Friday, January 24, 2014

Medical Book Review - Emergency Medicine. The Principles of Practice. Sixth Edition. Authors: G and S Fulde.

Medical Book Review – Emergency Medicine. The Principles of Practice. Sixth Edition.
Gordian Fulde and Sascha Fulde.

Churchill Livingstone/Elsevier Health Sciences
ISBN: 9780729541466 Publication Date: 27-09-2013 RRP: $109.93 (free delivery in Australia/NZ).
For further information see:

I have a previous fourth edition of this book by the highly credentialed Professor Fulde, which I was given whilst at medical school and has done good yeoman service over the years, but this new edition is an impressive replacement. It is also nice to see that Sascha Fulde is carrying on the family tradition. Professor Fulde recently appeared on the news bemoaning the prevalence of alcohol-fuelled violence, and is obviously still very much a ‘hands-on’ clinician as well as an academic writer. This bodes well for the practicality of the contents.

The new edition is considerably heavier, coming in at around 1,030 thin pages, but does have an in-built protective plastic cover which can be wiped clean, which is a definite advantage in terms of infection control. The old book was monochromatic and contained some tables and diagrams, but no photographs. The new edition has a blue, white and black colour scheme, and includes a number of black and white photographs as well as tables and diagrams.

Being a Basic and Advanced Life Support instructor, as soon as I opened the book I loved the fact that it has both the BLS and Adult ALS algorithms inside the front cover, and if you flip it over and look inside the back cover both the Choking and Infants and Children ALS algorithms can be found there. How easy is that!

Turn over another page and you find the “Quick Reference”, compiled by Fiona Chow. This section of 115 pages (with a list of Abbreviations at the end) is a handy little guide. An index is provided on the first page, but with white text on a blue background it is a little difficult to read in less than optimal lighting conditions. The two ALS algorithms are followed by that for newborns and a summary of suggested drug usage in adult and paediatric cardiac arrest. Sections follow on miscellaneous drugs used in adults and children. As well as recommended dosages and route of administration, some indications are also given. There are helpful sections on cardiology and ECGs, respiratory medicine, trauma, metabolic equations and electrolytes, thromboembolism and coagulopathy, neurology, important procedures, toxicology, drug infusions, paediatrics, orthopaedics, obstetrics and gynaecology, dental, common conversions, antibiotic prescribing and normal values. There is potentially some overlap with the discussion of antibiotics as common antibiotics are also listed in the earlier drugs section.

The book proper commences after the Quick Reference section.  The Contents sets out a  summary of what is in the following forty-eight chapters. These have been written by an impressive list of contributors, and the book has been reviewed by a shorter but equally impressive list of personnel.

As you would hope with an emergency medicine textbook, the chapters have a strong practical orientation and provide a lot of ‘how to’ guidance as well as enough of the ‘why’. Chapter 2: Securing the airway, ventilation and procedural sedation, is very comprehensive and detailed, and would provide a lot of comfort to the inexperienced practitioner. Chapter 3: Resuscitation and emergency procedures, provides a very helpful step-by-step guide to several common procedures such as IV cannula insertion. Chapter 4: Diagnostic imaging in emergency patients would probably have benefitted from some illustrations to go with the descriptions provided. The same might apply to the following chapter on ultrasound. A number of chapters dealing with cardiac and respiratory emergencies follows, including a thorough effort to explain the nemesis of many a student and doctor, the ECG.

It is nice to see a separate chapter on pain management in the ED, which is appropriately followed by a chapter on trauma. The chapters then jump around a bit. For instance, neurosurgical emergencies are some distance away from neurological emergencies. In the interim, the book travels through aortic and vascular emergencies, orthopaedics, hand injuries, urological emergencies, burns, patient transport and retrieval , mass casualty incidents and a handy chapter on ‘The seriously ill patient – tips and traps’. As someone who works in the pre-hospital setting and has trained in disaster medicine, I thought it was great to see both the retrieval and mass casualty chapters in this book as coverage of disaster medicine is certainly very common in American emergency medicine textbooks. (Upon checking, they were in the earlier edition also.) Following neurology, the book moves on to chapters on gastrointestinal  and endocrine emergencies and then acid-base and electrolyte disorders (another subject which strikes fear into many hearts but is comprehensively and clearly covered here). The very pertinent topic of poisoning, overdosage, drugs and alcohol follows. This is very detailed and provides advice and information for a number of commonly abused substances.

The final third of the book also jumps around quite a bit in terms of topics and ordering. Common orphans drowning and Envenomation follow next, then electrical injuries, hypothermia and hyperthermia, childhood emergencies, geriatric care, gynaecological emergencies, ophthalmic emergencies, ENT, dental, psychiatric presentations, dermatology, infectious diseases, the immunosuppressed patient and ED haematology.

The book concludes with a collection of six practical and interesting chapters which contain “something for everyone”. These are rural and indigenous emergencies, advanced nursing roles (which should enhance understanding  of what nurses actually do and thus team work), the general practitioner; working with IT (which deals with the vexed issue of interactions between GPs and EDs and provides a template for that essential discharge letter), administration, legal matters, governance and quality care in the ED (a catch-all chapter which contains some important advice on legal issues, including “How do you avoid a law suit?”), and two final chapters of immeasurable worth to residents and medical students: a guide for interns working in emergency medicine, and a student’s guide to the emergency department. It is nice to see that Sasha and Tiffany Fulde and Richard Sullivan, all doctors-in-training, have between them contributed to the pearls of wisdom in these chapters.

Whilst writing this review in the late afternoon and the transition to artificial light, I did find the pale blue headings in the chapters a bit difficult to read as they do not stand out well against the bright white of the pages. Paragraphs of pale blue text fortunately do not occur frequently in the book, but they are even harder to read in artificial light, especially as the pages are a bit shiny and the light source reflects off the surface of the page.

Another small criticism that I would have from recently ‘road-testing’ the book out on location is that the Index at the back could be better. For instance, I went to look up “penetrating eye injury” under E for eyes but it wasn’t there (not there under ‘penetrating’ either). I knew it would have to be in a book about emergency medicine, so went to the Contents and found the chapter on Ophthalmic Emergencies and of course it was there. There was one other similar example that I came across during testing.

My only other comments about things that ideally I might have liked to see is more intuitive chapter groupings and perhaps a few more diagrams and pictures where these could contribute to better understanding. Even if that is not possible, are there online resources that people could be referred to, such as YouTube? For instance, knowing how to reduce a shoulder dislocation is much easier if you can see it done properly first. (Apparently there is a separate eBook available for purchase which contains enhanced content, but this does not assist the purchaser of the print edition.)

As a review of the section on penetrating eye injuries demonstrates, this is a book grounded in emergency department practice rather than a first aid manual. It assumes that the first aid has been done and that the patient has come into the department and that you are getting on with history, examination and management. It is an enormously impressive resource, even though it did not always have quite as much detail as I would have liked on a particular topic. I guess everyone’s needs will vary in this regard, depending on your pre-existing knowledge and level of training and inquiry, but the authors have done a very good and solid job in covering the basics. Some chapters do drill down into a lot of detail.

The authors are also to be commended for including cutting-edge and imaginative topics amongst the chapters that are really going to provide practical value for doctors at the front line.

I feel this is a “must have” book for any Australian doctors interested in or involved in practising emergency medicine. It is written for local conditions by local authors from a variety of clinical backgrounds.

It is probably a bit thick and heavy to carry around in your pocket, but indispensible to keep in your bag for ready reference. For those with smartphones and tablets, the back cover of the book refers to standard and enhanced eBook versions and a PocketED app.

Verdict: Highly recommended!

Sunday, November 17, 2013

Movie Review: Gravity (3D)

This is an amazing movie and an absolutely vivid experience in 3D. I have no idea how the movie makers so convincingly created the impression of the actors being in outer space floating above the Earth (the movie was filmed at Shepparton Studios in England). The special effects are incredible, including several space walks, debris hurtling around the Earth, the space shuttle Endeavour, the International Space Station, a Chinese space station, a Soyuz capsule and its Chinese equivalent.

It is even more remarkable for the whole story being carried by only two actors (George Clooney and Sandra Bullock) and for a time the disembodied voice of Mission Control (Ed Harris - a neat tribute to his previous roles). Clooney plays a convincing role as jocular seasoned astronaut Matt Kowalski acting as mentor to nervous newbie Dr Ryan Stone.

This is a disaster movie, but a very personalised one. There is the customary large-scale destruction, with debris resulting from the Russians accidentally shooting their own satellite creating havoc and tearing at high speed through the space shuttle, the ISSS and the Chinese station and many other satellites, blacking out communication with Mission Control.

In the opening scene, Kowlaski, Stone and one other astronaut are outside the space shuttle conducting some repairs to the Hubble Space Telescope. Initially it seems that the debris will miss them, but due to a chain reaction it is suddenly heading their way. The three astronauts do not have time to get back inside the shuttle and end up floating in space. Stone is suitably panicked by the situation and starts hyperventilating and uttering lots of disconsolate grunts. Kowalski has a jet pack and manages to rescue her and clip them together, but their other colleagues are not so lucky. Ever calm, he hatches a plan to travel across a large expanse of space to the ISSS, from whence they will take a Soyuz capsule back to Earth. During their journey he manages to engage with Stone on a personal level and finds out that she tragically lost her only child, a daughter, at the age of four. As they approach the ISSS, it is clear that the station is deserted, with one Soyuz gone and the other is damaged, with the parachute deployed. Kowalski determines that it is still serviceable enough to hitch a ride across to the Chinese space station Tiangong, from whence they can take the Soyuz-equivalent capsule back to Earth.

By the time they near the ISSS, all of Stone's oxygen is gone apart from the air in her suit. By a combination of circumstances, they overshoot the station and are about to drift off into space. Miraculously Stone's foot is caught by the strands of the parachute. However, the pull of Kowalski's weight being tethered to her causes the grip to loosen. Kowalski can see that her only chance of survival lies with him unclipping their connection, and with a remark about breaking the spacewalking record, he lets go. Stone is distraught and insists that she will come and get him.

Drowsy from the lack of oxygen, Stone barely manages to get inside the ISSS. She recompresses the airlock, takes off her spacesuit and floats blissfully in a foetal position for what seems like an eternity. A journey through the station to Soyuz results in further disaster as a loose panel sparks when slammed shut but she does not realise this as she floats past. She tries to raise Kowalski and applies the same positive psychology techniques that he earlier used on her. Before too long the fire has taken hold and spread, and Stone once again barely manages to get into Soyuz and as a last-minute thought takes the fire extinguisher with her. At the time it seemed to be a bit of a strange thing to do, as surely there would be one inside the capsule, but like Gollum in The Lord of the Rings, this device has a future role to play for good or for ill.

Stone gets ready to propel the capsule off towards the Chinese station but the parachute anchors are holding tight. She sets off on another spacewalk to unscrew them just as the debris arrives on its second orbit, effectively destroying the ISSS as she struggles to set the restraining wires free. Having succeeded, she gets away from the mayhem only to discover that she is drifting in space with no fuel left.

