Episode 36: COVID-19


Case definition

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Current case definition for COVID-19 can be accessed here.

Risk stratification

This is the Emergency Medicine Specialty guide we discussed in the podcast, which includes use of the NEWS and 40 step test (edit: since recording the podcast yesterday (!) we’ve been made aware of the Sit to Stand test). Here is a review of both if you’d like to read more.


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As at May 1st, the advice from PHE is ‘There is currently sustained transmission of COVID-19 throughout the UK as defined by the four nations Public Health experts, therefore there is an increased likelihood of any patient having coronavirus infection. Therefore, whilst in this phase all patient contacts require level 2 PPE in accordance with Table 4‘: T4_poster_Recommended_PPE_additional_considerations_of_COVID-19

Level 2:

  • disposable gloves
  • disposable apron
  • fluid repellent surgical mask
  • eye protection (if risk of splashing)

Level 3:

  • disposable gloves
  • fluid repellent coveralls/long sleeved apron/gown
  • FFP3* or powered respirator hood
  • eye protection

*Where an FFP3 mask with a non-shrouded valve is worn, it should be accompanied by a full-face visor. If a visor is not available, then a risk assessment should be carried out regarding the risk of splash to the valve. If a large splash (as opposed to droplets) does occur, then the FFP3 mask should be replaced immediately.

There are a number of PHE PPE videos available, this is the one describing donning and doffing Level 2.

From PHE Guidance for ambulance trusts: Where AGPs such as intubation are performed, PPE guidance set out for AGPs (section 8.1) should be followed (disposable fluid repellent coveralls may be used in place of long-sleeved disposable gowns). For any direct patient care of patient known to meet the case definition for a possible case, plastic apron, FRSMs, eye protection and gloves should be used. Where it is impractical to ascertain case status of individual patients prior to care, use of PPE including aprons, gloves, FRSM and eye protection should be subject to risk assessment according to local context. PPE is not required for ambulance drivers of a vehicle with a bulkhead and those otherwise able to maintain social distancing of 2 metres. If the vehicle does not have a bulkhead then use of a FRSM is indicated for the driver (additional PPE would be as for other staff if providing direct care).

For the coverall-type Level 3 PPE most commonly being used by ambulance clinicians, have a look at these two guidelines on donning and doffing.

Aerosol generating procedures

Reference available here.

Aerosols are produced when an air current moves across the surface of a film of liquid; the greater the force of the air the smaller the particles that are produced. Aerosol generating procedures (AGPs) are defined as any medical and patient care procedure that results in the production of airborne particles (aerosols). AGPs can produce airborne particles <5 micrometres (μm) in size which can remain suspended in the air, travel over a distance and may cause infection if they are inhaled. Therefore AGPs create the potential for airborne transmission of infections that may otherwise only be transmissible by the droplet route.

The most recent assessment by WHO (2014) states that there is only consistent evidence that there is an increased risk of transmission for the following procedures: tracheal intubation, tracheotomy procedure, non-invasive ventilation, and manual ventilation before intubation as AGPs. This evaluation is based on a systematic review by Tran et al. whose review included 10 studies (5 case-control; 5 cohort), all of which investigated transmission of SARS from patients to healthcare workers in intensive care or other healthcare settings during the 2002-2003 SARS outbreaks.

Cardiac arrest

From PHE:

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First person attending scene

  • In order to minimise any delay attending a time critical cardiac arrest, it is acceptable for the first person to enter the scene wearing level 2 PPE (fluid repellent surgical mask, apron, gloves and eye protection). Where trained and equipped to use level 3 PPE, this may be used where it will not cause a delay
  • commence resuscitation where this is indicated by local clinical guidance. If resuscitation is not commenced, or is terminated before the arrival of other resources, provide an early sitrep to reduce the number of responders who need to enter the scene
  • do not place your face near the patient to assess breathing
  • where available, place a surgical mask or oxygen mask on the patients face
  • commence chest compressions, attach the defibrillator and defibrillate if indicated. None of these tasks are considered aerosol generating procedures (AGPs)
  • do not progress to airway management or ventilation
  • if not already available on-scene, request back up from a level 3 PPE trained response

Subsequent attendance at scene of responder(s) trained and equipped to use level 3 PPE

  • don level 3 PPE
  • enter scene and determine whether the resuscitation should be continued according to local clinical guidance.
  • if resuscitation is to be continued, take over patient management from any responder wearing level 2 PPE
  • all responders wearing level 2 PPE are to leave the scene (more than 2m away from the patient) prior to the commencement of any airway management, ventilation or other AGPs. Responders may later re-enter if trained and equipped to wear level 3 PPE
  • level 3 PPE responders to continue the resuscitation, including airway management and ventilation

Anyone who is not trained or does not have access to level 3 PPE must then withdraw from the scene.

From the Resuscitation Council:

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Click here for more from the Resus Council on COVID-19.

Just before you go … something to make you smile! (thankfully the music department at Plymouth Uni have got the tech to make me sound like I can actually sing!!!)


For more on the growing evidence base around COVID-19, please have a read of this blog from our colleague, and Defence Professor of Emergency Medicine, Jason Smith.

World Health Organization. Infection prevention and control of epidemic and pandemic-prone acute respiratory infections in health care. WHO guidelines. https://www.who.int/csr/bioriskreduction/infection_control/publication/en/ (2014).

Tran K, Cimon K, Severn M, et al. Aerosol generating procedures (AGP) and risk of transmission of acute respiratory diseases (ARD): A systematic review. PloS One 2012; 7. Conference Abstract.


Tim Cook PPE review: https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.15071

Health Service Journal: Exclusive: deaths of NHS staff from covid-19 analysed

Considering transmission from staff uniforms:

Infection Control and Hospital Epidemiology. Volume 31, Issue 5 May 2010 , pp. 560-561. Coronavirus Survival on Healthcare Personal Protective Equipment. Lisa Casanova (a1), William A. Rutala (a2), David J. Weber (a2) and Mark D. Sobsey (a1). DOI: https://doi.org/10.1086/652452

PLoS One. 2011; 6(11): e27932. Survival of Influenza A(H1N1) on Materials Found in Households: Implications for Infection Control. Jane S. Greatorex, 1  Paul Digard, 2  Martin D. Curran, 1  Robert Moynihan, 2  Harrison Wensley, 2  Tim Wreghitt, 1  Harsha Varsani, 1  Fayna Garcia, 1  Joanne Enstone, 3  and Jonathan S. Nguyen-Van-Tam 3 , 4 , * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222642/

Acute myocardial injury in COVID



See also: Clinical guide for the management of critical care for adults with COVID-19 during the coronavirus pandemic

Episode 35: The collapsed infant

collapsed infant

A: Optimal airway position for infants

Note how a rolled towel is placed under the baby’s shoulders to allow space for the occiput and avoid flexion of the neck and airway.

‘B’ assessment

Video links to examples of children with signs of respiratory distress:

‘D’ assessment

Example video showing a bulging fontanelle (excuse the slightly cheesy style!)

Non accidental injury

Sadly, NAI in under 2’s causes more than 10% of serious injuries to children.

Stigmata of possible NAI include:

  • Bruising on the cheeks, neck, genitals, buttocks and back
  • Pattern bruising from an implement including fingertip bruising
  • Burns to hands, legs, feet and buttocks
  • Subconjunctival haemorrhage
  • Epistaxis in infants

Example of subconjunctival haemorrhage:

2017 NICE guidance: When to suspect maltreatment in under 18s. 


UK sepsis trust logo

Click for UK Sepsis Trust guidance for different clinical settings. Scroll down for the Screening and Action tool for under 5s for prehospital care and ambulance services.

References regarding IM benzylpenicillin that Tim mentions:

  • Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8.
  • Hahné SJM, Charlett A, Purcell B, Samuelsson S, Camaroni I, Ehrhard I, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. BMJ. 2006 Jun 3;332(7553):1299–303.
  • Sörensen HT, Nielsen GL, Schönheyder HC, Steffensen FH, Hansen I, Sabroe S, Dahlerup JF, Hamburger H, Olsen J: Outcome of pre-hospital antibiotic treatment of meningococcal disease. J Clin Epidemiol 1998, 51:717–721.

