The sliding-door moments of life in remote and retrieval medicine
Originally published in YourED 2019 under the title ‘Remote Retrieval’.
It is an amazing experience to work as a specialist retrieval doctor, and get to see the beauty, contrasts and challenges of Australia’s great outback.
I feel privileged to impact positively on the outcomes of critically unwell patients in some of the remotest communities imaginable. I am passionate about Indigenous medicine, equity, and equality of access to healthcare, and remote environments – the more remote and rugged the better.
I want to describe the life journey that has led me to where I am now, illustrated by a few cases that have had lasting effects on how I approach medicine and life more broadly.
I moved from the faded industrial heartland of Northeast England to Alice Springs. I blame the mountains. As a medical student and junior doctor in the UK, I got dragged out hill walking. Over the years this evolved into mountaineering, and rock and ice climbing, in an attempt to tackle more remote and technically challenging mountains.
I became involved in the Northumberland National Park Mountain Rescue Team and from that stirred the primeval awakenings of an interest in prehospital medicine, search and rescue. At that point, I was a surgical trainee on the pathway to becoming an oesophago-gastric cancer surgeon and finding it increasingly difficult to reconcile the two parts of my life.
My solution was to leave the training program without an exit strategy and spend the next couple of years working in developing countries for expedition companies and a Rwandan mission hospital. This time was life-changing, and key in developing my interest in Indigenous medicine and access equality.
Rwanda
This story is the sliding doors moment of my life. The hospital I worked at in Rwanda was remote. Access for most of the surrounding villages was by foot. It was a 100-bed facility staffed by me and two other doctors. I did daily ward rounds but spent most of my time operating.
One morning, out of routine, I passed through the baby nursery. I found a baby in the incubator – which only worked for the roughly 50 per cent of the time that mains electricity was on.
Her mother had died at home giving birth to her, and the baby was left on the steps of the hospital. She weighed only 900g and was being given sugar solution as a comfort measure. No one thought she would survive.
“I learnt time and again what it means to make a difference to an individual and a community, and I mean a real difference to individuals and those around them, not applying band aids to a broken system. ”
Much to the amusement of the Rwandan nursing staff – I am not sure they knew what to think of this eccentric Englishman – I kangaroo nursed her for the next four months. She was too weak to suckle so I fed her naso-gastrically. We had no neonatal formula, so I made some with soya milk powder, olive oil, sugar and water from a recipe on the World Health Organization website. We had no IV equipment small enough, so when she had skin infections or became oedematous, I titrated tiny doses of antibiotics and frusemide and gave them sub-cutaneously.
Slowly she grew and when, after six weeks, she was finally strong enough to cry, I cried too.
I named her Rebecca but many of the nurses called her Good-Luck and both names stuck. She is now 16 years old and lives in a not-for-profit organisation that my wife and I run with the mission to empower and enable access to education for orphans in Rwanda.
In Rwanda, we dealt with typhoid, malaria, gastro, trauma, obstructed labour and many more pathologies with little resources. It was largely the medicine of disadvantage, poor health literacy and grinding poverty, and often a last resort, as most treatment was out of the price bracket that subsistence farmers can afford.
Presentation was late and children died of diseases that are easily treatable in early stages, or preventable. We had little or no options available in terms of critical care support for patients.
At times I was the anaesthetist and surgeon, obstetrician and paediatrician. I learnt a lot about how robust humans, and myself, can be. I also learnt time and again what it means to make a difference to an individual and a community, and I mean a real difference to individuals and those around them, not applying band aids to a broken system.
Alice Springs
Back in the UK, I fell into a job in emergency medicine. Having surprised myself by loving it, I joined the training program. After a few years’ experience I had the opportunity to work for the Great North Air Ambulance Service, the Helicopter Emergency Medical Service (HEMS) that covers a large swathe of Northern England, including remote and mountainous regions.
In 2008 I stumbled across an advertisement for a retrieval job in Alice Springs, applied and got the job. I had been to Alice before as a medical student on an overseas elective placement, so I knew what I was letting myself in for, but I am not sure my wife did!
As we left after the end of my 12-month contract, I had a feeling we would return. And I did, in early 2012, to take on the Director of Retrieval role. At that stage it was me and two registrars. The referral and coordination process was complicated, convoluted and chaotic.
The majority of patients that we retrieve come from remote Aboriginal communities and have a very similar demographic and clinical pathology profile to the patients who present to the ED in Alice Springs. Yet they were treated quite differently. Often, the nearest ED (Alice Springs) is hundreds of kilometres away – up to 750km! When I started, they had no access to emergency specialist care and oversight of the retrieval system was by primary care rural practitioners.
As I built up the service through a series of changes in improved staffing, governance and clinical oversight, the system slowly transformed into one with emergency physician oversight for emergency patients.
