National Rural Health Alliance. Aero Medical Evacuation in Remote Communities

Transcription

1 NRHA National Rural Health Alliance Aero Medical Evacuation in Remote Communities Geri Malone Senior Flight Nurse Royal Flying Doctor Service, NT 1st National Rural Health Conference Toowoomba 14th - 16th February 1991 Proceedings

2 76 NATIONAL RURAL HEALTH CONFERENCE Aero Medical Evacuation Remote Communities in Geri Malone Senior Flight Nurse Royal Flying Doctor Service, NT The organisation of a transfer from a regional base hospital to a metropolitan facility by a Specialist Retrieval team, does not pose major operational problems. The point of transfer will usually have a fairly large hospital with specialist doctors, up to date medical equipment, twenty-four hour licensed airport with electric lights and some flight service facility. But what of the remote community that is 400kms from this Base Hospital, accessed by unsealed roads subject to flooding in wet weather. Two Registered Nurses are responsible for the health care of the community of 800 people, equipment is minimal, the airstrip is authorised but not licensed, kerosene flares light the strip and communication is reliant on HF radio. This is where the definition of Emergency takes on a different perspective and where the availability and capability of an Evacuation service to respond to those situations, has much broader concepts. My qualifications for addressing this topic on Evacuations Services, is drawn from my experience working with the Royal Flying Doctor Service in two different roles, which although complemented each other, sometimes were in conflict. About two-thirds of my experience has been at the receiving end of a request to provide evacuation and the rest of the time was spent at the coal-face. So as for everything there are two sides to this provision of a service - the staff who are on the scene in a remote location with a critically ill patient, where two to three hours seems like a lifetime and then the staff at the other end who often, due to outside influences, find it difficult to get to that location within two to three hours. The whole issue when discussing the provision of an Evacuation Service for Remote Areas revolves around the fact that what constitutes an emergency when you are socially, geographically and professionally isolated is quite different to what constitutes an emergency in more populated surroundings. Australia has many locations that can be described as remote, where access by road is to say the least difficult, and in fact often inaccessible in wet conditions. For speed and efficiency the use of air evacuation is the most practical. How do you define a remote area? To some, mmoteness begins 20kms outside the metropolitan area. However for definition purposes, categories have been based on distance from tertiary health care and extend that to include distance from other social, cultural and educational facilities. Towns such as Alice

3 IDENTIFYING THE HEALTH NEEDS OF REMOTE AND RURAL COMMUNITIES 77 Springs, Kalgoorlie and Broken Hill are all rural and remote but one step further to communities such as Docker River, Kintore and Hungerford, the category is bush. Figure 1 and Table 1 indicate the locations of remote area nursing outposts in Australia, as of 1989, a total of 210. These locations vary from mining and Aboriginal Communities to small outback towns which arose as service centres to pastoral communities. Thereby the nurses that work in these locations have a wide variety of employing bodies which constitute a broad cross section of living standards and availability of resources. Figure 1 LOCATION OF AUSTRALIAN REMOTE AREA NURSING POSTS (Commonwealth Territories not shown) The size of these outposts may vary from 20 to In the Northern Territory and South Australia, 80% of remote area nurses work in Aboriginal communities. To give you an indication of the size of the area, the Northern Territory has an area of 1.35 million square kms. In 81 of a total of 86 remote communities identified, nurses and Aboriginal Health Workers are the onsite health care providers to more than 26,000 people. Just as the communities vary in size and type, so do the conditions that govern their accessibility to the outside world. Communication is a vital part of providing a service and a basic life line. Telecom and other agencies are certainly gaining strongholds throughout the inland of Australia with advances in technology. However, there are still some communities in every Royal Flying Doctor Service network that are dependant on battery operated radio transceivers. They are able to make telephone calls through Radphon facility but that allows no privacy whatsoever. Being dependant on HF radio and the nature of the way it works means that, at times, they can lose their avenue of communication. This may be due to atmospheric, solar or weather conditions. For those who do have phone access, they theoretically have the