Desperately trying to make communication with anyone, she issues a 'Mayday'. To her surprise, she picks up an earthbound signal which is coupled with interference. It is a language she does not understand (an Inuit from Greenland) and there is a dog and a baby in the background. Stone talks about realising that today is the day she is going to die, and turns down the lights and turns off the oxygen pressurisation dial in the capsule and lies back in her seat.

Suddenly the hatch opens and in climbs Kowlaski. In good humour, he says it is "quite a story" as to how he managed to be there. He immediately turns on the lights and the oxygen and pulls out a bottle of vodka from under the dashboard, having previously indicated that he knows where the Russians hide it, and takes a swig after offering it to Stone, who declines. Stone is agitated, as she explains that she is out of options as the fuel tanks are empty. Kowalski jovially retorts that there are always options, and the landing thrusters can still be used to propel them towards the Chinese station Tiangong from whence they can travel home as the Chinese capsule is exactly the same as Soyuz. Stone has been concerned about flying the capsule as she always crashed it in the simulator.

Equally suddenly, Kowalski is gone and Stone sits up with a jolt. She thanks Kowlaski for the insight and decides to go home. She asks him to remember her to her daughter. With the lights and oxygen restored, Stone determines how to separate the landing module from the other components of Soyuz and engage the thrusters. This successfully done, she heads off towards the Chinese station. As she nears the station, she has another moment of insight, dons her spacesuit and exits with the fire extinguisher. In scenes reminiscent of the Wild West, she tumbles and turns through space using the extinguisher as her jet pack. Once again she nearly overshoots, but manages to grab onto a railing at the last possible moment.

Once inside she heads for the Soyuz equivalent just as the storm of debris arrives again. This time all the lettering is in Chinese so there is an excruciating game of "eenie meenie miney moe" as Stone works how to disengage the capsule and head home. She is accompanied by a fiery band of debris from the now-destroyed space station heading alongside towards Earth.

Somewhat miraculously, the capsule lands in a lake not far from shore. When Stone opens the door, the capsule starts to flood and sink to the bottom. She eventually manages to swim out, but the weight of her spacesuit prevents her from rising to the surface. She discards it and swims upward towards the light and surfaces. In an echo of her foetal position on the ISSS, she floats blissfully on the surface and drifts towards the shore. Stone drags herself out of the water and grabs a handful of the red earth, savouring the feeling of being back on terra firma. Like a newborn foal, she struggles to rise to her feet, the effects of having been weightless for an extended period evident, and then triumphally succeeds. The film ends with the camera behind Stone, who is facing the wilderness in the knowledge that a rescue mission is on the way.

Sandra Bullock's extraordinary performance carries this film. It is unusual for a film to feature only two actors and even more unusual for the weight of the film to fall on only one actor. Apart from Clooney's brief cameo as a hallucination and the foreign language triumvirate of man, dog and child, Bullock's character is entirely alone in space.

At the start of the film, we are reminded that space is a completely inhospitable environment, where not only can no-one hear you scream, but unaided survival is impossible.

This is a classic story of salvation and survival against the odds. In the first act we discover the unsure and tortured rookie who finds a kindly mentor only to lose him again in tragic circumstances. He sacrifices himself and implores her to live. In the second act she finds her courage as a sole survivor in a truly remarkable way, but then seems out of options and decides to die in a controlled and dignified way ("pray for me"). At the start of the third act, after a delirious deus ex machina moment, she realises that she wants to live and finds the courage and the means to achieve this. It is a story worthy of any saga or heroic poem.

For a single actor to achieve in a convincing way such a depth of characterisation and range of emotion in terrifying circumstances where the odds are never good is nothing short of remarkable. Both terror and tension are palpable for much of the film, and it is all plausable enough for the willing suspension of disbelief. I did find Bullock's fearful grunts and vocalisations a bit wearing, but perhaps it was felt necessary to have some sound to interject into the silence. At other times the music score is quite powerful.

I would not be surprised if this film is the recipient of a number of Academy Award nominations. Does Bullock deserve an Oscar - yes, absolutely!

(P.S. A nice touch from the Australian perspective that astronaut Andrew (“Andy”) Thomas was an advisor to the project.)

Verdict: Highly recommended!

Getting a quote from an arborist – Simpson’s Tree Service, Melbourne

The rather large tree overhanging the back of several body corporate units needs a trim in order to preserve neighbourhood equanimity so it was time to get some quotes from qualified arborists. Three is always a good number, and the final quote was obtained from Simpson’s Tree Service as it had contributed to a feature article in the local newspaper not long ago and came off sounding as if it is an experienced and reputable company.

The first two gentlemen who came to quote (from other companies) had been personable and engaged in social niceties such as introducing themselves and shaking hands. In contrast, the representative from Simpson’s Tree Service (whom I will call "Mr STS") was taciturn and world-weary and did not offer his hand. However, he was thorough in assessing the tree and cited his lengthy experience and provided a well-considered quotation. I bade him farewell with a non-committal remark about being in touch later and some time went by without further contact.

Late last week I happened to be working at home and had the doorbell turned off as is customary unless someone is expected. There was a knock on the front window and as I approached the front door there was a strong stench of cigarette smoke. I opened the door and went outside and was surprised to see several men in work clothes standing around. The apparent leader made a scarcastic remark about the bees flying in and out of a gap in the masonry between units: "just admiring your bees' nest" and then said "can we get this car out of the way", referring to my car which was parked in the carport. I appeared puzzled and this man (wearing sunglasses and ear muffs) said "we're here to do the tree". I then realised that this was Mr STS. I indicated that I had not made a booking and I did not believe that any other owners had done so either. He seemed unconvinced and appeared annoyed, so I indicated that I would make a telephone call to check this. He also remarked "aren't we getting the job?", to which I indicated that it was my belief that a decision had not yet been made. I made the 'phone call and confirmed that no booking had been made and that confirmation of the chosen arborist was subject to Body Corporate ratification. I conveyed this information to Mr STS, who once again seemed unconvinced and attempted to persuade me to go ahead on the spot. I politely declined and reiterated that I was sorry, but no booking had been made. Mr STS appeared aggrieved but retreated. At no time did Mr STS remove his sunglasses whilst talking to me. As I turned to return inside I noticed that the offending cigarette butt had been thrown onto the front lawn just next to my car.

As there is no rear exit, the tree branches would have to be brought through one of the units and considerable preparation would be involved in rearranging furniture to provide clear access so it was simply not practicable to accede to his request to allow them to commence work "on the spot".

However, as a result of this episode, they will not be getting the job. I was not impressed with the attitude and behaviour of Mr STS and his crew, which I felt was unprofessional. I felt that I was not treated with respect and common niceties were dispensed with. I came away feeling that this had been an unsavoury experience and had the perception of having being stood-over by an unpleasant man in sunglasses who seemed unwilling to acknowledge that the problem had originated at their end.

WARNING - Do not buy from!

This is a bit of a belated review, but I had such a bad experience with I would like to warn others about this. In my experience this company engages in bait advertising and snowballing tactics and then fails to provide any customer service and delays providing a refund, using your money for working capital. This is the worst online ordering scam that I have encountered.

On Wednesday 8 May I received an email from Megabuy advertising the latest Apple iPod Touch 5th Generation 64Gb in yellow for $299.00 ($323.03 incuding courier and credit card charges). Since my iPod had been stolen at New Year and I had limited insurance money to replace it, this was the best price I had seen so I ordered one late in the evening. The next day I received another email advertising the same model in pink for the same price, so I rang up to change my order. I was assured that stock was available and that one would be put aside for me.

My credit card was debited on 8 May and I expected to receive my new iPod within a couple of days as per the delivery advice. I waited and waited and nothing arrived. A few days later I received an email saying that, as a new customer, I had to verify my identity in order to avoid fraud. I had to provide an alternative email address and/or a work telephone number and someone who could vouch for me being who I said I was. This appeared to be a scam to obtain personal information, and as the credit card payment had already been processed, it was a suspicious and inexplicable breach of privacy for a minor purchase.

After complaining about this and referring Megabuy to my public web presences that verified my identity, I received another email advising me that stock had run out and that my order could not be satisfied.

I complained about this and Megabuy claimed that, despite a unit having been put aside for me, they had "completely run out of stock" and offered me either a refund or a 32Gb model for the same price (half the capacity of the one that I ordered). Despite threats to report them to Fair Trading and the ACCC (which unfortunately I have not had time to do), there was no response to my complaints and insistence that the item be supplied as ordered and paid for, and I simply received an email on 31 May saying that my order status had been changed to "refund" and a refund would be provided within 24-48 hours. A refund was not received until 6 June 2013. Megabuy had my money for nearly a month.

In summary, Megabuy:

  • engaged in bait advertising;
  • confirmed that stock was available and set aside for me but later failed to honour this;
  • debited my credit card at the time of placing the order (rather than after confirming stock availability);
  • 'snowballed' on delivery through making a very suspicious demand for further personal employment and contact details;
  • subsequently claimed that all stock had run out;
  • offered an item of lesser value and capacity for the same price;
  • did not respond to my consumer complaints and threats to report them to consumer affairs authorities; and
  • took a month to refund my money utilising it for working capital in the meanwhile.

As a result, I strongly recommend against dealing with them no matter how good their prices sound - if it is too good to be true, it probably is, and no-one should have to go through this sort of experience if you are dealing with a reputable company.

Why are we waiting? - mixed experiences with Virgin Australia

I have recently made two day trips to Sydney to take workshops at some Advanced Life Support courses. Both times I flew with Virgin Australia and then took the airport train and a suburban train to within walking distance of my destination.

The first round trip was on a Friday in late October, and turned out to be a bit of a horror story from a flight perspective. I left home at 06:50 and then finally returned home at 22:30 for a very late dinner.

I drove myself to the airport and arrived in plenty of time as I did not have any luggage other than my carry-on backpack. I checked the departures screen on arrival, and was dismayed to see that my 08:30 flight had been cancelled. My blood pressure was already rising, as I had to be at my destination in Sydney no later than 12:30 to set up for the afternoon workshops. I wasn't sure what to do, as the check-in area was crammed with people and I knew from experience that it would take about 45 minutes to get to the front. I rang my colleague in Sydney and he suggested going to the barely populated Priority Check-In desk. I did this, only to be told off as I am a mere Velocity Red member as opposed to a Gold or Platinum member or Business Class flyer who would actually qualify to use this desk. However, fortunately they helped me anyway.

First of all I was told that I had been re-booked on a flight to Cairns at 09:00. Cairns???? It took some time to sort this out as of course I was going to Sydney. I was eventually re-booked on an 09:00 flight to Sydney, but there was further consternation and discussion as the fare class was more expensive than my original fare. Close to 30 minutes later I finally walked away with a new boarding pass in hand. At that stage I noticed that there was a Service Desk nearby, but its existence had been completely obscured by the crowd of people queued up around it and there were no overhead signs to assist in locating it. I went through Security and headed for the Gate Lounge.

Alas my new flight was not running on time either, and in the end was delayed by a further 55 minutes. By this stage it was a long time since I had eaten or drunk anything substantial and I started feeling both mildly hypoglycaemic and caffeine-deprived. By the time the complimentary coffee arrived on the aircraft I had quite a headache. However, I was pleasantly surprised to be given some yoghurt and a muffin as this was included with my new and improved fare class. I scoffed the yoghurt and saved the muffin for later, as I had a feeling that I would be needing it during the afternoon (which proved to be the case).

