Dr Keith Sai Kit Leung / Foundation Doctor / Yorkshire and Humber Deanery
Keith is an academic foundation doctor who is aiming to specialise in emergency medicine with a focus on pre-hospital critical care. For his final year elective, he spent four weeks in sunny South Australia split between pre-hospital critical care service, MedSTAR, and the Royal Flying Doctor Service (RFDS). Keith gives us the run-down of his elective: what to expect, the highlights, and how to plan your own.
MedSTAR Retrieval Service
MedSTAR is a part of the South Australian Ambulance Service and responds to adult, paediatric, and neonatal primary emergency retrievals as well as secondary inter-hospital transfers. The operational base located at Adelaide Airport includes a fleet of road ambulances, rapid response cars, and Bell 412 helicopters. Each retrieval team is formed of one retrieval doctor and either a nurse or a paramedic, all with a background in, and an ability to provide, critical care. Team activation and tasking are made by the decision of the medical retrieval consultant (MRC) supported by retrieval nurse consultants at the Emergency Operation Centre (EOC). MedSTAR also collaborates with RFDS to attend long-range or inter-state missions by fixed-wing aircraft when retrieval locations are out of coverage by helicopters.
Shift Pattern
Retrieval teams work in a 12-hour shift pattern, starting with equipment and vehicle checks, operational briefing with weather forecasts, and sometimes followed by teaching or simulation sessions. As an observer, I was expected to mirror the same working pattern as everyone else. Sometimes shifts run beyond 12 hours due to the clinical complexity or unexpected weather conditions which increased the mission’s difficulty (and duration). Finish times in retrieval medicine are a target, not a certainty, so don’t be too ambitious with your post shift social plans!
Typical Day
The typical day consisted of attending base, completing the morning briefings and then awaiting tasking for a retrieval. Some days were slower than others so it’s worth have a good book or a podcast handy. Even better, getting the opportunity to learn from the retrieval team and hearing their stories was fascinating. There is a specific observer bleep which goes off when there’s a tasking and you can choose whether to observe the adult or the paediatric retrieval teams. Every observer must go through a safety briefing and an orientation in the operational base and with RFDS on their first day before attending any missions. The only limitations of observers were that we were not permitted to attend helicopter primaries due to space and weight restrictions, or any helicopter missions that will fly over water as this requires completion of the Helicopter Underwater Escape Training (HUET).
Case Mix
During my time with MedSTAR and RFDS, I was able to shadow a huge variety of retrieval missions and interesting cases, on both helicopters and fixed wing aircraft, and no day was the same. Cases ranged from neonates with cyanotic congenital heart disease, adults with status epilepticus, major trauma, cardiac emergencies such as complete heart block requiring transvenous pacing, cardiac arrest post myocardial infarction, or any patient requiring critical care support and transfer to a larger hospital.
Unforgettable missions
Who to retrieve?
One of the most unforgettable cases was when we received a task to retrieve a patient with worsening respiratory failure due to Covid infection. On arrival, when we walked past the small rural resuscitation room, the staff approached and asked us to review another 2 critically unwell patients who also needed retrieval. Now we have 3 patients: a child with small bowel obstruction, a young adult with severe asthma, and a middle-aged patient with COVID pneumonitis. The aircraft was designed to accommodate one stretcher only, and herein lies the challenge of retrieval medicine: being able to prioritise, and work in resource poor environments with complex logistics. I questioned myself, if I were the retrieval doctor, what decision would I make? Through discussions with the emergency operations centre, senior clinicians at the statewide telehealth service, and doctors back in Adelaide hospital – alongside challenging logistics – a plan was made. Multi-disciplinary teamwork at its finest! Ultimately, the patient with Covid was flown to Adelaide, the child had their initial surgery locally and underwent delayed retrieval whilst the asthma patient was stabilised and no longer required transfer. Our team ended up returning to base at midnight!
Taking critical care to the patient
Another notable case was a large-volume variceal bleed secondary to end-stage liver disease. The patient was extremely agitated, haemodynamically unstable, with profoundly deranged coagulation and metabolism. One of the challenges of retrieval medicine is the environment of flying – you often have limited access to your patient, you have limited equipment, supplies, and personnel, all the while it’s cramped, noisy and there’s multiple distractions. Ideally, patients need to be stabilised pre-flight and any procedures completed before take off. This patient required central venous access, an arterial line to monitor inotropic requirements, multicomponent blood product resuscitation and multiple intravenous infusions and was intubated and ventilated. The process took 4 hours on the ground – bringing critical care skills to the patient is one of the key aspects of retrieval work. However, the most difficult part of the retrieval was not managing the patient’s condition, it was the logistics of transfer. From resus to ambulance, ambulance to aircraft, aircraft back onto an ambulance, then ambulance to ICU, multiple times of bed-to-bed transfer, can you imagine how chaotic it is when you have to take care of a patient who might deteriorate anytime en route, while cautiously looking after all those tubes, lines and machines?