4 78 NATIONAL RURAL HEALTH CONFERENCE - - AUSTRALIAN Table 1 REMOTE AREA NURSINIG POSTS Western Australia 1. Kalumburu 2. Oombulgurri 3. Argyle 4. Turkey Creek 5. Balgo Hills 6. Christmas Creek 7. Noonkenbah 8. Looma 9. One Arm Point 10. Lombadina 11. Beagle Bay 12. La Grange 13. Shay Gap 14. Warralong IS. Yandeyarra 16. Marble Bar 17. Nullagine 18. Jigalong 19. Tjukali 20. Tjukula 2 I. Warburton 22. Blackstone 23. Jamison 24. Wingelina 25. Wiluna 26. Cue 27. Coonana 28. Eucla 29. Leinster 30. Exmouth 3 I. Denham 32. Kalbarri 33. Mingenew 34. Eneabba 35. Leeman 36. Jurien Bay 37. Lancelin 38. Beacon 39. Koorda 40. Bencubbin 4 1. Dowerin 42. Hyden 43. Lake Varley 44. Walpole South Australia 1. Kalka 2. Amata 3. Fregon 4. Emabella 5. Mimili 6. Indulkana 7. Marla 8. Oodnadatta 9. Moomba 10. Marree 11. Andamooka 12. Cook 13. Oak Valley 14. Yalata 15. Tarcoola Tasmania 1. Zeehan 2. Savage River 3. Tullah 4. Roseberry 5. Strahan 6. Tarraleah 7. King Island 8. Flinders Island Queensland Torres Strait Islands 1. Boigu 2. Dauan 3. Saibai 4. Mabuiag 5. Badu 6. Mea 7. Murray Island 8. Damley Island 9. Stephen Island IO. Yorke Island 11. Coconut Island 12. Yam Island 13. Sue Islander Mainland 14. Bamaga 15. Lockhart River 16. Weipa South 17. Auruklm 18. Coen 19. Edward River 20. Kowenyama 2 1. Hopevale 22. Wujul Wujul 23. Laura 24. Chillagoe 25. Dimbulah 26. Karumba 27. Croydon 28. Georgetown 29. Forsayth 30. Millaa Millaa 3 1. Palm Islander 32. Magnetic Island 33. Camooweal 22. Elliott 34. Dajarra 23. La jamanu 35. Boulia 24. Warrabri 36. Birdsville 25. Willowra 37. Momington Island 26. Ti Tree 38. Mount Surprise 27. Y uendamu 39. McKinlay 28. Papunya 40. Monument 29. Kintore 41. Jundah 30. Docker Ril 42. lsisford 3 1. Hermannsl 43. Muttaburra 32. Santa Ther 44. Aramac 33. Mututjulu 45. Alpha 34. Mount Ebc :nezer 46. Jericho 35. Urapunt ja 47. Woorabinda 48. Many Peaks New South WI 49. Eidsvold I Tibooburrz 50. Mount Perry 2. Engonnia 5 1. Munduberra 3. Goodooga 52. Proston 4. Lightning Ridge 53. Cherbourg 5. Toomelah 54. Tambo 6. Wanaaring 55. Morven 7. White Clif ts 56. Bollon 8. Wilcannia 57. surat 9. Menindee 58. Wallumhilla 10. Ivanhoe 59. Wandoan 11, Gulargamt,one 60. Cecil Plans 12. Quambone 61. Thargomindah 13. Tullihigeal I 62. Capella 14. Hill End 15. Lord How e Island Northern Territory 16. Weethalle 1. Port Keats 2. Peppimenarti Victoria 3. Pulumpa 1. Datmoor 4. Tipperary 2. Harrow 5. Adelaide River 3 Balmoral 6. Goulbem Island 4. Lake Bala, c 7. Millingimbi Penpelli 5. Dingee 8. Maningrida 6. Lockingto n 9. Jabiru 7. Underbool 10. Ramingining 8. Patchewol lock I 1. Elcho Island 9. Woomelor is 12. Lake Evella 10. Dargo 13. Pine Creek Il. Swifts Cre ek 14. Daly River 12. Buchan 15. Bamyili 13. Gelantipy 16. Mataranka 14. Cann Rive r 17. Roper River 15. Ma&coot. a 18. Borroloola 19. Timber Creek Commonweal th 20. Victoria River Territories Downs 1. Cocos Isla nds 2 1. Wattie Creek 2. Christmas Island --

