Aeromedical Evacuations

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Aust. J. Rural Health (2006) 14, 270–274

© 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc. doi: 10.1111/j.1440-1584.2006.00828.x

Blackwell Publishing AsiaMelbourne, AustraliaAJRAustralian Journal of Rural Health1038-5282© 2006 The Authors; JournalCompilation © 2006 National Rural Health Alliance Inc.? 2006146270274Original ArticleREMOTE AREA AEROMEDICAL EVACUATIONS

D. PEIRIS

ET AL.

Correspondence: Dr David Peiris, Ngalkanbuy Health Centre,PMB 230 Galiwin’ku community, Elcho Island, Galiwin’kuCommunity, Northern Territory 0822, Australia. Email:[email protected]

Accepted for publication 22 September 2006.

Original Article

Aeromedical evacuations from an east Arnhem Landcommunity 2003–2005: The impact on a primary health

care centreDavid Peiris,1 Cherryl Wirtanen1 and John Hall2

1Ngalkanbuy Health Centre, Galiwin’ku, Elcho Island, Northern Territory, and 2School of Public Health,University of Sydney, New South Wales, Australia

Abstract

Objective: To understand the profile and impact of

aeromedical evacuations in remote Indigenous

communities.

Design: Descriptive study.

Setting : A primary health care centre in east Arnhem

Land, Northern Territory, Australia.

Participants: Four hundred and ten evacuations from a

total population of more than 2200 were analysed from

February 2003 to August 2005.

Main outcome measures: Patient demographics, sea-

sonal variations, diagnostic categories, utilisation of

staff resources.

Results: On average 6.5% of the community were evac-

uated to hospital every year with an evacuation occur-ring every 2.2 days. Children aged under five years were

3.3-fold overrepresented in evacuations (comprising

37.7% of those evacuated versus 11.3% of the commu-

nity, P < 0.001). Four diagnostic categories accounted

for 61% of evacuations: respiratory disease (21%),

obstetric conditions (15%), gastroenteritis (14%) and

injury/poisoning (11%). Over the study period four

patients required intubation at the clinic. Evacuation

rates were higher in the monsoon season. Forty-seven

per cent of evacuations occurred after hours. The wait-

ing time for plane arrival ranged from one hour to

21 hours with a median wait-time of three hours.Conclusion: Aeromedical evacuations place a heavy

burden on primary health centres. Clinic staff are regu-

larly required to provide hospital-level acute care, often

for several hours at a time. Meeting this burden

competes with primary prevention programs and regu-

lar clinic duties. The age and diagnostic profiles encoun-

tered in this study have significant implications for therange of skills required to provide an adequate acute

care service. This study highlights the need for remote

area health centres to be well resourced to meet these

needs.

KEY WORDS: emergency, Indigenous health,

prehospital care, remote area nursing , service delivery

to Indigenous population.

Introduction

The long-standing and growing health disparity

between Indigenous and non-Indigenous Australianshas been well described in successive Australian Institute

of Health and Welfare and Australian Bureau of Statis-

tics reports.1–4 One aspect of this disparity is the high

rates of Indigenous hospitalisation for most acute con-

ditions. Aside from renal dialysis, the most common

reasons for Indigenous hospital separation were preg-

nancy/puerperium (15.8% of female separations),

injury/poisoning (12.3% male, 7.3% female) and respi-

ratory (11.0% male, 7.8% female).5 Although circula-

tory disease is the greatest contributor to Indigenous

adult morbidity and premature mortality,6 it plays a less

prominent role in acute hospital admissions accounting

for only 4.2% of Indigenous male and 3.2% of

Indigenous female hospital separations in 1999–2000.5

For children, the disparities are similar. Indigenous

infants are 1.3-fold more likely to be hospitalised overall

and threefold more likely for respiratory, infectious and

skin conditions.5 These figures occur, however, in the

context of a significant decline in Indigenous infant mor-

tality over the last two decades.3,7,8 In the Northern

Territory (NT) there was an 85% decline in mortality

in children aged under five years between 1966 and

2001.9 Improved quality of health care and accessibility



REMOTE AREA AEROMEDICAL EVACUATIONS 271

© 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc.

has been an important factor in this decline. In a study

of all admissions in Western Australia for acute gastro-

enteritis between 1990 and 2000 there were no recorded

deaths from this condition compared with 69 deaths of

Aboriginal children between 1970 and 1979 and ninedeaths between 1980 and 1989.10

