Ambulances & Vehicle Ops, Operations, Patient Care

Australia’s Royal Flying Doctor Service is the World’s Largest Aeromedical Response Service

Issue 4 and Volume 40.

Covering a land mass of 2,969,907 square miles, Australia is slightly smaller than the 3,119,885 square-mile area covered by the contiguous United States and Great Lakes. The distances east to west across both the U.S. and Australia are also similar. In addition, both are First World countries with modern healthcare systems.

Further, Americans and Australians have an expectation of high-quality healthcare, and the transport of injured patients and those suffering acute illness are integral to their healthcare systems.1

A major difference between the two countries, however, is that the population of Australia is far less than the population of the U.S.—23.6 million compared to 316.2 million. In fact, the population of Australia is slightly less than the 26.5 million who live in Texas.

Most Australians live near the coast, primarily in one of six cities, with the consequence that the Australian Government Institute of Health and Welfare categorizes most of Australia as either “remote” or “very remote.”2

These vast distances and sparse populations provide the Royal Flying Doctor Service (RFDS) with particularly interesting challenges for the provision of aeromedical response and retrieval across the immense Australian land mass, which includes the majority of mainland Australia, Tasmania, and smaller island communities including Christmas Island and the Cocos Islands.

The concept of the RFDS was first proposed by the Reverend John Flynn in 1918. He envisioned a medical service that would provide a “mantle of safety” for people living in the geographically remote and often environmentally hostile Australian country.3

Two RFDS Pilatus PC-12 aircraft offshore over Rottnest Island. Photo courtesy Royal Flying Doctor Service

 

Delivering Care in the Outback

The RFDS began operations in 1928 with a single aircraft based in the remote Queensland town of Cloncurry in northeastern Australia. The service has now grown to a fleet of 67 aircraft at 22 bases nationwide.

Delivering high-quality healthcare to the Australian Outback—as the vast areas of remote and very remote Australia are known—shares challenges with other remote areas worldwide. These include: a highly centralized health system primarily within cities; very limited health infrastructure throughout most of the Outback; few health resources available on the ground and even fewer medical specialists; small populations in isolated settlements; indigenous communities with unique health challenges; itinerant mobile communities associated with mining, oil and gas exploration, cattle ranching, or fishing; the inherently dangerous nature of these industries; and increasing demand for healthcare including aeromedical retrieval as these industries grow.

In order to meet the aeromedical retrieval needs presented by these challenges, the RFDS utilizes a “donut” model of retrieval. Helicopters are used in and around major metropolitan centers whereby patients suffering acute illness or trauma can be reached quickly, stabilized and transferred to definitive hospital care. Beyond a radius of approximately 130 miles, fixed-wing aircraft are used to retrieve patients. At this distance, the faster flying speeds and greater payloads of fixed-wing aircraft tend to exceed the advantages afforded by the ease of take-off and landing (without the need for an airstrip) provided by helicopters.4

In particular, the greater payload of fixed-wing aircraft allows for a larger medical team plus a larger quantity of medical equipment to be brought to the patient in order to extend hospital-level care to the patient.

The effectiveness of this model has been proven in the U.S. by a comparison of in-hospital mortality for patients transported to a trauma center within a city with those transported up to 800 miles by fixed-wing aircraft. No differences in mortality were identified.5

The effectiveness of this model has been proven in Australia through a comparison of the risk of death from major trauma in rural and remote areas being found to be more than double that of metropolitan populations. Yet if a patient survives to be retrieved to a major metropolitan center by the RFDS, their mortality rates are equal to people living in the metropolitan area.6

The interior of the PC-12 showing stretchers for two patients and seating for two medical crew. Photo courtesy Royal Flying Doctor Service

 

Aircraft

The aeromedical retrieval resources of the RFDS include 31 Pilatus PC-12 and 34 King Air B200/B350 fixed-wing aircraft. The interiors of these aircraft have been transformed from the normal configuration to an intensive care configuration to allow the medical team to conduct surgical, intensive care and obstetric procedures while the aircraft is on the ground or in flight.

These 65 turboprop aircraft are the mainstay of the RFDS. Configured to handle two patients, each have comprehensive medical interiors inclusive of integrated oxygen piped to standard medical outlets and high-level suction piped to standard medical suction inlets. Aircraft DC and domestic AC electricity is provided to power medical equipment.

Additional features include special cabin lighting, stretcher loading devices and an extended intercommunication system to include two-way communications between all medical staff and the flight crew. In addition to the standard aircraft VHF and HF radios, each aircraft is equipped with a satellite telephone and specialist radios.