Drug calculator

Watch logoExample of a paediatric drug calculator from WATCh.


Episode 34: Back pain


So, where is the Cauda Equina?


From Core EM

How does a herniated disc cause CES?

Herniated disk

This fab infographic summarising the key points about the CES guidance was produced by @DrLindaDykes and @saspist.

Linda Dykes infographic Cauda Equina

Here is the full guideline from The Society of British Neurological Surgeons and The British Association of Spinal Surgeons.

NICE guidance on Low back pain and sciatica in over 16s: assessment and management

NICE clinical knowledge summary on Cauda Equina Syndrome red flags.

Thinking about posture:

Episode 32: Ketamine




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Huge thanks to the team at World Extreme Medicine and WEM Cast for sharing the interview with Richard Harris.





These are a guide only, each patient will need a bespoke approach depending on their pre-existing condition, degree of cardiovascular compromise, conscious level and drugs already administered. Clearly you also need to remain within your scope of practice and the guidelines for your organisation.

  • For analgesia (IV/IO): 0.1 – 0.5mg/kg
  • For analgesia (IN): 3mg/kg
  • For sedation (IV/IO): 1mg/kg
  • For sedation (IM): 4-5mg/kg
  • For anaesthesia (IV): 1-2mg/kg

Click here for an example of how ketamine can affect patients.

Know the concentration you carry!

Click here for an example of what can occur if the incorrect concentration of ketamine is administered.


  1. The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. YMEM. American College of Emergency Physicians; 2015 Mar 1;65(3):248–254.e1.
  2. McQueen C, Crombie N, Cormack S, Wheaton S. Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Emergency Medicine Journal. 2014 Dec;31(12):1029.
  3. Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emergency Medicine Journal. 2014 Oct;31(10):840–3.
  4. Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012 Jun 1;59(6):504–12.e1–2.
  5. Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial. Ann Emerg Med. 2012 Jan 11.
  6. Bredmose PP, Lockey DJ, Grier G, Watts B, Davies G. Pre-hospital use of ketamine for analgesia and procedural sedation. Emerg Med J. 2009;26(1):62–4.
  7. Howes MC. Ketamine for paediatric sedation/analgesia in the emergency department. Emerg Med J. 2004 May 1;21(3):275–80.
  8. Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–4.
  9. Gunning M, Perkins Z, Quinn T. Trench entrapment: is ketamine safe to use for sedation in head injury? Emerg Med J. 2007 Nov 1;24(11):794–5.
  10. McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J. 2004 May 1;21(3):290–5.
  11. Roback MG, Wathen JE, MacKenzie T, Bajaj L. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006 Nov 1;48(5):605–12.
  12. Newton A, Fitton L. Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study. Emerg Med J. 2008 Aug 1;25(8):498–501.
  13. Chang LC. Raty SR. Ortiz J. Bailard NS. Mathew SJ. The Emerging Use of Ketamine for Anesthesia and Sedation in Traumatic Brain Injuries. CNS Neuroscience & Therapeutics. 2013; 19: 390–395
  14. Morris C. Perris A. Klein J. Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009; 64(5): 532-539.

Episode 31: Stroke & Dizziness

stroke and dizziness


The Danish mnemonic to help remember the elements of a cerebellar neurological examination:

danish mnemonic

There are lots of Youtube videos to demonstrate these signs, here are a few which I thought were particularly helpful:




Intention tremor

If you would like to read more, there is a blog post Martin and I wrote here on the subject of dizziness, including some videos demonstrating elements of the HINTS exam, and another one from the St Emlyns team.

This is the paper Martin mentions.

Want to know more about stroke thrombolysis? Have a listen to this episode from our friends over at The Resus Room.

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Episode 30: Head injury


Quite a few of our previous podcasts include content which is relevant to this Head Injury one. Why not go back and have a listen to:

Episode 3: Hyperoxia

Episode 20: End Tidal Carbon Dioxide

Episode 28: LOST (Low Output State in Trauma)

Munroe-Kellie Doctrine

The Munroe-Kellie Doctrine is illustrated by the following pictures:

Monroe Kellie doctrine diagram

Or, alternatively, by Elfyn’s pint of Guinness analogy!


Allows giraffes to drink from pools without a rush of blood to the head and eat leaves from trees without fainting.

This graph shows what happens to cerebral arterioles in uninjured brains, taken from Researchgate.net (Pires et al., 2013.)


Without autoregulation, in an injured brain, the arterioles will not change diameter in response to variations in blood pressure, and cerebral blood flow will have a linear relationship with blood pressure.

Cerebral perfusion pressure

Cerebral perfusion pressure = Mean arterial pressure – intracerebral pressure

The diameter of the arterioles, and therefore Cerebral perfusion pressure, is also affected by extremes of oxygen and carbon dioxide. If you would like to read more about this, have a look at this Life in The Fast Lane post.


The Brain Injury Foundation guidelines which Fliss mentions can be accessed here.

Doubts over head injury studies. Roberts I, Smith R, Evans S. BMJ. 2007 Feb 24; 334(7590): 392–394. (This is the paper Elfyn mentions regarding the now redacted original publications on the use of mannitol)

Wakai A, McCabe A, Roberts I, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD001049. DOI: 10.1002/14651858.CD001049.pub5

The HIRT trial: https://emj.bmj.com/content/32/11/869

The HITS-NS trial: The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study.

Wilson et al. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. 

Impact Brain Apnoea. https://www.ncbi.nlm.nih.gov/pubmed/27211834

And finally…

…. if you would like to hear more on the subject of Head Injury – have a listen to what the Resus Room team have to say about it:

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Episode 29: Major Incidents

major incidents image


Another invitation to the Trauma Care Conference this year inspired us to combine two of the excellent speakers into this podcast considering major incidents. Thanks to both our speakers for sharing their talks from the conference.

Trauma Care logo


Trauma Care offer more than the annual conference; there are monthly webinars and regional meetings too, click here for more information.



The Joint Emergency Services Interoperability Programme (JESIP) website and National Ambulance Resilience Unit (NARU) website have lots of resources to support your response to a major incident.


The papers which Chris mentions regarding IED injury patterns and management in children are both from the Journal of the Royal Army Medical Corps:

Thompson, Crooks, Clasper, Lupu, Stapely, Cloke. The pattern of paediatric blast injury in Afghanistan.

Ramasamy, Hill, Clasper. Improvised Explosive Devices: Pathophysiology, Injury Profiles and Current Medical Management


Episode 28: LOST



Cardiac arrest is the end point, it is the symptom, not the diagnosis. The pathophysiological process varies, and this is particularly relevant in trauma vs medical. In medical cardiac arrest, the pathological processes tend to affect the heart’s ability to pump: eg primary cardiac event, chemical/electrolyte abnormality, but full circulation. In trauma the process is generally not primarily due to pump failure, but due to hypovolaemia or obstruction. It might be better to consider traumatic cardiac arrest as a completely different disease eg LOST: Low Output State due to Trauma

The 2015 European Resuscitation Council and UK Resuscitation Council Algorithms for Traumatic Cardiac Arrest:


To read the whole ERC guideline on special circumstances cardiac arrest including trauma, click here.

Ultrasound during TCA: Cureton et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma. 2012; 73: 102-10.

The outcomes from different resuscitative interventions in a haemorrhagic shock model in porcine model:

Screen Shot 2018-04-16 at 21.01.33

From: Watts et al. Closed chest compressions reduce survival in a model of haemorrhagic-induced traumatic cardiac arrest . EMJ 2017; 34: 860-900. (A866)

Impact brain apnoea: Wilson et al. Impact brain apnoea – A forgotten cause of cardiovascular collapse in trauma. Resuscitation. 2016; 105: 52-58.


