Dr Sam Goodhand / Anaesthetics and Intensive Care Registrar / Brighton, UK
Dr Sam Goodhand is an anaesthetics registrar and widely published opinion-piece writer with an interest in aero-medical retrieval. He worked with the Central Australian Retrieval Service in 2019. Here he tells us about the “Tyranny of Distance” in Australia’s Red Centre and how this contributes to healthcare inequalities suffered by the Aboriginal communities living days away from medical care.
All we have are vague reports of a serious car accident. We bump through our descent, and the corrugated grey homesteads beam back the early morning sun beneath our wingtip. It’s the first sign of life for over an hour of flight, which has taken us across glaring white salt lakes and the bulk of Uluru. The pilot orders silence for landing; giving me and the flight nurse a few moments to mentally prepare for the job ahead.
Grief was already echoing through the hills which enclose this remote Aboriginal community ever since a previous tragedy. My colleague had scrambled to the town weeks earlier to retrieve a suicide victim who had later succumbed despite the best efforts of the team. But today, a car has been found on its roof, with one seriously injured occupant and another passenger already dead. In the cool of the village’s tiny medical bay, the remote area nurses are busy at work. The wake of the last tragedy had led to alcohol being smuggled into the town in contravention of their self-regulated ‘dry’ status. Some teenagers had been drink-driving late at night and rolled it over. Due to the remoteness of the town, it was only at daybreak that they were discovered.
‘Golden hour’ urban medicine this is not. From the Royal Flying Doctor Service Base in Alice Springs – a small hub at the heart of Australia’s landmass – the Central Australian Retrieval Service covers an area the size of Germany. Helicopters would barely make a dent with their range, and have no role in providing healthcare to this thinly populated expanse of Outback. The ‘tyranny of distance’ is unforgiving and presents unique challenges – it may take many hours for us to reach our patients, by which time critical and traumatic illness have gained a firm grip. Whole weather systems and availability of airstrips influence our plans and dictate our time-window to administer treatment on the ground. Furthermore, the indigenous occupants of Australia’s ‘Red Centre’ suffer from a number of chronic health conditions which, according to the United Nations contribute to Aboriginal Australians dying up to twenty years earlier on average than their white immigrant countrymen.
We administer treatment to our trauma patient, and roll out to the medical centre’s Toyota ‘troop carrier’ – the ubiquitous Outback ambulance. This will take us back to our plane, for the 500km journey to the hospital in Alice Springs. The community stand quietly in vigil; with the occasional shout of farewell in their indigenous tongue. ‘We might see you again soon” the exhausted nurse says with foreboding. Several people have missed kidney dialysis sessions during the Sorry Business. “And there could even be payback when this patient returns”, she adds as an afterthought. Payback is a traditional physical punishment, dealt to those who have harmed others and broken customary law. This village’s chapter of tragedy and violence may not yet be over.
The threat posed to health by such enormous distance drove the Reverend John Flynn to establish the Royal Flying Doctor Service, in 1927. Ten years earlier, Flynn had been particularly moved by the case of ranch hand Jimmy Darcy, who fell from his horse in rural Western Australia. He was hauled on a cart for many miles, before being operated on by a local postmaster under instruction by morse code, from a doctor who resided hundreds of miles away in Perth. The distant mentor, Dr Joe Holland, then made an epic two-week journey by cattle ship, car and horseback to tend the patient himself, only to arrive hours after the unfortunate Darcy’s death. This fascinating story was well-publicised in Australia at the time, and was instrumental in Flynn’s desire to establish a ‘mantle of safety’ for rural Aussies.
Despite modern technology and methods, Dr Holland’s dusty travails would pop into my head on several occasions during my time with The Service. One spring evening sticks in mind. My tasking consultant phoned to tell me about a young patient who has been hit by a road-train lorry on a remote highway. There is a dirt airstrip several kilometres from the scene, but it’s entirely unsafe for night flying. We would need to improvise.