The aircraft can maintain a pressurized cabin equivalent to sea level, which makes the aircraft particularly useful for patients with conditions sensitive to changes in atmospheric pressure (e.g., penetrating eye injuries).

The ability of the Pilatus PC-12 to cruise at speeds of 280 mph at an altitude of 25,000 ft., and the King Air B200 to cruise at speeds of 320 mph at an altitude of 31,000 ft., enables rapid movement of patients and medical teams and provides the opportunity for pilots to navigate around large weather systems common to Australia.

Most importantly, these aircraft are able to land on Outback airstrips and roads, which optimizes the speed with which the aircraft can deliver medical teams to patients in need of care.

The RFDS fleet also includes a Hawker 800XP Life Flight Jet with medical, oxygen, suction, power and communication capabilities similar to other RFDS fixed-wing aircraft. This jet has the capacity to carry three patients on stretchers plus three seats, or two patients on stretchers plus five seats. The seats are available for similar configurations to other RFDS aircraft and a neonatal cot can be fitted to cater for seriously ill infants.7

The Life Flight Jet cruises at speeds of 460 mph at an altitude of 39,000 ft. This jet’s speed, together with the distance that can be covered without the need to refuel, make this aircraft particularly valuable for responding rapidly and effectively to mass casualty incidents.

This jet has become invaluable for aeromedical retrievals from very distant locations within mainland Australia and offshore locations, including the Cocos and Christmas Islands that require round-trip retrievals with overwater distances of up to 3,250 miles.

In addition to the RFDS’ fleet of aircraft, it’s often necessary to utilize helicopters for aeromedical retrievals within a 130-mile radius of a major medical center, or when the patient is located within inhospitable terrain, or on a cruise ship or offshore oil or gas rig.

Float planes are also used to access remote fishing communities or offshore facilities. If all aircraft are tasked or a jet is required and the Life Flight Jet is already tasked or undergoing maintenance, additional fixed wing turboprop or jet aircraft are chartered.

Interior of the Life Flight Jet showing the configuration for two stretcher and three sitting patients. Photo courtesy Royal Flying Doctor Service

 

RFDS Medical Crews

The typical medical crew on a fixed-wing aircraft comprises a doctor and nurse. All RFDS nurses are experienced with emergency care and are also qualified midwives. RFDS doctors are experienced in a variety of medical areas, with many being emergency physicians or anesthesiologists. The typical medical crew for rotary wing aircraft is a doctor and paramedic.

Phone or radio calls are received in a coordination center and transferred to a retrieval doctor. The retrieval doctor prioritizes urgency and determines the patient’s clinical needs. Calls are categorized by priority as follows:

Priority 1 is a life-threatening, time-critical emergency (e.g., a patient with ruptured aortic aneurysm or myocardial infarction at a remote location). The aircraft and crew will depart rapidly from the base nearest to the patient.

Priority 2 is an urgent medical transfer (e.g., a patient experiencing pre-term labor or acute abdominal pain).

Priority 3 patients are often seriously ill, but time isn’t a critical factor in their care (e.g., acutely disturbed mental health patients who may be heavily sedated). These patients are accommodated as soon as possible, yet are dependent on more urgent priority 1 and 2 patients preceding them.

A mercy flight can be called if a patient requires unusual aircraft activity that would otherwise contravene federal aviation regulations. For example, the patient location may require an aircraft to land on a road, or time constraints may require a pilot to exceed their regulation number of flying hours.

An RFDS Pilatus PC-12 aircraft attending a vehicle rollover during a mercy flight emergency landing on a road in remote North West Australia. Rollovers are all-too-common in remote locations where the high speeds of vehicles combine with driver fatigue. Photo courtesy Catarina Widing, MD

 

Patient Diagnoses

Typical patient diagnoses for the RFDS are summarized in Table 1. Patients suffering from injury or poisoning comprise approximately a quarter of all aeromedical retrievals.

Trauma, often multi-trauma, occurs largely because of the inherently dangerous nature of work-related activities undertaken in remote and very remote areas, or as a consequence of mishaps while traveling in a hostile environment. Transport of these patients to the nearest trauma center has been found to have a considerable positive impact on patient mortality, conservatively increasing survivability by 25%.8

Australia is a country with a well-deserved reputation for having a large number of poisonous reptiles and invertebrates. Consequently, envenoming is sufficiently serious to require aeromedical retrieval to definitive care for a significant number of patients.

By far the most common acute illness is cardiovascular disease, and patients with this illness represent approximately one-fifth of retrievals.