  1. Barnard et al. Epidemiology and aetiology of TCA in England… Resuscitation; 110 (2017): 90-94.
  2. Russell RJ et al. The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services. Phil Trans R Soc. 2011; 366. Doi: 1098/rstb.2010.0232
  3. Wise et al. Emergency thoracotomy ‘how to do it’. EMJ; 2005: 22-24.
  4. Morrison et al. Resuscitative thoracotomy following wartime injury.
  5. Jeffcoach DR et al. Use of CPR in hemorrhagic shock, a dog model.
  6. Lockey et al. Traumatic cardiac arrest: who are the survivors? Annals of Emergency Medicine; 2006.
  7. Grasner et al. Cardiopulmonary resuscitation in traumatic cardiac arrest – there are survivors. Critical Care; 2011.
  8. Zwingmann et al. Survival and neurological outcome after OOH TCA in pediatric & adult populations: a systematic review. Critical Care; 2012.
  9. Slessor et al. To Be Blunt: are we wasting our time? Emergency Deaprtment Thoracotomy following blunt trauma: a systematic review & meta-analysis. Anneals of EM; 2015: 297-307.
  10. Leis CC et sl. TCA: should advanced life support be initiated? J Trauma. 2013; 74: 634-8.
  11. Jacobs et al. Effect of adrenaline on survival in out of hospital cardiac arrest: randomised double-blind placebo controlled trial. Resuscitation. 2011; 82: 1138-43.
  12. Smith et al. Traumatic Cardiac Arrest. Journal of Royal Society of Medicine. 2015; 108: 11-16.
  13. Sperry et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008; 64: 9-14/

Episode 27: Checklists


We recommend reading Atul Gawande’s book ‘The Checklist Manifesto’. It’s a well written, fascinating story about the introduction of the WHO Safer Surgery checklist and the impact it had. This link will take you straight to Amazon if you want to buy a copy (other internet retailers exist!!)

To understand the how human factors failed in the death of Martin’s wife, Elaine, please watch this video:

The fabulous Life in the Fast Lane have also produced a blog on the case.

There are lots of resources available on the Clinical Human Factors Group website.

Episode 26: Tranexamic Acid

txa 2-2


The paper which we discuss in the interview is available open access here

How does tranexamic acid work?


Taken from: https://pbrainmd.wordpress.com/2015/10/15/1335/

Critical appraisal aids

To understand more about hierachy of evidence and how a systematic review fits into this please have a look at these resources available from the Cochrane group.

Cochrane consumer logo


Cochrane training logo


The CASP checklist can be used for assessing the quality of a meta-analysis.

More TXA research trials

Want to know more about the ongoing Crash 3 trial?


Want to know more about the Halt it trial?

Halt it logo



  • CRASH-2 (available open access here)
  • The WOMAN Trial (available Open access here)
  • The meta-analysis of topical tranexamic acid which Ian mentions is a Cochrane review, available here.

Episode 25: Tension pneumothorax 2

tp2 fin

Where can you undertake decompression of a pneumothorax?

Be particularly careful when using the 2nd intercostal space mid-clavicular line that you are sufficiently lateral. For example, here are the locations identified as ‘2nd ICS mid clavicular line’ amongst 25 EM physicians in a 2005 EMJ paper.


From http://emj.bmj.com/content/22/11/788

The Three Kings: George Clooney’s recommended approach to decompression of a tension pneumothorax. Note – again please do not use this location!

Devices used for decompression:


Dressings available for covering an open pneumothorax +/- thoracostomy in a spontaneously breathing patient:



  • Ball, C. G., Wyrzykowski, A. D., Kirkpatrick, A. W., Dente, C. J., Nicholas, J. M., Salomone, J. P., et al. (2010). Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Canadian Journal of Surgery Journal Canadien De Chirurgie53(3), 184–188.
  • Barton, E. D., Epperson, M., Hoyt, D. B., Fortlage, D., & Rosen, P. (1995). Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. The Journal of Emergency Medicine13(2), 155–163.
  • Beckett, A., Savage, E., Pannell, D., Acharya, S., Kirkpatrick, A., & Tien, H. C. (2011). Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line? The Journal of Trauma71, S408–S412. http://doi.org/10.1097/TA.0b013e318232e558
  • Cullinane, D., Morris, J., Bass, J., & Rutherford, E. (2001). Needle thoracostomy may not be indicated in the trauma patient. Injury32, 749–752.
  • Ferrie, E. P., Collum, N., & McGovern, S. (2005). The right place in the right space? Awareness of site for needle thoracocentesis. Emergency Medicine Journal22(11), 788–789. http://doi.org/10.1136/emj.2004.015107
  • Fitzgerald, M., Mackenzie, C. F., Marasco, S., Hoyle, R., & Kossmann, T. (2008). Pleural decompression and drainage during trauma reception and resuscitation. Injury39(1), 9–20. http://doi.org/10.1016/j.injury.2007.07.021
  • Givens, M. L., Ayotte, K., & Manifold, C. (2004). Needle thoracostomy: implications of computed tomography chest wall thickness. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine11(2), 211–213. http://doi.org/10.1197/j.aem.2003.09.015
  • Harcke, H. T., Mabry, R. L., & Mazuchowski, E. L. (2013). Needle thoracentesis decompression: observations from postmortem computed tomography and autopsy. Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals13(4), 53–58.
  • Inaba, K., Branco, B. C., Eckstein, M., Shatz, D. V., Martin, M. J., Green, D. J., et al. (2011). Optimal positioning for emergent needle thoracostomy: a cadaver-based study. The Journal of Trauma71(5), 1099–103– discussion 1103. http://doi.org/10.1097/TA.0b013e31822d9618
  • Inaba, K., Ives, C., McClure, K., Branco, B. C., Eckstein, M., Shatz, D., et al. (2012). Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Archives of Surgery (Chicago, Ill : 1960)147(9), 813–818. http://doi.org/10.1001/archsurg.2012.751
  • Jadder, U., & McAuley, D. (2005). Transthoracic ultrasonography to diagnose pneumothorax in trauma. BestBETS.org, 1–3.
  • Jones, R., & Hollingsworth, J. (2002). Tension pneumothoraces not responding to needle thoracocentesis. Emergency Medicine Journal19, 176–177.
  • MD, A. R. M., MD, M. E. R., MD, C. S. C., & MD, J. L. M. (2015). Ultrasound determination of chest wall thickness: implications for needle thoracostomy. The American Journal of Emergency Medicine, 1–5. http://doi.org/10.1016/j.ajem.2010.06.030
  • MD, B. B., & MD, J.-M. T. (2012). Initial Management and Resuscitation of Severe Chest Trauma. Emergency Medicine Clinics of NA30(2), 377–400. http://doi.org/10.1016/j.emc.2011.10.010
  • MD, E. J. C., MD, C. H. C., BS, R. M., PHD, C. L. A., RDMS, C. A. K. M. M., RDMS, S. S. M., & RDMS, J. C. F. M. (2013). Ultrasound in Emergency Medicine. The Journal of Emergency Medicine44(1), 142–149. http://doi.org/10.1016/j.jemermed.2012.02.032
  • Netto, F. A. C. S., Shulman, H., Rizoli, S. B., Tremblay, L. N., Brenneman, F., & Tien, H. (2008). Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications? The American Journal of Emergency Medicine26(5), 597–602. http://doi.org/10.1016/j.ajem.2007.08.016
  • Rathinam, S., Grobler, S., Bleetman, A., Kink, T., & Steyn, R. (2014). Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion. Emergency Medicine Journal31(1), 59–64. http://doi.org/10.1136/emermed-2012-201821
  • Rathinam, S., Quinn, D. W., Bleetman, A., Wall, P., & Steyn, R. S. (2011). Evaluation of ThoraQuik: a new device for the treatment of pneumothorax and pleural effusion. Emergency Medicine Journal28(9), 750–753. http://doi.org/10.1136/emj.2009.082297
  • Sanchez, L. D., Straszewski, S., Saghir, A., Khan, A., Horn, E., Fischer, C., et al. (2011). Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine18(10), 1022–1026. http://doi.org/10.1111/j.1553-2712.2011.01159.x
  • Wax, D. B., & Leibowitz, A. B. (2007). Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesthesia and Analgesia105(5), 1385–8– table of contents. http://doi.org/10.1213/01.ane.0000282827.86345.ff
  • Yamagiwa, T., Morita, S., Yamamoto, R., Seki, T., Sugimoto, K., & Inokuchi, S. (2012). Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan. Injury43(1), 42–45. http://doi.org/10.1016/j.injury.2010.11.022
  • Zengerink, I., Brink, P. R., Laupland, K. B., Raber, E. L., Zygun, D., & Kortbeek, J. B. (2008). Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? The Journal of Trauma64(1), 111–114.  http://doi.org/10.1097/01.ta.0000239241.59283.03

Episode 24: Tension pneumothorax 1


Firstly, go and read Simon and Tim Harris’ great 2005 paper on the subject which we reference repeatedly in the podcast. It is available free open access here.