When I arrived at Sydney Airport the Visitor Help Desk was not manned, and the person I waited to speak to at the city bus counter had not heard of the private hospital that I had to travel to, but helpfully looked it up on his iPhone and made a suggestion as to the nearest train station. I went down to buy an Airport Train ticket, and the service person wasn't sure where I had to get off either, but sold me a ticket to what he thought would be the nearest station. I had to change at Central, and as I still wasn't clear where I was going, I asked the lady in the control booth. Miraculously she was familiar with the hospital and the area and was able to suggest both the nearest train station and how to walk to the hospital from there.

Sydney has marvellous double-decker suburban trains, and it was a bit of a thrill to travel across the Sydney Harbour Bridge by train. Eventually I arrived at St Leonards, but the girl in the ticket office had no idea where the Mercy Hospital was, and time was marching on, so I went out the front and took a taxi for the final leg. The hospital was more or less straight down the road, but it was certainly quicker by taxi. I arrived at 12:25, but there was no time for lunch and half a sandwich later it was on with set-up. The workshops were fairly full-on and then we had to pack up all the equipment afterwards. My colleague drove me back to the airport, arriving at 17:20.

This was a day when lightning did indeed strike twice. The flight home was delayed and the gate was also changed without telling anyone until I noticed that my flight had disappeared from the lounge display screen and made an enquiry. I was missing my afternoon coffee and was getting increasingly hungry and headachey, so after consuming the banana muffin I decided to self-medicate with a large cappuccino from the airport McDonalds, this being the best value. After an extremely long wait, the coffee was finally mine. It was actually very nice. It was a dark but smooth roast with depth of flavour. My strength renewed, I approached the gate lounge staff to ask whether it might be possible to change to an earlier flight, but unfortunately it was completely full, so I went back to waiting.

I think that my frustration was made worse as my work colleague had been telling me how nice it was to spend time in the Qantas and Virgin lounges whilst waiting for a flight. These provide a quiet and comfortable environment with free internet access, food and drink. As he travels frequently there is no problem with maintaining enough "status points" to get into the lounges. However, whilst I have a massive number of Velocity points I have nowhere near enough "status points" to gain access to the lounge.

On the fight back complimentary tea, coffee and alcohol were offered, but no food. I felt this was very inappropriate as the flight had been badly delayed and most people would be ravenous and it is never a good idea to drink alcohol on an empty stomach.

My flight departed 65 minutes late and I eventually landed in Melbourne at 21:30. After catching the bus back to the Long Term Car Park I drove home to enjoy my now very soggy fish and ships at about 11pm.

In total I spent 5 hours and 50 minutes waiting around at the airports waiting for delayed flights. It really was a physically draining ordeal on top of all the other travelling time. At the end of it I was actually hesitant at the thought of ever flying Virgin again.

However, as I am trying to accumulate enough Velocity points to get a "reward" flight to travel to an overseas conference next year, I bravely agreed to take another Virgin return trip the following time that I had to go to Sydney for work.

Fortunately the second time went more smoothly. The morning flight ran to time, but as it was a Sunday there were multiple delays due to the infrequency of trains. I took the Airport Train to Central and then travelled to Westmead and walked to the Private Hospital. Amazingly the major road I had to turn down did not have a signpost so for some distance I was not sure that I was actually on the right road! This time I arrived at 12:15 and had a little time to eat before we had to set up for the workshops. The workshops went well, and my colleague dropped me back at Westmead station shortly after 16:30. I had to wait for a train to Central and then wait at Central for the Airport Train. I actually found the stop to get off at a little confusing, as I recalled Mascot being the name of the airport "in the olden days". Wrong! I alighted in confusion at Mascot station and it turned out that this is now a suburban station and the domestic airport was one stop further along. After another fifteen minutes' wait I finally arrived at the airport.

According to the Departures board my 19:00 flight was now scheduled for 19:40. Dismayed I approached the check-in desk shortly before 18:00 and asked if it was possible to take an earlier flight. The lady at the desk very kindly helped me and transferred me to the 18:30 flight. I was in a hurry to get to the gate lounge, but there were delays at the security screening and just as I started to run for the gate I was grabbed by the man with the explosives screening wand and forced to submit to my bag and my shoes being checked, and during this process I was further distressed that my computer was knocked off the small shelf that my bag was on and fell onto the floor. Fortunately it does not appear to be damaged.

Food-wise this time I had planned ahead and had brought a thermos of coffee and a muesli bar. I ate this together with the last few mouthfuls of cold coffee whilst I was waiting at Mascot.

The return flight was mercifully running more or less on time and I arrived home for another late dinner just after 21:00.

Virgin did much better the second time around but both times it was a very long and tiring day. It would have no doubt been a lot easier and more pleasant if it was possible to pop into the Lounge whilst waiting, and I can't imagine doing a regular commute of this nature on any other basis.

Vale Fatso the Warfarin-resistant mouse

Over the past few months it was not unusual whilst sitting at the kitchen table and working to catch a glimpse out of the corner of your eye of a daredevil dark brown shape darting across the floor. This 'Scarlet Pimpernel' of the mouse world could be seen at any hour of the day or night and seemed to have a voracious appetite for Ratsac pellets (which contain a Warfarin equivalent). This little mouse appeared to be plump and prosperous, with a sleek and shiny chestnut coat. As a result he was dubbed 'Fatso' and almost was around for so long that he almost became a household pet!

Some days after a small and considerably skinnier grey mouse succumbed to the pellets, I came downstairs one morning with a migraine and noticed a dark shape stationary on the floor near the pantry. Once fortified by analgesia I returned to the spot to investigate. There sat an unwell-looking plump brown mouse. Alas Fatso had consumed one pellet too many.

I pondered what to do. It was a lovely warm and sunny day, and in the end I decided the most humane thing to do was to scoop Fatso up in a small container and take him outside to enjoy the sunshine before he too finally succumbed. You could tell that the spirit was willing but the flesh was weak and he was unable to put up much of a struggle. I deposited him on top of the rich mulch at the base of a huge Desert Ash tree and left him in peace.

His chestnut coat glistened and looked positively beautiful in the sunlight and his perfectly formed little feet were gorgeous. Even though he qualifies as vermin, it was still a sad moment as I knew that he was not long for this world. I also paused to think how ironic it is that mice and rats have done so much to help humans through medical research whilst simultaneously causing so much havoc and disease, the most famous case of which being the transmission (by rats) of Yersinia pestis ("the Black Plague").

Fatso was certainly a survivor, and perhaps even a genetic mutant - he also had a curiously bent tail. However, it is possible that he acquired this via the thrillseeker run through the refrigerator fan, which was a cause of mortality for at least one of his colleagues.

Vale Fatso - a memorable character!

Thursday, October 24, 2013

Comparative Review of Hansells Probiotic Yoghurt (now stocked in Coles) and EasiYo

Over the past couple of years Coles stocked three plain varieties of Hansells packet yoghurt alongside a wider range of the EasiYo products. From 1 July 2013, Coles discontinued the EasiYo range and replaced it with a wider Hansells range and the Hansells yoghurt-making container.

This is a review of the Hansells yoghurts that have been tried (and a couple of EasiYo varieties that I was able to purchase at Woolworths). Sadly overall they do not stack up against their EasiYo counterparts, and it remains a pity that Coles decided to discontinue the range. However, EasiYo is still available for purchase online and may be available at other supermarkets. (I have since discovered that Woolworths sells both EasiYo and Hansells - what a pity that Coles does not do the same!)

In summary, the two flavoured Greek Yoghurts I tried were of acceptable quality, but as far as the other flavours are concerned I much prefer the EasiYo equivalents and found the Hansells varieties disappointing.

Hansells Passionfruit
This was bland and watery. I would not buy it again.

Hansells Thick and Creamy Yoghurt Boysenberry
This was also fairly bland and not as fruity in taste as the EasiYo. I would not buy it again.

Hansells Lite Yoghurt 99% Fat Free - Strawberry
This was fairly bland and had a floury/chalky taste and left a feeling in my mouth a bit like a film of toothpaste. I would not buy it again.

Hansells Thick and Creamy Yoghurt - Strawberry
There is an occasional hint of a nice piquant strawberry flavour, but overall a bit bland and disappointing. The consistency in the mouth is more of a claggy/pasty feel than creamy. I would probably not buy it again if I could get the EasiYo Strawberry instead..

EasiYo Greek and Coconut Bits
This was a new one to try, and this was interesting to compare with the Hansells. The EasiYo variety is creamy, sweet and delightfully light and refreshing with a gentle coconut taste. It reminded me of sitting on a tropical beach in the shade with a light zephyr of a breeze drinking a Pina Colada! I would definitely buy this in preference to the Hansells (reviewed below).

EasiYo Mixed Berries and Bits
This was also another variety that I had not tried before. Wow! It is creamy, tangy and tart with a summery taste and a generous smattering of berry bits (blackcurrants, blackberries and raspberries). I will definitely be getting this one again.

Hansells Thick and Creamy Yoghurt with Bits - Greek and Coconut Style
This was indeed thick and creamy and had a nice coconut taste. Unfortunately a lot of the coconut settled to the bottom so a periodic stir would be in order to avoid getting a mouthful of coconut when you are getting to the end of the container. I would probably buy this one again.

Hansells Thick and Creamy Yoghurt - Greek and Honey
This is the final one which I tried. It is also indeed thick and creamy. The flavour is fairly subtle but the overall result is a soft sensation of being slightly sweet. I would probably buy this one again. The two Greek Yoghurt combination flavours are by far the best of what is on offer.

Hansells Lite Yoghurt 99% Fat Free - Apricot
This was fairly bland and had a floury/chalky taste and left a feeling in my mouth a bit like a film of toothpaste after a couple of mouthfuls. As it aged in the container there was a bit more of a tangy apricot taste.  I would not buy it again.

Hansells Lite Yoghurt 99% Fat Free - Berry
This one actually had a nice fresh and consistent berry taste but the same sensation of a slight chalky film left behind on your teeth after a couple of mouthfuls. The most surprising thing about this one was just how much water separated out from the solids within the first 24 hours. There was a large quantity of pinkish fluid that I kept having to pour off. Ironically this led to a thicker and stickier yoghurt. Just because this one actually has some taste I might consider buying it again if there was no EasiYo available.

Sunday, October 20, 2013

ETM Course - Emergency Trauma Management Course

The ETM (Emergency Trauma Management) Course test run day yesterday was really great. Congratulations to Andy, Amit and team on all their hard work. Good content, lots of hands on, good company and terrific discussions, good food and good coffee - what more could you want? The manual is looking great and full course should be fantastic, with some lectures but an emphasis on the practical with lots of small group work. The course will be quite unique in being built from the ground up (and staffed by) by emergency doctors for doctors who want to learn more about emergency management of trauma for the whole spectrum of patients.

