Chapter #1 – Introduction to the Course

Welcome to the introductory podcast episode of the Auckland Helicopter Rescue Trust simulation based, pre-hospital critical care curriculum. This episode will introduce the ARHT education team and outline the goals and structure of the curriculum.

Below you will find some more information relating to the concept of a “flipped classroom” as well as the use of simulation in medical education.

Web links:

Review of Flipped classroom –

The 7 thing’s you should know about the flipped classroom –

How Flipping the Classroom can improve the Traditional Lecture –

Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence.
McGaghie WC1, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB.
Acad Med. 2011 Jun;86(6):706-11.

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.
Issenberg SB1, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ.
Med Teach. 2005 Jan;27(1):10-28.

Could simulated emergency procedures practised in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review.
Lamb D.
Intensive Crit Care Nurs. 2007 Feb;23(1):33-42.

The utility of simulation in medical education: what is the evidence?
Okuda Y1, Bryson EO, DeMaria S Jr, Jacobson L, Quinones J, Shen B, Levine AI.
Mt Sinai J Med. 2009 Aug;76(4):330-43. doi: 10.1002/msj.20127.

Simulation as a tool to improve the safety of pre-hospital anaesthesia–a pilot study.
Batchelder AJ1, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N.
Anaesthesia. 2009 Sep;64(9):978-83.

Greater Sydney Area HEMS podcasts


Our colleagues from Sydney have created an excellent group of podcasts about pre-hospital and retrieval medicine:

NEUROPROTECTION – covers retrieval of patients with neurological and neurosurgical emergencies; also view their helicopter operating procedure HERE

INTERHOSPITAL PATIENT ASSESSMENT – overview of the assessment of a critically ill patient requiring transfer from one facility to another

THE TRAPPED PATIENT – overview of the approach to a patient trapped in a vehicle


ARHT Surgical Airway Skills Session

One of the challenges of resuscitation and pre-hospital medicine is that there are multiple high-risk but rarely performed procedures that clinicians must be ready to perform. The difficulty is that we may go our entire careers and only perform them once or even more likely never. However, the difference from success and failure for these procedures can mean life or limb. Consequently we must remain competent despite the challenges with practice.  There is an excellent article that articulates these issues by Cliff Reid & M Clancy which I highly recommend reading (for anyone interested in the topic).

(a primer video I integrated into a recent cric teaching session to get our participants into the mood!)

These life-saving, rarely performed procedures happen to be an interest of mine. It’s a fascinating exercise in education and cognition to maintain competence in performing these procedures yet have virtually no real-life patient practice. The likely result is that clinicians are not competent or they do not remain competent in performing them. More optimistically, some clinicians will maintain their skills through simulation. However, I would bet that a survey of most staff emergency physicians would reveal virtually no hands on practice of many of these life-saving procedures. One of the most talked about and important of these procedures is the surgical airway (or cricothyroidotomy). This is only performed when a patient who requires emergency airway management but they cannot be intubated or ventilated. For most of us, we’ll go through our careers never performing one. But every time we intubate a patient, there’s a risk that this scenario could develop and we’ll have to act accordingly.

At ARHT last week, I ran an inter-professional session for the paramedics, doctors and crewman on surgical airway performance (or cricothyroidotomy). The goal was to integrate our new cricothyroidotomy task trainers into the educational curriculum and combine them with some group discussion and simulation. For those looking to do replicate the event or simply looking for ideas, I will outline our session.

In addition to the introduction of our new task-trainers we also used this opportunity to review our performance of surgical airway. From an educator’s perspective, the most important step for success of this session is preparation. Those who know me, know that I’m not a detail oriented person but planning for everything from big picture stuff to the smallest detail can make a huge difference. In an effort to encourage the sharing of information (FOAMed) I’ll describe our itinerary.

Before the session I sent 2 emails. Our group is relatively new to the flipped classroom, or sending material first then promoting discussion within the classroom/learning site. Something I took home from SMACC 2013 is start with videos (easy to digest material) if you’re implementing a flipped classroom approach for the first time. A follow up email was sent with the videos again and this time along with 2 articles:

  1. Cricothryoidotomy bottom-up training review: battlefield lessons learned
  2. Emergency Surgical Airway: 24 successful cases leading to a simple “scalpel-finger-tube” technique 


  • The learning outcomes were outlined
  • The MOST important aspect was to outline the ground rules and expectations. In our case, we were not using this session as an evaluation but instead as an opportunity to practice and engage our entire team. If you are evaluating learners, let them know!
  • We used  both task trainers and simulation to ensure an environment that promotes psychological safety  and learning for all participants

Content Presentation (using powerpoint)

  • I kept this short – about 20min so that everyone remained engaged (some of our doctors have fairly short attention spans!)
  • Review the indications (contraindications…not really any), complications and considerations in performing a surgical airway
  • Review the controversies regarding surgical airway (more to come on this in a later post)
    • preferred technique (surgical vs. percutaneous)
    • vertical vs. horizontal incision
    • team positioning
    • Integrated 2 videos – the impact of engaging the audience is impressive…especially when you have the luxury of using some pretty amazing footage
No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture...)

No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture…)

Task Trainers

  • We had 3 stations of task trainers with inter-disciplinary teams (paramedic, doctor, crewman)
  • Teams rotated every 15 minutes
  • Station 1 – pediatric needle airways
  • Station 2 – open/surgical cricothyroidotomy using a variety of tools & instruments
  • Station 3 – participants were blindfolded, relying on their tactile sense and team communication to complete the procedure
Our cric station set up. A variety of equipment that allowed participants to try various methods

Our cric station set up. A variety of equipment that allowed participants to try various methods

Our crew practicing a surgical airway on a task trainer

Our crew practicing a surgical airway on a task trainer

Several participants trying out a needle jet ventilation technique

Several participants trying out a needle jet ventilation techniqu

Brainstorming session

  • While we already have a cric kit in our packs, we used this opportunity to discuss the equipment that participants used in the task-trainer session
  • Then we packed a cric kit following this discussion (based on consensus) for a team to use in the next section – an outdoor simulation
  • This usablity testing allowed participants to directly observe their decisions for kit composition in practice!