A pneumothorax exists when air accumulates in the potential space between the visceral and parietal pleura:

Pneumothorax during respiratory cycle

From: www.wisdomjobs.com

A tension pneumothorax exists when the air in the pleural cavity is under high pressure resulting in compression of the surrounding structures.

Simon mentions Rutherford’s diagram in the podcast. This is taken from a 1968 paper examining the progressive pathophysiology of a tension pneumothorax. The graph shows the changes in intrapleural pressure (on the ipsilateral and contralateral sides) in spontaneously breathing goats who had air injected into one side of their chest. We can’t find the full article free/open access anywhere I’m afraid. But this is the reference: THE PATHOPHYSIOLOGY OF PROGRESSIVE, TENSION PNEUMOTHORAX. Rutherford RB, Hurt HH, Brickman RD, Tubb JM. Journal of Trauma and Acute Care Surgery, March 1968,8(2):212-227

Diagram from Rutherford's 1968 paper on tension pneumothorax

The imaging findings of tension pneumothorax might look like this:

More plain film images are available in this article on the Radiopaedia website.

And you can see what a CT scan of a patient with tension pneumothorax looks like in this vimeo shared on the Life in the Fast Lane website.

If you want to know about ultrasound findings of pneumothorax, check out this great R.E.B.E.L.EM post.


Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? EMJ. 2005; 22:8-16.  doi.org/10.1136/emj.2003.010421

Roberts DJ, Leigh-Smith S et al. Clinical Presentation of patients with a Tension Pneumothorax – a systematic review. Annals of Surgery. 2015; 261: 1068-78. doi: 10.1097/SLA.0000000000001073

Episode 23: Intraosseus access

IO Access 2

The various devices which Tony discusses are:

This video shows the rapidity of infusion entering the circulation from a humeral IO.

This is the paper mentioned by Tony, which shows the stepwise improvement in mortality amongst combat casualties from military conflict 2003-2012, including the ‘unicorn’ graph:

Fig 2 from Penn-Barwell et al 2015

Anatomy of bones and the humerus related to intraosseus access

Long bone anatomy

Humeral anatomy


The surface anatomy of the shoulder

Surface anatomy of shoulder

The bony anatomy of the shoulder

Bony anatomy of shoulder

Muscular attachments of the shoulder

Muscular anatomy of shoulder

Blood vessels and nerves around the proximal humerus

A demonstration of the landmarking process for humeral intraosseus insertion is available here.

Want to know more about EZ-IO access?

The education resources which Tom mentions are available here.


Episode 19: Surgical Airway

surgical airway


The West Midlands surgical skills course offers cadaveric training for PHEM and EM practitioners on rare life saving procedures. Click here to go straight to their page.


Screen Shot 2017-06-22 at 13.43.36

The Guidelines

Screen Shot 2017-06-22 at 13.20.19

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk et al. Difficult Airway Society: Intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

For more information, have a look at the Difficult Airway Society website.

AAGBI Safer Prehospital Anaesthesia

Click here for the 2017 guidelines

The Kit

Know what your service carries, practice with that equipment, then you will be familiar with the kit you are using in the heat of the moment.


Minimal kit: scalpel, bougie, tube

Tracheal dilators and tracheal hook

The Technique

For a demonstration of the DAS recommended technique for surgical front of neck access, have a look at this video, recorded by colleagues over at openairway.org:

Just a Routine operation

The video we mention in the podcast produced by Martin Bromiley after the death of his wife, Elaine, in a can’t intubate can’t oxygenate scenario is available here:


And have a look at the website for more of Martin’s work with the Clinical Human Factors group.

Other fantastic #FOAM resources regarding airway management are available:

From Nicholas Chrimes  at http://vortexapproach.org

From the fabulous people over at Life in the Fast Lane including a video demo from Scott Weingart from EMCrit: https://lifeinthefastlane.com/ccc/surgical-cricothyroidotomy/


This is Tim’s recent publication we mention in the ‘cast!: Nutbeam, T., Clarke, R., Luff, T., Enki, D. and Gay, D. (2017), The height of the cricothyroid membrane on computed tomography scans in trauma patients. Anaesthesia. doi:10.1111/anae.13905

Aslani, A., Ng, S.-C., Hurley, M., McCarthy, K. F., McNicholas, M., & McCaul, C. L. (2012). Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesthesia and Analgesia, 114(5), 987–992. http://doi.org/10.1213/ANE.0b013e31824970ba
Bair, A. E., & Chima, R. (2015). The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 22(8), 908–914. http://doi.org/10.1111/acem.12732
Bennett, J. D., Guha, S. C., & Sankar, A. B. (1996). Cricothyrotomy: the anatomical basis. Journal of the Royal College of Surgeons of Edinburgh, 41(1), 57–60.
Boon, J. M., Abrahams, P. H., Meiring, J. H., & Welch, T. (2004). Cricothyroidotomy: a clinical anatomy review. Clinical Anatomy (New York, NY), 17(6), 478–486. http://doi.org/10.1002/ca.10231
Buonopane, C. E., Pasta, V., Sottile, D., Del Vecchio, L., Maturo, A., Merola, R., et al. (2014). Cricothyrotomy performed with the Melker™ set or the QuickTrach™ kit: procedure times, learning curves and operators’ preference. Il Giornale Di Chirurgia, 35(7-8), 165–170.
Cook, T., Woodall, N., & Frerk, C. (2015). Appendix 4 NAP4 Summary: major complications of airway management in the United Kingdom. British Journal of Anaesthesia (2011) 106 (5): 617-631. https://doi.org/10.1093/bja/aer058
Dover, K., Howdieshell, T. R., & Colborn, G. L. (1996a). The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clinical Anatomy (New York, NY), 9(5), 291–295. http://doi.org/10.1002/(SICI)1098-2353(1996)9:5<291::AID-CA1>3.0.CO;2-G
Frerk, C., Mitchell, V. S., & McNarry, A. F. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia (2015) 115 (6): 827-848. https://doi.org/10.1093/bja/aev371
Hubert, V., Duwat, A., Deransy, R., Mahjoub, Y., & Dupont, H. (2014). Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology, 120(4), 999–1008. http://doi.org/10.1097/ALN.0000000000000138
Langvad, S., Hyldmo, P. K., Nakstad, A. R., Vist, G. E., & Sandberg, M. (2013a). Emergency cricothyrotomy–a systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 43. http://doi.org/10.1186/1757-7241-21-43
Nakstad, A. R., Bredmose, P. P., & Sandberg, M. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 59. http://doi.org/10.1186/1757-7241-21-59
 Navsa, N., Tossel, G., & Boon, J. M. (2005). Dimensions of the neonatal cricothyroid membrane – how feasible is a surgical cricothyroidotomy? Paediatric Anaesthesia, 15(5), 402–406. http://doi.org/10.1111/j.1460-9592.2005.01470.x
 Prithishkumar, I. J., & David, S. S. (2010). Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy. Emergency Medicine Australasia, 22(1), 13–20. http://doi.org/10.1111/j.1742-6723.2009.01245.x
 The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. (1999). The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. Clinical Anatomy (New York, NY), 12(1), 43–54. http://doi.org/10.1002/(SICI)1098-2353(1999)12:1<43::AID-CA7>3.0.CO;2-W



Episode 17: Broken? Impact on the rescuer


This episode has been compiled over a year – many thanks to our four contributors, who have shared their stories and knowledge. They were interviewed at TraumaCare 2016, TraumaCare 2017 and the BASICS/FPHC Conference 2016.