The actual course will go for three days. It is planned to hold courses monthly in Melbourne. To find out more go to:

Course dates for early in 2014 have now been released - the course is competitively priced at $1,999 for three days. From the web site:

Included in the course price:
  • Pre-course manual in iBook or pdf format
  • Gourmet morning tea, lunch and afternoon tea
  • Evening social function
  • Opportunity to meet and network with Emergency Physicians and Registrars from across Australasia
Run over 3 full days at our training venue in Melbourne's CBD, course sessions will include:
  • Simulation/scenarios
  • Skills Workshops
  • Small group interactive sessions
  • Short, focused lectures
  • "Ask the expert" case discussion sessions
  • Expert instructors with first hand Emergency Department trauma experience
  • Small group sizes with a 6:2 ratio of participants to instructors
  • Web 2.0 and social media interactivity during the course.
(The first course has just been run in Melbourne - for reviews see:

Monday, August 5, 2013

How much water should you drink? A scientific assessment.

Water: Mysterious and marvellous
Water needs to be consumed according to need, not rules, so knowing when and how often to drink it involves staying once step ahead of thirst.
Author: Professor David Cameron Smith
(Originally published in CHOICE Health Reader, June 2013, page 3.)

Water is essential for life. The right to clean water, along with food, are basic human rights endorsed by the General Assembly of the United Nations. Many people, however, continue to live in areas where the scarcity or pollution of water makes daily life a struggle.

Water makes up between 30-70% of total body mass, depending upon levels of body fat. Of the parts of the body that are not comprised of fat, including the muscle, brain and internal organs, water is on average 73.2% of the total weight. Within each of these tissues the level of water is carefully managed to ensure optimal cellular function.

Managing water levels in cells is an ongoing process where electrolytes (salts) are continually pumped in or out of cells to control the osmotic pressure. Water moves from areas of low electrolytes (and hence high water concentration) to areas of high electrolytes (and lower water concentration).

Managing water in the body is even more complex because it is continually lost through a variety of ways. Everyday water is lost in respiration (expired breath), urine, faeces and sweat. Balancing this loss is water that is consumed in liquids or as part of foods, like some fruits and vegetables.

The desire for fluids is driven by changes in blood volume and the concentrations of electrolytes. Both mechanisms are not activated by subtle changes in hydrated status, so thirst is often felt well after considerable amounts of water are lost from the body.

Consumption guidelines
The wide variation in physical activity, climate and body size make prescribing required water each day extremely difficult. Given the widespread (and sometimes inaccurate) reporting that inadequate hydration impairs mental and sporting performance, it has become commonplace to accept the dogma that humans need ‘at least eight glasses of water a day’. There is no scientific basis to this statement.

Fluid intake, preferably water, needs to be adaptable and increase when water loss is likely to be greater. Continuous swigging of water from an ever-present water bottle has no advantages, particularly in the absence of exertion in an ambient environment. In fact, there is some evidence that athletes perform slightly better by running themselves ‘a little dry’.

Daily fluid needs remain difficult to determine and fluid intake should be dynamic and not rigid. Water has few health risks, although there is a small risk of hyponatraemia (when the amount of water in the body dilutes the electrolytes enough to affect heart rhythms). Only dangerous in extremes and found mainly in endurance athletes, hyponatraemia is unlikely in the general population. The other side effect of excessive drinking is frequent urination. Exactly what constitutes enough water depends on your day, so drink responsibly and according to your body’s needs.

For reference: Rush EC et al. Water: neglected, unappreciated and under researched. European Journal of Clinical Nutrition 2013; Jan 30. doi 10.1038/ejcn.2013.11. [Epub ahead of print].

First aid practices - Update re control of bleeding and CPR and rescue breaths

Clarification of first aid practices:
Position Statement re Control of Bleeding and CPR and Rescue Breaths
ASPA Medical Advisory Committee – July 2013

Over the past couple of months some queries have been raised with the Medical Advisory Committee as to current recommended practice with regard to control of bleeding, CPR and rescue breaths and hands-only CPR. The purpose of this document is to clarify ASPA’s position on these issues.

1. Control of Bleeding
ASPA continues to endorse the practices outlined in ARC Guideline 9.1.1 ((November 2008): Principles for the Control of Bleeding for First Aiders. A copy of this Guideline is being circulated with the latest issue of Asparations. These practices are also referred to in the current ASPA Manual.

In summary, at first instance responders should seek to identify the source of external bleeding and then attempt to control it via firm direct pressure (e.g., using hands or a pad) and maintain this pressure. If bleeding continues, apply another pad over the top of the first pad and a tighter dressing over the wound. This should be combined with elevation and immobilization of the affected part and restricting the movement of the casualty.

If major bleeding continues then the pad(s) may be removed in order to better identify the specific source of the bleeding and then a further direct pressure pad and dressing applied.

Embedded objects should not be removed and padding and pressure should be applied around/above/below the object.

A tourniquet may only be used as a last resort when all other methods of controlling bleeding have failed. A wide bandage (at least 5cm) should be applied high above the bleeding point and should be tight enough to stop both all circulation to the affected limb and stop the bleeding (and the time noted). Once applied a tourniquet should not be removed until the casualty is handed over to definitive care.

2. CPR, Rescue Breaths and Compression-Only CPR
ASPA continues to endorse the practices outlined in ARC Guideline 5 (December 2010): Breathing, Guideline 8 (December 2010): Cardiopulmonary Resuscitation and Guideline 10.1 (March 2013): Basic Life Support Training.

The Medical Advisory Committee has received reports that suggest some training organizations in New South Wales are teaching that compressions should not be paused for ventilations and that rescue breaths are no longer an important part of CPR, compression-only CPR is acceptable for trained rescuers and that these organizations prefer to use the American Heart Association guidelines rather than the ARC Guidelines. These suggestions raise a number of issues.

By way of background, in 2010 the American Heart Association updated its own guidelines, and changed from an “A…B…C…” approach to a “C…A…B…” approach in order to emphasise the importance of commencing chest compressions as quickly as possible. However, these guidelines clearly state both that rescue breathing remains an integral part of CPR for trained rescuers and that hands-only CPR is better than no CPR in the case of an untrained lay responder (such as someone receiving CPR instructions over the telephone from an emergency dispatcher). The guidelines also refer (in numerous places) to compressions being paused for ventilations and emphasise the importance of minimizing interruptions to compressions and providing high-quality CPR. The only circumstances in which compressions are not paused for ventilations is if an advanced airway (for instance an endotracheal tube) is in situ.

An oropharyngeal (“Guedel”) airway is not an advanced airway and should not be used routinely in CPR. Under the ASPA guidelines (refer to the ASPA Manual), these devices should only be used by qualified patrollers where airway patency (and thus ventilation) is inadequate using standard airway management practices.

Aside from the matter of “ABC” versus “CAB”, the ARC and AHA Guidelines are completely consistent in their recommendations regarding CPR. As ASPA acknowledges the ARC to be the peak body for resuscitation practices in Australia, ASPA continues to support the “A…B…C” approach recommended by the ARC.

ARC Guideline 10.1 (March 2013): Basic Life Support Training states:
“At a minimum, mouth to mouth rescue breathing must be taught and assessed (in conjunction with the learning objectives outlined (in this Guideline)), in any training program.” The Guideline also recommends regular refreshing and annual recertification of CPR skills.

ARC Guideline 8 (December 2010): Cardiopulmonary Resuscitation states:
Current consensus is that a universal compression-ventilation ratio of 30:2 (30 compressions followed by two ventilations) is recommended for all ages regardless of the numbers of rescuers present. Compressions must be paused to allow for ventilations.”

ARC Guideline 5 (December 2010): Breathing states:
“If the unconscious victim is unresponsive and not breathing normally after the airway has been opened and cleared, the rescuer must immediately commence chest compressions and then rescue breathing. Give 30 compressions and then two breaths allowing about one second for each inspiration following the Australian Resuscitation Council and New Zealand Resuscitation Council Basic Life Support Flowchart (Guideline 8). … Care should be taken not to over-inflate the chest.

Look for rise of the victim’s chest during each inflation. If the chest does not rise, possible causes are:
• obstruction in the airway (inadequate head tilt, chin lift, tongue or foreign material);
• insufficient air being blown into the lungs;
• inadequate air seal around mouth and or nose.

If the chest does not rise, ensure correct head tilt, adequate air seal and ventilation.” Following inflation of the lungs, rescuers should check for chest fall/exhalation.

In practical terms in order to minimise interruption to compressions for ventilations, some simple strategies may be of assistance. If the person doing the compressions counts down the last few compressions, then the person delivering the ventilations can be ready to deliver the first breath on the upstroke of the thirtieth compression. If the person doing the compressions continues to rest their hands gently on the chest during ventilations, this can serve a dual purpose of monitoring rise and fall of the chest and being ready to restart compressions as soon as exhalation from the second ventilation has occurred. 

From the physiological perspective, both circulation and oxygenation are required in order to give the casualty the best possible chance of neurologically intact survival. This requires both good quality CPR and effective ventilations.

As mentioned above, unless there is an advanced airway in place, both the ARC and the AHA state that compressions must be paused for ventilations in order to facilitate effective delivery of air into the lungs. Forceful chest compression at the time of delivering a rescue breathing ventilation is likely to result in mechanical obstruction and ineffective ventilation, gas exchange and oxygenation. There is also a risk of trauma to the casualty from raised airway pressure against an obstruction and that air will preferentially travel down the oesophagus as a path of least resistance into the stomach, increasing the risk of regurgitation and aspiration.

Compression-only CPR
It is important to note that this is only currently recommended for trained rescuers in situations where standard CPR is not possible and as being better than no CPR for untrained lay responders.

ARC Guideline 8 (December 2010): Cardiopulmonary Resuscitation states:
“If rescuers are unwilling or unable to do rescue breathing they should do chest compressions only. If chest compressions only are given, they should be continuous at a rate of approximately 100/min.”

There is an expectation that ski patrollers (as trained rescuers) will always attempt rescue breathing in addition to compressions unless there is a compelling reason as to why this is not possible.

The ARC has placed some explanatory information in the Frequently Answered Questions” section of its website dealing with compression-only CPR. This is reproduced below by way of information.

Australian Resuscitation Council - FAQ 9 – Compression-only CPR
The available published data reveals conflicting evidence regarding benefit versus no benefit for compression-only CPR. Strategies to improve the number of cardiac arrest patients receiving bystander CPR should be encouraged but not to the abandonment of conventional CPR.

Compression-only CPR should be viewed as the first resuscitation step which should be followed as soon as possible by rescue breathing and other basic life support interventions.

The Australian Resuscitation Council continues to hold the view that any attempt at resuscitation is better than no attempt, and if rescuers are unwilling or unable to do rescue breathing they should do chest compressions only. If chest compressions only are given, they should be continuous at a rate of approximately 100/min.

Australian Resuscitation Council – FAQs - The End of CPR as We Knew it?
In a recent email [date unknown ] from the USA, it was quoted: “In what may prove to be the biggest shift in emergency care of cardiac arrest in 40 years, cities across the country are leading a move away from the familiar practice of using mouth-to-mouth resuscitation. In its place, the cities are recommending simple chest compressions pushing down repeatedly on the victim’s chest – to mimic a steady heartbeat.

