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Retrieval Medicine
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Retrievals & Transfers
‘On retrievals, no one can hear
you scream’
A multiple choice question
• C Cylinder: 440L• D Cylinder: 1600L• E Cylinder 3800L
Barometric Considerations• Oxygen: PaO2 60mmHg at 5000 ft• Gas expansion: 1/3 at 5000 ft
– ETT cuffs– Entrapped gas in body
• Equipment
Preparing• General principle is to increase the level of
care• Pre flight preparation decisions are based
around dealing with the consequences• Communication with the transferring and
receiving hospital is essential• Documentation is vital
Mode of Transport
Choice of Mode
• Distance (Transit and Transfer)
• Escort requirements• Geographical considerations• Availability & resources
Private Car & Commercial Aircraft
• Non urgent problems
• Usually no escort requirements
Road Ambulance
• < 200km from Regional Centre or Tertiary Centre
• Volunteer / paramedic skill set• Local depletion of critical
resource• Can stop
Cervical Spine Immobilization Pre RFDS Arrival
RFDS WA
Requesting a transfer1800 625 800
Operator for basic details
Retrieval doctor for clinical details.
Prioritises and determines crew and flight parameters.
Advises on management and preparation for flight.
Liaises with receiving hospital including bed finding.
Tasking, fuel, hours, vermin checks, logistics.
Clinical Coordinator
RFDS Operations Centre
5 RFDS Bases In WA
RFDS National Priorities (WA figures for 2009/2010)
• Priority 1 (n=557)– Life / limb threatening– “ One for One!” time of call to doors closed <60 mins
• Priority 2 (n=2987)– Urgent– Depart for patient within 4 hrs
• Priority 3 (n=2223)– “Routine” – within 48 hrs– Timeframe can be specified
The Fleet-Now All PC 12s
ICU in a phone box• All operations consistent with
Joint Faculty standards. Intensive Care Medicine
• Ventilators, Monitors with invasive pressures, ETCO2
• Blood Gases, electrolytes• Ultrasound• Transcutaneous pacing/12 lead
ECG• Infusion pumps.• O neg packed cells.• Time critical drugs, eg
antivenoms, digibind
The ideal sick patient
Paediatric ECMO
Some challenges
Poor preparation: Would you be happy to retrieve this ?
A bigger challenge
A solution but a problem prior
Would you have pushed or objected ?
If you would have pushed!
• RFDS has ACEM and Anaesthetic accredited terms
• One term has come up at short notice for next year
• Email [email protected] if interested
• (if you objected, join the radiology training program)
An unstabilizable patient: What priority, 1, 2 or 3 ?
Do you retrieve this patient?
The reality: Do you retrieve this patient?
The FESA chopper
Bell 412• Twin turbine medium lift helicopter• 1800 shp PT6T-3D Twin Pac engine• Crusing speed 130 knots (240 kph)• Single pilot IFR• Empty weight 3079 kg• Max take off weight 5398 kg• Useful payload 2200kg• 350 nm (630 km) range • Usually tasked within a 200km radius
Range
Broad Tasking Criteria
• Skill critical– Skills of RFDS MO/CCP
• Time critical– Time to tertiary hospital
• Access– No road, Rottnest, no airstrip, rescue requirement
• Resources– No fixed wing aircraft or other resources available
• Likely to improve patient outcome
Road v Helicopter
0 50 100 150 200
Helicopter
Road
To Hospital
Initial Resus
Waiting transport
Transport
Example of patient awaiting retrieval in Narrogin
)
Airway 1
Case presentation:Multi-casualty incident at SX
Major incident
• Defined by the need for extraordinary resources (location, number, severity, type of live injuries)– Natural vs. manmade– Simple vs. compound (infrastructure intact vs.
damaged)– Compensated vs. uncompensated (whether
additional resource mobilization sufficient)
Initial call19:33
Rescue 65tasking
RFDS informed
19:49
Rescue 65stood down
3 October 2012 15:50hrs:• RIO: Broome- JT• OWD: Albany- JT• OWI: JT- Margaret River• YWO: KG- Mount Magnet• OWG: Carnarvon- JT• OWQ:Marble Bar- PD• OWA: At JT• OWR: At KG• NWO: At PD• ZWO: At DBY
Call 19:49 Auth 19:52
Bunbury:Task 20:00 SX 21:37 JT 04:01
Jandakot:Task 20:18 SX 22:22 JT 01:31
Meekatharra:Task 21:00 SX 00:11 JT 03:16
Kalgoorlie:Task 00:35 SX 01:50 JT 03:21
(Bunbury patient)Task18:28BN20:00
Re-task22:00 PMH 02:58
Jandakot to SX:
740km round trip
• Bell 412: 10” + 3’50” = 4 hours (+ refuel)
• PC-12: 45’+ 1’50”+ 40” = 3 hour 15 min• 800XP: 1’30” + 55” + 1’ = 3 hour 25 min
4mo: Not walking – Is breathing – RR70 - 1yo: Not walking – Is breathing – RR40 – CRT <22yo: Not walking – Is breathing – RR603yo: Not walking – Is breathing – RR30 – CRT <24yo: Is walking25yo: Not walking – Is breathing – RR5032yo: Not walking – Is breathing – RR4035yo: Is walking62yo: Is walking63yo: Not walking – Is breathing – RR20 – P140
• P1• P2• P1• P2• P3• P1• P1• P3• P3• P1
TRIAGE SIEVE
WALKING
BREATHING
RESPIRATORYRATE
CIRCULATION
Breathing Restored after Airway Manouevre
Priority 3(Green-Delayed)
Priority 1(Red-Immediate)
Priority 2(Yellow-Urgent)
Dead(White/Black)
YES
NO
YES
NO NO
YES<10
>29
CRT 2 sec or more(PULSE 120 or more)
10 - 29
CRT <2 sec(PULSE <120)
Sieve & Sort
• P1• P2• P2• P2• P3• P2• P2• P3• P3• P1
RFDS coordination issues:
• Multiple aircraft at SX airfield• Infant on lap against CASA• OSD into coordination centre until 9pm- 3am• Hospitals kept ringing - annoying• Adequate resources• Tele Health doctor interaction
Discharge summaries:
4mo: Complex skull fracture with secondary seizures1yo: Skull fracture with extradural, diffuse axonal injury, #tib/fib2yo: Renal laceration3yo: # clavicle, scalp contusion4yo: Scalp laceration, cervical whiplash, abrasions25yo: Multiple rib fractures, pneumothorax, # humerus, #
metatarsals, # metacarpals, # TP L232yo: # 5th rib, pneumothorax, multiple lacerations35yo: # 1st metatarsal, multiple lacerations62yo: Abrasions only63yo: Abdominal wall hernia, multiple rib fractures, pneumothorax,
lung & splenic contusions, liver & renal lacerations, TP #’s of 5 scattered vertebrae, PIPJ dislocation
Questions ?