If you ever need to talk about the impact of stresses and work experiences on you, please find a friend, colleague, GP, work Occupational Health Service, or one of the charities listed below.

Tony’s article describing his experience of providing medical care to those involved in the Shoreham air crash:


Links to some of the resources Matt mentioned:

Mind Blue Light Campaign:



Watch this excerpt from the West Wing:

If you would like to check your own resilience score, you could use this tool recommended by Matt:




More information from Rusty’s interview:


By FireflySixtySeven using Inkscape, from Maslow’s A Theory of Human Motivation.

Want to know more about EMDR?


Rusty recommended The Howl – EMS Wolfpack podcasts for more on this subject:


This is the article written by fire fighter Rob Norman


Episode 15: Paediatric Trauma & How to Do Sim


Paediatric Trauma

TARN report: Severe Injury in Children


ATACC:The Anaesthesia Trauma and Critical Care course

Thanks to Mark Forrest (@ObiDoc) for sharing these videos:


  1. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. EMJ. 2016.
  2. Bredmose PP, Habig K, Davies G, Grier G, Lockey D. Scenario based outdoor simulation in pre-hospital trauma care using a simple mannequin model. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2010.
  3. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Quality & Safety. 2013; 22: 468-477.
  4. Boet S, Bould MD, Layat Burn C, Reeves S. Twelve tips for a successful interprofessional team-based high-fidelity simulation educational session. Medical Teacher. 2014; 36: 853-857.

Episode 14: Thoracotomy



Details of the surgical skills course mentioned in the podcast can be found here:


The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document:

Policies and Procedures

An excellent ‘how to do it’ paper, published in 2005, by the London HEMS team, can be accessed via the link below:

Click to access v022p00022.pdf


Equipment required for resuscitative thoracotomy:equipment-required-for-thoracotomy

Surface anatomy:


Appearance of pericardial clot


A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.


An open chest with aortic compression


Simulation of resuscitative thoracotomy by London HEMS team.

For an entertaining and insightful discussion about the impact of undertaking thoracotomy, listen to Dr John Hinds talk from SMACC 2015. Highly recommended.


And for a summary of the evidence and recommendations, have a look at the St Emlyns blog:



  • Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16.
  • Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24.
  • Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19.
  • Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4.
  • Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298
  • ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309.
  • Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969.
  • Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111.
  • Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197

Episode 12: Breaking Bad News


YouTube videos:

From the police officer’s perspective: https://www.youtube.com/watch?v=toaA_TNwcxg

From the mother’s perspective: https://www.youtube.com/watch?v=0KJZXOKStao

The paper about watching resuscitation is this one:


This is a section taken from the London Ambulance Service clinical bulletin, from 2011, which includes the SPIKES mnemonic:


The alternative mnemonic mentioned in the podcast is GRIEV_ING, which has been developed for use in the ED.



Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. Spikes – a six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist. 2000; 5: 302-311.

Hobgood C, Harward D, Newton K, Davis W. The educational intervention “GRIEV_ING” improves the death notification skills of residents. Journal of Academic Emergency Medicine. 2005; 12: 296-301.

Jabre P, Belpomme V, Azoulay E et al. Fanily presence during cardiopulmonary resuscitation. The New England Journal of Medicine. 2013: 368 (11): 1008-1018.

Episode 11: Gentle Patient Handling

Gentle Patient Handling


The paper we mentioned by Jonathan Benger and Jules Blackham can be accessed here:


Stable versus unstable spinal injury

The location of an injury and involvement of different structures defines the stability of a spinal injury.

Screen Shot 2016-07-14 at 12.02.03

Anterior column: anterior longitudinal ligament and the anterior half of the vertebral body/disc.

Middle column: posterior half of the vertebral body/disc and the posterior longitudinal ligament.

Posterior column: facet joints, ligamentum flavum, the spinous processes and the interconnecting ligaments.

An injury involving only the anterior column is considered to be stable, as will an isolated fracture of a spinous or transverse process. An unstable injury is one which involves all 3 columns and often one in which 2 columns are disrupted.

Screen Shot 2016-07-14 at 12.20.03


  1. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510–8.
  2. Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: A systematic review. Injury. Elsevier Ltd; 2015 Apr 1;46(4):528–35.
  3. Smyth M, Cooke MW. Value of a rigid collar: in need of more research and better devices. Emergency Medicine Journal. 2013 May 13;30(6):516–6.
  4. Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. MRI study of effectiveness of cervical spine immobilisation- a pilot study. The University of Warwick. 2007 Aug 1;:1–18.
  5. BOAST2: SPINAL CLEARANCE IN THE TRAUMA PATIENT. British Orthopaedic Association Standards for Trauma (BOAST); 2008. 1 p.
  6. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 2008 Apr 15;5(3):214–9.
  7. Prasarn ML, Horodyski M, Dubose D, Small J, Del Rossi G, Zhou H, et al. Total Motion Generated in the Unstable Cervical Spine During Management of the Typical Trauma Patient. Spine. 2012 May;37(11):937–42.
  8. Gill DS, Mitra B, Reeves F, Cameron PA, Fitzgerald M, Liew S, et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emergency Medicine Journal. 2013 Jul 19;30(8):679–82.
  9. Leech C, Porter K, Bosanko C. Log-rolling a blunt major trauma patient is inappropriate in the primary survey. Emergency Medicine Journal. 2013 Dec 22;31(1):86–6.
  10. Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR II. Removing a Patient From the Spine Board: Is the Lift and Slide Safer Than the Log Roll? J Trauma. 2011 May;70(5):1282–5.
  11. I J, A M, Yu E, Tulman D, Jones C, Stawicki S. A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients afternormal cervical spine CT. Journal of Emergencies, Trauma, and Shock. 2014 Feb 11;7(4):251–5.
  12. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
  13. Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emerg Med J. 2007 Jul 1;24(7):501–3.
  14. PhD JRE, PhD JWS, OTD TLS, MSOT JLE, EMTP JSSM, MD RSN. Selected Topics: Prehospital Care. J Emerg Med. Elsevier Ltd; 2013 Jan 1;44(1):122–7.
  15. Connor D, Greaves I, Porter K, Bloch M, consensus group Faculty of Pre-Hospital Care. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J. 2013 Dec 1;30(12):1067–9.
  16. Fattah S, Johnsen AS, Andersen JE, Vigerust T, Olsen T, Rehn M. Rapid extrication of entrapped victims in motor vehicle wreckage using a Norwegian chainmethod – cross-sectional and feasibility study. 2014 Jul 3;14(1):1–5.
  17. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008 Apr 22;178(9):1141–52.
  18. Edwards MA, Verwey J, Herbert S, Horne S, Smith JE. Cervical spine clearance in the elderly: do elderly patients get a bad deal? Emerg Med J. 2013 May 23.
  19. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
  20. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009 May;10(2):74–8.
  21. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993 Mar;34(3):342–6.
  22. Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. Journal of Trauma and Acute Care Surgery. 2015 May;78(5):943–8.
  23. Benger J, Blackham J. Why do we put cervical collars on conscious trauma patients? Scand J Trauma Resusc Emerg Med. 2009;17(1):44.

SMACC – Innovate, Explore, Connect, Belong, Inspire


2 weeks post SMACC and I have finally got around to sharing some thoughts. The first is to say that it is difficult to outline what I learnt during my 4 days in Dublin. To summarise, it was more about ‘how’ I practice medicine, than ‘what’ I do. But, here are some of my highlights.