  • 3 volunteers (crewman, doctor, paramedic) representative of our duty crew at ARHT
  • Participated in a simulation of a patient with a trapped patient, unable to be extricated and deteriorating mental status and respiratory status. There was considerable
Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! manikins were harmed during this educational session (except a few cuts to their necks)

Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer…no manikins were harmed during this educational session (except a few cuts to their necks)


  • Debriefing of the simulation and the entire day
  • We used this opportunity to ask participants what equipment, methods and preferences they would like integrated into our standard operating procedure

This entire process included usability testing for participants – allowing them to use different techniques & equipment they may otherwise not try.  This also provides an additional opportunity for inter-professional education that is extremely important for such a high risk, rarely performed procedure. Proper planning and training for all team members involved will only make the process better.

SMACC and the power of FOAM

I have just had the pleasure of attending the SMACC (Social Media And Critical Care) conference in Sydney – wow!

Any thoughts that this conference was going to be the same as many college scientific meetings were rapidly dispelled when the (alleged) ‘welcome’ speaker, who was delivering a tedious stuttering analysis of statistical irreleventia was picked up and thrown from the stage (with his lectern) by a masked wrestler wearing the SMACC logo.


Another one bites the dust! Photo from

From the first sessions of the conference it became rapidly apparent that most of the audience were far more Twitter-literate than I was. At first I thought it was a sign of rudeness that over half the audience were tapping away on various mobile devices while speakers were delivering their talks; I then realized that most of the activity was people sending out ‘tweets’.

Each person was tweeting to several hundred people at once.

Tweets contained the speaker’s key ‘take home messages’ and pearls of wisdom, complete with pictures, slides, and links to resources.

It dawned on me that this was instantaneous dissemination of cutting-edge medical information and ideas across oceans and borders.

(plus, of course, the presumably drunken tweet from the Gala Dinner: “F@#$ yeah! This vegan dinner is the s#!t!”)

AucklandHEMS in action: Chris Denny competing in Sonowars

AucklandHEMS in action: Chris Denny competing in Sonowars

The power of social media for medical use was brought home to me in a talk delivered by Minh Le Cong about airway management.

He played a video of a recent intubation he performed in the retrieval setting., involving a combative patient with a predicted difficult airway, hypoxia despite high flow oxygen via a non-rebreather, and bilateral pneumonia.

This is the sort of clinical scenario that gives acute care doctors and paramedics nightmares, but Minh navigated it successfully with a delayed sequence intubation (premedication with fentanyl allowing enough behavioral control to pre-oxygenate), pre-oxygenation with BiPAP instead of a traditional BVM, providing apneic ventilation with nasal cannulae during the period of paralysis, and placing a Fast-Track (an intubating LMA device) prior to passing a tube through it.

Some of the key elements of airway management listed above have been disseminated largely through social media over the last year. They have been blogged, tweeted, podcasted, vodcasted, and facebooked – not just the techniques themselves but people’s experiences, cautions, and refinements. The end result is that changes in practice have occurred in a timeframe that five years ago would not have been possible. Relying on traditional media (peer-reviewed journals and textbooks) places the timescale for changes in clinical practice into years.

Scott Weingart explains why patients drop their blood pressure once anaesthetised

Scott Weingart explains why patients drop their blood pressure once anaesthetised

Clearly there are risks associated with this sort of process. The internet represents pure anarchy when it comes to information dissemination, and it would be very easy for dangerous misinformation to be presented as gospel, aided by slick-looking multimedia pieces (have a look at some of the NZ anti-immunization websites if you want to see misinformation presented in a nice-looking pseudo-scientific form!). A considerable proportion of the conference involved discussions around ways dealing with the uncontrolled nature of FOAM (free open-access meducation) via social media – whether regulation and oversight is needed, how to deal with disputes and misinformation, and how academic colleges (which rely heavily on  preset curriculums and traditional media).

The answers to these questions are far from clear.

Having spent the SMACC conference observing the power of social media (specifically for FOAM), I came to the following conclusions:

1)   Social media for FOAM is tremendously powerful, and it is here to stay. We should embrace it as a teaching tool.

2) The power of FOAM lies in the ability to transmit not just medical information, but EXPERIENCE – i.e valuable lessons that you would otherwise learn the hard way in resus or on the road.

3)   Although there are risks in using FOAM, the benefits vastly outweigh them.

4)   There is a moral (but possibly not legal) responsibility on the part of someone producing/disseminating FOAM material to ensure that it is as accurate as possible.

5)   The legal responsibility for translating FOAM material into clinical care ultimately lies with the clinician who provides care to the patient

Conclusion 5 is potentially vexatious for clinicians – how do we know what is valid/safe and what is not? Stating “I got this technique from a blog’ is not a defence in the setting of a medicolegal disaster.

The way I have reconciled this is that before applying FOAM material in clinical care, I must make a judgement as to the safety of information, the validity (or otherwise), how and whether it applies to the patient in front of me, how to manage the risk, what the accepted standard of care (and the supporting evidence) is in similar situations, and whether my decision would be defensible in the event of a poor outcome.

Sounds like a complicated and risky process, doesn’t it?

It’s called the Art of Emergency Care, and whether FOAM is involved or not, we are ALREADY doing it every day.