Rural Medicine
GP Anaesthetist
The sheer size of Australia means you can be a long way from a hospital and healthcare. Practitioners providing rural healthcare require a unique set of skills. While attending retrieval missions in the outback, I discovered several fascinating concepts that do not exist in the UK. According to the Australian Institute of Health and Welfare, about 28% of the Australian population, approximately 7 million people, live in rural areas [2]. Nevertheless, most rural hospitals are too small to maintain 24/7 specialist services onsite, for which I discovered the role of rural GP anaesthetist (RGA) [3]. The training programme itself was first launched in 2023, with the aim to provide rural generalists skills to deliver better care for remote communities to meet thedemand for anaesthesia in emergency and elective surgeries, maternity, resuscitative and post-resuscitative care.
Standardisation for emergencies
Standardisation of healthcare in the rural setting was evident when attending remote hospitals. Across all resuscitation rooms, there are “Can’t Intubate, Can’t Oxygenate” (CICO) kits. This equipment is standardised across hospitals in the entire SA region. Although CICO is an extremely rare airway emergency, it is time critical, and the presence of the standardised CICO kit allows a shared mental model and process for all staff involved in resuscitation. The kits are prepared for “grab and go” in such a situation and the procedure delivered rapidly by the team [4].
Enjoying Australia
Time at work was fantastic but I also made the most of my time outside of it. The weather was stereotypically Australian, being perfect every day with sunshine all round! I had chance to catch up with relatives in Sydney and got shown shown round the city taking in some of the iconic spots including the Opera House and Harbour Bridge. Australia is known for it’s brunch and coffee culture and it did not disappoint! As a space enthusiast, I couldn’t resist visiting the Australian Space Discovery Centre the moment I landed in Adelaide. Most weekends were spent having a walk at the Botanic Garden, followed by wine tasting at the National Wine Centre of Australia or beer in the sunshine, and of course, who doesn’t like an ice cream on the beach?
Reflections
I thought retrieval medicine was attending incidents and performing dramatic procedures to save patients from life-threatening injuries. I soon realised this was not true when I shadowed my supervisor for a shift in the Emergency Operation Centre. Retrieval medicine presents many challenges beyond the clinical. Coordination, resource allocation, remote clinical advice is just as important. From the moment a retrieval referral has been made, the consultant provides clinical advice to the referrer, determines the urgency and complexity of the case, sends the most suitable team with the most appropriate mode of retrieval (by air or land), plans the landing site and receiving destination, as well as updating all involved parties. Not to mention, all decisions are limited by multiple factors, including weather conditions, destination terrain, crew/aircraft/bed availability. Now take a minute to put yourself in the retrieval consultant’s shoes (or crocs), imagine the challenges of bandwidth, cognitive overload, decision fatigue and need for continual communication. I really enjoyed the dynamism of retrieval work and it was a privilege to get an insight into this unique area of medicine.
Elective Opportunities
MedSTAR
The MedSTAR observership elective programme only takes two international students per year. Only one medical student observer can be accommodated at one period of time (usually between 4-6 weeks) to maximise learning opportunities and exposure. No elective fee is required and in return observers are expected to do an end-of-placement presentation and assist with any ongoing audits/research. Uniforms are provided but observers need to purchase a pair of safety footwear. I booked my accommodation in Adelaide city centre which is 15 minute commute to the operational base by car. Public transport takes 40 minutes by bus and cycling is an alternative option.
“Find a job you love, and you will never have to work a day in your life”. I loved every second of my time with MedSTAR, I have never felt so alive even though the job itself can be extremely demanding! I would like to thank my supervisor Dr. Perry, clinical director Dr. Pearce and admin Tricia for offering and organising such a fantastic opportunity for me to join this observership. It was my privilege to work with all those incredible human beings in SAAS, MedSTAR and RFDS.
Funding
I would like to thank The Royal College of Surgeons of Edinburgh, Binks Trust and the Turing Scheme. Their generosity allowed me to cover the majority my travel and accommodation costs. Further information can be found on their website. I’m also happy to provide advice for others who are thinking of applying for a retrieval medicine elective.
Twitter @keithleung102 / LinkedIn https://uk.linkedin.com/in/keith-s-k-leung
References
[1] Araiza, A., Duran, M., Surani, S. and Varon, J. (2021). Aeromedical transport of critically ill patients: A literature review. Cureus, [online] 13(5). https://pmc.ncbi.nlm.nih.gov/articles/PMC8180199/ DOI: https://doi.org/10.7759/cureus.14889
[2] Australian Institute of Health and Welfare (2024). Rural and remote health. [online] Rural and remote health. Available at: https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health
[3] Australian College of Rural and Remote Medicine (2023). Rural Generalist Anaesthesia (RGA) [online] Available at: https://www.acrrm.org.au/fellowship/discover-fellowship/ast/rga
[4] Ti, J.S., Dwyer, S.P., McTernan, C.N., Dunlop, B.K. and Firth, M.J. (2020). Impact of ‘Can’t Intubate Can’t Oxygenate’ (CICO) kit ergonomic design on the timed responses of participants in simulated CICO crises: A randomised, crossover pilot study. Tasman Medical Journal, [online] 3(1), pp.45–51. Available at: https://tasmanmedicaljournal.com/2020/11/impact-of-cant-intubate-cant-oxygenate-cico-kit-ergonomic-design-on-the-timed-responses-of-participants-in-simulated-cico-crises-a-randomised-crossover-pilot-st/
