CASE 39

Tasking and retrieval coordination are crucial aspects of pre-hospital and retrieval medicine (see also Case 20). The role demands high-level decision making, often in the presence of incomplete or confusing clinical information. Triage, resource allocation, effective interpersonal communication and astute clinical acumen are required of coordinating staff.

The following incidents should be considered as being independent of each other. In each case, the decision to mobilise, coordinate and support the PHR team rests solely with you.

Incident A

A 24-year-old patient with schizophrenia has stopped taking medication and is now behaving bizarrely and threatening violence. He has been accepted for admission under the psychiatry team in a secure psychiatric unit. He is currently at a single-doctor clinic one hour flight by rotary wing aircraft from the psychiatric unit and has required moderate doses of sedative hypnotics to calm him down.

39.1 Discuss the issues that should be considered when coordinating this retrieval.

Incident B

A 74-year-old man with severe chronic obstructive pulmonary disease (COPD) has presented to a nurse-only clinic 45 minutes’ fixed-wing flight from the nearest appropriate hospital. He was reported to have a GCS 6 (E1, V1, M4) on arrival but has responded well to non-invasive ventilation (NIV) and is now GCS 13 (E3, V4, M6). He has been accepted for continuing NIV and optimisation by the general hospital. The patient has been previously assessed as a ‘poor’ candidate for invasive ventilation by the local intensive care unit. Rotary wing and road transport platforms are available.

39.2 How will you coordinate the retrieval of this patient? Explain your decisions.

Incident C

A 25-year-old primigravid patient has spontaneously ruptured membranes at 29 weeks’ gestation. She is having periodic abdominal pains and needs retrieval to a general hospital with obstetric and neonatal facilities. The patient is located in a single-doctor and nurse clinic on a small offshore island, 15 minutes’ helicopter flight from the hospital. The nurse has midwifery skills.

39.3 What are the concerns with retrieving this obstetric patient? How would you go about coordinating it?

Discussion

Incident A

39.1 Retrieval of the acute psychiatric patient generates a unique set of problems for the coordinating and PHR teams. The over-riding issue is team safety followed by patient safety. The coordinating staff (working with the local medical staff) are directly responsible for the initial assessment and risk management. The challenges of managing a mentally ill and unstable patient in the pre-hospital and retrieval environment should not be underestimated especially if there is an aeromedical aspect to the retrieval plan.

Method of retrieval

If at all possible, such retrievals should be done by land ambulance. The risk to the patient and the team is still evident but the consequences of that risk are greatly reduced using land transport. In addition, it is easier for patient escorts (including family, health workers or police) to travel with the patient. If necessary, the police can also escort the ambulance in a separate vehicle. Medical management is still a challenge in the back of an ambulance but the option of diverting to a local facility or pulling over to the roadside to carry out treatment simplifies the retrieval process. Under normal circumstances, aeromedical retrieval could be considered for retrievals that would take over one or two hours by road. For these complex psychiatric retrievals, it may be justified to increase or even double that timeframe. There are occasions when the distance or the terrain precludes land transfer in which case aeromedical retrieval will need to be considered. In such cases, the relative calm of the fixed wing aircraft cabin is preferred to the rotary wing equivalent. The tasking agency should also be aware that local resource issues may lead to reluctance among ambulance personnel to release a land ambulance and its crew for what could be a six to eight hour round trip.

Urgency of transfer

Most aeromedical accidents happen at night and in bad weather.1.^{and 2.} (see Case 20) While psychiatric patients may have a life-threatening illness (particularly with regard to suicide risk), waiting until the following morning may be appropriate. If so, the local clinic will need to be supported in order to keep the patient under observation with sedation. Advice from an appropriate psychiatric specialist should be an integrated component of such support. As a general rule, psychiatric aeromedical retrievals should not take place at night or in bad weather. On the rare occasion when immediate retrieval is essential, careful thought should be given to general anaesthesia and ventilated transfer. This is often indicated when the dose requirements for sedative agents are escalating and the patient remains a risk to both themselves and the local staff. The coordinator should suggest the patient be kept nil by mouth for 6 hours prior to the PHR team’s arrival to allow safe intubation and ventilation if required. Further detail of psychiatric retrievals can be found in Case 37.