Students — 5 September 2023 at 10:01 am

A Pre-Hospital Elective in the Skies

Dr Laura Appleton / Foundation Doctor / London

Dr Laura Appleton recently completed her medical degree at King’s College London and now works as a Foundation Year 1 Doctor in London. As a student, Laura developed interests in expedition and pre-hospital medicine and was involved with the university’s Wilderness Medicine Society. In this article, she shares with us stories and advice from her elective with the Royal Flying Doctors Service (RFDS) in Western Australia. Laura recounts in-flight intubations, lightning strikes and avoiding snakes during what sounds like the ultimate pre-hospital elective.

I was very fortunate to do an international elective following the pandemic. My key goals for elective were to have an experience unique to standard UK hospital placements and to experience different cultures. A retrieval medicine elective with the RFDS in remote Western Australia ticked every box.

Royal Flying Doctors Service

RFDS is a national retrieval and patient transfer service, which also operates remote GP clinics. I was in Port Hedland, a remote town in Western Australia. I joined a range of retrieval flights, both doctor-accompanied and flight nurse-only flights. Flight taskings are categorised as:

  • Priority 1 (P1): Life-threatening emergency. Always doctor-accompanied, and the flight departs as soon as possible.
  • Priority 2 (P2): Urgent medical transfer. The flight departs quickly and will be doctor-accompanied if there is the possibility of patient deterioration or complex management.
  • Priority 3 (P3): Elective transfer for routine transfer of patients, with a target response of <48hrs. These are flight-nurse only, and can often be collected as add-ons after other patients.

Joining a number of P1s meant I had a truly unforgettable experience. P1s ranged from blunt force abdominal trauma from a mine site equipment injury to early labour. Most commonly, I joined P2s, with conditions such as appendicitis and pyelonephritis. During these flights, I assisted in basic A-E assessments, history-taking and documentation. In addition, owing to the size of Western Australia and most tertiary care being in Perth, RFDS receives funding to transport patients between hospitals. One particularly moving experience involved returning a patient with terminal cancer to her hometown and loved ones after a lengthy hospital admission in Perth.

The most memorable experience of my elective was a P1 for a suspected PR bleed in an elderly patient. Upon arrival at the airstrip, the patient was shocked (systolic BP <50mmHg). A rapid handover and assessment did not reveal signs of bleeding or an obvious cause for the patient’s condition, with the patient being drowsy but responsive. The patient rapidly deteriorated once in the aircraft, becoming extremely agitated and combative. The doctor, flight nurse and I tried to prevent the patient from thrashing around, which escalated to a safety issue. Consequently, an emergency in-flight rapid sequence induction was performed to intubate, which had been deemed a last resort given how haemodynamically unstable the patient was. For over three hours the doctor administered vasopressors and emergency drugs, set up the ventilator, and intubated the patient, before inserting an NG tube as we came into land. Meanwhile, the flight nurse was administering drugs and running blood gases. I was drawing up additional morphine and midazolam, and assisting with calming the patient. All of this in the back of a small aircraft was a truly eye-opening experience into retrieval medicine. I learnt valuable lessons in teamworking, communication, the importance of preparation and drawing up emergency drugs prior to flight.

Cultural Differences

A poster describing the Martu Wangka words for various body parts. Martu Wangka is an Aboriginal language used in Western Australia.
Martu Wangka is an Aboriginal language used in Western Australia.

My elective provided a fantastic insight into the differences between British and Australian healthcare, including respective healthcare systems and patient populations. Roughly 3% of WA’s population are Aboriginal or Torres Straight Islanders (ATSI), with this figure ranging from 18% in Port Hedland to 85% of the population further inland. I learnt about the beliefs that ATSI people hold about their land, society and relationships. For example, ‘dreamtime’ refers to the understanding of the deep connection to the land and their ancestors, which I often saw depicted in beautiful artwork. I also learnt about the differences in communication practices used to ensure respect. ATSI patients have higher rates of renal disease, diabetes and rheumatic heart disease. High alcohol intake among some members of the ATSI population can compound some of the deprivation and social determinants of health. In addition, people that move between communities can experience worse health outcomes due to lack of follow-up and regular care.

