Disturbed Patient Retrievals' by Minh Le Cong (Feb 2012)

Disturbed patient retrievals

By Dr Minh Le Cong

RFDS Cairns, February 2012

•WHAT WE ARE GOING TO TALK ABOUT

TODAY

•Legalities

•Risk assessment

•Restraint

•Sedation

•Emergencies

Online survey of Australian retrieval doctors’ opinion of disturbed

patient management

•Emailed survey invitation to

32 retrieval doctors,

December 2011

•3 question anonymous

survey

•17 respondents

•Open comments from respondents

were...

Legalities of aeromedicine

•Mental Health Act

•Guardianship Act

•Civil Aviation Act

Risk Assessment

RFDS QLD Revised Risk Assessment tool ,2010

What is the risk here?

• 40 yo man with chronic back pain in rural

hospital

• Referred for investigation ? Disc

prolapse..can’t sit due to pain

• Agitated and demanding analgesia and wish

to smoke frequently

Why don’t we use this?

Physical restraints in aeromedical

setting • RFDS QLD protocol

• Restraints – quick release, velcro fasteners, 4 points

• RFDS SA – body net

• Patient explanation if possible prior to use

• Police restraints

• Careful medical monitoring during use

• Avoid prone position

• Avoid patient struggling against restraints (SEDATE!!)

RFDS Central section restraint

Check out www.emcrit.org

Sedation

Sedation trivia questions • What was the DORM study?

• What are the recommended acute

sedatives in Queensland mental health

units?

• What is the safest route of sedation : oral,

intranasal, intramuscular , intraosseous or

intravenous??

Air Med J, 31:1, 2012

What would you prepare and how would you give it?

DOES FASTING MATTER AND DRUG CHOICE??

Let’s try an example

•37yo woman with acute

suicidal ideation, refusing

admission

•PMH – antisocial personality

disorder, past conviction for

stabbing police officer

•PMH : sleep apnoea, obesity

•OE: BMI 40, BP 120/60,

SaO2 99% on air

•Handover : cooperative

with IV access, demanding

cigarette

My approach

Run it like procedural sedation

•Set up for RSI..you may

need it

•Ketamine infusion

(adjunctive midazolam prn)

•Non invasive capnography

ON ketamine 80mg/hr

Restraints on, infusion running, more sedation ready

Use a sedation score

Inflight emergencies

“No one f#$@s with a 100 of sux”

•Yes or no?

•Is ketamine IMI as good?

•Is midazolam IMI as good?

DO YOU HAVE TO INTUBATE ALL HIGHLY

COMBATIVE PATIENTS FOR FLIGHT?

Check out the following presentation

•http://www.isas.org.au/img.

ashx?f=f&p=christchurch_2

010%2fExtreme+Psychiatric

+Patient+-

+David+Bowie.pdf

•WHAT WE TALKED ABOUT TODAY

•Legalities

•Risk assessment

•Restraint

•Sedation

•Emergencies

Thankyou!