Retrieval of the Disturbed Patient

What is the best thing you can do with your time when you’re stuck in an aircraft hangar being baked by the blazing sun in remote North Queensland?

Record a video slidecast on the ‘retrieval of the disturbed patient’ for LITFL of course!

This slidecast discusses the issues involved in the aeromedical retrieval of agitated, psychotic or violent patients in remote Australia, as well as strategies (such as sedation with ketamine) to help keep everyone safe.

Editor’s note:

Any credit for awesomeness goes to Minh…
Any blame for dodgy audio and slide transitions, etc, can be directed at me…
— Chris

Additional references and links

  • Bowie D, Rattray D. Transferring the Extreme Psychiatric Patient. (pdf of slideshow)
  • Burnett AM, Watters BJ, Barringer KW, Griffith KR, Frascone RJ. Laryngospasm and Hypoxia after Intramuscular Administration of Ketamine to a Patient in Excited Delirium. Prehosp Emerg Care. 2012 Jan 17. [Epub ahead of print] PMID: 22250698.
  • Chalwin R. Propofol infusion for the retrieval of the acutely psychotic patient. Air Med J. 2012 Jan-Feb;31(1):33-5. PMID: 22225562.
  • Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010 Oct;56(4):392-401.e1. PMID: 20868907. [Featured in R&R in the FASTLANE 010]
  • Le Cong M, Gynther B, Hunter E, Schuller P. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J. 2011 May 12. [Epub ahead of print] PMID: 21565879.
  • Weingart S. EMCrit Podcast 60 — On Human Bondage and the Art of Chemical Takedown.
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  1. Andrew Perry says

    Great slideshow Minh about a hot topic. I have sent this on to a nameless ICU Consultant who has expressed concern at the intubation of agitated patients for aeromedical transport and I hope it gives more perspective and evidence to the issue.

  2. says

    Nice stuff Minh. Really up to date.
    As you know this is my “hot button” topic.

    My practice has really changed in the last 12 months thanks to your and other sources of great strategies and evidence.
    1) Ketamine infusion rocks for the agitated patient -- we can avoid a lot of tubes
    2) Ketamine bolus also rocks for doing procedures -- getting the 2nd IVC, the IDC, moving into ambulance etc

    3) Droperidol is nice for sedation, anti-emesis etc.. Ignore the QTc, get an ECG if you can

    4) my biggest change though is talking the plan through with the flight team, agreeing on a specific plan A, B so they have a well packaged, tried and tested patient when they arrive

    Stay safe

  3. says

    Hi Andrew
    For the ICU folk who abhor the idea of intubating otherwise fit Psych patients just for transfer -

    I would rather ‘electively’ secure an airway and sedate if in doubt. The alternative in reality is sedation to the point of aspiration and then having to intubate for good “ICU reasons”.
    The morbidity of “not intubating” must be weighed against the morbidity of intubation and prolonged ventilation. It is not black and white.
    And remember I also have a duty of care to my staff -- serious injury to staff is not something I am prepared to live with. Add this into the balancing act and it gets wholly unclear sometimes.

    Minh’s work on ketamine has made this reality much less common in my practice! Hurah for Minh!

    For more background on the remote Docs perspective on this tough conundrum -- please check out the Psych Sedation section at the bottom of the Broome Docs blog --
    Casey @bromedocs

  4. Minh Le Cong says

    Hi Chris
    thats intrguing about Larson’s point for laryngospasm relief! After my fellowship, I Studied medical acupuncture out of Monash uni. That point is also recognised as a common acupuncture point. I have used it in treating facial neuralgia. never knew it had been studied for laryngospasm! great tip, thankyou.