I joined two rural GP clinics at nursing posts out in the community, one of which involved flying into Australia’s hottest town. During these clinics, members of the community can see the RFDS GP or nurse for appointments and follow-ups. I learnt about different aboriginal terms for common healthcare terminology and saw patients that presented with MSK problems, mental health, rheumatic heart disease and dermatological conditions. In another rural GP clinic, I saw a patient who had received a nasty, wide facial laceration, but had not seen a healthcare professional for a month due to moving between communities, resulting in poor wound closure with likely significant scarring afterwards.

All RFDS nurses are dual-trained midwives. I joined flight tasks into remote outback areas, where aboriginal pregnant women may have limited antenatal care, either through lack of access or engagement. One young patient whose retrieval I joined was in early labour in an extremely remote area, whilst another pregnant patient had abdominal pain with a tragic history of three previous neonatal deaths during pregnancy or post-partum. Fortunately, both these women were flown to the regional hospital before subsequent transfer to Perth for the safe deliveries of their babies.

The Impact Of Weather

The RDFS plane on the runway at sunset.
Sunset on the runway.

Whilst I avoided the tropical cyclones possible for that time of year, I certainly experienced the impact of the weather! Port Hedland’s base has two aircraft, which have a maximum altitude of 30,000ft. On some occasions, we were able to fly around storms or plan a delayed approach. However, on one return to Port Hedland with a patient, there was a very loud bang and a bright flash of white light – we had been struck by lightning! We came into land, with one very nervous patient and a worried flight nurse. After a full examination of the aircraft by the pilot, the aircraft was placed out of action, as the shockwave from the lightning strike to the propeller had travelled through the aircraft and damaged the engine. We had luckily avoided a possible nasty outcome. For those who do not like turbulence, I would reconsider an aeromedical retrieval elective, as I had my fair share of bad turbulence going through storms and in the hot, rockier descents, which produce more turbulence.

Another unforgettable experience was flying to a regional hospital to retrieve a patient having seizures after a prolonged collapse in a freezer. The storms that had been rolling in as we landed intensified whilst with the patient, causing a delayed transfer due to the risk of being exposed on the tarmac with the patient if further lightning was to occur. Once in the aircraft, the patient continued to have regular seizures, and with the storms not calming down, a ‘meet’ with another crew was organised. We landed in a remote base and handed the patient over to a crew in one of RFDS Western Australia’s two jet planes, which can fly at higher altitudes (therefore avoiding the storm).

The Area And Other Things To Be Aware Of

A view from through the front windscreen of a car driving on a remote road in the Australian outback, with the end of the road disappearing in a straight line over the horizon.
Driving in the outback.

Port Hedland is a fairly isolated town that acts as a gateway to many of the Pilbara’s mine sites, and is one of the largest ports for iron ore export. It wasn’t quite the golden beach location I had had in mind, but there was a fantastic community spirit amongst the crew, and it was certainly a very different experience from London. RFDS staff welcomed me in every way, attending BBQs and pub nights regularly during my stay. I also joined a staff trip to Karijini National Park, walking through the gorges and desperately trying to avoid any snakes.

Due to the vast size of Western Australia and the remote nature of the Pilbara, there were limited opportunities to explore at weekends over my 4-week placement. The only flights out of Port Hedland are very expensive flights to Perth. Broome is an approximately eight-hour drive away (and Perth 18hrs). Luckily, I joined a group of Australian students doing a rural health placement year, exploring Pilbara spots, such as Cape Keraudren. You do have to be wary of crocodiles in some areas, and I was always on the lookout for snakes. I was glad not to have been present when one of Australia’s most venomous snakes (an Eastern Brown) made an appearance within the base, but I did brave putting an empty bin on a small snake (later confirmed as a legless lizard!) at the base. I did however get a bit of a surprise at a rural nursing station, where I found the toilet to be regularly inhabited by frogs!