The first session of day 1 was the John Hinds plenary. John Hinds was a prehospital doctor and anaesthetist who died shortly after SMACC last year in a motorbike crash. His lecture last year was one of my favourites – well worth a listen/watch.

HINDS: Crack the Chest. Get Crucified.

His partner, Janet, and colleague spoke wonderfully about the funny, committed and irreverent man they knew. One of the key messages from his talk last year was to ensure your intentions are always honourable, and they encouraged us to use the hashtag #whatwouldjohndo.

Feedback & developing performance

Victoria Brazil – so you think you are a resuscitationist?

Has there ever been a time when you were deluded about your performance? The Dunning-Kruger curve illustrates the relationship between experience and confidence and how we may think we are better than we are.


This graph was taken from Sandra Viggars talk on Day 3

The counterbalance to this position is imposter syndrome: we don’t think we deserve to be in the position we are in.

So how do we close the gap? Victoria argued that it was through feedback, and described an incident from her early career when she had completely misread her performance at a prehospital incident and then demonstrated how to give good feedback.

She said the road to knowing how good we are (self-insight) lies with other people. And recommended the following top tips for giving and getting feedback:

  • be honest
  • do it often (get into the habit)
  • we need to actively seek feedback
  • Be a mirror, this is what I saw, this is what I thought, lets have a conversation….

She acknowledged that this can be quite hard as you become more senior (rather than trainees).

Kettlebells for the brain (Meditation)

Scott Weingart

Scott delivered a podcast live on stage about the role of meditation as a work out for your brain. It was really challenging and there were some interesting concepts which are best understood by listening to it yourself! It’s not out in full yet but here is the sneak preview:

EMCrit Wee – Vipassana Meditation

The case for HEMS

Gareth Davies

Started with admitting his bias! And acknowledged that evidence is scant. He emphasised that when we judge helicopters they should be delivering ‘full bore’ medicine – maximum commitment, maximum effort, uncompromising, full armourmentarium.

And encouraged the audience to ensure:

  • Do your best
  • Attention to the basics
  • Translation from other areas (require support of peers, delivering hospital care out of hospital eg REBOA)
  • Demonstrate a commitment to clinical excellence
  • The notes you write are beyond reproach
  • Governance package in ED/PHC that is second to none
  • Present at grand round, speak at cardiothoracic audit day (battle for credibility lies outside of the ED, outside of the EM journal)
  • Not just trauma

And to provide students with examples of exemplary care, inspirational clinicians and the best education experience of their training.

Elderly care

There were some themes from the Emergency Medicine stream which are relevant to PHEM – most notably, in my opinion, the growing population of older people requiring our care.

Suzanne Mason’s presentation was entitled ‘Acute Care of the Elderly’ and she advocated learning to love frailty!

Some idea of the numbers: patients in the over 65 age group represent approximately 25% of attendances to EDs; 90% of them are necessary and 60% are admitted. She shared the following video which is incredibly thought provoking:


We all have a role to play, and there is good evidence to support prehospital interventions. For example, paramedics trained to assess patients following falls – 25% reduction in ED attendances, and 6% reduction in subsequent admissions.

Adrenaline in cardiac arrest

Jim Manning reviewed progress in resuscitation and compared ‘artificial perfusion’ with the effective interventions of ‘artificial ventilation’ and defibrillation. He argued that artificial perfusion is where we are least successful and reviewed the evidence for adrenaline.

Adrenaline is given to try and improve coronary perfusion pressure, and research shows that coronary perfusion pressure > 15 mmHg is associated with ROSC. There is also a demonstrable improved ROSC rate and admission with adrenaline, but no difference in hospital discharge or neurological outcome vs placebo. Where does this leave us? Well, with quite a few questions!

  • Why doesn’t it work? Perhaps because we are giving it IV and in those with a poor coronary perfusion pressure it is sitting in the vein.
  • Should we give up?
  • How about intra-aortic/intra-arterial adrenaline?

Watch this space!

The Boston marathon bombing

Christina Hernon (@EMedTox) talked about her experience as an ‘Impromptu Immediate Responder’. She was already at the scene when the bombs went off but not in a formal immediate care role. It was an extremely powerful presentation and I would recommend listening to/watching it when it is released later in the year at http://intensivecarenetwork.com/smaccmedia/, but some of the things she talked about were:

  • Is the scene safe? – yes, no, I don’t know.
  • Shit can happen anywhere, you might be there.
  • How to be safe in an unsafe scene
  • Try not to move patients
  • Haemorrhage control and maybe airway opening manoeuvres are all you can do + set up some form of triage areas
  • Be very wary of your stress response

For those of us responding after an incident such as this, be kind to these Impromptu Immediate Responders.

From a bigger picture point of view, should we have some form of community preparedness? This might then have an impact then on recovery of those exposed.

Coaching for medicine

Tom Evens (@DocTomEvens) is a coach for British rowing and he talked about the similarities between medicine and sport, and what we can learn from the principles of coaching sport.

 Find your talented person and believe in them.

 As a senior clinician you are able to see what a trainee could become at the beginning of their career, when they are not. What is their goal? What is the standard required to reach that goal? Be humble in the face of that standard. Success comes from an aggregation of good choices – commit to a standard.

Marginal gains – questioning assumptions.

The reality of progress: increments, inches, persistence, progression. But there is a risk of concentrating on the small stuff at the expense of missing the big stuff – must focus on the basics.

Self compassion

Help people thrive in their training programme, not just survive. Athletes have to engage in their training. The danger of being a perfection driven person is if you don’t recognize your humanity. A negative response to a failure can impede your performance for days.

The Greatest Presentation in the World

Ross Fisher

As well as delivering a fabulous presentation entitled ‘Things that scare me’, Ross shared his presentation secrets in a very entertaining and inspiring talk. Rather than reading what I took home – have a look at his blog which covers everything you need to know about improving your presentations.


Further reading

For more reflections on the conference please see this St Emlyns post and their further reading list and the podcasts they recorded each day.

SMACCDUB – A Trainee’s Perspective. St.Emlyn’s

Episode 10: Stress Inoculation

Inoculation training

Big thanks to Anand Swaminathan @EMSwami, Chris Nickson @precordialthump, Jesse Spurr @Inject_Orange, Chris Hicks @HumanFact0rz, and Tom Evens @doctomevens

Their pre-workshop reading/listening recommendations:








Visualisation tips:



Episode 9: Maternal Collapse

Mat collapse-2

Apologies for the quality of the sound – we recorded in a very echo-ey office!

The Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline is accessible here:


We have talked about ramping previously, in Episode 6: Oxygenation. This is how a pregnant patient should be positioned for airway manoeuvres and interventions, for example induction of anaesthesia and intubation.

Screen Shot 2016-03-17 at 10.09.34

The ILCOR 2015 update pertaining to Cardiac Arrest Associated with Pregnancy is accessible here:


Including this picture demonstrating manual displacement of the uterus:Manual displacement

The concept of deliberate practice is discussed in more details on these sites:

This is Cliff Reid (resus.me) talking about his lecture from the Royal College of Emergency Medicine Conference in 2015:


And this is Simon Carley’s (St Emlyn’s) blogpost on the subject:


And last, but not least, Scott Weingart (EMCRIT) from SMACC 2013




Advanced Life Support (7th Edition). Resuscitation Council UK. 2016.

Parry R, Asmussen T, Smith JE. Perimortem caesarean section. EMJ. 2016; 33: 224-229.

Clark SL, Cotton DB, Pivarnik JM et al. Position change and central hemodynamic profile during normal third trimester pregnancy and post partum. Am J Obstetrics & Gynaecology. 1991; 164: 883-887.

Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anaesthesia & Analgesia. 2003; 97: 256-258.

Lee SWY, Khaw KS, Kee WN, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. British Journal of Anaesthesia. 2012; 109: 950-956.

