-MedSTAR Retrieval have a role to play, the initial care at the roadside is invariably provided by a first responder.  If lucky he or she may be a part of an emergency system…or they may be in another capacity (CFS, SES, Police, Parks etc). Of course they may also be an immediate responder – a passerby who is caught up in the situation and expected to render help.

Most prehospital incidents will require input from several agencies

At a typical vehicle crash, there will be representatives from Road Crash Rescue (CFS or SES), Ambulance – typically these are unpaid volunteers in rural. Add to that Police, then RERN, and Retrieval…it can be hard to both know ‘who is who in the zoo‘ and more importantly what they can do!


A typical rural road crash (source ABC)


Training together has clear advantages – it emphasises the need for simple interventions to make a difference and that such interventions can be performed by appropriately trained and equipped individuals regardless of agency. It also allows discussion of current protocols and equipment (such as the value of first responders, whether ambulance, fire or SES having access to tourniquets, and a suitable haemorrhage control device).


Simple kit to deal with haemorrhage control – in my opinion this should be in every rural ambulance, SES or CFS truck, police car, parks vehicle and tour bus. Is it?

Understanding and sharing of each other’s treatment priorities (scene control & safety, patient extrication and medical needs) can be practiced by scenario training, allowing effective communication, a shared mental model and planning for ‘the real thing’

It’s time to ditch the notion of each agency training in silos and instead practice regular ‘real life’ multiagency scenarios

The MediSim team provided local Kangaroo Island first responders with a solid foundation to develop further local community resilience.  Lectures covered the concept of a ‘zero survey’, triage. effective handover and of course the nuts & bolts of trauma care.



The Emergency Bandage (formerly known as the Israeli Bandage) – cheap and essential kit for any first responder



Checking out the MediSim ‘crash car’ designed to be used for practice extrication – it would be a simple project to make one of these for local use on KI, potentially in partnership with TAFE & Crash Repairs

The day involved practical, hands on task-training sessions on triage, on helmet removal and immobilisation, on haemorrhage control and basic airway management.


Helmet removal – can be done safely; either let patient do it themselves or perform if trained – but get the helmet off early, not late!

Skills learned in the workshop were reinforced by scenario-based training on managing a casualty, involving scene awareness, leadership, role allocation and the delivery of basic care in an effective manner (simultaneous extrication, treatment and packaging of the patient) underpinned by clear communication both on-scene and with central comms.



Challenges of leadership and teamwork, under stress, with limited resources in an unfamiliar environment – one which KI local volunteer teams coped with exceptionally well

All in all, a wonderful effort by the CareFlight MediSIm team and by the local Kangaroo Island volunteers who gave up their own time to attend this trauma workshop.

I am hopeful that we can run similar exercises in the future using local expertise.  To my mind the benefits of team members who are aware of each other’s roles and operational capabilities, who have trained together and share a common goal offer immediate tangible benefits to victims of trauma.

Moreover we live in a small community – the more first responders who are trained and equipped, the more resilient our response can be – whether for an accident at home, at the roadside or in the case of a community-wide catastrophe.


A Kangaroo Island Resilience Model, akin to those overseas, is achievable if we work together.

Thanks again Careflight for visiting Kangaroo Island – come again next year!


COI – I received a bottle of wine from the MediSim team as a reminder of my time in Orange NSW back in 2011 (anaesthesia training and trauma care). I am not influenced in my report by this gift…although there MAY be a subliminal message they want to convey…


Recommended Reading

Read more about Careflight MediSim HERE

Careflight are also active in sharing their knowledge through social media; check out the Careflight Collective blog here

Learn about how the Isle of Arran (Scotland) has developed a local resilience model for multi-agency training and trauma care

Principles of trauma care are taught on many courses; I recommend

Emergency Trauma Management (ETM) course – etmcourse.com (COI I instruct on ETM)

Anaesthesia, Trauma & Critical Care (ATACC) course – atacc.co.uk (COI am trying to persuade Mark Forrest to bring this course ‘down under’)

The Holmatro Rescue Experience (COI have facilitated with Holmatro extrication guru, Ian Dunbar on this in Australia, mostly teaching SES and CFS volunteers)

Many clinicians worldwide share knowledge and skills – regardless of whether background in emergency, anaesthesia, rural medicine, critical care or whether involved as doctor, nurse, paramedic or volunteer. Our common goal is to care for the patient from whatever background.  By sharing such knowledge we can all become better.