I took one Friday off and had a mammoth weekend of driving down to Coral Bay. Driving 800km in a day through the outback alone, in 40+C weather and dodging kangaroos and cattle was quite the experience, but was more than worth it. I did a marine safari, where I was able to swim with manta rays, a leopard shark, baby reef sharks, several turtles and a vast array of coral and aquatic life. I did have a rather worrying experience driving the 800km back the following day when I nearly ran out of fuel alone in the outback in 44C, but fortunately made it to the next roadhouse just in time.

I had an incredible experience with the RFDS. Having said that, it was an intense 4 weeks, with very long (15hrs+) days not uncommon. I threw myself in for the experience, but it definitely isn’t sitting on a beach after clinic for a couple of hours. Different people will want different things out of their elective, so it is definitely something to consider. I had four weeks with RFDS, immediately followed by three weeks at the Royal Melbourne Hospital (doing anaesthetics) in an eight-week elective period. With hindsight, I wish I had organised a shorter second half to build in more time to travel/relax. I would recommend building time before/after an RFDS Port Hedland elective to explore the Kimberly and the beautiful regions of southwest Australia.

Electives can be a significant financial undertaking. I tutored a lot prior to and following elective in order to save/recoup as much as possible, and applied for grants and elective funds. I am thankful to the Association of Anaesthetists for their £300 contribution towards my elective. I claimed back costs for accommodation and car hire afterwards via the NHS travel bursary, but this can take a long time to be processed, and you have to front the money first. The remote nature of Port Hedland increases the cost of most things beyond what would be expected, so it is unfortunately not a cheap opportunity. A typical food shop could be nearly double that of the UK due to the costs of importing to such a remote area. Accommodation is very limited and very expensive, but fuel is cheaper than in the UK.

Final Thoughts

If you are fortunate enough to have the opportunity and means to go abroad and experience different cultures and healthcare systems, I would 100% encourage it. There will always be more time to experience a UK hospital environment. Being a student means you are afforded the opportunity to shadow and join unique experiences that become much harder once qualified as a doctor. I have found that on the whole, people are helpful and receptive to facilitating students if you put yourself out there and try. I am incredibly grateful to all patients I encountered but particularly to members of the local communities for allowing me to participate in their RFDS experiences. Gaining an insight into aboriginal culture and beliefs promoted both my healthcare knowledge and general personal development.

Further Information

When: January to March 2023

Costs: $1500 AUD elective fee for RFDS. £600 hire car (this was an absolute requirement due to the lack of public transport/size of the Hedland area). Free Australian tourist visa.

Accommodation: There is very limited accommodation in the area, and prices are inflated because of the costs the mining companies can pay for transiting workers. I booked the only available AirBnB for approximately £1800 for four weeks, which was significantly more than anticipated. The NHS travel bursary covers up to £55 per night for elective costs. The Western Australian Centre for Rural Health (WACRH) have a student house in Port Hedland, for which they offered a room for $110 AUD/week after I explained my situation. Unfortunately, I did not hear back for months, at which point I had paid for the non-refundable AirBnB.

Vaccinations: Pertussis booster (not common as a one-off in the UK – I had to go to a private clinic), rabies, hep B&C booster, BCG, and tetanus/diphtheria/polio booster. Three covid vaccinations. MRSA test between finishing placement pre-elective and departure for Australia.

Weather: Very hot and humid. Ranging from 35-42C daily in Port Hedland, reaching 46-48C in some mining site landing strips. January to March was tropical cyclone season. Luckily, I didn’t encounter any cyclones, but one did hit the Pilbara and the Kimberley not long after I left. I saw some fantastic thunder and lightning.

Essential Items: A wide-brimmed sunhat that covers your ears and neck is an absolute necessity. Sunglasses and sun cream (lots of it). Insulated water bottle to keep your water cool. Sturdy/durable shoes are advised (I wore my hiking boots).

Contact: Each state has its own RFDS branch, with contact addresses on each state’s subpage on the RFDS website. The RFDS Western Australia branch was the only one to get back to me. I contacted with my CV approximately 11 months prior to my elective, and received my offer in July 2022 for a January 2023 elective. I know of other medical students who have had equally fantastic experiences with RFDS in South Australia and in rural New South Wales.