Retrieving patients from rural locations in Australia for medical care poses several logistical and medical challenges. These considerations are critical due to Australia’s vast geographic expanses, varied terrain, and often sparse population distribution. Here’s an overview of the primary considerations involved in patient retrieval from rural settings:
- Distance and Accessibility:
- Rural and remote areas can be hundreds to thousands of kilometres away from tertiary care facilities.
- This vast distance is a major challenge, as it affects both the time it takes to reach a patient and the time to transport them to a suitable facility.
- Accessibility issues are further compounded by varied terrains, weather and issues such as flooding.
- Transportation Modes:
- Road Ambulances:
- Commonly used for relatively short distances and when time and terrain allow.
- Road ambulances are equipped with essential life-support equipment.
- Using them for retrieval may involve leaving the local community without an ambulance for 2 hours per 100 km
- Half-way meets – where the ambulance from the origin meets an ambulance from the destination can reduce this time problem by 50%
- Fixed Wing Aircraft:
- Fixed-wing aircraft are frequently used for longer-distance retrievals
- Retrieval aircraft are equipped with essential life-support equipment.
- These aircraft fly at around 550 km/hr and have an unrefueled range of > 1000 km
- It is important to recognise there is a “packaging time” at both ends
- It takes time to get a patient off a hospital bed and onto an ambulance stretcher
- It takes time to get a patient off an ambulance stretcher and on the the one that fits in the plane
- It takes time to get the aircraft locked down and in the air
- So, for a journey of 500km the 1 hour packaging (at each end) + 1 hour flight time = 3 hours
- But, for a journey of 250km this time is 2.5 hours and it would have been just as quick to go by road ambulance under lights and sirens
- The Royal Flying Doctor Service (RFDS) is a notable example, providing extensive air retrieval services across the Australian outback
- Helicopters:
- Helicopters are sometimes used for short-distance retrievals
- Retrieval helicopters are equipped with essential life-support equipment.
- These aircraft fly at around 250 km/hr and have an unrefueled range of ~ 500 km
- Helicopters have the advantage of (in many cases) being able to fly point to point, i.e. from one hospital to the other.
- Unfortunately, they fly at half the speed of fixed-wing aircraft, have < half the unrefueled range and have significant weight and space limitations (ie taking a support person with the patient may not be possible)
- Water Transport:
- In some island communities, boats may be necessary to transport patients to a location where they can be transferred by air or road transport.
- Atmospheric Pressure:
- Fixed Wing turboprop retrieval aircraft can often fly over the weather at 25,000 feet
- In normal operations, their cabin pressure is ~8000 feet so any gas that can expand will expand and mild hypoxia is normal
- Sea level pressurisation can be achieved up to an altitude of ~ 18,000 feet
- Some patients, ie divers with the bends, pneumothorax patients, and recent abdominal surgery patients, need sea-level pressure for safe transport
- Other patients, i.e. patients with respiratory compromise from APO, Asthma, COPD, or pneumonia, may not be able to cope with the hypoxia or non-sea-level pressure transport.
- Helicopters are typically unpressurised, so if sea level pressure is required, sea level altitude is required (think in the weather and bumpy as all hell)
- Road Ambulances:
- Timing and Urgency:
- The urgency of medical conditions significantly impacts retrieval operations.
- There are far fewer retrieval aircraft than ambulances, so they are rationed and routinely get diverted to move urgent cases.
- Emergency cases such as heart attacks, strokes, severe trauma, or complicated childbirth require immediate and rapid transportation to enhance survival and recovery chances.
- Planning and coordination must be swift and efficient and involves coordination between local healthcare providers, retrieval teams, and the receiving facilities.
- Medical Support During Transit:
- Maintaining ongoing medical care during transport is crucial.
- This includes continuous monitoring, administering medications, and performing interventions as needed.
- The rule of thumb is to never downgrade a patient’s level of care
- So, while a patient might arrive at a small rural hospital in the back of a ute…
- We would typically prefer ambulance transport to the airport
- Medical teams accompanying the patient often include a doctor + a nurse/paramedic
- This team often specialises in aeromedical retrieval and critical care transport.
- It is extremely difficult to intubate a patient in and aircraft so if the airway is at risk this should be done prior to leaving the origin facility
- Communication:
- Effective communication is vital throughout the retrieval process.
- In a perfect world, you, as the remote doctor, have one point of contact – the retrieval co-ordinator
- The retrieval coordinator is often an emergency doctor/nurse team managing the day’s operations
- In a less perfect world, you, as the remote doctor, may also have to find an accepting hospital and organise things with the retrieval co-ordinator
- ISOBAR is a standardised way of communicating the current status of a patient in need of retrieval
- Technologies such as satellite phones may need to be used to maintain contact, especially in areas where conventional communication systems are unreliable.
- Weather and Environmental Conditions:
- Weather conditions can severely impact the choice of transport and the ability to safely retrieve a patient.
- Fog, rain, thunderstorms, or extreme heat can delay air transport.
- Environmental conditions, including fires or floods, can also restrict access to certain areas, requiring alternative strategies or routes ie helicopters
- Training and Preparedness:
- Teams involved in patient retrieval need specialized training to handle the challenges of rural and remote medical transport.
- Regular training ensures that teams can efficiently handle emergencies.
- Cost and Resource Allocation:
- Patient retrieval from remote areas is expensive, involving sophisticated equipment and highly trained personnel.
- Services like the RFDS are funded by both the state and federal governments.
- Patients do not need private health insurance to access these retrieval services.
- Cultural Considerations:
- When retrieving patients from Indigenous communities, cultural sensitivity and respect are crucial.
- This may involve including family members in the process, respecting cultural practices, and employing health workers who are culturally aware.
The coordination of patient retrieval in rural Australia is a complex operation that requires meticulous planning and coordination across various services. It is a vital component of ensuring equitable healthcare access across the vast and diverse landscapes of Australia, aiming to deliver critical care where and when it is needed most.