Although hospitalisation data are relatively easily

accessible a review of several databases failed to find

any descriptive analyses of evacuations to hospital from

Australian remote areas. The Royal Flying Doctor Ser-

vice is the major provider of aeromedical services in

Australia with the exception of the Top End of the NT,

which is serviced by the NT government through the

Northern Territory Aerial Medical Service (NTAMS). In

2003/2004 the Royal Flying Doctor Service performed

3804 primary medical evacuations from rural and

remote areas.11

Forty-two per cent of these occurred inthe Alice Springs region alone representing an average

of more than four evacuations per day. Two studies in

Papua New Guinea found obstetric, trauma and respi-

ratory conditions as the leading reasons for evacuation

from remote area clinics.12,13 A west-Australian study

found a median transfer time to hospital of more than

nine hours for 440 trauma patients.14 Aside from these

scant facts little else is known. Thus our study is the first

known in Australia to perform a descriptive analysis of

aeromedical evacuations to hospital from remote area

clinics.

Methods

Setting and participants

The remote Indigenous community is located in east

Arnhem Land. Population figures vary from the town

council estimate of 2200 to the health centre figures of

2813 regular clients. The former is most likely an under-

estimate whereas the latter includes clients of the service

who do not regularly reside in the community. Table 1

lists the percentage breakdown of age groups in the

community based on clinic records. This is consistent

with Australian Bureau of Statistics 2001 census data,

which quote the median age for east Arnhem Land as

22 years with 34.1% of the population under 15 years

of age.15

Over the study period the health centre provided 24-

hour acute care services via six Aboriginal health work-

ers (AHWs), five Registered Nurses (RNs) and one

resident doctor (either a GP or a GP registrar). An AHW

is first on-call for all after-hours presentations and is

supported by either an RN or the resident doctor who

share the second on-call roster. The resident doctor was

therefore not expected to be involved in all evacuations

but was available as a third on-call in more extreme

emergencies. Patients requiring evacuation travel by

plane to either Nhulunbuy’s Gove District Hospital

(45 min flight time) or Royal Darwin Hospital (75 min

flight time). The community has a 24-hour accessible,

sealed airstrip. Despite this landings can be rendered

impossible in the monsoonal season (December–

March). The NTAMS has three bases in the Top End

with Beechcraft Kingair B200C planes on site at

Darwin, Katherine and Nhulunbuy. The Nhulunbuy-

What is already known on this subject :• Indigenous Australians are hospitalised

at higher rates than non-Indigenous

Australians with obstetric, injury and

respiratory illnesses being the most common

reasons.• There have been no known studies published

to look at the burden of acute illness

requiring evacuation to hospital from

remote communities.

What this study adds:• This study is the first in Australia to provide

a detailed descriptive analysis of aeromedical

evacuations to hospital from a remote or

rural primary health care setting.

• Children bear the greatest burden of acuteillness requiring evacuation to hospital.

• Remote health centre resources are

considerably stressed to meet the acute care

needs of the community.

TABLE 1: Age breakdown of an east Arnhem community

based on clinic records

Age group (years) No. % Cumulative %

Under 5 412 14.6 14.6

5–9 388 13.8 28.4

10–19 513 18.2 46.6

20–29 538 19.1 65.8

30–39 417 14.8 80.6

40–49 291 10.3 91.0

50–59 150 5.3 96.3

60 and older 104 3.7 100.0

Total 2813 100



272 D. PEIRIS ET AL.


based NTAMS performs the majority of evacuations

with a small proportion of ambulant, self-caring

patients evacuated to hospital using daytime chartered

or routine passenger commercial flights.

When an evacuation is contemplated health centre

staff consult the District Medical Officer at Gove Dis-

trict Hospital who assesses the suitability and priorityfor evacuation. The NTAMS frequently needs to coor-

dinate evacuations from multiple remote communities

and this impacts on the waiting time to pick-up. A flight

nurse attends all evacuations and a flight doctor attends

more severe cases. Occasionally Darwin-based specialist

staff are required, particularly for paediatric and obstet-

ric emergencies.