The emergency medical directors who are behind the shift say research in Seattle and
Richmond, Va, suggests it will save many lives. The movement became a full-fledged national trend last week at a meeting of emergency medical services (EMS) medical directors from 21 of the nation’s largest cities. Doctors from a dozen cities, including New York, Los Angeles and Chicago, decided to make the switch. They join at least seven other cities that are already advising 911callers to do chest compressions without mouth-to-mouth “rescue breathing””.

This issue has received media attention in the USA following a recent meeting of EMS medical directors. There has also been a recent article in the Weekend Australian newspaper. It mainly results from a study by Dr Hallstrom and published in Critical Care Medicine in 2000. In this study, callers to EMS reporting a cardiac arrest and who did not know CPR, were asked if they wanted to be instructed on how to do CPR. Those agreeing were randomised to receive instructions over the phone to either do full CPR or just chest compressions. This is often referred to ‘dispatcher assisted CPR’. The results of the study showed that the number of survivors in each group to be similar (14.6% for compression only vs 10.4% for full CPR)

It is important to note that the findings of this study refer only to situations where no trained bystanders were performing CPR. It shows that giving minimal telephone instructions (i.e. compressions only) seems to be as effective in terms of survival as giving full CPR instructions over the phone. However, this study does not compare the outcomes of untrained rescuers who receive dispatcher assisted CPR with that of CPR being performed by trained rescuers.

As such, inferring that mouth to mouth is not required when doing CPR is not supported by any clinical evidence. Furthermore, it ignores other causes of cardiac arrest such as drowning, and cardiac arrest in children, where ventilation (ie mouth to mouth) is vital. Readers should be aware that the recommendations of the EMS directors were that “compression only” CPR advice should be given to callers receiving assistance from EMS dispatchers. It did not recommend removing mouth to mouth ventilation from CPR training or practice, as has been generally presented in the media.

Futher Reading:
Hallstrom AP. Dispatcher-assisted "phone" cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. Critical Care Medicine 2000;28(11 Suppl):N190-N192.

The Chair of the ASPA Medical Advisory Committee has had the privilege (on a couple of occasions) of participating in a meeting of the National Council of the Australian Resuscitation Council and has observed at first hand the scientifically rigorous, lengthy and complex procedure that is involved in creating and updating the ARC Guidelines. This work is done by people who are internationally recognised experts in resuscitation science and is based on the best available evidence and expert opinion. The Guidelines are the “gold standard” and a safety net for first aid providers. Emergency responders who choose to operate outside the Guidelines are potentially placing both themselves and casualties at risk. ASPA wishes to protect both patrollers and casualties and will continue to look to the ARC for guidance on resuscitation practices.

For and on behalf of the ASPA Medical Advisory Committee
July 2013

"Springing the Pelvis" - An evidence-based assessment of first aid practices

ASPA Medical Advisory Committee – Briefing Paper re “Springing of the Pelvis”
July 2013

The Medical Advisory Committee (“MAC”) has been asked to provide a recommendation as to whether the practice of “springing the pelvis” as part of the Secondary Survey should be continued as part of Ski Patrol first aid teaching and practice.

It has been anecdotally reported that some (un-named) first aid training organisations are no recommending or teaching “springing the pelvis”.

As well as making a recommendation with regard to “springing the pelvis”, it would also be worthwhile for the MAC to consider whether the section on Pelvic Fractures should be revised to amplify the information describing when to suspect a pelvic fracture and management and specifically mention application of a pelvic binder.

Based on available publications, there would appear to be fairly persuasive evidence that the practice of “springing the pelvis” in the pre-hospital setting should be discontinued. It would also appear that there is scope for improving the information in the ASPA Manual regarding suspicion and management of pelvic fractures.

(Copies of the individual articles and guidelines referred to in this paper are available on request.)

1.         Summary of evidence and opinions regarding the practice of “springing the pelvis”.
2.         Sections of the ASPA Advanced Emergency Care Manual which refer to the pelvis.
3.         Published recommendations regarding “springing the pelvis”.
4.         Opinions regarding “springing the pelvis”.

1.         Summary of evidence and opinions regarding the practice of “springing the pelvis”.

Not Recommended
ABC of Prehospital Medicine
2007 – MJ Heetveld (NSW Trauma Guidelines) (*heavily qualified endorsement)
1990 – PT Grant (Archives of Emergency Medicine)
2004 – MJ Heetveld et al (World Journal of Surgery)
MICA Flight Paramedic
2007 – Lee and Porter (Emergency Medicine Journal)
Orthopaedic Surgeon
2009 – White, Hsu and Holcomb (Injury)

2009 – Trauma Emergencies

2010 – Ambulance Victoria

2012 - Royal Melbourne Hospital Trauma Guidelines – Pelvic Fracture

2013 – J Brun et al (Injury)

 2.         Sections of the ASPA Advanced Emergency Care Manual which refer to the pelvis and/or “springing the pelvis”.             Pelvis
The pelvis is composed of two pelvic bones that are held together at the front, and connected to the sacrum at the back, by very strong ligaments. It provides attachment for back, abdominal and leg muscles supports the body weight and protects major organs, e.g. bladder or pregnant uterus. The pelvic bones are very vascular and bleed profusely if badly fractured.             Lower Extremities
The upper leg contains the longest bone in the body (the femur). At its top end the head of the femur fits into a socket in the pelvis (hip joint). The shaft of the bone is strong and surrounded by heavy muscles while the lower end of the femur is broadened to form the upper part of the knee joint.

2.9                   Reproductive System
The reproductive system includes the organs necessary for natural conception and childbirth.

The female organs, including the ovaries, fallopian tubes, uterus, and vagina are protected by the bony pelvis, which also protects the developing foetus for the first fourteen weeks.

In the male, the testes and penis are exterior to the bony pelvis and more prone to injury.

The process of conception, gestation, and childbirth, though apparently simple, requires a balanced interaction of male and female endocrine and reproductive systems.             Principles of Examination
·         Be systematic: use the same process every time to avoid omitting any part of the examination. Start with the head, then the spinal column (neck, spine), upper torso (shoulders, chest), lower torso (abdomen, pelvis), and limbs. Be consistent in examining limbs, always working from the trunk to the periphery or vice versa.
(…)             Specific Examination
The Lower Torso
·                Feel the abdomen systematically, in all four quadrants, gently checking for pain, distension, or rigidity of the muscles, each of which may indicate intra-abdominal trauma.
·                Gently spring the pelvis by applying lateral pressure. Pain may indicate possible fractures.
·                Note any urinary or faecal incontinence, which may indicate internal injury to the pelvic cavity.

(Figure 30 Springing the pelvis – lateral recovery position)

3.5                   Approach to the Casualty – Summary Flowchart
Secondary Survey
·         Examination must include whole body: head, neck, back, chest, abdomen, pelvis and limbs.
Lower Torso
o Check the 4 quadrants for signs or symptoms of injury
o Spring the pelvis (once only)
o Check the groin for wetness, bleeding.

6.1.5                Internal Bleeding
Internal bleeding may result from the tearing of an organ such as the spleen or the lung, or from a closed fracture. Internal bleeding may manifest itself externally from the:
·         Lungs: blood may be coughed up; it will be bright red and frothy.
·         Stomach: blood may be vomited; fresh blood will be bright red but blood which has been sitting in the stomach for some time will be black, like coffee grounds. The longer the blood has been in the stomach, the darker it will be.
·         Bowel: fresh red blood may be mixed with the faeces; blood which has spent some time in the digestive tract will produce black, tarry bowel motions with a very strong odour.
·         Rectum: bright blood is mixed with the faeces.
·         Kidneys and bladder: blood escapes with the urine, which may be smoky or red in appearance.
·         Female genital tract: bright blood or clots appear at the opening of the vagina.
·         Muscles: swelling will be present over the site of injury; the swelling may be coloured, as in a bruise, and may have a fluid ‘feel’ when palpated.

At other times, internal bleeding may not be evident. Bleeding from the liver, spleen, and aorta, or in association with fractures of the femur or pelvis will be hidden. Bleeding may take place into the abdominal cavity; this will not appear outside the body. Hidden internal bleeding can be life threatening and should be suspected after trauma to the abdomen with signs and symptoms of shock but without obvious bleeding.

6.1.6                Internal Bleeding at Fracture Sites
Fractures of large bones may bleed significantly, but examination of the fracture site may not always reveal the presence of swelling that signifies internal blood loss. One or two litres of blood may escape into the thigh from a fractured shaft of femur, and two or more litres may be lost with severe pelvic fractures. Treat these casualties as for internal bleeding. Bleeding from fractures of the tibia and other long bones is less severe, but can still present a problem.             Severity of Shock
When assessing hypovolaemic (or haemorrhagic) shock, consider that:
·                A normal healthy person easily compensates completely for acute blood loss of up to 10% of the blood volume (i.e. 500 to 700 mL in an average adult; as in a blood donation).
·                The normal blood volume is 5 to 6 litres.
·                Signs of shock appear when blood loss exceeds 15% to 30% of blood volume in a short period of time (i.e. 800 mL to 1500 mL blood).
·                Life cannot be sustained with an acute blood loss of 2 to 2.5 litres (i.e. 40–50% of blood volume).
·                Closed fractures of the femur or pelvis can cause substantial blood loss into the tissues, however not all victims with these fractures will develop shock. Bleeding usually slows after an initial ‘torrent’ (i.e. when the tissue pressure reaches blood pressure levels).

8.1.3                Principles of Management
In managing fractures, the patroller should:
·         examine for:
o   nerve function, by checking for sensation and movement below the injury before commencing treatment;
o   vascular function, by checking distal pulse and capillary return below the injury before commencing treatment;
o   signs of hypovolaemic shock, especially with open fractures (remember however that major closed fractures such as pelvic or femoral can also cause hypovolaemic shock);

9.3                   Lower Limbs
9.3.1                Pelvic Fractures
Pelvic fractures usually result from a direct blow or crushing injury but can also occur when landing upright on the leg(s) after a fall from a height (e.g. over 3 metres). This injury can shear the pelvis through the pubic symphysis and sacral joints or force the femur up through the pelvis.

·         Signs: a simple fracture of a pubic ramus may produce minimal pain; extensive crush fractures will produce early bruising and severe diffuse pain, not focused on the site of injury; blood loss may be significant and result in hypovolaemic shock; there may be pain on leg movement; tenderness and crepitus may be elicited when the pelvis is compressed or sprung.

·         Management: expect and prepare to treat for hypovolaemic shock; immobilise the casualty and transport urgently to medical care in a scoop stretcher; notify medical care (a doctor) early so that fluid resuscitation can be commenced as soon as possible.

·         Complications: primarily arise from hypovolaemic shock. Other complications arise if the bladder or urethra (male) is damaged, especially if it is full at the time of injury; any urine passed by the casualty should be kept for later evaluation by a medical practitioner.

(Figure 132: Fractured pubic ramus.)

9.3.3                Dislocated Hip
·         Complications: generally arise through associated fractures of the pelvis or femoral head complicating dislocations. Avascular necrosis of the head of the femur with subsequent early arthritis is a disabling complication.

