Milestones come in all forms, the easiest to acknowledge are numerical ones. A few days ago I made my retrieval “ton”. It didn’t seem so long ago that I was doing my first few and it all seemed very exciting. Now, after over a year of doing these jobs, I realise that a great deal are very run-of-the-mill. The novelty has definitely worn off and I’m after the more thrilling stuff. Unfortunately the nature of the job isn’t like that and I’m going to have tolerate the boring jobs while waiting for the juicy ones to come along.

If nothing else, doing the boring jobs restricts jaunting round the state. I’ve been to Modbury rather too many times and there are still lots of towns out in the country I’ve not been to yet. Hopefully if I keep doing this job long enough, I’ll eventually see them all …. and that will be another milestone!

Over the past month or so, I have been in a bit of a slump at work. Many of the jobs we do are interesting both in terms of clinical and logistical aspects. It also has seen us travel to some diverse parts of the state. Unfortunately this has not been the case lately and, while my caseload has stayed high, I have been stuck with a lot of what we call “milk runs”. This refers to a job that is unchallenging clinically, sees us go somewhere uninteresting (like a metro hospital) and not have to do any interventions. While they get us out of the building, and are better than sitting around, they offer no satisfaction.

The last couple of the days have seen a change in fortune, one of the fickle aspects of retrieval medicine. I have had to handle a few difficult airway cases and today got to fly to the roadside again. These cases are always rather unfortunate as some poor sod has to be badly injured for us to get our “good” mission. Today’s was no exception with another motorcyclist dying in an accident at Yundi, and us having to transport his battered and bruised mate to the Flinders Medical Centre. It is a strange dichotomy, that in order for us to have interesting and challenging work, some unfortunate person has to be severely unwell or badly injured.

Just to cover the title and tagline. In amongst the tragedy of death and destruction, we noticed that the recent rains have greened the Fleurieu Peninsula to resemble the rolling Leicester countryside we left to come here. Always trying to see some good even in the worst of situations.

Today it was the turn of MedSTAR to present to the weekly Retrieval community teleconference. There are a number of organisations similar to ours around Australia including CareFlight and Adult Retrievals Victoria. Since these services are based primarily in state capitals, and are few in number, the great Australian phenomenon of “The Tyranny of Distance“. This makes it difficult to get the small number of specialist together in any one place at the same time.

Fortunately technology comes to the rescue and we conduct shared teaching sessions remotely. The slant of these sessions is to discuss or impart issues that are specific to retrieval medicine, and the unique clinical, technical and logistical considerations. Along with 3 of my colleagues, we presented case reports as a springboard for deeper discussion. Our topics included “Chest Drains“, “Rationale for Retrieval“, “To intubate or not to intubate” and “Stay’n'Play vs Load’n'Go“.

Like many of my colleagues, I have presented to many meetings and teaching sessions, but always thus far to people in the same room. It was a strange experience not being able to see the majority of the audience. Even stranger then to have questions fired at you from a phone rather than being able to see your challenger. Overall I think our subject matter and points for discussion went down well and it certainly generated a fair amount of debate.

So this will be yet another thing to put on my CV – presentation to a multi-agency, interstate aeromedical education forum. For relatively little effort, this sounds fairly impressive. Every little helps.

Yesterday we were tasked as a rapid response to Snowtown where a mentally-disturbed man had injured a number of people. Two patients had been hit-and-run by the man’s pickup truck and he had also stabbed 2 women in the neck. We expected the worst and sent up two teams for urgent retrieval back to Adelaide. We ended up coming back with two patients in the helicopter, with the pedestrian trauma case being extremely unstable in flight.

The media followed us up there, and by the time we were loading the patients onto the helicopter for the return leg, the cameras were on us. I have to say I found the whole experience of having a television camera pointed at us quite intimidating. While I wanted to tell them to “<insert expletive> off”, we have to maintain a professional exterior and so had to remain mute. It was a little surprising how close they got, especially since shooting footage of injured people undergoing medical care is a breach of patient confidentiality.

Anyways, without further ado here is the link to the footage of the event, including a few shots of us unloading one of the patients from an ambulance and loading him onto the chopper.

On the way, we have already done our best to keep the patient stable, and even in some cases actually continue to work on improving their clinical status. While 15 minutes out we tend to “patch through” to the receiving hospital to notify them of our imminent arrival. Where we go depends very much on what platform we are using. Fixed-wing retrievals obviously require an airport landing, which means a short ambulance ride to the destination. With rotary-wing jobs we tend to use either the Royal Adelaide or Flinders Medical Centre since they have helipads allowing us to expedite transfer of the patient.