Difficult Airway Training – The Wookie Wins!

Full credit for this goes to Dr James DuCanto, airway geek and innovator from Milwaukee, USA. It’s been my great privilege (and crazy pleasure) to facilitate with Jim at smacc airway workshops in Chicago and Dublin, using the SALAD sim (suction assisted laryngoscopic airway decontamination).

This is a great setup to teach techniques to manage the contaminated airway and tends to put even experienced operators under a degree of stress.  Check out more on SALAD here or make your own…


smaccDUBAirway Workshop@jducanto @theneurosim @rallydoc @kangaroobeach

But DuCanto is also notorious for innovative education – who can forget the ‘laryng-o-beer’ task trainer from smacc Chicago – a laryngoscope blade attached to a full beer bottle, with the challenge to see if could perform gently epiglottoscopy without inadvertently detaching the lid and losing the beer…

Screen Shot 2016-06-30 at 11.24.42 AM

Laryngobeer Hinds

John Hinds has a crack at laryngobeer #smaccUS

Meducation – in the Pub!

After a hectic full day of meducation at the smaccDUB airway workshop, we de-camped to the EMS Wolfpack ‘pop up’ session.  This was one of many satellite get-togethers that happen at a conference like smacc, wherever there are like-minded people around.  Walking into a small Irish pub, we were warmly greeted by prehospital colleagues…and with a few minutes drinks were poured, ultrasound gel was applied and the meducation (ultrasound & airway) began.

The Dublin folk, bless them, seemed to take this in their stride, calmly sipping on Guinness whilst around all around them live demos of sonography and intubation took place!


Suction, beer and a licence to thrill…what could go wrong? Meducation with the #EMSWolfPack



Andy Brainiard @TheSharpEnd nudes up in pub to demo ‘pint-of-care’ USS

Difficult Airway Training with Chewie

A stand out success was the ‘Chewbacca mask’ challenge.  If you haven’t already seen them, the Chewbacca mask emits a wookie roar when the mouth is opened.  It is, quite simply, one of the silliest things on the market and has become a bit of an internet sensation.  Of course, the roaring of a wookie is just what is needed when practicing difficult intubation….


Now this is idea is definitely DuCanto’s baby…but I have to share my impressions after making my own Chewbacca Difficult Airway Trainer post-smacc. It is great fun – not only to hear Chewie roar, but also to practice…


Chewbacca Intubation #smaccDUB Airway W’shop

The premise is simple – take a Chewbacca mask and add it to the Laerdal airway trainer oropharynx; you can pick both up from eBay with relative ease (although needless to say the Chewbacca mask is easier to source)


The next step is to drill a couple of small holes in the Chewbacca mask and attach the oropharynx model; there is also a chin plate inside the mask – use fine picture hanging wire or fishing line to invisibly anchor the oropharynx to this pate within the mask (there are a couple of small screws on the oropharynx model that can be removed, wire threaded and then replaced)


Secure the oropharynx to chin plate so it moves freely when jaw opens

I mounted the whole ensemble on some wood offcuts from the shed – the mask straps allow it to be slipped on/off with ease.  Raising the mask allows the oropharynx to be placed in different positions, markedly changing the difficulty of this airway trainer….


Raising the oropharynx onto blocks makes it a Grade I view…


DL view – hard to capture with camera, but is Grade I for intubator


View with the KingVision VL – nice and easy…

Shades of Difficulty?

Now I am no expert at Wookie anatomy, so it took some experimentation to work out what was happening.  With the oropharynx dropped distally, the intubation became a lot easier


Optimal intubation position for the Wookie trainer

But dropping the entire oropharynx lower (a degree of retrognathia), the intubation became incredibly gnarly…


Note position of oropharynx compared to previous….