10.3.6              The Scoop Stretcher
The scoop is ideal for use in: casualties with suspected spinal injuries (including all unconscious casualties); casualties with pelvic fractures or hip injuries where lifting may be very painful;

10.3.7              Spine Board (Supine Position)
6.         Secure the casualty to the spine board using the straps. Apply strap 1 from the shoulder, across the chest, to the opposite pelvic region, strap 2 across the other shoulder, as per strap 1. strap 3 across the pelvis and strap 4 across the upper legs above the knees. (Alternatively, strap 3 &4 can be crossed from pelvis to opposite knee area).

10.3.10            The Kendrick Extraction Device (KED)
The KED is mainly used for spinal injuries but can be used as a splint for other injuries, e.g. neck of femur, pelvis injuries. It can be washed with soap and water. Originally the KED was developed to extract people with spinal injuries from car seats. It is particularly useful for extracting casualties from tight situations. The instructions below are a summary of the full Ferno™ training manual for this device. Click on the Ferno symbol above to open that manual.
3.         Apply the upper thigh system by sliding the male buckle under the leg, at the knee, and see-saw upward until positioned in the crotch area. Engage the buckle. A click signals that the buckle is locked. Cinch the strap until the traction pole receptacle is positioned at the belt line or pelvic crest. (Note: assure that male genitals are clear of the strap).
11.       The leg straps secure the pelvis to the lower portion of the KED to stabilise the lumbar area. Whether using either of the configurations for leg straps shown below, you must position the straps as close as possible to the casualtys body midline.

10.3.11            The Hare Traction Splint
When traction is applied to the leg through the ankle hitch, counter-traction is applied by the padded half-ring against the ischial tuberosity of the casualty’s pelvis. Proper counter-traction is essential to the correct functioning of the splint.

3.         Published recommendations regarding “springing the pelvis”.
ABC of Prehospital Medicine, edited by Tim Nutbeam and Matthew Moylan.
Published by John Wiley & Sons (Google eBook, July 2013).

Chapter 16. Trauma: Pelvic Injury
Matt O’Meara, Keith Porter and Tim Nutbeam.
(Pages 85-86)
Pelvic binders
Pelvic binders should be applied at an early stage (as part of the ‘C’ assessment) and not removed until significant pelvic injury has been excluded (Figures 16.4 and 16.5). The binder performs two roles:
1. Anatomical reduction of the pelvis – reducing pelvic volume; and
2. Stabilising all forms of pelvic fracture – limiting movement through mechanical splinting.

·         Application: First correct shear by drawing feet level and binding feet/ankles and knees together. Then reduce A-P rotation through application of circumferential compression with binder at greater trochanter.
·         Indications: All patients with a mechanism of injury which may have caused pelvic injury and are either (a) unevaluable (e.g., head injury, intoxication, intubated) or (b) complaining of back, pelvic or lower abdominal pain.
·         Combined fractures: With suspected combined femoral and pelvic fractures, first apply manual traction to the legs drawing feet and ankles level. Next apply a pelvic binder before applying Kendrick or equivalent (see Chapter 17 on extremity injury) traction splint to each leg suspected of having a femoral fracture. Apply traction aiming for anatomical reduction. Bind feet together to prevent external rotation.

Avoiding iatrogenic injury
Pelvic fractures should be assumed to be unstable – additional iatrogenic injury may be caused by the movement of bone fragments and movement causing changes in pelvic volume and/or architecture.

Do not spring the pelvis – it adds little relevant clinical information but can cause significant damage.

Care must be taken when removing patient clothing e.g., motor bike leathers. These clothes may be holding fractures in a reduced position – on removal significant damage may be caused by changes in pelvic volume/architecture.

Log roll is not recommended and should be minimized (10-15 degrees maximum). A split scoop-style stretcher is ideal for lifting and transporting patients.

Tips from the Field:
·         Avoid iatrogenic injury by minimal handling techniques, avoidance of log roll and not springing the pelvis.
·         Have a high index of suspicion: if in doubt apply a pelvic binder.
·         PR or PV bleeding may represent an ‘open’ fracture into a hollow viscus, these have a mortality of > 50%.
·         Pelvic binders need to be applied at the level of the greater trochanters (even though they may look better around the waist!).
·         Do not allow anyone to mistake a pelvic binder for a board strap and accidentally unclip it!

Further Reading
Joint Royal College Ambulance Liaison Committee (IRCALC) Prehospital Guidelines 2006. Warwick: University of Warwick, 2006.
Lee C, Porter K. The prehospital management of pelvic fractures. Emergency Medicine Journal 2007; 24: 130-133.

[This is a key paper which many of the other references refer back to.]
Grant PT. The diagnosis of pelvic fractures by 'springing'. Archives of Emergency Medicine, 1990; 7: 178-182

Thirty-six patients were studied prospectively to assess the benefit of 'springing' the pelvis in traumatized patients, to confirrn or refute a fracture of the pelvis. None of the patients was multiply injured and half of those with fractures were elderly, sustaining their injuries in simple falls. Springing the pelvis was a poor predictor of the presence or absence of a pelvic fracture, at best it yielded a specificity of 71% and sensitivity of 59%. Its routine use in clinical examination should be abandoned.

I would suggest that there is no easy answer to the best method of detecting these fractures clinically and one must resort to the use of X-rays liberally, not just in major injury but also in the more minor, especially elderly patient who may only have vague groin discomfort or a mild limp following relatively trivial trauma. I feel that 'springing' the pelvis should no longer be taught to medical students and junior doctors alike, and should be completely discarded from our clinical practice.

Heetveld MJ, Harris I, Sclaphoff G, Balogh Z, D’Amours SK, Sugrue M. Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines. World Journal of Surgery 2004; 28: 904–909.

“Clinically, a suprapubic hematoma may be palpable, suggesting pelvic arterial and/or venous hemorrhage. The sensitivity of pelvic springing to detect pelvic ring instability is only 59%, and we do not advocate springing, which is also painful in conscious patients.” [34 - Grant PT. The diagnosis of pelvic fractures by ‘springing’. Arch. Emerg. Med. 1990;7:178–182].

Lee C, Porter K. The prehospital management of pelvic fractures. Emergency Medicine Journal 2007; 24:130–133.
Pelvic fractures are one of the potentially life-threatening injuries that should be identified during the primary survey in patients sustaining major trauma. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of Hypovolaemia and to allow appropriate triage of the patient. The assessment and management of pelvic fractures in the prehospital environment is reviewed here. It is advocated that the pelvis should not be examined by palpation or springing, and that the patient should not be log rolled. Pelvic immobilisation should be used routinely if there is any suspicion of pelvic fracture based on the mechanism of injury, symptoms and clinical findings.
This paper aimed to review the literature and analyse current practices in order to identify the
optimum management for a patient with a suspected pelvic fracture in the prehospital environment.

The most common mechanism of injury resulting in pelvic fracture is road traffic collisions (20–66%), with an increased likelihood if the patient is sitting in the front of the vehicle in head on collisions, on the struck side or with near intrusion. Pelvic fractures resulting from pedestrian collisions (14–59%) and motorcyclist collisions (5–9.3%) are also common.10 12 14 16 Falls from heights, or from a low level by elderly patients with osteoporosis are also implicated in the aetiology and, more rarely, crush injuries.

Pelvic fractures should be identified by the circulatory assessment of the CAcBCDE assessment following resuscitation of catastrophic haemorrhage, airway and breathing problems.

Traditional teaching encourages the practice of ‘‘springing’’ the pelvis as part of this assessment to identify tenderness or instability as an indicator of pelvic fracture and therefore a source of internal haemorrhage.17 A variety of methods of springing have been described: most involve compression or distraction of the fracture site.18 However, the current belief is that this is an unreliable test, which will only detect major pelvic disruption and is dangerous in dislodging clots and promoting further blood loss.

In 1990, a level three prospective study first dealt with concerns about examining the pelvis, looking at 36 patients with blunt trauma (excluding multiple injuries). The results found that springing the pelvis had a specificity of 71% and a sensitivity of 59%, suggesting that routine use of this examination should be abandoned.19

Several studies have looked at the likelihood of a pelvic fracture being present depending on
whether a patient has symptoms of pain or suspicion on clinical examination, as a means of
reducing the use of routine pelvic x rays in a patient sustaining blunt trauma (table 1).

The limitations of most of these studies are that they were performed on patients with a Glasgow Coma Scale (GCS) of >13 who were co-operative and alert. The examiners could, therefore, only verify the reliability of examination in these circumstances and the studies were thus not applicable to patients with severe multiple injuries and reduced consciousness
levels due to intracranial injury, shock or the influence of alcohol or drugs. In cases where injuries were missed, the authors of these studies suggest that painful distracting injuries at other sites may also have been a contributing factor.

In the meta-analysis, the diagnostic accuracy was confirmed as being much lower in those
studies which included patients regardless of GCS (three of these studies were on children).20
In the Gonzalez et al’s9 study of patients with GCS 14 or 15, the most common positive finding in patients with pelvic fractures was of the patient complaining of pelvic pain (67% of
97 patients) whereas only 32% had pain on iliac compression and 37% had pain on palpation of the pubic symphysis.

In summary, the prehospital practitioner first needs to assess the mechanism of injury to be able to predict a potential pelvic fracture.

Alerting features suggestive of significant pelvic injury during examination include deformity, bruising or swelling over the bony prominences, pubis, perineum or scrotum. Leg-length discrepancy or rotational deformity of a lower limb (without fracture in that extremity) may be evident. Wounds over the pelvis or bleeding from the patient’s rectum, vagina or urethra may indicate an open pelvic fracture. Neurological abnormalities may also rarely be present in the lower limbs after a pelvic fracture. Discrete rectal or vaginal bleeding or a high-riding prostate will not be detected in the prehospital environment.

In the alert, orientated, cooperative patient with no distracting injury, it will be possible for the prehospital practitioner to ask the patient about the presence of pain in the pelvic area,
including the lower back (assessing the sacroiliac joint), groin and hips. Any positive reply should call for routine immobilization of the pelvis. In the absence of any symptoms or signs of pelvic fracture as described above, discharge from scene is an option, provided there are no other injuries requiring transfer to a hospital.

In the case of the unresponsive trauma patient, the pelvis should not be palpated for tenderness or instability. A pelvic fracture should be assumed to be present and routinely
immobilised as described below.

Traditional teaching advises that the emergency management of pelvic fractures includes internal rotation of the lower limbs to reduce the pelvic volume and circumferential wrapping of a sheet around the pelvis as a sling.17 Reduction and stabilization of pelvic ring injuries should occur as soon as possible after injury,23 while clotting mechanisms are still intact, before irretrievable haemorrhage has occurred and before the patient’s movement and transport.
Prehospital management of a suspected pelvic fracture should adhere to the following principles:
·         Read the mechanism of injury.
·         Ask the alert patient about the presence of pain in the pelvic, back or groin regions and routinely immobilise the pelvis if there is any positive reply.
·         Examination is unreliable (especially if reduced GCS, or distracting injuries) and the pelvis should not be palpated, to avoid further internal haemorrhage.
·         If there is any suspicion of fracture, immobilise the pelvis using an external compression splint (commercial or modified eg, sheet).
·         Do not fully log roll the patient.
·         Use a scoop stretcher to facilitate the patient’s movement on to a spinal board or vacuum mattress for transport. In the emergency department, this process should be reversed.
·         Fluid resuscitation to maintain a radial pulse only.
·         Do not remove a pelvic splint in the presence of a suspected unstable pelvic injury until it is radiologically confirmed that there is no fracture or the patient is in a theatre.