We tend to unload “cold”, i.e.: with the rotors stopped, for safety reasons. It is often quite an ordeal to lift the stretcher, loaded with patient and equipment, out of the helicopter and onto a trolley. Fortunately we are met by a Helipad Landing Officer and orderly, who facilitate moving the patient to the destination ward. Unintubated and trauma patients tend to go to Accident & Emergency, whereas already intubated medical and surgical patients go straight to ICU.

The most important duty we have at this stage is a detailed handover. This is to enable the receiving team to seamlessly continue care and even escalate as necessary. In retrieval circles we talk about the “clinical vacuum”. This refers to a loss of momentum in the care of a patient while the new team work out what is going on and then get to work. The ideal handover will make this as short as possible and even non-existent if done properly.

In the new service we have to be quick as the helicopter waits on the roof for us. The pilots tend to give us a 20 minute deadline, after which they have to return to the base. In reality they would probably wait longer but we have not tested their patience yet.

And so our job is done. The task completed with the patient moved to definitive care. This occasionally leaves us with a sense of loss as we now have no more involvement in the case. Being removed from the Royal Adelaide and based at the airport means it is difficult to find out the fate of the patient. However from time to time we do get feedback from the destination hospital and find out that all the effort did make a difference.

Last night I had a very busy shift with 2 trauma calls. As I’ve mentioned in previous posts we will respond to serious accidents in the rural areas surrounding Adelaide and retrieve the patients to a metropolitan hospital by helicopter. Since we’ve moved to the airport our response time has reduced considerably, and we can now be airborne in as little as 5 minutes from “activation”.

The first call was to the Dukes Highway at Cooke Plains. A man in a Ford Ka had collided with a van travelling in the opposite direction. Since both vehicles were moving at about 100kph the energies involved were considerable.

The patient had not been wearing a seatbelt and so was thrown out during the crash. We found him in a field some 30 metres from his car. He was badly injured with a badly lacerated scalp and fractured humerus and pelvis. More concerning was his fluctuating level of conciousness suggesting a severe head injury. It is the first time I have had to intubate anyone by the side of the road at night, so the adrenaline was flowing. We then packaged him and departed for the Flinders Medical Centre.

Not long after returning to base we were activated again by SAAS Control. This time it was an roll-over truck accident up at Tarlee.

Fortunately he was not so badly injured with a fractured humerus and tibia. Our response was swift enough that we arrived almost at the same time as the ambulance road crew. We did a quick assessment of him and then it was time to return to The Royal Adelaide Hospital.

It is hard to know exactly what precipitated each accident. It is possible that both drivers were drowsy and simply lost control. Alcohol may also have played a part in the first accident. Either way both demonstrated that at high speed and at night there is little margin for error. That and the consequences of error can be devastating. I have become a far more cautious driver since I started doing retrievals, and last nights jobs really gave me cause for thought.

The media publicise these incidents, often with graphic detail, but it doesn’t seem to prevent the ongoing toll on the roads. While doing these jobs is challenging and satisfying from a professional point of view, and an airbourne trauma service is necessary, it is still a shame that such preventable incidents still occur.

The media have finally been summoned to advertise the existence of MedSTAR to South Australians. Although the service has been in existence for the past 2 weeks, it has taken till recently that the chaos was organised enough to show off to the politicians and media. Fortunately I was spared having to make nice for the journalists as the management team grabbed the limelight instead.

If you want to see my boss interviewed by the media then click the following link:
http://www.abc.net.au/reslib/200903/r347546_1588642.asx

Yesterday marked one such day. We officially launched the new Statewide Retrieval Service named MedSTAR. This stands for Medical Service for Transport Assistance and Rescue. A little complicated I grant you, but the emphasis has been put on our many capabilities. We now provide adult and paediatric aeromedical, mobile intensive care and remote reinforcement services. This means we can be tasked with any requirement for provision of all medical services occurring outside hospital. This sees us wearing many different hats as I’ve mentioned in previous posts.

The new service also meant a change in uniform. Out went the dignified navy that we wore while working for Mediflight. Instead we have been given bright red flight suits. They certainly are noticeable as there is no missing us. A photo will make the point:

We’ve already been subjected to some gentle piss-taking by colleagues in the various hospitals we both pick patients up from and deliver to. The jokes have been pretty predictable usually involving references to Santa. So far we have tried to be good natured and play along, but I suspect the jibes will get very tired very quickly.

