50 Shades of Brown


  • 2/1/13 – Airway – LMAs
  • 3/1/13 – Airway – Basic Adjuncts (Oro- & Nasopharyngeal Airways)
  • 3/1/13 – Airway – Adjuncts to Intubation (Stylet & Bougie)
  • 5/1/13 – Circulation – enFLOW fluid warmer
  • 6/1/13 – Airway – Airway Planning
  • 7/1/13 – Circulation – Epistaxis
  • 14/1/13 – Airway – RSI Practicalities (follow on from Airway – Planning)
  • 14/2/13 – Circulation – IV access
  • 28/4/13 – Doctors Bag
  • 19/5/13 – Burr Holes in the Bush


Rural Doctor Update

I’m interested in improving care of the critically ill patient from a rural perspective. Casey Parker over at BroomeDocs has been inspirational in delivering high-quality FOAMed resources for rural doctors and together we’ve discussed the need to ‘bring quality care, out there’.

We are blessed in South Australia with an excellent retrieval service, MedSTAR. But of course the whole process of managing critically ill patients is a continuum…from the roadside or home to the small country hospital…to the retrieval service…to the metro hospital ED … then to Theatre & ICU…we are ALL players in patient care. It is simply not good enough for rural doctors to be passive players in managing these patients – we need to be au fait with current concepts in critical illness and trauma – and sadly courses like EMST/APLS/RESP just don’t go far enough.

Critical illness is not necessarily an everyday occurrence for the rural doctor. In fact such incidents are few-and-far between, leading to a risk of de-skilling and adding to uncertainty on how best to manage the patient or perform a procedure. FOAMed resources are invaluable to rural doctors. I was talking to a former ‘rural doctor of the year’ recently, who told me that he had used a YouTube video to refresh his memory on chest drain insertion – a wonderful example of asynchronous learning, not from knowledge gained on a course – but from using bedside FOAMed resources at 3am in remote Australia.

Hence the need for ‘fifty shades of brown’ – a resource guide to help rural docs and nurses with managing components of care prior to retrieval of their patient.

In this section I’ll be adding a series of short videos – covering the basics BUT with added information collated from FOAMed resources and aimed squarely at the needs of rural clinicians.

You can also check out the FOAM procedure video database from the LITFL crew

I’ll be adding more content over the next few months, so keep checking…

BACKGROUND (coming soon)

Rural Doctors in Critical Illness
Avoiding Clinical Inertia and Therapeutic Vacuums
Checklists, Handover
Team Training & Human Factors


Basic Adjuncts (Guedel, Nasopharyngeal)


Intubation Adjuncts (Stylet, Bougie)


Laryngeal Airways (cLMA, sLMA, iLMA)


Airway Planning


What’s new in RSI for the Rural Doc


Difficult Airway Algorithm

Meanwhile here’s a 2012 paper on rural GP-anaesthetists and difficult airway equipment – some interesting results.

See also the video presentation of the paper below


If you are wondering which difficult airway equipment to stock and are on a budget, check out


Videolaryngoscopy can be a game changer for difficult airways. New devices are around $1000 and affordable for rural health units. I try and use VL on every elective list, just to keep my hand in for when I really need it.

Will VL replace DL? I doubt it. But is VL useful when DL is difficult – you betcha! Here’s an example of VL using the KingVision


…and here’s another on an anticipated difficult airway (Mallampati IV, Patil 6cm, interincisor distance 2.5cm, limited prognath) in an elective situation. Had to pass the tip UNDER the epiglottis, which is not standard



Ultrasound and Pneumothoraces

Needle vs Finger/Tube Thoracostomy
NIPPV with the Oxylog 2000 plus


Shock Assessment
Access to the peripheral circulation – IVs, Intraosseous and Rapid Infuser Catheters
Permissive Hypotension
Infusions & Inotropes
Monitoring the shocked patient
Massive Haemorrhage in Rural Setting

IV access


En-Flow fluid warmer


Epistaxis Management or “Will daddy ever stop bleeding?”



Neurotrauma – the basics
What size drill bit? A quick video on emergency Burr holes for bush docs…




Heating & Cooling

Control & Modification of the ED Environment

Doctors Bag – here is a short video on the contents of a rural doctors’ bag

RURAL DOCTOR UPDATE – DOCTORS BAG from Tim Leeuwenburg on Vimeo.


…and another on ‘Burr Holes in the Bush’ with Mr Mark Wilson of HEMS London


<iframe src=”http://player.vimeo.com/video/64985630″ width=”500″ height=”281″ frameborder=”0″ webkitAllowFullScreen mozallowfullscreen allowFullScreen></iframe>




Vac mat
Minimum volume infusion lines

Other Teaching Videos

I have become obsessed with the dreaded CICV situation and training around it – not least because I’ve been in the unenviable position of having to do this a few times over past 10 years in various scenarios (mostly pre-hospital, one memorable time on the wards)

These videos are a good introduction to talking to other staff about both the technical aspects of CICV rescue procedures, as well as vital crisis resource management & human factors issues – an area sadly neglected in medicine but seeing increasing interest from anaesthetic, prehospital and ED perspectives. Rural clinicians would do well to incorporate this into their practice, especially as critical illness is infrequent, high-risk and frankly nerve-wracking for all team members.

“Just a routine operation”

[vimeo http://www.vimeo.com/50029603 w=400&h=300]

“Surgical airway – Bodies TV series”

[vimeo http://www.vimeo.com/50029859 w=400&h=300]

Both of the above CICO videos are pretty confronting and invariably generate discussion about human factors, training and equipment amongst clinical staff.

The UK TV series ‘Cardiac Arrest’ was memorable for being a gritty portrayal of the NHS within which I trained. Alrhough pegged as a black comedy, it didn’t make it to series three as the public refused to accept it as realistic. Myself? I felt it was like a documentary and still get goosebumps when I hear the bleep go off. Never had a Reg like Clair Maitland though…

Anyhow the clip below on EPISTAXIS is useful when discussing management in small rural hospitals. Do YOU have the kit to deal with a big posterior epistaxis?


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