NSW Health. Adult Trauma Clinical Practice Guidelines. Management of haemodynamically unstable patients with a Pelvic Fracture.
Citation: Dr Martin Heetveld 2007, The Management of Haemodynamically Unstable Patients with a Pelvic Fracture, NSW Institute of Trauma and Injury Management.
(Page 9) Physical assessment is highly sensitive in determining the presence of fracture of the pelvis in a conscious and orientated patient. Findings warranting a plain pelvic X-ray are hip pain, groin pain, low back pain, tenderness to palpation over the pelvic girdle, obvious deformities and ecchymosis or abrasions around the pelvic area.21 To detect an unstable
fracture pattern of the pelvic bones at physical examination springing of the pelvis is advocated, but unless one is experienced in pelvic fracture surgery, the sensitivity of pelvic springing is only 59% and is painful in the awake patient.22 [Grant P 1990, The diagnosis of pelvic fractures by springing, Archives of Emergency Medicine 1990;7(3):178-82.]

The most common mechanisms of pelvic fractures are motor vehicle accidents (57%), pedestrians hit by motor vehicles (18%), motorcycle accidents (9%), falls (9%) and crush injuries (4%).23

[Note: This appears to be a heavily qualified endorsement of “springing the pelvis” and it is strange that the author cites an article which categorically states that “springing” should not be used. It also undermines the author’s credibility that in 2004 he was part of a team of authors stating that “we do not advocate springing”, citing the same article by PT Grant.]

(Page 25)
6.         How to optimally mechanically stabilise the pelvis?
Rotationally unstable APC types II and III, LC type III pelvic fractures benefit most from external stabilisation. If vertical instability is also present, such as in VS and combination type pelvic fractures, rotational stabilisation needs to be supplemented by skeletal traction on the injured side. (Level of Evidence: III-3)

The optimal time-effective and safe pelvic external stabilisation device in the haemodynamically unstable patient is non-invasive. A bed sheet wrapped and clamped tightly around the pelvis is a good option. There are a variety of non-invasive proprietary devices available. The device should be applied so that it allows both laparotomy access and femoral artery access for angiography. (Level of Evidence: IV)

(Page 26)
Approach in the emergency setting
In the situation of haemodynamic instability, stabilisation of the pelvis in APC type II and III,
LC type III, VS and combinations of these fractures, must be performed in the shortest possible time. Two kinds of pelvic stabilisation can be considered: non-invasive techniques and invasive fixation.

Non-invasive techniques have advantages: they are safe, time-effective, do not require the presence of an orthopaedic surgeon in the resuscitation room and do not interfere with further resuscitation efforts.88 Simple, popular options include the use of a bed sheet wrapped and clamped tightly around the pelvis or a vacuum beanbag to provide emergent pelvic stability. (36;78;88) There are also a number of more expensive proprietary devices specifically
designed and marketed for such use. These non-invasive options should be considered as
temporising measures bridging the gap from injury to more definitive stabilisation.75 Pelvic stability promotes venous bleeding tamponade and protects the soft tissues from further injury.70;87

Appendix A contains photographs of a step-by-step pelvic sheeting technique. (It was not possible to reproduce this here.)

White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury 2009; 40:1023–1030.
Pelvic fractures account for approximately 3% of all skeletal injury after blunt trauma. In large series, most result from motor vehicle crashes.12,27,43,76,81,105 Though injuries combining mechanically unstable pelvic fractures with haemodynamic instability are rare, comprising less than 10% of all pelvic fractures presenting to Level I centres, they represent the bulk of mortality of this group.39,43,56 To disrupt the integrity of the pelvic ring requires an instantaneous deceleration of approximately 30 miles per hour and as this energy dissipates, it often causes trauma to the head, chest, abdomen or extremities which adds to the over-all physiological burden of injury.54,96,105 In fact, more than 80% of patients with unstable pelvic fractures will be found to have additional musculoskeletal injuries.25,54,80 Injury severity score (ISS) is indicative of the degree of destructive energy applied to the body as a whole, and ISS, not type of pelvic instability, appears to be the most important factor in predicting mortality in patients with pelvic fractures.3,39,76,80,96,114,118 Only a small proportion of deaths are directly attributable to the pelvic fracture alone.31,90,95

Focus should then be turned to reduction of venous bleeding by stabilisation of pelvic ring injuries. This is most expeditiously accomplished with a longitudinally folded bed sheet wrapped circumferentially around the pelvis, placed between the iliac crests and greater trochanters, and secured anteriorly by clamping97,100,110 (Fig. 2), or with simple commercially available devices which also provide circumferential pelvic stabilisation
and may permit the applied reduction force to be controlled to a pre-determined level.27,100 Both the improvised and commercially available binders stabilise the pelvis and allow for clot formation. While binders and external fixators may decrease the pelvic volume of ‘‘open-book’’ injuries,9 it is controversial whether they can create a tamponade effect, since the retroperitoneum is disrupted.47,53 The ‘‘splinting’’ of pathological pelvic motion is more likely to be the mechanism that aids in haemostasis. Moreover, the reduction in volume of the true pelvis is much less than expected. A large pubic diastasis of 10 cm only corresponds to a 35% increase in pelvic volume or 479 cm3.120

Pelvic binders also assure continued access to the abdomen, pelvis and lower extremities, do not require special training to place and are generally free from complications with short-term
use. As such, ATLS guidelines recommend their placement by pre-hospital personnel and providers in rural settings before transport of these patients. In fact, the use of pelvic binders
results in significantly lower transfusion amounts and length of hospital stay compared to external fixation.27 Long periods of tight immobilisation may cause tissue necrosis, nerve injury and/or abdominal or extremity compartment syndrome(s) although this time course is not well defined.75,100,108,126 There is a case report of skin breakdown affecting patient management secondary to circumferential anti-shock sheeting.106 A recent study raised concerns about prolonged use of binders due to pressure over bony prominences.70 Pelvic sheeting or compressive devices usually remain in place until the patient is haemodynamically stable and transfusion requirements have ceased, usually in one to two days, or if the patient continues to bleed and another intervention is necessary.11,123 Military antishock trousers (MAST) trousers limit access to the traumatised regions and have also been associated with these complications with no evidence of benefit and should not be used for this purpose.32,43

Clinically, a palpable haematoma above the inguinal ligament, on the proximal thigh, and/or over the perineum (Destot sign) may indicate pelvic fracture with associated bleeding; ecchymosis about the flank (Grey Turner sign) is associated with retroperitoneal haemorrhage. Pelvic springing involves applying alternating compression and distortion over the iliac wings to detect pelvic ring instability and is a poor predictor of the presence or
absence of pelvic fracture. Additionally, it may dislodge adherent clot further exacerbating haemorrhage, is painful to the conscious patient and should therefore be avoided.52,59 [Grant PT. The diagnosis of pelvic fractures by ‘springing’. Arch Emerg Med 1990; 7:178–82.; 59. Heetveld MJ, Harris I, Schlaphoff G, et al. Hemodynamically unstable pelvic
fractures: recent care and new guidelines. World J Surg 2004; 28:904–9.]

Major Pelvic Trauma – New Guidance. Trauma Emergencies, May 2009. (8 pages)
·         AIRWAY
·         BREATHING
·         DISABILITY (mini neurological examination).

Evaluate whether patient is TIME CRITICAL or NON-TIME CRITICAL following criteria as per trauma emergencies guideline. If patient is TIME CRITICAL, correct A and B problems, stabilise the pelvis on scene, and rapidly transport to nearest suitable receiving hospital. Send a Hospital Alert Message. Enroute, continue patient management of pelvic trauma (see below).

In NON-TIME CRITICAL patients perform a more thorough patient assessment with a brief Secondary Survey.

5.1 Specifically consider
Pelvic fracture should be considered based upon the mechanism of injury.67

Clinical assessment of the pelvis includes observation for physical injury such as bruising, bleeding, deformity or swelling to the pelvis. Shortening of a lower limb may be present (see also limb trauma guideline).68 Assessment by compression or distraction (e.g. springing) of the pelvis is unreliable and may both dislodge clots and exacerbate any injury and should not be performed.69-71
[Relevant footnotes:
69. MacLeod M, Powell JN, MacLeod M, Powell JN. Evaluation of pelvic fractures. Clinical
and radiologic. Orthopedic Clinics of North America 1997;28(3):299-319.
70. Fox MA, Mangiante EC, Fabian TC, Voeller GR, Kudsk KA. Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome. Southern Medical Journal 1990;83(7):785-8.
71. Sauerland S, Bouillon B, Rixen D, Raum MR, Koy T, Neugebauer EAM. The reliability
of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis.
Archives of Orthopaedic & Trauma Surgery 2004; 124(2):123-8.]

Any patient with a relevant mechanism of injury and concomitant hypotension MUST be
managed as having a time critical pelvic injury until proven otherwise.

Reduction and stabilisation of the pelvic ring should occur as soon as is practicable whilst still on scene, as stabilisation helps to reduce blood loss by realigning fracture surfaces, thereby limiting active bleeding and additionally helping to stabilise clots.67 72 Reduction of the pelvis may have a tamponade affect, particularly for venous bleeding; however there is little evidence to support this belief.73

Log rolling of the patient with possible pelvic fracture should be avoided as this may
exacerbate any pelvic injury;67 where possible utilise an orthopaedic scoop stretcher to lift
patients off the ground and limit movement to a 15ยบ tilt.

6.1 Oxygen Therapy
Major pelvic injury falls into the category of critical illness and requires high levels of
supplemental oxygen regardless of initial oxygen saturation reading (SpO2). Maintain high flow oxygen (15 litres per minute) until vital signs are normal; thereafter reduce flow rate, titrating to maintain oxygen saturations (SpO2) in the 94- 98% range (refer to oxygen guideline).

6.2 Pelvic Stabilisation
There is currently no evidence to suggest that any particular pelvic immobilisation device or
approach is superior in terms of outcome in pelvic trauma and a number of methods have
been reported.32 74-86 Effective stabilisation of the pelvic ring should be instigated at the earliest possible opportunity, preferably before moving the patient, and may be achieved by:
·         use of an appropriate pelvic splint 32 74-78
·         application of circumferential support, however care must be taken to ensure that over-compression does not occur.79-82

Expert consensus suggests the use of an appropriate pelvic splint is preferable to improvised immobilisation techniques. In all methods, circumferential pressure is applied over the greater trochanters87 and not the iliac crests. Care must be exercised so as to ensure that the pelvis is not reduced beyond its normal anatomical position.

Pressure sores and soft tissue injuries may occur when immobilisation devices are incorrectly fitted.88

6.3 Fluid Therapy
There is little evidence to support the routine use of IV fluids in adult trauma patients; please refer to the fluid therapy guideline for specific guidance.