5 IDENTIFYING THE HEALTH NEEDS OF REMOTE AND RURAL COMMUNITIES 79 ability to consult medically with a Doctor at the Base location. However, in reality emergencies don t always occur next to the only phone in town and by Murphy s Law, someone else is bound to be having an emergency at the same time as you are. Equally important as reliable communication is physical access. Outback roads are mostly unsealed and we are made very aware by media that during wet weather, roads may be impassible for long periods of time. When the roads are inaccessible, the only option is access by air, and likewise availability of airstrips is dependant on many factors. Many communities are unable to have a landing area due to geographical limitations. Contrary to what you may see on a certain television series, it is quite impractical to clear a landing area of trees as the plane circles overhead. For safety of aircraft and crew, there are minimum requirements for landing areas, although these are not so strict as to be unrealistic. In the bush most of the strips are designated as Authorised Landing Areas. What this means is that they have to meet minimum criteria specified by Civil Aviation Authority for obstacle clearancegradients, although that is usually only estimated (not surveyed). Thosecommunities that do have an Authorised Landing Area, due to their remoteness do not have ground based navigational aids to assist the pilot in locating the airstrip or carrying out approach procedures in times of bad weather. Consequently in these situations we may require certain minimum weather conditions to be able to carry out the landings and we rely very much on the opinion of the person on the ground to confirm airstrip suitability. As you can appreciate, that opinion can be personally biased proportional to the perceived urgency of the situation. The other major consideration is the availability of night landing areas. To qualify, they must satisfy more requirements than for daylight landings, mostly in relation to terrain and provision of adequate lighting. Lighting may vary from electric (not very common), battery operated lights, kerosene flares, hurricane lamps, to toilet rolls soaked in diesel. We are ever mindful of that element of risk in operating aircraft into unknown areas at night time. As I referred to earlier, the resources available to these communities varies greatly. By resources I mean health care staff, social and welfare support groups, provision of clinic facilities, housing, store supplies and medical equipment. In 1984 a survey of remote nursing posts in six states revealed that 12% did not have such basic resuscitation equipment as an Air Viva. The provision of a reliable water storage and safe sewage disposal cannot be assumed. It is these extra stresses on living in these communities that can make a seemingly minor incident take on bigger perspectives because the resources we have to fall back on are just not available. Aerial Evacuation Service for Remote Areas That leads to the question as to what are the requirements in providing an efficient Aerial Evacuation service for remote areas. To discuss this I am going to look at four main areas. 1. Communications Avenues of communication are vital to any provision of service and as already mentioned, the provision of this basic commodity that most of us take for granted cannot be presumed in remote areas. However, even if there is a physical means of communication, either radio or telephone, they are only as good as the system that is in force to ensure that lines of communication are open. This includes such things as: Twenty four hour monitored system. Regardless as to whether the communication is via telephone or radio it has to be monitored around the clock. The telephone emergency number is diverted to an existing facility that has 24 hour cover i.e. Ambulance service. Likewise the radio can be activated by pushing an

6 80 NATIONAL RURAL HEALTH CONFERENCE Emergency Button which is also connected to the same service who then diverts the call to the appropriate place. 1.2 Rostering of Medical Staff Obviously there has to be a qualified person available to answer these after hours calls and to make the decision regarding the need for evacuation. 1.3 Paging System An extension of the above is to have the on-call crew on standby via a paging system, which incorporates the coding of evacuations to establish the urgency. 1.4 Communication systems in aircraft It is possible to maintain communication with the onground location once the crew are airborne. This is important to provide updated information of the patient s condition, a two way exchange of advice regarding treatrnent and conditions on the ground to ensure a safe landing. It needs to be reinforced that the people on the ground at the remote location keep the radio switched on and monitored until the exercise is complete. 2. Aircraft Types of aircraft Size: Aircraft must be of a suitable size to enable stretcher patients to be carried and allow sufficient freedom for the medical crew to work. Performance: A compromise must be made between speed and take off and landing requirements. Fast aircraft often require longer, smoother runways than are available at most bush communities. Pressurise&lowpressurised Pressurised aircraft provide far greater flexibility in an aero-medical role through the control that is available over the cabin environment. The ability a pressurised aircraft has to be able to climb to a sufficient height to clear most weather aids patient and crew comfort. New pressurised aircraft are less compllex, lighter and generally cheaper to operate. Medically dedicated Modification: Aircraft are usually produced to carry passengers in various seating configurations. Prior to being put into an aero-medical role they must be modified to carry the required medical systems and stretchers. Systems: Medical power: While not vital, an ability to power mefdical electrical independent of the aircraft battery is desirable. equipment Oxygen/Suction: A store of medical gases and provision for suction is necessary. Lighting: Normal passenger reading lamps are often inadequate for illumination of the medical work area and must be supplemented. Stretcher systems: If possible aircraft stretchers and ambulance stretchers should be compatible to minimise the need for having to move patients from one type of stretcher to another.

