EmergencyPedia

International On-call

The last week saw four days of relaxation in Sydney waiting for the phone to ring.

Just as I thought I was off the hook the phone rang.

The next three days of work involved some interesting International Retrieval work around the South Pacific Rim to bring some Australian Patients home…

Leaving Sydney

Noumea (New Caledonia) – On Route to Fiji

I was tasked on two jobs by the Careflight International Air Ambulance (CFIAA) who in liaison with International SOS and various insurance companies had organised a retrieval to the South Pacific to repatriate two separate Australian patient cases…

Being involved (in just the medical aspects of their care) gave me a new appreciation of the high level of logistics and planning that go into an international retrieval.  In addition, I had a new appreciation for the incredible costs involved as well as teamwork aspects and planning for moving patients safely from remote locations in the Pacific Ocean…

In terms of aviation, my previous work on rescue helicopters made me realise that Jet Engines burn a lot of fuel but the quantities that the Sydney helicopters burn seemed to pale into insignificance compared to the volumes used by the various jet aircraft.  As a side note, these aeroplanes use Jet A1 fuel – which actually has special additives with the Kerosene that stop it changing consistency at high altitudes’ freezing temperatures.

Map Showing the Location of the Two Jobs

The first job was to Nauru (marked as B on the map above) and the second job was to Fiji (marked as C on the map above)

Nauru is a very small island.  It was a German colony until around 100 years ago and since has been first a semi-independent country (from the United Kingdom) and then the world’s second smallest Republic (after the Vatican City).

Nauru

The island is constituted of huge phosphate deposits which have been heavily exploited over the years by mining companies and the island is located near the equator between Papua New Guinea and Hawaii.  The island enjoyed one of the highest per capita GDPs up until recent years but the decline of the mining sector and political problems have lead to relatively poor infrastructure and a mixture of levels of wealth on the island.  The island has been dependent on foreign aid in recent years.

We actually didn’t see much of the island (as it was the middle of the night) but I gained an appreciation of the strong Australian presence on the island.  This influence has recently increased due to the Immigration Detention centre (controversially) located on the Island and recently reopened by Julia Gillard’s government.

From a medical point of view the resources were very limited, with the ambulance being limited to a converted 4wd van and appropriately enthusiastic paramedics with a good local knowledge.

We were lucky to fly on the citation jet (pictured below) which only took 4 hours to fly to Nauru.  This jet flies at 4/5 or more of the speed of Sound (Mach 0.8), which I am informed by the pilots is pretty fast.

Next was a second retrieval job to the pacific island of Fiji.

Fiji

This time we travelled to the capital (Suva) with a much smaller aeroplane called a Beechjet (pictured below).  This job took over 36 hours in total and had a significant fatigue toll which had to be managed by the crew (doctor and nurse) and the 4 pilots who swapped at the various refuelling stops for mandated rest breaks.    Discussing fatigue with the pilots was interesting.  On reflecting on these discussions I now believe it is important not to ‘martyr’ yourself to medical care when you are severely fatigued or unwell, your insight into your performance may be poor and your are at risk of making mistakes and harming patients.

Logistically, this tasking was impressive in the manner and accuracy of its execution.  The completion of the mission in good time required good communications and thorough planning.

This approach to careful communication and documented planning can teach us lessons for the Emergency Department especially in terms of disaster planning and administration tasks.

The Beechjet in Sydney

Medical Lessons and Take Home Points

• Thorough planning is important when moving a patient long distances – this includes medical logistics and Crisis Resource Management (CRM) skills:
  • Batteries for Monitoring as well as adequate power supplies
  • Overseas Adapters
  • Adequate Oxygen Supply (I planned to take enough for a ‘worst case scenario’)
  • Medications: taking adequate and appropriate drugs for Rapid Sequence Intubation (RSI) and subsequent analgesia/sedation in a remote location
  • Secondary Equipment (as backup for failure of primary devices) – e.g. suction
• Occupational Health and Safety
  • Safe Transfer of patients requires time and care in all clinical settings
  • Rushing can risk inadvertent removal of cannulas, endotracheal tubes and other catheters from the patient…
• Communication and Paperwork
  • Ensuring clear Handover (using ISBAR) at both ends of the Retrieval Job
    • I am —-
    • Situation is
    • Background is
    • Assessment is
    • Response Required is
  • Patient documentation – complete and accurate
  • Passports (required for international retrieval)
  • Permission for Carrying Controlled Drugs (also mandatory)
  • Careful documentation and observation of vital signs over time
• Flight Physiology
  • Cabin Pressure and Gas Laws
    • Relative Hypoxia at altitude (clinically apparent in one of our cases)
      • (Dalton’s Law)
    • Expansion of Gas at Altitude (Bowel, Pneumothorax and Middle Ear)
      • (Boyle’s Law)
    • Change of flow rates may be required from the oxygen regulator at altitude
      • (Charles’ Law)
    • Motion Sickness and Nausea related to Travel (Promethazine is more effective than Metoclopramide or Ondansetron – though all 3 can potentially be used with care)
    • Fatigue – an issue for pilots, medical crew and patient

Conclusion

In conclusion, a brief experience of two international retrievals gave me a snapshot of some of the  work that retrieval specialists are doing outside of Australia and some of the challenges involved in moving a patient back to Australia from overseas.  I was glad to be back safe and sound after 3 days of interesting experiences.