This is the first of what we hope will be a series of posts from Dr Paul Bailey who works as a Medical Director for CareFlight International Air Ambulance. Paul will try to provide insights into the challenges of managing retrievals across oceans. Here’s the starter. 

In his real life, Paul Bailey is an Emergency Physician based in Perth, Western Australia who dabbles in the Greyhound racing industry (having owned 10 dogs and never been to the track).  He can often be found in the outer at an Aussie Rules football oval, most commonly critiquing the performance of the umpires in an entirely constructive manner.  Past lives include a molecular biology PhD – in Jellyfish venom – don’t ask – and being a glassy in various drinking establishments in Western Australia. 

 Paul has previously undertaken international retrievals, helicopter work supporting Australian Army exercises and time with Queensland Rescue at Cairns. He now makes cameo appearances on the International Medical Director roster, as a medical director for retrievals in the NT and the Inpex oil and gas business.

 

If you’ve decided to be involved in retrieval, why think local when you can think global? After many years of toiling through school, then medical school, and then advanced training in the acute care specialty of your choice, you’re now in the hot seat ready to go.

Living the Dream

You’ve always fancied yourself as an airborne medico ever since you sat on your Dad’s knee watching “The Flying Doctors” in the late ‘80s and thinking how cool that would be. Truth be told, you also liked Top Gun and from time to time have drawn a laugh with the immortal line: “Negative Ghostrider, the pattern is full.” But you still buzzed the control tower anyway.

Or perhaps more likely you rode that little bit too close to your Mum on your BMX. You’ve also heard, along the way that everyone in retrieval gets a nickname and you’re tossing up between Maverick and Goose.

And it’s safe to say you have bought the Ray Ban Aviators already.

 

Living the Reality

So what’s it really like? Different to that, not surprisingly.

CareFlight International Air Ambulance (CFIAA) is an ever changing beast, with our clinical teams and aircraft based in Darwin and Sydney. Over the journey we have also had aircraft in Perth and Cairns. Depending on where the team is on duty, they are most likely to be flying between Indonesia, East Timor, Papua New Guinea, Darwin and Adelaide (for Darwin crews) and Fiji, Noumea, Norfolk Island, Sydney and Brisbane if you are based in Sydney. Of course, it’s international so there actually isn’t a spot on the globe that shouldn’t be thought of as up for grabs.

Co-ordinators and Medical Directors sit behind the team at all times and, due to the miracle of mobile phones and the internet can be almost anywhere. Many of these folk never meet in person but are always looking over everybody’s shoulder.

More of that later, in this awe inspiring opening to the series I though I’d start with how it all gets going – who pays for it all?

 

The People with the Deep Pockets – Travel Insurers and Governments

When your average citizen takes out travel insurance, it is most likely to protect against such tragedies as losing an iPhone overseas, dropping a wallet in the ocean or perhaps finding himself in Vietnam and his luggage in downtown Boston. Having been in this game a while now, it is my opinion that if losing your iPhone is the worst thing that happens on your holiday you’ve had a pretty good time.

It may surprise you to know that a travel insurance policy is, by and large, a health insurance policy. Greater than 95% of the spend of travel insurance companies relates directly to health costs.

Each travel insurer has a series of service providers sitting behind them, one of which is an assistance company. There are a relatively small number of assistance companies that engage in this type of work. They have 24h call centres with co-ordinators, nurses and doctors (much like us).

In the event that John Q Citizen becomes unwell or is injured whilst they are away – by getting gored by a bull in Pamplona for instance – they or their relatives call the assistance company and a whole train of events unfolds, which might include directing patients towards local health care facilities to help with their medical problems.

The assistance company will maintain contact with the now patient and their family, and depending on how things in the event that the medical issue is of a serious nature, things tend to pan out in one of two ways that relate to the quality of health care available locally and the underlying urgency of the patient’s medical condition.

Let’s focus on the sicker end of the spectrum because clearly many issues are of a minor nature and never come anywhere near us.

If “definitive care” is available locally AND the quality of local medical care is high AND treatment of the matter is urgent assistance companies will usually head down the route of electing to keep the patient where they are for treatment in the theory that that is both (a) best for the patient and (b) cheaper than an international medical retrieval.

If “definitive care” is NOT available locally OR the quality of local medical care is questionable it is then the key decisions become urgency and mode of transport.  There are, again, an array of transport options available but seeing as we are in the Air Ambulance business, again we might focus on that.

 

Send in the Big Bird

The assistance company, having decided that medical evacuation is required and that this is most appropriately by air ambulance asks its panel of Air Ambulance providers for a quote. At this stage, the available information usually consists of the patient location and their ultimate destination. No clinical information is available.

Our co-ordinator submits a quote, and due to the price of aviation fuel the retrieval company with the aircraft that has to do the least amount of flying to get the job done is usually cheapest. Paperwork is exchanged and the job confirmed.

Clinical information is then available and at this stage the CFIAA Medical Director is brought into the discussion – to liaise with treating clinicians at the hospital of origin as well as the destination unit. How many times is it quick and easy to have a chat with someone you’ve never met in the hospital? Well, it is fair to say that these conversations can be difficult – finding the right person in an overseas hospital at a sometimes odd times of day and surmounting the language barrier is not straightforward.

We are often going to locations where the quality of the medical and nursing staff are excellent but the broad array of diagnostic equipment that many of us consider routine are just not available. Similarly there are many locations where the patient will have a problem that is unable to be treated effectively with the resources available locally. It’s part of the game, and in many ways it’s why we are needed in the first place. A lot of the legwork for the coordinator is about trying to construct a story that is useful for the retrieval team and help plan for every contingency.

So, that’s a summary of all the things that happen before you get to find out about a case. We haven’t even got to the challenges of the actual patient yet.

I might finish off with a thought for the day:

If you can open your packs blindfolded, upside down and in a thunder storm – and know where everything will be, you have satisfactorily completed orientation.