Data collection and analysis

The health centre routinely records data on aeromedical

evacuations. A de-identified version of these existing

data was used to undertake this study. No additionaldata collection or interviews were performed. Written

consent to perform the data analysis was obtained from

the community council and the health centre manage-

ment. Analyses were conducted using SPSS version 12.0

statistical software (SPSS Inc., Chicago, IL, USA).

Results

There were 410 aeromedical evacuations recorded

between February 2003 and August 2005 representing

an average of one evacuation every 2.2 days. Most evac-

uations (84%) were performed by either the Gove- orDarwin-based NTAMS team with the remainder trans-

ported to hospital via either a chartered commercial

aircraft or the routine passenger plane. Sixty-eight per

cent of evacuations were to Gove District Hospital and

32% to Royal Darwin Hospital.

The majority of evacuations (86%) involved the

transfer of one patient. The majority (88%) of patients

were evacuated only once during the study period. A

small number (n = 9) were evacuated three or more

times – the most common reason being missed renal

dialysis. Taking into account patients who were evacu-

ated more than once, on average 6.5% of the commu-

nity required acute transfer to hospital every year.

Gender representation was roughly equal in all adult age

groups except for the 20–29 years group where 74% of

people evacuated were women and in the 30–39 years

group where 61% evacuated were men.

Figure 1 shows the age distribution of the evacuated

population. Overall, this population was significantly

different to the non-evacuated population (χ2 = 189.7

with seven degrees of freedom P < 0.001). Adjusting for

people evacuated multiple times, the under five years age

group were 3.3-fold overrepresented in evacuations

(comprising 37.7% of all evacuations despite constitut-

ing only 11.3% of the community). This overrepresen-

tation was highly significant (χ2 = 173.4 with one degree

of freedom P < 0.001). The median age for evacuation

was 18.3 years.

Figure 2 shows that a seasonal trend was observed

with an increase in evacuation rates over the monsoonal

period from late December to March.

Diagnostic categories

Table 2 below outlines the diagnostic categories for

evacuations over the study period. In the respiratory

group 53 of the 85 evacuations (12.9% of all diagnoses)

were children with bronchiolitis or pneumonia. All chil-

dren had moderate-to-severe respiratory distress with an

oxygen requirement. Adult pneumonia, chronic

obstructive pulmonary disease and asthma exacerba-

tions accounted for the remaining 32 cases. In the

FIGURE 1: Age distribution of patients evacuated to hospi-

tal from an east Arnhem community 2003–2005.

0

20

40

60

80

100

120

140

160

Age group (years)

N u m b e r o f e v a c u a t i o n s

Under 5 5–9 10–19 20–29 30–39 40–49 50–59 60 or over

FIGURE 2: Seasonal variation in aeromedical evacuations

from an east Arnhem community February 2003–August

2005.



REMOTE AREA AEROMEDICAL EVACUATIONS 273


obstetric group 52 of the 62 evacuations were for labour

(12.6% of all diagnoses). The majority of these labours

(63%) were preterm. Eleven women delivered term

babies in the community prior to departure to hospital.

In the ‘gastroenteritis and failure to thrive’ category

almost all patients had moderate-to-severe dehydration.

Two children required intraosseous needles inserted for

fluid resuscitation. In the trauma group 17 patients had

major trauma with a further 17 having upper limb frac-

tures. Eight patients were evacuated for potentialenvenomations (either jelly fish stings or snake bites).

Over the study period four patients (three adults and

one child) were intubated and ventilated at the clinic.

The conditions requiring intubation were status epilep-

ticus, myocardial infarction with a ventricular fibrilla-

tion arrest, severe pneumonia and severe bronchiolitis

with febrile convulsions.

Utilisation of staff resources

Eighty-five per cent of evacuations required a combina-

tion of staff to provide care to the patient. RNs were

involved in 80% of evacuations, doctors in 64% of

evacuations and AHWs in 63% of evacuations. Eight

per cent required aeromedical or specialist staff to pro-

vide care on site prior to evacuation. The waiting time

between the decision to evacuate and actual evacuation

ranged from one hour to 21 hours with a median wait

time of three hours. Sixty-six per cent of evacuations

had wait times less than four hours, 28% between four

and eight hours and 6% beyond eight hours. In 53% of

evacuations the majority of clinical care took place in

normal working hours, in 31% of cases some care took

place between 17:00 hours and midnight and 16% of

cases required care after midnight.

