Retrieval Medicine in Western Australia

Retrievals & Transfers

‘On retrievals, no one can hear

you scream’

A multiple choice question

• C Cylinder: 440L• D Cylinder: 1600L• E Cylinder 3800L

Barometric Considerations• Oxygen: PaO2 60mmHg at 5000 ft• Gas expansion: 1/3 at 5000 ft

– ETT cuffs– Entrapped gas in body

• Equipment

Preparing• General principle is to increase the level of

care• Pre flight preparation decisions are based

around dealing with the consequences• Communication with the transferring and

receiving hospital is essential• Documentation is vital

Mode of Transport

Choice of Mode

• Distance (Transit and Transfer)

• Escort requirements• Geographical considerations• Availability & resources

Private Car & Commercial Aircraft

• Non urgent problems

• Usually no escort requirements

Road Ambulance

• < 200km from Regional Centre or Tertiary Centre

• Volunteer / paramedic skill set• Local depletion of critical

resource• Can stop

Cervical Spine Immobilization Pre RFDS Arrival

RFDS WA

Requesting a transfer1800 625 800

Operator for basic details

Retrieval doctor for clinical details.

Prioritises and determines crew and flight parameters.

Advises on management and preparation for flight.

Liaises with receiving hospital including bed finding.

Tasking, fuel, hours, vermin checks, logistics.

Clinical Coordinator

RFDS Operations Centre

5 RFDS Bases In WA

RFDS National Priorities (WA figures for 2009/2010)

• Priority 1 (n=557)– Life / limb threatening– “ One for One!” time of call to doors closed <60 mins

• Priority 2 (n=2987)– Urgent– Depart for patient within 4 hrs

• Priority 3 (n=2223)– “Routine” – within 48 hrs– Timeframe can be specified

The Fleet-Now All PC 12s

ICU in a phone box• All operations consistent with

Joint Faculty standards. Intensive Care Medicine

• Ventilators, Monitors with invasive pressures, ETCO2

• Blood Gases, electrolytes• Ultrasound• Transcutaneous pacing/12 lead

ECG• Infusion pumps.• O neg packed cells.• Time critical drugs, eg

antivenoms, digibind

The ideal sick patient

Paediatric ECMO

Some challenges

Poor preparation: Would you be happy to retrieve this ?

A bigger challenge

A solution but a problem prior

Would you have pushed or objected ?

If you would have pushed!

• RFDS has ACEM and Anaesthetic accredited terms

• One term has come up at short notice for next year

• Email hakan.yaman@rfdswa.com.au if interested

• (if you objected, join the radiology training program)

An unstabilizable patient: What priority, 1, 2 or 3 ?

Do you retrieve this patient?

The reality: Do you retrieve this patient?

The FESA chopper

Bell 412• Twin turbine medium lift helicopter• 1800 shp PT6T-3D Twin Pac engine• Crusing speed 130 knots (240 kph)• Single pilot IFR• Empty weight 3079 kg• Max take off weight 5398 kg• Useful payload 2200kg• 350 nm (630 km) range • Usually tasked within a 200km radius

Range

Broad Tasking Criteria

• Skill critical– Skills of RFDS MO/CCP

• Time critical– Time to tertiary hospital

• Access– No road, Rottnest, no airstrip, rescue requirement

• Resources– No fixed wing aircraft or other resources available

• Likely to improve patient outcome

Road v Helicopter

0 50 100 150 200

Helicopter

Road

To Hospital

Initial Resus

Waiting transport

Transport

Example of patient awaiting retrieval in Narrogin

)

Airway 1

Case presentation:Multi-casualty incident at SX

Major incident

• Defined by the need for extraordinary resources (location, number, severity, type of live injuries)– Natural vs. manmade– Simple vs. compound (infrastructure intact vs.

damaged)– Compensated vs. uncompensated (whether

additional resource mobilization sufficient)

Initial call19:33

Rescue 65tasking

RFDS informed

19:49

Rescue 65stood down

3 October 2012 15:50hrs:• RIO: Broome- JT• OWD: Albany- JT• OWI: JT- Margaret River• YWO: KG- Mount Magnet• OWG: Carnarvon- JT• OWQ:Marble Bar- PD• OWA: At JT• OWR: At KG• NWO: At PD• ZWO: At DBY

Call 19:49 Auth 19:52

Bunbury:Task 20:00 SX 21:37 JT 04:01

Jandakot:Task 20:18 SX 22:22 JT 01:31

Meekatharra:Task 21:00 SX 00:11 JT 03:16

Kalgoorlie:Task 00:35 SX 01:50 JT 03:21

(Bunbury patient)Task18:28BN20:00

Re-task22:00 PMH 02:58

Jandakot to SX:

740km round trip

• Bell 412: 10” + 3’50” = 4 hours (+ refuel)

• PC-12: 45’+ 1’50”+ 40” = 3 hour 15 min• 800XP: 1’30” + 55” + 1’ = 3 hour 25 min

4mo: Not walking – Is breathing – RR70 - 1yo: Not walking – Is breathing – RR40 – CRT <22yo: Not walking – Is breathing – RR603yo: Not walking – Is breathing – RR30 – CRT <24yo: Is walking25yo: Not walking – Is breathing – RR5032yo: Not walking – Is breathing – RR4035yo: Is walking62yo: Is walking63yo: Not walking – Is breathing – RR20 – P140

• P1• P2• P1• P2• P3• P1• P1• P3• P3• P1

TRIAGE SIEVE

WALKING

BREATHING

RESPIRATORYRATE

CIRCULATION

Breathing Restored after Airway Manouevre

Priority 3(Green-Delayed)

Priority 1(Red-Immediate)

Priority 2(Yellow-Urgent)

Dead(White/Black)

YES

NO

YES

NO NO

YES<10

>29

CRT 2 sec or more(PULSE 120 or more)

10 - 29

CRT <2 sec(PULSE <120)

Sieve & Sort

• P1• P2• P2• P2• P3• P2• P2• P3• P3• P1

RFDS coordination issues:

• Multiple aircraft at SX airfield• Infant on lap against CASA• OSD into coordination centre until 9pm- 3am• Hospitals kept ringing - annoying• Adequate resources• Tele Health doctor interaction

Discharge summaries:

4mo: Complex skull fracture with secondary seizures1yo: Skull fracture with extradural, diffuse axonal injury, #tib/fib2yo: Renal laceration3yo: # clavicle, scalp contusion4yo: Scalp laceration, cervical whiplash, abrasions25yo: Multiple rib fractures, pneumothorax, # humerus, #

metatarsals, # metacarpals, # TP L232yo: # 5th rib, pneumothorax, multiple lacerations35yo: # 1st metatarsal, multiple lacerations62yo: Abrasions only63yo: Abdominal wall hernia, multiple rib fractures, pneumothorax,

lung & splenic contusions, liver & renal lacerations, TP #’s of 5 scattered vertebrae, PIPJ dislocation

Questions ?