Advanced Wilderness Life Support

Recently I had the pleasure of attending a superb AWLS course in Queenstown. The course was run by a group of intrepid clinicians who decided several years ago to import AWLS from the United States. You can read about the group (and more importantly, book a place on the course!) here:


Wilderness medicine is in may ways the ultimate in prehospital care – it involves providing care to patients in an frequently austere environment with often very limited personnel, equipment, and communications. For emergency department doctors like myself, it also separates us from the security of readily accessible diagnostic investigations.

At its core wilderness medicine represents the same pathologies as emergency medicine, although environmental issues are obviously more common than in our urban ED and regional HEMS (check out this article about some recent lightning strike patients treated in Waikato ED!). The challenges encountered by treating clinicians however are very different, and solutions rely on communicationimprovisation, adaptation, clinical judgement, and common sense… plus (of course!) duct tape and a pocket knife.

The course itself included a variety of teaching formats including interactive lectures, group discussions, practical skill stations, and in-situ simulation. The organizers successfully arranged significant rainfall on one of the simulation afternoons – ever tried running a trauma resuscitation in the rain under a tarpaulin? (Credit is also due here to some of the local medical students, who were quite willing to become hypothermic for the sake of medical education)

Without giving away too much of the detail on the course, here are some examples of the material covered:

Single rescuer rolling a trauma patient with cervical spine control:

photo (1)


photo (2)



Improvised rope sling carry for patient unable to walk

Improvised cervical collar

Improvised cervical collar

photo (4)

C-spine immobilization with Sam splint/backpack, alternatively device for restraining combative ED consultant – Logan Stuckey from Nambour

Splinting of fractured femur with ski pole

Splinting of fractured femur with ski pole

photo (6)

In situ simulation: Body on the shore – what will you do?

Pre-hospital external warming device (at least, that was the explanation given)

Pre-hospital external warming device (at least, that was the explanation given)

Resuscitation team in the rain!

Resuscitation team in the rain!

Trauma airway in prehospital and retrieval medicine – Minh Le Cong

This presentation is from the ANZCA Airway Management and Trauma Special Interest Group Meeting in June 2013. It is delivered by Minh Le Cong (RFDS medical officer, Assistant Professor in Retrieval Medicine, and the world’s most ardent advocate for ketamine..)

If you haven’t already checked out Minh’s superb prehospital website, click HERE

Prehospital scene management


As hospital doctors working in acute care, we have a considerable amount of control over the scene in which we work. Our ED resus bays have adequate space, lighting, and equipment (which is in the same place every time we need it). We have a huge number of team members we can draw upon for support in our patient care, and with prehospital notification of impending patient arrival we can assemble an appropriate team, set up relevant equipment ahead of time, and establish control over the scene before the patient arrives. We even have waiting areas for family and friends of critically ill patients and can delegate staff to look after them while a resuscitation is occurring.

In the prehospital setting, many of the factors above are unachievable, and to doctors this represents both a source of challenge and considerable discomfort.

One of the most interesting aspects of working as a doctor in the prehospital setting (both in practice and simulation) has been watching my paramedic colleagues in action at a prehospital scene – in particular the skill, calm, and aplomb with which they assess and manage a prehospital scene, and the adaptability with which this process occurs under highly variable circumstances.

While as HEMS doctors it would be uncommon for us to be in a position where we have a significant role in scene management – this role would usually be performed by ambulance staff already at the scene or by the helicopter paramedic – it is important for us to understand the process.

There is comparatively little literature available in this area. There are resources detailing ASSESSMENT of a scene, such as this chapter from the Prehospital Trauma Life Support manual.

With regards to MANAGEMENT of a prehospital scene, the authors of this study, published in EMJ in 2009, conducted interviews with experienced paramedics to generate a theory as to how paramedics manage a scene. The model that resulted was called “the space control theory of paramedic scene management”, which states that paramedics manage a scene by controlling the activities that occur in the space immediately around the patient “Space” is interpreted to include both physical and human (non-physical) elements.

“Although there are physical realities that present problems for scene management, for the most part the management of the scene involves how paramedics interact with other people. Indeed, it is through working with others that paramedics are able to solve the problems presented by both physical and human elements. This means that scene management is a dynamic social activity comprised of social processes.”

This figure from the paper provides overview of the theory:

space control theory

This model has multiple “human factors” elements – analogous to the increasingly recognised importance of human factors in hospital care.

Another useful resource for doctors at a prehospital scene is this 2007 slide set from Tony Smith – ADHB Intensivist, Medical Advisor to St John Ambulance, and Auckland HEMS doctor:


Full-text pdf for this post is available here (secure area limited to ADHB staff only – ADHB has online subscription access to this journal through the Philson Library at the University of Auckland School of Medicine)