Discussion

The provision of primary health care in remote

Australian Indigenous communities presents unique

challenges for health practitioners. Wakerman defines

remote area practice as one characterised by:

… isolation which is geographical, social and profes-

sional; a small dispersed and highly mobile popula-

tion; climatic extremes; high population morbidity

and mortality; an extended practice role; a strong

multidisciplinary approach and cross cultural issues

affecting practice and everyday life.16

Aeromedical evacuations in remote settings epitomise

these characteristics. With an evacuation occurring just

over every two days on average, this study highlights

the significant impact of providing high-level acute carein a remote, primary health care setting.

The prominence of respiratory, obstetric, gastrointes-

tinal and injury/poisoning-related conditions in the

diagnostic breakdown of our study concurs with the

available national data on hospital separations for

Indigenous people. Like the national data, cardiovascu-

lar conditions accounted for only a small proportion of

evacuations despite there being a high burden of these

diseases and their risk factors in this community.17,18

Children aged under five years bore the greatest burden

of acute illness requiring hospital admission (especially

due to gastroenteritis and bronchiolitis). Our study sup-ports national findings that young Indigenous children

are hospitalised at higher rates than non-Indigenous

children. Although the high childhood evacuation rates

might appear grim news it might be one of the most

significant contributions to reductions in Indigenous

infant mortality. Prompt treatment and evacuation of

children with gastroenteritis now makes deaths from

this condition exceedingly rare. As gastroenteritis and

bronchiolitis tends to occur in outbreaks, primary

health centres need to be adequately equipped and staff

appropriately trained during these times. Staff in this

study can expect to see at least one child present with

life-threatening respiratory distress or gastroenteritis

every year. Anticipation of these occasions can greatly

alleviate the stress of providing care in extreme circum-

stances. Similarly clinic staff at this community can

expect to be regularly providing care for women in

labour (particularly preterm labour) and the delivery of

around four babies each year. This occurs despite NT

health department policy to evacuate all antenatal

women to hospital for delivery. Once again this has

implications for staff training. Over the study period the

community was fortunate to have excellent health cen-

TABLE 2: Diagnostic categories for evacuations to hospital

from an east Arnhem community 2003–2005

Principal diagnostic group Frequency %

Respiratory 85 21

Obstetric 62 15

Gastroenteritis/failure to thrive 59 14

Injury/poisoning 44 11

Neurological 25 6

Renal 18 4

Cardiac 15 4

Mental health 14 3

Infectious disease 13 3

Other GIT 12 3

Haematological 8 2

Rheumatological 8 2

Other 47 11

Total 410 100

GIT, gastrointestinal tract illness.



274 D. PEIRIS ET AL.


tre staff with the necessary skills to provide a high level

of acute care. Low staff turnover rates, weekly scenario-

based education sessions, regular in-services in Darwin

and Nhulunbuy and a health centre policy that requires

a midwife to be available at all times have been factors

that contributed to this high level of care.

This study showed the NTAMS to be prompt inresponding to patient needs with two-thirds of requests

for evacuation responded to in less than four hours.

Despite this, staff must be prepared to manage acute

illness for many hours at a time especially for the 47%

of evacuations that occurred after hours when there was

less staff support and waiting times were longer. This

high after-hours utilisation of staff has a significant

impact on planning and allocating resources for other

clinic activities. Although the study period was only two

and a half years a seasonal trend was observed that could

also be useful for health centre planning. Staff can expect

to be busier in the monsoon season months and conse-

quently might recruit extra staff and/or downscale otherclinic activities during these months. Similarly the drier

months might be more opportune for expanding other

clinical programs or allowing more staff to take leave.

This study is the first known in Australia to look at

the impact of evacuations to hospital on a remote pri-

mary health centre. More work is required to see if the

observations and trends highlighted here remain consis-

tent over time. Comparison with other communities

would also provide a more comprehensive picture.

Several factors have been raised that can be useful for

health centre planners to meet the considerable burden

of acute care in similar settings.

Acknowledgements

Sincere thanks to the staff at Ngalkanbuy Health

Centre. Statistical advice was given by Dr Petra

Macaskill and Mr Kevin McGeechan. Jane Ryan and

Tony Parsons from the RACGP library assisted with the

literature review. Drs John Setchell and Didier Palmer

provided valuable information on aeromedical services

research in the Northern Territory.

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Aeromedical Evacuations