7 IDENTIFYING THE HEALTH NEEDS OF REMOTE AND RURAL COMMUNITIES 81 Communications: Facilities must provide adequatecommunicationsbetween medical staff and pilot (Intercom) and air-ground communications. 2.4 Fixed wing VS Rotary Fixed wing aircraft are generally faster than rotary wing (Helicopter) but lack the flexibility for take off and landing. 3. Crew Minimum crew required is that of pilot and flight nurse. Throughout Australia, nurses are the backbone of aerial evacuation services. On the average, 80% of flights are nurse attended only, which means that doctors only go on 20% of flights and that is nearly always with a nurse as well. Obviously quite different to specialist retrieval teams where doctors are always part of the crew. This requires that the standard of qualifications and experience of these nurses to be high. With some variation, the minimum qualifications for employment are registered in general and midwifery nursing with a minimum of five years post basic experience. Highly desirable is experience in critical care nursing or previous aero-medical nursing, remote area experience, maternal and child health. Generally the nurses need to have a broad experience but particularly the ability and confidence to act in a professional manner in isolation from their peers. Statistics collated from evacuation flights show that the classification of patients varies considerably from neonates, paediatrics and obstetrics to head injuries, spinal and general trauma, and cardiac. Some sections reflect higher percentages in some classifications than others e.g. Central Australia has highest percentage in paediatric cases. This cross-section of medical conditions afflicting the patients dictates that the nurses need to be diverse and resourceful. It is an important requirement for all medical staff working in this area to have a good knowledge of Aviation Medicine, its implications in the management of patients and the importance of stabilising conditions pre-flight. Flight nurses, like Remote Area Nurses can be in the position of having to act outside normal nursing roles and without medical supervision. Recognition of Aero-medical and Remote Area Nursing as a speciality, is virtually non-existent within the nursing profession and the medical fraternity, as is the provision of education for that role. Pilots are obviously the key member of the crew and again a high standard of training and experience is required. The team work element is a very high requirement as it is often a two member crew who need to rely on each other for support and co-operation. On ground engineering staff as well as radio operators are other vital members of the team. 4. Equipment The selection of equipment is not just on adhoc arrangement but involves consideration of many points: 4.1 General multi purpose use It has already been mentioned that we encounter a broad cross section of patients, however it is impractical to carry equipment specifically designed for one use only. Due to restrictions on space and weight the kits which contain the basic equipment need to be adaptable to different situations. The ability to have the appropriate minimum equipment to handle any emergency is the aim of aero-medical kits.

8 82 NATIONAL RURAL HEALTH CONFERENCE 4.2 Portability Due to the fact that we do not land right next to where the. patient is in the case of the road accident and that we are often the primary medical contact, the emergency equipment needs to be able to be taken to the patient. This includes monitoring equipment as well as the general multi-purpose kits. 4.3 Size and Weight The payload capability of an aircraft is a term we all become familiar with. In respect to our operation it means that we have to be very mindful of the weight of all equipment we add to each flight. Extra weight in equipment and passengers means less fuel capacity. 4.4 Back up equipment for special requirements Although we do not carry specialised equipment on all flights there is a requirement to have it available. A good example of this is a Neonatal Transport Unit and the relevant resuscitation equipment. The provision of adequate backup equipment in the event of a disaster situation is another requirement and this presents a particular challenge in portability and weight. When you look at all of the above points, it is clear that it is notjust amatterof putting a patient on the back of an aircraft and off you go. There are considerations regarding the patient s condition in relation to change in altitude, the suitability of equipment you may need to use and restraint of that equipment; and the availability of oxygen s,upply, how long it will last and aspects of air safety which all crew members have to be endorsed onapart from responding to emergency situations, an Aeromedical Evacuatio n Service for remote areas is usually required to provide other services, such as: 6) Transport of primary health care staff to communities for regularly scheduled visits. The frequency to each location varies according to need as do the type of staff that attend. (ii) Provide transport for specialist medical services. In some areas specialists such as E.N.T., ophthalmology and dermotology make regular visits to remote centre. (iii) Repatriation of patients. (iv) Transport of administrative support staff. Transport of a variety of other services, from the vet to the cake decorator. rovide support for remote area staff. Operational problems There are always inherent problems with any system and these can occur at either end. Usually it comes down to complaints regarding the expedienc e with which the task was carried out or the oversight of some basic requirement. Thankfully, the problems do not usually result in a major incident causing detriment to the care and well-being of the patient. However, I think that some of the common pitfalls are worthy of mention. Communication is often a cause of the problems. This may be in terms of difficulty in establishing it in the first instance, to maintaining it to the end of the exercise. To keep open that line of communication is important for providing support to the staff who are having to cope with the emergency, as well as providing the pilot with onground information. It is vital for safety to have information regarding weather conditions, to provide guidance for the setup of lights and a reminder to check for livestock on the strip.