Then, with the launch of the Medical Retrieval and Consultation Centre (MRaCC) in February 2018, we finally had direct specialist contact with 24/7 medical retrieval consultants taking calls, giving advice and supervising the retrieval registrars. There is telemedicine support for remote clinicians, mainly remote area nursing (RAN) staff. Now, patients presenting to remote clinics can have the same, or better, timely access to FACEM advice as those who are brought to ED by ambulance.
Having achieved the goal of equitable access, robust governance, and retrieval physician oversight and coordination, I stepped back from the managerial role last year, and can now enjoy the reason I am here – the clinical work. I will use a couple of cases to illustrate why I have the best job.
The teenage buckaroo
Three hundred kilometres away, a teenage jackaroo has come off his motorbike while mustering cattle. He is in the soft sand of the dry riverbed. The nearest airstrip is on a neighbouring cattle station 1.5 hours’ drive across rough ground and deep sand, and we have no rotary wing.
A RAN has been sent from a nearby Aboriginal community clinic but won’t arrive for at least an hour. The only clinical information we have is that the buckaroo is conscious, but in a lot of pain from his back and abdomen. Our crew consists of myself, a critical care-trained flight nurse and a pilot with first aid training. We are met at the airstrip by the cattle station manager’s wife and a station hand with a Ute to transport us to the scene.
“ I look back on the moments of personal connection with a scared young man, where he would look at me and ask for a hug, as a real and unique experience few get in clinical medicine. ”
We get a situation report, from the RAN who has just arrived on scene, that the patient is in too much pain to move, although his physiology is okay. The manager arrives with a mustering chopper and offers to take me and limited equipment directly to the scene so I can start assessment and packaging while the rest of my team are on the way.
When I arrive, the patient is under a hastily erected temporary shelter but is already badly sunburnt, dehydrated and hyperthermic. Although his obs are ‘normal’ he has a tense abdomen and screams in pain from his back every time he is moved. He is still lying in the hot, deep river sand and it is around four hours since his injury.
Given the environment and team complexity, I elect to manage him with conscious sedation, analgesia, fluids and a vacuum mattress. The next three hours across rough terrain to the cattle station airstrip were a physical and cognitive stamina test. Despite drinking several litres, I was dehydrated. The patient had T12, L1, 2 and 3 fractures and traumatic pancreatitis.
I have often looked back on this case critically and thought I should have intubated him; that would have meant an easier three hours for me cognitively compared to the 4WD adventure, and maybe more comfortable for him. But I also look back on the moments of personal connection with a scared young man, where he would look at me and ask for a hug, as a real and unique experience few get in clinical medicine.
I followed him up a few days later – one of the advantages of working in a system with a single receiving hospital from which the retrieval service is based — and he was so grateful.
From bariatrics to neonates
The final case I present describes the variety of situations we see, as well as the cognitive flexibility required to be a ‘retrievalist’, where there is no other help available.
I had been tasked to a routine adult case of acute pulmonary oedema in a bariatric patient in Tennant Creek Hospital, 500km north of Alice Springs, and we had tailored our equipment to match the size and weight of the patient.
“As a reformed surgeon, I always assumed that it would be trauma in emergency medicine that was the big-ticket item for me, but as my training progressed, I found the critical aspects of really sick medical patients much more fascinating. ”
While on the ground assessing the patient, we received an urgent re-task and were diverted to a nearby remote community clinic for an ex-premature neonatal respiratory arrest on the background of respiratory sepsis. The baby needed IO access, intubation and ventilation, and inotropes.
The challenges were many. We had not taken the neonatal ventilator to an adult bariatric job. I had to hand bag the baby for three hours; it was winter, the temperature was eight degrees and we did not have the cot. We had to change our planning for one extreme of patient group to the opposite extreme. The clinic staff, although performing admirably, were well out of their comfort zone and required significant input from a team management perspective. The child’s mother, as you can imagine, required significant support.
Things did not go entirely smoothly for the whole retrieval – mucous plugging made for interesting ventilation, maintaining body temperature proved impossible, and she had a temperature of 33 degrees at handover. There was a brief requirement for chest compressions and boluses of adrenaline during descent into Alice Springs Airport. The baby did, however, do well enough and after treatment for pneumonia in PICU in Adelaide, she came back to Central Australia.
I have seen her several more times in retrieval and in ED, growing and thriving.
As a reformed surgeon, I always assumed that it would be trauma in emergency medicine that was the big-ticket item for me, but as my training progressed, I found the critical aspects of really sick medical patients much more fascinating.
Don’t get me wrong, I look back on trudging for several hours in crampons to pluck a guy with an open femur off an ice fall on the north face of the Cheviot, or tubing someone with a severe head injury on a roundabout in central Leeds, with relish – but give me a sepsis on the background of CKD5, RhD and cardiomyopathy in Ampilatwatja, Northern Territory, any day.
There is an excitement about jumping in and out of helicopters and dangling on winches for dramatic rescues and juicy traumas. But the complex critical care medicine in a population who are truly disadvantaged, isolated and marginalised gives central Australian retrieval medicine the best overall experience.