I can claim another first – the inaugural mission for the new service. One of the nurses and I came on duty at seven o’clock yesterday morning, and within an hour were already on our way in the helicopter to pick up a patient from an accident scene some 50 kilometres from the city. All went well and we delivered her safely to hospital. In fact yesterday was a very busy day and by the end of my 12 hour shift I had done another 2 jobs and clocked up quite a few flying hours. And it wasn’t just me getting all the fun. The fledgling service ended up doing 8 jobs by the end of the first 24 hours. Not a bad way to start. Hopefully I’ll have more interesting stories to tell very soon.

One such example is the view we had from the helicopter on the way out to Peterborough this morning. The cloud cover was fairly thick and layered up to about 5000ft. This is in the upper normal operating altitude for the helicopter so for most of the way we flew just above the cloud-tops. It’s an unusual visual, almost surfing along through the “waves” that the clouds form.

The photo doesn’t really do it justice, but suffice to say this was one of the most striking things I have seen in some time – all courtesy of Mother Earth.

Generally when we pick patients up, it is from the controlled environment of a hospital. While many of these hospitals are very small and have limited resources, it is still affords a degree of security due to the backup of other staff and ease of communications with our bosses back in Adelaide. Regardless of comfort, at some point we have to get going as, in many situations, the treatment the patient really needs is being in a big tertiary centre.

By now we have already packaged the patient, started medicines and done sufficient procedures to make them as fit as possible for retrieval. Then we load them onto our transport platform and high-tail it back to Adelaide. Once en-route there are a number of important considerations unique to retrieval medicine:

Access to the patient:

Every mode of transport we use is very limited in space. This applies across ambulances, helicopters and planes. The patient is strapped to a very narrow stretcher and usually has to be placed against one bulkhead/wall. This means we can only get at the patient from one side. Therefore if we need to give medicines through a drip in the arm closest to the wall, it is difficult unless we have already set up a contingency IV line.

It is not just access to one side of the patient that is difficult. We are also limited in space at the “head-end” of the stretcher. This makes performing interventions like intubation far more tricky and stressful. In a hospital there is plenty of space and we can always move the patient’s bed to get more space – not so on retrievals. For that reason we often electively perform procedures that would not be necessary in hospital, so there is one less thing to worry about in transit.

Hypoxia:

If you have ever seen a picture of a climber on Everest you will notice that they, on the whole, have an oxygen mask on. The reason for this is the drop in ambient atmospheric pressure with increasing altitude. Just as there is less air available, there is less oxygen. For healthy people this makes little difference, as evidenced by airline passengers feeling comfortable whilst in the air, even though they are being exposed to the equivalent altitude of 6000 feet above sea level. Unfortunately sick patients do not fare so well and are often intolerant of the decreased oxygen tension. This leaves us with a few options.

Firstly, we can either come back by road – no problems with oxygen, but it obviously takes longer. Secondly, if going by helicopter, we can ask the pilot to fly at a lower altitude. The trade off is slower flying speed but we can often reach a compromise on altitude rather than coming back over the tree-tops. Finally, if coming back by RFDS plane, we have a neat little trick available. The planes have been modified so they can create a sea-level cabin – that is the plane can pressurise the cabin beyond that available on commercial aircraft. You might think we use this facility often but actually we tend not to as it uses a great deal of fuel and makes for a bumpy ride as the plane has to fly lower.

Acceleration/deceleration syndrome:

The human body is designed to be upright most of the time. The entire cardiovascular system is based on our evolution as bipedal. This means we put some of our patients at a disadvantage by lying them flat on a stretcher. Most tolerate it fairly well so this isn’t the principle problem. The main issue is where blood flows under inertia. Consider how you feel if you do a handstand, or hang your head over the edge of the bed. Pretty stange isn’t it. This happens to the patient when we decelerate sharply as occasionally happens in the ambulance. The opposite often occurs (with blood rushing away from the heart) during the climb in the RFDS plane. Either can be significantly detrimental to the patient and lead to significant haemodynamic instability.

Extremes of temperature:

In summer this state gets very hot and in winter very cold. When moving patients between buildings and vehicles we expose them to ambient temperature. In winter we can always cover them with blankets, but we are limited in summer in lieu of a portable air-con unit!

In transit this is also a problem. While sitting on the tarmac the planes equilibrate with outside temperature until the engines are started and the climate control runs. The same applies to ambulances and helicopters too. The latter presents the greatest challenge since we have no means of controlling temperature inside the cabin. In summer it can often be warmer than outside and in winter just as cold. It would be nice to say that there is a solution but unfortunately helicopters are not luxurious limousines.

So as you can see, we face many problems whilst en route to definitive care. But all of these are irrelevant by comparison to the consequence of leaving the patient in extremis with inadequate facilities and staff to manage them. As I said earlier – the most important part of retrieval medicine is the retrieval!