We would use Alice’s ambulance service, which has a mind-boggling catchment of some two hours driving time out of town. Driving North for almost ninety minutes, we arranged a rendezvous with a Troop Carrier. Inside the “Troopy” were two remote area nurses, who had driven forty minutes from their own post to load our critically injured patient from the roadside onto their gurney. They passed us so fast we almost missed them. Together we transfer their human cargo onto the ambulance stretcher; clinging desperately to life. Under the stars, lit only by iPhone torchlight and with the trolley rocking on the uneven brush of the roadside, we got to work. Decompressing the victim’s crushed chest, inducing anaesthesia and commencing ventilation for the two-hour trip home. The feeling of professional isolation and exposure is exhilarating and unsettling in equal measure. Cold is also a killer in trauma patients, and as we rack up the heating to maximum in the back of the ambulance, I wish I’d brought more than a small bottle of water.
Great distance is but one hardship. There’s the savage, inescapable heat – getting back into the cramped interior of a Pilatus PC12 in 46 degree heat is memorable. And then other extremes of weather – hailstones the size of golfballs, blinding sandstorms, and rains which almost overnight turn the red landscape chameleon-like to a verdant green when seen from the skies. All have deep implications for our patients.
To outwit the collusion of great distance and fast-changing conditions, we must be prepared to rapidly adapt. We found our unfortunate dirt-biking tourist in an empty ‘donga’ (shed) on the edge of our airstrip. He’d been driven there by a gold mine employee after hitting a trench and flying over the handlebars. We had barely clapped eyes on his unnaturally twisted forearms, before our pilot told us we must leave immediately, or be stranded for hours by the incoming storm. His hands had an intact circulation, so we abandon our plan to straighten and splint his arms, and opt to “scoop up and run”. We will have to hope that pain relief will make the bumpy flight bearable. Just as we prepare to leave, our pilot returns. Good news – we have a thirty minute window before the storm descends. The nurse and I work fast, administering ketamine through a drip in the motorcylist’s foot, and pulling both arms to a natural length, while our pilot grimaces and turns away. The man wakes with a drugged grin at 18,000 feet, with the nearby storm flashing into the cabin.
It’s not all trauma and critical illness, and not everybody is pleased to see us. Transferring patients with severe mental illness hundreds of miles to hospital for ongoing care poses one of the greatest challenges. We need to have great patience to stabilise the psychotic patient in their community, often with the support of town elders who may persuade them to travel “to town” with strangers for treatment. Usually, chemical sedation is also needed. Precision and care are key for the long flight home – despite the temptation for such reassuring control, intubation and ventilation is increasingly seen as over-invasive for these patients. We must maintain sufficient sedation to keep our patient calm with a stable airway and breathing, and to keep our aircraft and crew safe in the skies. As ever, we bargain on not being able to perform any intervention in the plane’s tight confines for the duration of flight. An intravenous sedative infusion and a reinforced restraining blanket are deployed in case of agitation at altitude, before the pilot gives the final say-so on safety to fly. It remained thankfully untouched, but I never made the trips without a syringe of propofol, paralysing agent and a supraglottic airway device in my trouser side pocket. It all sounds very hairy, but sometimes it was.
Arriving into the cool of the city hospital’s emergency department after a long mission is the bizarre collision of two worlds. There are few starker contrasts than Australia’s interior and too easily forgotten history, and its infancy as a modern nation. For the Outback’s custodians and occupants – the indigenous peoples and the white farmers, its red earth exerts a powerful magnetism. I will hand over to the hospital team and say my farewells to the patient – if they’re awake, you can bet they’ll ask me one final question – when can they get back “out bush”?
For anyone inspired by this piece, get in touch with the Central Australian Retrieval Service. Placements are generally 6-12 months, and benefit from a broad background with experience in emergency medicine, anaesthesia and critical care. Those with travel sickness need not apply.