Trauma Care Day 3

There were several streams running simultaneously today which were interesting for prehospitalists, not least the PHEM/HEMS Programme. We tried to get to as many as possible to share some of the key learning points and interesting messages, and again we have recorded some interviews which we will share in future podcasts.

‘One RTC – 3 perspectives’ – Darren North

The fire service have only had a statutory duty to attend RTCs since 2004. Their role is to protect people from harm – patients and practitioners.

Strategy of the Fire Service at RTCs “The Team Approach”:

  1. Safe approach and control of hazards (risk assessment starts in the fire station and planning en route – share message with the team, role allocation)
  1. Stabilisation (car needs to be solid so the patient and initial rescuers are safe) and initial access. When a car is on it’s side, if fire service not yet there, consider placing one individual at either end of the car to stabilise it.
  1. SRS/Glass management – cover glass, open windows/sunroof (but wary of environment), make safety systems safe eg airbags
  1. Space creation – remove shopping, luggage, parcel shelves etc
  1. Full access – depending on plan, following liaison with medical service
  1. Patient extrication & transport (in some regions fire service have role in taking patients to hospital)
  1. Evaluate and training (hot debrief – at the back of the fire engine on scene, but this is limited to fire service as health providers have usually taken the patient to hospital)

What can the fire service offer the medics:

  • A safe working environment
  • Rapid initial access
  • Free entrapment ASAP
  • Extra pairs of hands
  • Medical assistance/equipment
  • Debrief (hot and structured)

Key messages

  • Identify who is charge, generally officer in charge will have Incident Commander tabard, not necessarily the ‘white helmet’
  • Speak plain English
  • IMG_6616
  • Always try to be better
  • Be honest about time frames
  • Train together
  • Be careful what you say

And then I moved into the Trauma in Children Programme, to listen to:

The Highs & Lows of Pre Hospital Paediatric Trauma – Dr Kevin Enright

We have interviewed Kevin to share in a future podcast but hear is a summary of his talk.

Very serious injuries in children is rare – so exposure to severely injured children prehospital is infrequent and the evidence is sparse – highlights the importance of shared experience.

Children are brave, honest and constructive. This should be remembered when assessing and treating seriously injured children.

Recent report covering the last 2 years of TARN data:


When children are injured/ill and scared they regress. Remember this, especially when managing adolescents; children may not be as interactive or as co-operative as you would expect for their age.

Significant cervical spine injury in children is exceptionally rare. Three cases described: high speed RTC, traumatic cardiac arrest. Patients had high cord injuries.

What do an advanced prehospital team offer at scene to a seriously injured/ill child?

  • CRM (experience + discipline – there is one way to do this and we must do it fast and efficiently)
  • Leadership
  • Order & calm (slightly more exposure)

Policy that paediatric patients are not declared dead at scene. If the prehospital team consider the patient to be futile they will take them to the nearest local hospital. This has a huge impact on the local hospital – is that fair? It is hard enough for those who work in MTC paediatric centres. Should the prehospital team make the decision and not attempt resus in hospital at all?

Prehospital paediatric RSI

  • We do it less despite similar injury aetiology/patterns
  • Most children’s airways can be managed by basic manoeuvres
  • However, children with a significant head injury deserve best airway care – ventilation, metabolic, haemodynamics, positioning. Must have appropriate training & experience otherwise risk/benefit balance is skewed.
  • Children’s airways are different, be prepared for this (NB don’t even think about it though with children with craniofacial deformities)

Injured children are compensating to try and survive.


Top tips

  • Analgesia, warmth & splintage
  • Confidence & rapport (the healthcare professional is the right person to do this, not the parent – how can they be constructive?)
  • Mechanism of injury
  • Clinical assessment
  • Compensatory mechanisms (but they will be getting acidotic, coagulopathic)
  • Fluids? (2-5ml/kg, ideally blood products but crystalloid ok)
  • Scoop & run

The Evidence for Night HEMS – Leigh Curtis

This was a review of the 2 year trial KSS air ambulance conducted into night HEMS. If, like me, you thought that night HEMS is “Expensive … dangerous … pointless”, the data that Leigh presented was interesting. For their geography and population it turned out that they flew 1373 missions, and contacted 942 patients (1.9 missions on average per night), who had an average ISS of 23.5. Offline 15% of time due to weather minima.

Immersive Simulation in PHEM – Mark Forrest

We have interviewed Mark to share in a future podcast, but he had lots of great ideas, and recommended that we build SIM into everyday, using an example from Sydney HEMS; small and often.

Thinking about Pre-Hospital Death – Gareth Grier

This was an excellent talk which I recommend you watch when the video is available as it is difficult to reproduce the content here. One important point was:

We take a burden home with us when we have attended an incident when a patient has died. It can be a lonely place.

This is a topic we will revisit in future podcasts.

Pre Hospital Thoracotomy for Blunt Trauma – Tom Konig

We are going to catch Tom for a podcast tomorrow, but for now here is a taster:


Developing high performance through marginal gains – Adam Nash

Adam introduced the concept used by Team SKY and GP Olympic Cycling team: Focus on doing a few small things really well, once you do this aggregating these gains will become part of a bigger impact on performance.

To read/here more about it, try these St Emlyns resources:



Adam used the concept in a project to examine patient packaging. By working with some student paramedics to adjust techniques they were able to reduce packaging of a simulated time critical patient from nearly 13 minutes to just over 5.

Paediatric trauma patients: do they get a worse deal? – Phil Hyde

We were hoping to record a podcast on this for you – but Phil had to shoot off. We will catch up with him at a later date – but in the interim, here are the learning points.

In one word – yes: children get a raw deal.


  • Trauma is the biggest killer of children, with two peaks of death – the under 1s (injuries inflicted by other humans) and 6 +.
  • The mechanisms of trauma death in children are: RTCs, falls and other humans hurting them
  • The main cause of death is due to severe head injury.

Providing PH care to little humans:

Data from the Confidential enquires into head injuries in children 2010

In patients with a GCS of 8 or less transported by ambulance:

  • Oxygen not provided in 30%
  • Saturations not measured in 70%
  • BP not measured in 55%

This seems unbelievable – and definitely unacceptable.

Lots of ambulance services (in 2010) did not have appropriate kit to deal with small humans– including 92% not having appropriate sized supraglottic devices.

Phil raised his concerns around safe transport to the correct destination: very short drive times for low GCS patients – getting the balance right between this, and getting patients to the right centre first time is difficult – and we probably haven’t got the balance right yet.

In the UK our child mortality from trauma is high. We are performing very poorly compared to comparators, the mortality is 8.6% of children majorly injured, increasing to 18% when GCS<15. This is the same as Sweden in the early 1980’s the Swedish trauma systems have decreased mortality 3 fold during this time…

PH care is made more difficult as there is a fear of criticism from the paediatric fraternity. Children are considered very special / difficult and different – they require special training and equipment… This attitude is not helpful in the delivery of high quality Prehospital care. PH care delivery is generic in terms of training and experience of personnel – it is impractical to provide a ‘special’ service for children.

In PH care children require the same as adults – physiological support of their (injured) organs. Post PH care they can enter a paediatric specific system.

How we improve the care we offer to little humans:

  • We become experts in supporting HUMAN physiology, HUMAN trauma care, HUMAN medical logistics.. (no matter how big the humans are).

What do we need:

  • Generic, human SOPs
  • To spend time around sick small humans – best place is PICU, many will offer observational placements on request.
  • https://www.spottingthesickchild.com
  • Airway / Breathing / Circulation Kit for humans
  • Monitoring for humans
  • Transport for humans

We are empowered to:

  • Become expert in human trauma care
  • Make our system fit for humans
  • Make emotion positive
  • Embrace injury prevention



Trauma Care Day 2

Today has been a really good day at Trauma Care – there were several lecture streams running and I also gave a presentation on Pelvic Binders so I didn’t get to hear as many as I would like to have done, but here are a couple of summaries which I hope you will find interesting. We have also recorded a three interviews already which will feature in future podcasts. Many of the lectures were recorded today and will be available to view soon on the Trauma Care website.