9 IDENTIFYING THE HEALTH NEEDS OF REMOTE AND RURAL COMMUNITIES 83 Often a source of dissatisfaction arises from a lack of understanding of the roles of the staff in the remote community and of the aero-medical staff. There may be a lack of appreciation of the stress levels of remote area staff created by the fact that they may have to cope with situations that threaten their personal safety as well as that of the patient. The aero-medical crew may make judgements regarding the need for evacuation based only on the medical diagnosis, however there may be other social and political pressures involved that influence the decisions. Due to the inadequate preparation the remote area staff have for their role in the community it can sometimes be a cry for help. On the other side, there is a similar lack of understanding for the operational considerations of an aero-medical service. This may include a lack of appreciation of safety issues as well as the fact that there may be other evacuations to attend to that have been prioritised higher than their need. Other problems often experienced by aero-medical teams is the lack of understanding of their role by metropolitan hospitals in the instance of inter-hospital transfers. These often involve very long flights and there is a lack of back-up to relieve the crew of their critically ill patient. At many destinations it is difficult, in fact near impossible, to get a retrieval team out to the airport to escort the patient to hospital so that you do not spend an extra l-2 hours out of contact from the community you are primarily responsible for. The attitude of the receiving staff is often less than professional. Another area of concern is the lack of availability of medical staff with a desire and suitable experience to work in remote areas. Turnover of doctors is particularly high and a lack of local knowledge, experience in aviation medicine and remote consultations is usually reflected in the tasking of evacuations. Until the doctor gains experience and confidence in these areas the number of evacuations requested tends to be excessively high. Evacuation of patients from remote areas can be further complicated when air evacuation is not possible due to weather conditions or the lack of landing facilities. In these instances transfer by road is the only option. This makes for a long uncomfortable trip for the patient and it takes the staff who are already at a minimal level, out of the community for several hours. This time factor may be reduced by the organisation of a half way meet with the town based Ambulance crew. The other situation where air evacuation is not possible is in the suitability of the patient. The use of pressurised aircraft where you are able to maintain sea level cabin conditions helps alleviate some of the problems associated with air evacuation of some medical conditions. However, the carriage of mentally disturbed patients is one area that may cause a problem if the patient is not able to be sedated. There are Civil Aviation Authority regulations regarding the carriage of such patients. Generally most of the problems I have mentioned are not insurmountable, but are a result of the particular conditions that health services in remote areas work under. The inequalities arise from the provision of services under conditions of geographical, social and professional isolation. The provision of an Evacuation Service in remote areas has the requirement to have multiple roles, and ability to cope with a broad cross-section of patients and medical conditions in a professional manner. There is no doubt that it is an expensive service, when you combine aviation, medicine and communications the costs are substantial. Australia will always have a need for provision of health services in areas described as remote and bush, requiring rationalisation of what is available at the community level along with a provision of backup for what is lacking. Primary health care should form the basis of health care services for remote areas and within that context the decisions regarding evacuation of patients should be made. Who to evacuate, when to evacuate them, at what stage of their condition and where is the most

10 84 NATIONAL RURAL HEALTH CONFERENCE appropriate place to evacuate to, are all important factors. BecaLuse of the complexity and ramifications of these decisions, it is important to establish that the person with that role is the most appropriate. This whole issue like many others can be referred back to the provision of equality in health care for all Australians regardless of race or creed or distance from the Sydney Opera House. References 1. Council of Remote Area Nurses. Submission to the Committee of Inquiry into Medical Workforce, 1986, pp Platt E Nurses Working in Areas where there is no resident Doctor. Remote Area Nurses National Conference Proceedings, Adelaide, 1984.