Best view obtained with videolaryngoscope; DL is Grade IV

In fact, at one point the ONLY view I could get of the cords was via the orbit…


…and of course airway geeks will be familiar with the ‘trans-orbital intubation technique’ – it’s in the literature and kind of makes sense…provided the eye is enucleated completely along with the orbital floor (see Fernando et al Anaesthesiology 2014 121 654 doi:10.1097/ALN.0b013e31829b36af)


Fernando et al Anesthesiology 09 2014, Vol.121, 654


What else is great about this trainer?

  • Well, it’s cheap and easy to make
  • It encourages you NOT to put their hands in the mouth when placing supraglottic devices (else Wookie may bite)
  • Allows move from Grade I to IV view (and all stages in-between) depending on positioning of the oropharynx
  • Can compare DL and VL views with a variety of devices (I will post some views of the C-Mac and D-blade soon)
  • Can practice the art of gentle epiglottoscopy & limited mouth-opening, lest one inadvertently unleashes the Wookie roar!
  • Ideal trainer for fibreoptic skills, in context of limited mouth-opening
  • It’s stupidly fun.


Thanks to the mad genius of Dr James DuCanto for this idea

Imitation is sincerest form of flattery…



Next up, proposed improvements to the SALAD SIM…

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On simple research and the gift of sharing…

A nice little paper caught my eye in this months Emergency Medicine Australasia.  Entitled “Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service” this is a really simple paper; basically an audit of the medications carried and used over a 12 month period by the Sydney HEMS service.


Everyone likes playing with drug kits – but what REALLY needs to be in the bag?

There’s a fair chance that you may not be able to get passed the EMA ‘pay-per-view’ firewall, unless you have institutional access or can blag a copy off the author (thanks guys). So what did I like about this paper?

“Two is one, one is none”

First up, it’s a simple piece of research – a retrospective review of missions (2566 total; 848 prehospital, 1662 interhospital & 56 mixed) and the medications used.  The first author was a medical student at the time. The paper provides a useful summary of commonly used medications for both primary and secondary retrievals….more importantly, it also informs which medications are perhaps unnecessary to carry.

Why does this matter? Well a retrieval service needs to be able to function autonomously.  Kit space is limited and cost/weight considerations need to be made, especially for kit infrequently used. Cost and stability need to be factored in.

The maxim ‘two is one, one is none‘ is often applied in retrieval – place two IVs in case one is ripped out, carry spare batteries in case power fails, have redundancy in clinician skills and training….

WARNING <RANT MODE ON> Why some retrieval services don’t use a model that allows alternating RSI by doctor and RN/paramedic escapes me – better to have redundancy in airway management IMHO providing clinicians are trained to appropriate standard and operate under an agreed SOP <RANT MODE OFF>

Whilst the contents of kit packs are often determined by historical and expert opinion, as well as driven by SOPs, a retrospective audit of actual use can inform future stocking – more so if additional information from other services is shared.

Of course, the majority of cases reviewed in this paper were inter-hospital missions; it would be interesting to see how many of the medications were available at the referring institution (ie source of medication used in this retrospective analysis of case cards) as there may be scope to avoid carrying medications that are commonly available either on roadside (ambulance) or hospital eg: ipratropium, metoclopramide etc

Relevance to Rural?

Unlike the UK & NZ, only a very few rural doctors are involved in the prehospital space in Australia (a 2012 survey showed that over 50% of rural GP-anaesthetists had responded to a prehospital incident in the previous 12 months).  Worryingly such responses were informal – typically activated by ambulance comms; the clinicians attending had no formal agreement for call out criteria, equipment, training nor ongoing CPD.

Of course in South Australia we have the RERN system, designed to ‘value add’ in specific cases, typically where local (mostly volunteer) ambulance officer responders cannot offer the appropriate intervention and when State-based retrieval services are not available in a timely fashion. The tyranny of distance in Australia dictates that reliance purely on metropolitan-based retrieval services and volunteer-based ambulance responders represents a potential therapeutic vacuum, where appropriately trained and equipped rural doctors with ongoing skills in emergency care/anaesthesia could value add – akin to UK BASICS.

I will certainly be re-assessing the contents of my RERN prehospital packs based on this paper, although I suspect not much will change.  Similarly the results of this sort of publication may help inform the stocking of small rural hospitals.