6.4 Pain Management
Patients’ pain should be managed appropriately (refer to pain management guidelines);
analgesia in the form of Entonox (refer to Entonox drug protocol for administration and
information) or morphine sulphate may be appropriate (refer to morphine drug protocol
for dosages and information).

(Five pages of relevant references are supplied with this article.)

Notes from the office of Operational Quality and Improvement (Ambulance Victoria)
Topic: Pelvic and Femur Fractures

Hello All,

The coming 2010 CPE has a session on major trauma with a part devoted to Pelvic fracture management. This was visited only a couple of years ago but will be repeated for a few reasons. Firstly, the amalgamation has meant that the SAM pelvic splint as used in AAV and rural shall be introduced for use into metro.

In metro, the major option for pelvic fracture management has been the Pelvic Wrap 'big nappy' technique. This works pretty well and should not be discarded out of hand. It has a couple of limitations though. The compressive force applied is variable and dependent on operator application. It is also possible to loosen as the patient is moved and transported. The other thing creative ambos do is use the KED as a pelvic splint. Invert it so that the larger chest part sits over the pelvic area and pull the straps tight. The lower part can be used to grab the legs and tied off with a bandage etc. This isn't specified as a use by the manufacturer but seems to work okay. Again though, you cannot govern the pressure applied and there is no evidence that it really does work. Also, it can be a bit harder to get the force in just the
right place which can count for a lot.

Pelvic traction should be applied to the lower part of the pelvis in the area of the femur trochanters. This is a bit lower than many would first guess. The SAM splint is a great device designed just for binding up the truly stuffed pelvis. It applies just the right amount of force and doesnt let go in transit.

Why splint a pelvic fracture? Like all fractures, movement allows for further soft tissue damage and increased pain so splinting is usually good. In the case of the pelvis, there are a lot of fairly important blood vessels travelling through. If these are damaged, outcomes are often bad. Further, the pelvis itself is fairly vascular (you can even stick intra-osseous needles into it). When a pelvis is broken clean through and loses its shape ('open book fracture') two things can happen. The smaller vessels in the bone itself bleed more and the larger vessels passing through have a bigger space to bleed into. Splinting increases the tamponade effect within a reduced pelvic space reducing both sorts of bleeding. Also, by returning bones to the right place, the smaller bleeding bone vessels can be better controlled.

How do you pick a pelvic fracture? The mechanism and pattern of injury are the first clues. Patients fallen from a height, in a head on (your knees ramming your femurs back into your pelvis by the dashboard will do it pretty well) or a good T-bone into the victims door are good. Signs and symptoms are not perfect for detection. It can be hard to pick a pelvic fracture without X-ray or CT. Hip/groin/lower back pain, pelvic tenderness, hematuria or vaginal bleeding are all clues. Lower back injuries and upper femur fractures can be very hard to distinguish from a pelvis. The open book fracture is only a small percent of all fractures but is the bad one. This will likely involve more severe pain, evidence of pelvic deformity, shortening or leg rotation, crepitus, bruising to the groin area and poor perfusion. If the hips and upper thigh(s) look a bit stuffed, assume the pelvis is broken. Though perfusion can be attacked by other injuries, a hip/pelvis injury and poor perfusion is a good chance to be an open book fracture.

Though it says crepitus, you shouldn't go looking for this. Springing the pelvis is not a great idea. Not only might it hurt, we don't normally wiggle other fractures around just to check if anything really is broken. You can worsen the injury. Many fractures won't be revealed by this technique anyway so it isn't really diagnostic. Gather all the evidence as described above. If you are in any doubt, treat as if it is an open book pelvic fracture. A SAM splint may not be much help for a fracture that isn't open book but it will do a lot for it when it is.

What about if there is a femur fracture(s) as well? Well, you can die from a broken pelvis. You don't usually die from a femur or even two (though you would probably look and be pretty crook with two). The pelvis gets priority. It takes a lot of trauma to break a pelvis or a couple of femurs. When you splint a pelvis, the pressure is across the body and doesn't really impact on the lower limb. So a pelvis shouldn't upset the femur fracture. The femur pushes up into the pelvis when traction is applied. The amount of push is usually not enough to upset the pelvis; it is more against the ischial tuberosity. So you can apply a Donway splint on a fractured pelvis even though some traction splint manufacturers advise against it. The SAM splint when properly placed over the trochanters still shouldn't interfere with the ischial ring of the Donway; the latter sits a tad lower. You shouldn't use a traction splint if a knee or ankle joint is cactus. Advice from the Alfred Trauma centre is that if in any doubt, splint up the pelvis. Then rotate and pull the legs into as best as normal alignment as you can (this helps pull the pelvis back into shape and a fair bet might hurt without a good dose of analgesia first). Finally use basic techniques like figure of 8 on the ankles and broad bandage to truss the legs together. It is arguable how much benefit can be gained from traction in the pre-hospital setting but there is no question as to the value of immobilisation. I can hear the dinosaurs moaning 'MAST suit' in their agonised sleep from here.....

And remember, once applied, no pelvic splint should be removed by us once applied. It should be removed slowly and only with an emergency physician in attendance as dramatic deterioration can follow.

Jeff Kenneally, Acting Manager Clinical Effectiveness & Research
Operational Quality and Improvement
Ambulance Victoria, 375 Manningham Road Doncaster Vic 3108

Royal Melbourne Hospital Trauma Service. Trauma Service Guidelines - Haemodynamically Unstable Pelvic Fracture Guideline.
Developed by: K. Gumm, R. Judson, P. Page, M. Richardson & ACT
Created: February 2005; Version 1.0
Revised: July 2012 Version 2.0
Revised By: K. Gumm, R. Judson, A. Bucknill, A. Oppy, M. Walsh, D. Pascoe
Pelvic fractures are relatively uncommon and account for only 3% of all skeletal injuries after blunt trauma, most result from high velocity injuries such as motor vehicles, pedestrians, motor bike, falls and crush injuries. They occur in 20% of multi-trauma cases and most commonly in 15 to 30 year olds and in the over 60’s, with 75% of all injuries occurring in men 2-8.
Patients who present with or develop haemodynamic instability with a suspected or known pelvic fracture will require a primary and secondary survey.

Initial inspection should be for signs of external blood loss and for blood loss from long bone fractures. A chest x-ray will rule out a large haemothorax.

If a fracture is seen on pelvic x-ray there is a 32% probability of arterial bleeding in the pelvic retroperitoneum 11-13. Signs and symptoms of a significant pelvic fracture include: 2
·         Deformity
·         Bruising and swelling over bony prominences, pubis perineum, and/or scrotum
·         Leg length discrepancy or rotation deformity of a lower limb
·         Wounds over the pelvis or bleeding from rectum vagina or urethra
·         Neurological abnormality.

Springing the pelvis is an unreliable test in detecting major pelvic disruption and is dangerous as it may dislodge a clot promoting further bleeding in the unstable patient.

Disruption of the pelvic ring requires a high energy decelerative force of approximately 50 km/hr 2, 3, 6, 9. These forces cause multiple other organ injuries up to 90% of patients with an unstable pelvic fracture have other associates injuries and 50% have sources of haemorrhage other than the pelvic fracture 3, 8, 13, 14. Including long bones (40%), intrathoracic (29%), spleen (32%), liver (20%), bladder (15%), bowel (10%), kidney (7%)11, 13. Therefore it is crucial to exclude other causes of shock including tension pneumothorax, pericardial tamponade and neurogenic shock. Whilst continuing with fluid resuscitation a rapid systematic evaluation of the whole body is needed to manage patients with pelvic fractures.
Pelvic Sling 3, 7, 8, 15, 16.
The pelvic sling is a non-invasive external pelvic stabilisation device. It is easy to apply and readily available in the trauma bays in emergency department. The sling when applied to the greater trochanters will affect pressure and cause the legs to internally rotate, assist in decreasing pelvic volume, improving mechanical stability and prevent disruption of haemostatic clots. A pelvic sling should be considered as early as possible in patients with suspected pelvic fractures, the sling should not be removed until the patient is haemodynamically stable, normothermic and not coagulopathic (see the RMH Pelvic Sling Guidelines for full use instructions:
(A page of references is supplied with this Guideline.)

(Article in press): Brun J, et al. Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients. Injury (2013),

“During the pre-hospital phase, it was recommended to place pelvic belt for patients with suspected displaced pelvic fracture or ongoing haemorrhage originated from the pelvis.”

4.         Opinions regarding “springing the pelvis”.
Subject: Re: medical query for ASPA procedures - springing of pelvis

My immediate thoughts on out-of-hospital recognition of the fractured pelvis;

Physical and historical assessment (with associative indicator confidence)
·         Unable to raise legs or straighten bent legs due to 'clear' pelvic-area pain (moderate to
·         high)
·         Pelvic pain on 'springing' pelvis, that is, palms on iliac crests progressively pushing
·         down, then lateral inwards pressure (high)
·         Painful/rigid/firm lower abdomen (low to moderate)
·         The unconscious trauma patient (Suspect it and you won't miss it)
·         Blood in urine (not an appropriate out-of-hospital exam. Blood can be present in urine,
·         but requires urinalysis to confirm)
·         Failed attempt to ambulate from pelvic pain (low to moderate)
·         Direct pelvic impact described, that is, mechanism (low)

How do you increase the likelihood of ensuring correct identification? Combine these all
together. The more positives you get in the above, the more likely a fractured pelvis is present.

I respectfully disagree with the assertion about 'unwanted' transports and radiography. If you
think it's there with reasonable evidence, THEN IT IS! COMMIT TO EARLY OFF MOUNTAIN EVACUATION. This is a fundamental of pre-hospital medicine, and indeed a trauma centre would not hesitate to conduct x-rays with a modicum of suspicion. However I do reinforce the point of 'reasonable' evidence. Mechanism alone is usually not sufficient evidence, unless the patient have other significant injuries or is unconscious.

(MICA Flight Paramedic)
*   *   *   *   *
The word springing in the pelvis means different things to different people.

The test that orthopaedic surgeons usually use for suspected pelvic injury is to put a hand on either side of the pelvis just above the greater trochanter of the thighs and push the iliums together.  If this does not cause any pain then it is unlikely that there is any significant injury to the pelvic ring which includes the sacroiliac joints, the iliums and the pubic rami.

If the patient is supine then pressing on the pubis may cause pain if there are fractures to the pelvic ring and/or a disruption of the symphysis pubis.

 Once again doing this test cannot cause any new damage.

I believe that ASPA should be careful not to be over conservative which may result in the following:

1.         An unnecessary trip by ambulance from the snowfield to the  nearest hospital.
2.         Completely unnecessary investigations such as x-rays and CT scans all of which are harmful.
3.         Unnecessarily increasing the anxiety of the injured skier and/or the accompanying persons.

If the ski patroller seriously believes that the patient may have a significantly nasty pelvic injury then the patroller should get the patient to pass urine. If they cannot then that is not a good sign and if they can and there is no blood in the urine that is a good sign.

(Orthopaedic Surgeon)
 *   *   *   *   *
(Note: Research and document collation was undertaken  26-29 July 2013.)