Calming the Hulk: Sedating and Restraining Aggressive Patients

Take home points Always try to find the cause of agitation and talk the patient down if possible. Call for security or police early.  Better to over-call than under-call. Sometimes it is good just to step back and wait.  Sometimes you need to intervene early before things escalate further. You have a responsibility to restrain […]


Meningococcal sepsis – lest we forget

  Meningococcal sepsis and meningococcal meningitis Meningococcal infections are something we don’t see often but we need to know about.  There was an outbreak in Suva, Fiji while I was there. They may present with meningococcal sepsis, meningitis or both.  They may or may not have a rash.  They may or may not have neck […]


A Beginner’s Guide to STEMI Thrombolysis: 5 Minutes Door to Needle

The Case A 57-year-old man was brought in by ambulance with 1 hour of left shoulder pain, nausea and feeling faint. He had a history of obstructive sleep apnoea and recurrent low back pain. Paramedics had given aspirin and clopidogrel, obtained IV access and called us saying probable inferior STEMI. He goes into a resus […]

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A Beginner’s Guide to Procedural Anaesthesia in ED

Procedural anaesthesia is providing IV anaesthesia to allow a painful procedure to be performed.  Very rarely it will be performed to rapidly control dangerous behaviour. It has also been called conscious sedation or procedural sedation but usually we don’t want our patient to be conscious and we want them to be anaesthetised, not just sedated.  […]

Master Splinter

Contagious Calmness. Mindfulness at Work

By practicing mindful meditations we can find calmness within us and then bring this into our work. We may find that the calmness starts to spread and appears in unexpected places. Be the calmest person in the room no matter what is going on. Focus on the people around you, patients, family, workmates, as a […]

R main stem intubation

The crashing intubated patient: DOTTS

Whenever a patient you have just intubated deteriorates, or a patient on a ventilator deteriorates quickly: DOTTS Disconnect and let them exhale: This gets the ventilator out of the equation and simplifies things / reduces our cognitive load: we understand BVMs (bag-valve-mask), ventilators and circuits confuse and scare us.  It also stops ventilation for a […]

Sgarbossa 10.13.23 pm

LBBB and Sgarbossa

  Left bundle branch blocks cause a lot of confusion. People often mistake the normal anterior ST elevation of LBBB as an MI Less frequently people miss significant concordant ST segment changes which may be a STEMI (by Sgarbossa Criteria) The Law of Discordance or the Law of Appropriate Discordance In a normal LBBB the […]

Military trauma

Trauma: Lessons from the Military. Wing Commander Dr Paul Nealis

    Key points Stop bleeding! Tourniquets are great. Pack bleeding wounds firmly.  A roll of gauze works well. “Haemostatic dressings” eg quik clot, don’t seem to make much difference.  It appears the pack needs to be absorbent probably because they absorb water out of the blood in the wound thereby increasing the concentration of […]


Disaster Medicine. Wing Commander Dr Paul Nealis

Be prepared. Be prepared for the unexpected, logistical challenges, politics and politicians, strange infections, psychological stress,  Aussie docs not recognising melioidosis and a mysterious man in a Hawaiian shirt … with a small fleet of Black Hawk helicopters. You need to be flexible, creative and psychologically tough. Military doctor Paul Nealis discusses disaster medicine in […]

mass cas

Mass Casualty and Hazardous Substances Management

  Key points   Declare an Mass Casualty Event -> telephonists automatically call in multiple staff from many departments Lock down the hospital Send triage nurses outside front door and ambulance door (with PPE if HAZSUB) with security and radio to triage people in or away from hospital Assign roles in ED ED staff to […]