All things Pre Hospital Ketamine – Minh Le Cong

Key point: patients remember if you manage their pain well.

Ketamine covers the full range of PH analgesia and anaesthesia, and can be administered IN, IV, IM, sublingual. It is highly lipophilic, rapidly absorbed, therefore particularly suitable for IN and SL admininstration.

Ketamine can be particularly useful in bariatric patients, where large doses of opiates in addition to past medical history of respiratory problems or chest injuries may not be ideal. Also good for patients on chronic pain long term opiate therapy with acute injury

Minh told a story about a patient who had undergone a prehospital amputation following the Christchurch earthquake – the full account can be heard here:


He also talked about the outcomes of the SKEPTIC trial which was a retrospective review of patients who’d received ketamine vs those who had not, comparing shock index. The periscope video of the SKEPTIC trial presentation is accessible here:


The Royal Flying Doctors Service (RFDS) use infusion of ketamine to manage agitated mental health patient without need for intubation. The paper published describing this and the protocol they use are linked below:



Emergence phenomena – Minh reports 12 cases during his career. This possibility should be respected but not feared. Key is to consider environment, perhaps it is unsurprising that patient’s get agitated when the aircraft starts up!

Following the lecture I found this on Minh’s PHARM website: a review of prehospital ketamine administrations.



Extrication & Immobilisation continued…. – Rob Fenwick

Extrication – a patient centred approach

Why does extrication matter?

  • Trauma is a killer, road trauma is a killer (leading cause of death of people aged <40 yrs), 4-5 deaths per day in the UK, 20-30% have a significant entrapment
  • For each patient that dies, 10x more a significantly injured
  • 50% die in first hour, 18% die between 1-6 hours, 15% preventable

Brown et al – patients requiring prolonged extrication increases mortality

Life saving interventions cannot be delivered while the patient is in the car.

The longer the time a patient is in the car in cold weather, the colder they will get, and mortality increases for every degree reduction in temperature.

Physical vs medical entrapment: Only 11% of patients ‘requiring extrication’ were actually physically trapped

Why do we extricate the way we do?

  • fear of exacerbating spinal injury
  • fear of being sacked when we ‘cause’ a spinal injury
  • fear of being sued when we ‘cause’ a spinal injury
  • that is how we have been taught
  • based on expert opinion + isolated case reports

What are we trying to do?

  • Reduce secondary injury – by restricting movement
  • Limited case reports suggesting that patient’s injuries had got worse between their initial assessment in at scene and in hospital – BUT were these really just natural progression of disease with spinal oedema increasing signs/symptoms?

Spinal fractures occur in 2% of all major trauma. Unstable spinal fractures occur in all major trauma 0.7%. Remember this when you get on scene – 98% of patients will not have a spinal injury.

The awake patient will develop a position of comfort with muscle spasm protecting the injured spine. Hauwald, 2002

A co-operative patient does not require immobilization unless their conscious level deteriorates. Muscle spasm is superior to any artificial method. Blackham & Benger, 2009.


Immobilisation with cervical collar is not harmless

  • Uncomfortable
  • Causes delays
  • Increased ICP
  • Increased risk of aspiration
  • Pressure sores
  • Reduced airway opening
  • Reduced respiratory efficiency

Forget immobilisation, deliver spinal care

  • Stop hypoxia
  • Stop the bleeding
  • Minimize force
  • Minimse movement


Episode 6: Oxygenation


To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful!


Some of the stuff we talked about:

Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here.Screen Shot 2016-03-17 at 09.28.46

But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible.

Screen Shot 2016-03-17 at 10.09.34Taken from: http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices

A water’s circuit looks like this:

Labelled waters circuit

This is an image of the oxygenation dissociation curve mentioned in the podcast. Taken from Weingart & Levitan 2012.Screen Shot 2016-03-17 at 10.14.50

Here are some other great resources which demonstrate some of the principles we have discussed:

Our Birmingham Emergency Medicine colleagues review the evidence so far for apnoeic oxygenation:


There are some short videos from Scott Weingart demonstrating some of the techniques discussed available here:


A well written blog post summarising the key features of a BVM from the Life in the Fast Lane team:


This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation.


Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376.

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175.

Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355.

Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010;

Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72.

Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67.

Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial)

How to cite this podcast:

Nutbeam T, Bosanko C. Oxygenation. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

Episode 4: Chemical incidents


We hope you enjoyed this PHEMCast. Please feedback your comments via the blog, twitter or email us on PHEMCAST@gmail.com.

The NARU video we mention in the podcast can be accessed here:


And the paper we discuss is:

  • Chilcott RP. Managing mass casualties and decontamination. Environmental International. 2014; 72: 37-45.

This is the Step 1,2,3 tool described:

Screen Shot 2016-01-04 at 12.15.12

For more information on the toxidromes associated with various chemicals, biological agents and radiation sources have a look at this document (admittedly it’s a few years old but the content is still good, especially the flow chart which is pasted below):


Screen Shot 2016-01-04 at 12.11.00

What is an anti-muscarinic chemical?

  • Anti-muscarinic = blocking the muscarinic receptors, ie blocking the effect of acetylcholine, hence also called anti-cholinergic. Impacts on parasympathetic stimulation. Antimuscarinic effects include dilated pupils (leading to blurred vision), reduced secretion of saliva (hence dry mouth), sweat and digestive juices. Relaxation of smooth muscle causing urinary retention, ileus. Also tachycardia, confusion progressing to delirum/coma.
  • Nerve agents inhibit anticholinesterase therefore there is an excess of acetylcholine resulting in opposite features: diarrhoea, urination, miosis, increased bronchial secretions, bronchoconstriction, vomiting, lacrimation, salivation.


Always ahead of the curve… St Emlyns have recently published a blog post on this very topic! It’s great, so have a read:



Further Reading

  1. Monteith RG. Pearce LDR. Self-care Decontamination within a Chemical Exposure Mass-casualty Incident. Prehospital and Disaster Medicine. 2015; 30: 288-296.
  2. http://chemm.nlm.nih.gov/mmghome.htm
  3. Centers for Disease Control and Prevention. Chemical Suicides in Automobiles – Six States, 2006-2010. JAMA. 2001; 306(16): 1751-1753.
  4. http://www.msdmanuals.com/en-gb/professional/injuries;-poisoning/poisoning/general-principles-of-poisoning#v1118045
  5. https://www.england.nhs.uk/wp-content/uploads/2015/04/eprr-chemical-incidents.pdf
  6. JRCALC http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/chemical_biological_radiological_and_nuclear_incidents_2006.pdf


How to cite this podcast:

Nutbeam T, Bosanko C. Chemical Incidents. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk



Paris attacks


Screen Shot 2015-12-07 at 11.22.54

I have just finished listening to the excellent podcast produced by the St Emlyns team following the terrorist attacks in Paris. The interview with one of the receiving Emergency Medicine physicians, Youri Yordanov, is informative and thought provoking. Although they discuss the in hospital response to the attacks, there is still much of relevance to prehospitalists. I was really interested to hear Dr Yordanov talk about how he never thought it would happen to him and his department. We can probably all recognise this in ourselves, and as someone who was previously responsible for major incident planning, in our colleagues. The podcast highlights the value of reading and knowing your organisations major incident plan, so that, as Dr Yordanov describes, the actions to take are already embedded in your brain. At a time when your bandwidth will undoubtedly be overloaded, you can carry out the predetermined key actions to ensure your major incident response is effective from the beginning; bring order to chaos. Simon pulls out some really key features of an effective major incident response, the impact of which are described succinctly. It is reassuring to know that the planning and principles do work; huge respect to our colleagues in Paris for delivering good care in very challenging circumstances. If you are part of an organisation which may need to provide front line services in the event of a mass casualty event… everyone… have a listen, reflect and think about what it would be like. Then, if the worst happens, at least you will have exercised it in your mind.