More importantly, the published experience of Sydney HEMS in regard to post-intubation sedation protocols has immediate applicability to rural hospitals (if you can’t access the paper, my recommendation based on reading would be to use fentanyl>morphine and propofol>midazolam). Whilst my practice may not have changed, it MAY change the practice of other rural hospitals where M&M (morph/midaz) sedation may be the default. Development of a post intubation sedation SOP is one of the recommendations from this paper.


A system built on excellence also inspires excellence in others. Except this chap. Obviously…


The real value is knowledge-sharing

Another thing I liked about this paper is that I know most of the authors! Luke Regan, John Glasheen and Brian Burns have all, at various times, supplied me with copies of their talks, their research and their ideas.  This is because of the commonality that comes from the FOAMed community. The commitment to share.

More than that, the service within which these individuals work also has a demonstrated commitment to sharing their experience, skills and knowledge – not only by publishing such low-hanging fruit as this (and let’s face it, reproducing such a paper is an easy ‘gimme’ for any service), but also by their commitment to sharing protocols and information through other channels.

Sydney HEMS use of Twitter, Blogs and even a YouTube channel is well-established.  The outcomes of their Clinical Governance Days are blogged online, along with relevant resources.  Despite the potential for concerns (often expressed by health administration), sharing such information has had little disadvantage and instead offered significant advantages to the quality of the service!

Why is this important? Because I think many of the lessons from prehospital are applicable not just to those in the prehospital space, but also the rural doctor cadre and of course the wider community working in ED. We all benefit when such knowledge is shared.

We’ve seen this with lessons on safety (human factors, sim training, resus room management, action cards, checklists) and in the commitment to excellence (metacognition, measurement and refinement of training to lead to incremental change). And these lessons are now shared on a global stage.

This of course echoes the words of Stephen Hearns at Glasgow pre-smaccDUB

Plan & Practice the Predictable

Reflect, Learn & Change 

Share Information

In short, there’s no point in any organisation planning and practicing excellence, unless also reflect and learn – and most importantly, to share this information with others.

This is where Sydney HEMS have set the lead for others to follow – by enot just a commitment to clinical excellence, but also by committing to share this information widely – their engagement in use of social media, at both an individual level and institutional, has reaped significant benefits to both sharers and recipients.

By sharing they not only raise the bar for others – they raise the bar for themselves by benchmarking

Globally, clinicians looking to attend a ‘finishing school’ in prehospital care will no doubt be applying to work at Sydney HEMS as a first choice, and rightly so.

In short, this paper (although very simple research) demonstrates a useful overview of appropriate medications in the PHARM environment.

However for me it also reflects as a demonstration of the value of SoMe and FOAMed at an institutional level.



Some of the Sydney HEMS SoMe resources here

YouTube – GSA HEMS

Blog Site – SydneyHEMS.com including lessons and resources from their Clinical Governance Days

Affiliated sites – Resus.me (the enigmatic Cliff Reid)

Twitter Accounts : @SydneyHEMS @jglash @HawkmoonHEMS @LukeARegan @drbear13 @DrGeoffHealy @cliffreid @karelhabig @allegorical (apologies – am sure there are others I’ve missed out)

Also cross-pollination with others…Natalie May currently on sabbatical ‘down under’ (let’s hope can keep her and partner) writs here for StEmlyns on the educational excellence of GSA-HEMS.

Bringing the Outdoor Classroom Indoors – #MedEd at #smaccFORCE #smaccDUB


Hayward M, Regan L, Glasheen J, Burns B (2016) Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service Emergency Medicine Australasia (2016) 28, 329–334 doi: 10.1111/1742-6723.12584

Appendix 1 Number of patients receiving agent by mission, case and patient type
Appendix 2  Stock medications of the Greater Sydney Area Helicopter Emergency Medical Service.

Hearns S & Weingart S – On creating a system of excellence via emcrit.org blog

Leeuwenburg T & Hall J (2015) Tyranny of distance and rural prehospital care: Is there potential for a national rural respnder network? Emerg Med Australasia. 2015 Oct;27(5):481-4. doi: 10.1111/1742-6723.12432. Epub 2015 Jun 24.