Anaesthesia and critical care in unusual and transport environments SIG
HAZARDS, HORSES AND HELICOPTERS
J.E. (Fred) Gilligan
Royal Adelaide Hospital, Adelaide, SA
In the early 1970s, a series of largely preventable deaths and major adverse effects occurred in South Australia with patients in rural hospitals and in transit to the capital city. An initial proposal to combat these problems by providing mobile ICU services to attend rural locations, using public hospital anaesthetists and ICU nurses was viewed with suspicion by health bureaucrats - until evidence emerged of lives saved.
The account published was the first on the topic in Australia and arguably motivated the evolution of similar services in other parts of Australia and New Zealand 1. Subsequent papers indicated management and outcomes, with particular reference to in trauma 2 3.
From the establishment of the colony (1836), a small rural population spread over its 983,000 sq km, mainly in the southern half. Remoteness added to the hazards of rural existence: the distance to the capital from the West Coast areas exceeded that from Melbourne – Adelaide. Communication and transport were major obstacles. Basic (“pedal”) radio was developed for the outback 4. Transport initially utilised horses, which continued in some degree until the 1950s. Emergency transport of patients to Adelaide from many areas was rendered difficult by indifferent roads, a jagged coastline and a large offshore island.
Initial recruitment of doctors was irregular and sometimes bizarre. As the population grew, general practitioners, often single-handed, had to provide all surgical, obstetric, paediatric and anaesthetic services 5. Rural specialists were limited to a few provincial cities.
The first air ambulance saw service in Whyalla in 1965, against the advice of ambulance executives. Airborne retrieval missions began in 1974. The RFDS provided only outback operations from 1955, till they also incorporated air ambulance activities in 1988, and a dedicated aircraft for airborne intensive care work was developed 6.
Anaesthetists and ICU medical staff and RNs staffed the teams, and later, emergency physicians were incorporated. Surgical staff were included for selected neurosurgical 7 8 and obstetrical emergencies. The greatest service demands involved trauma and neonatology, the latter having evolved in line with services elsewhere. One particular development involved a period of carrying portable decompression chambers in aircraft 9. Teams have also been involved in counter disaster operations and in international medevacs.
The evolution of compact ventilators, monitors and pumps assisted in providing care. Better road vehicles and pressurised fixed wing aircraft enhanced safety and effectiveness of transport. Rotorcraft were incorporated for roadside attendance, attendance at closer hospitals, and rescue missions.
Effective emergency communications were crucial. A simple development aiding rural doctors was the provision in 1977 of direct emergency telephone links, bypassing manual switchboards in public hospitals, after an unfortunate mishap. Close liaison with the Ambulance Service and RFDS has been productive in providing an effective service, with ambulance radio also linking with the relevant ICUs and the RFDS for improved communications. Telemedicine now complements phone lines.
Critical care retrieval operations now constitute an essential community service, complementing those of the RFDS and Ambulance Service and similar models adapted to local needs have been developed throughout Australia and NZ. Planning is in hand to maintain the future efficiency of the service.
Time of Presentation
Saturday 13 May 2006 - 1530-1700
References
I. Gilligan JE, Phillips GD, Nicholson B, et al. Retrieval of the critically ill in South Australia: a co-ordinated approach. Med J Aust (1977). 2. 849-855.
II. Gilligan JE., Griggs WM, Jelly M, et al. Mobile intensive care services in rural South Australia 1984-95. Med J Aust (1999) 171. 617-620.
III. Griggs W, Gilligan JE. The role of medical retrieval teams and the outcomes following trauma (abstract, Airmed 2000). Scand J of Trauma and Emerg Med (2000) No. 2. Vol. 7. 4. (Suppl.)
IV. McKay, F. Traeger. Boolarong Press, Moorooka, Queensland, 1995.
V. Seager, Joy. Kangaroo Island Doctor. Rigby, Adelaide. 1980.
VI. Maughan G, Gilligan JE, Goon P, Griggs W, Haslam R, Scholten A. An airborne intensive care facility (fixed wing). Anaes Intens Care. (1996). 24: 245-253.
VII. Wong AS, Simpson DA, Jones NR, Gilligan JE. Camel racing: a new cause of extradural haemorrhage in Australia. J Clin Neuroscience 9(6): 719-21, 2002 Nov.
VIII. Simpson DA, Heyworth JS, McLean J, Gilligan JE, North JB. Extradural haemorrhage: strategies for management in remote places. Injury. 1988: 19, 307-312.
IX. Gorman DF, Gilligan JE, Millar I. Use of an airborne transportable recompression chamber and transfer under pressure to a major hyperbaric facility. Proc. XIV Annual Meeting, European Undersea Biomedical Society. (Aberdeen 1988).