Pregnancy and childbirth are also significant diagnoses. Although routine pregnancy and childbirth is usually cared for by government healthcare providers, the RFDS is called in for unusual or complex complications with pregnancy and childbirth.

Illnesses of the digestive system account for 10% of patient diagnoses. Also accounting for 10% of retrievals are unusual symptoms, signs and abnormal findings. These are particularly challenging for an aeromedical retrieval service and require careful judgment and prioritization.9

Other diagnoses include respiratory and genitourinary illnesses; psychological and behavioural disorders; infectious and parasitic diseases; musculoskeletal, neurological and neoplasms; skin and subcutaneous conditions; perinatal, endocrinological, nutritional and metabolic conditions; haematological, immune and congenital illness; and conditions affecting the eye and eye adnexa.

Table 1: Number and proportion of diagnoses for patients of the RFDS Western Operations Section, July 2013—June 2014

Aeromedical Retrieval Minimization

The RFDS has developed and adapted a number of strategies for minimizing the need for aeromedical retrieval. These strategies afford multiple advantages: providing immediate care to patients; reducing the need for patient retrieval; aiding in the management of chronic illnesses and therefore preventing these illnesses from deteriorating into acute medical conditions; reducing the disruption patient evacuation causes to the families of patients (particularly within the communities of Indigenous Australians); and extending primary healthcare to remote and very remote locations.

Telehealth & medical chests: The RFDS pioneered telehealth within Australia in 1929 by distributing radios to isolated communities. With the invention of a pedal-powered generator, these radios were able to be distributed to locations too remote or too small to have electrical power. Patients, their care givers, and health workers were then able to contact the RFDS and obtain medical advice.

The RFDS also pioneered the distribution of specialized medical chests throughout Australia that contain a standardized supply of medical and first aid equipment as well as prescription drugs. Items within these chests are located within specific drawers and clearly marked with explicit numbers corresponding to a chart. Copies of this chart are distributed with each chest, and are available at all RFDS bases and on RFDS aircraft. There are currently 2,600 RFDS medical chests distributed in remote, very remote, or offshore locations. Each chest is registered to a particular location and to a particular custodian who’s responsible for chest security and usage.

The chests include injectable, oral and topical medications. During telehealth consultations, doctors instruct patients or their care givers about what items should be used from the chest and how they should be used. This is important to ensure the right dose of the right drug is administered to the right patient via the right route at the right time. Use of prescription drugs is authorized by a doctor via radio or phone using a system of consultation codes. These codes also allow the RFDS to monitor the usage of chest items and assists with restocking.

The combination of these medical chests and telehealth consultations via radio, phone, satellite phone and, more recently, via video conference is a powerful strategy by which critical, acute and chronic care can be supported.

The outcomes of RFDS telehealth vary from providing reassurance to a patient or their caregiver, providing guided care to a patient, launching a medical team to attend the patient on scene, or undertaking an aeromedical evacuation. The timely use of telehealth and medical chest resources is often sufficient to sustain a patient while aeromedical retrieval is launched until medical care can reach the patient.

Clinics: RFDS clinics bring healthcare to remote and very remote locations, treat chronic illness and follow up with patients who may have recently been repatriated following aeromedical retrieval. Depending on the remoteness of the location of the clinic to an RFDS base, the clinic medical staff and equipment may be flown to the patient’s location or transported in a 4×4 vehicle.

If a fly-in clinic is required, this is usually undertaken using a chartered non-RFDS aircraft to allow the medically equipped RFDS aircraft to continue their primary role of aeromedical retrieval.

Although these clinics are principally operated to provide healthcare to the patients who use these services, a direct consequence of these clinics is to reduce the incidence of acute illness, to reduce the incidence of chronic illness deteriorating to a heightened medical condition, and to educate potential patients about optimizing their health. In turn, this leads to a reduction in the need for aeromedical retrievals.

Table 2: Summary of RFDS annual activity, July 2013—June 2014

Case Load

RFDS annual and daily case loads are summarized in Table 2 for July 2013 through June 2014.10 During this 12-month period, the 67 aircraft of the RFDS transported 54,705 patients, averaging 148 patients per day. The RFDS held 16,096 healthcare clinics and conducted 82,305 telehealth consultations. RFDS aircraft flew a total of 16.4 million miles, averaging 44,961 miles per day—equivalent to a journey to the moon every 10 days.

Funding

Perhaps the most surprising factor about the RFDS is that it’s a nonprofit charity. Whereas the service receives funds from federal and state governments for the provision of some discrete health-related services, aeromedical retrieval is funded through charitable donations. Patients requiring retrieval due to trauma or illness receive this service free of charge.

A custom-equipped 4×4 RFDS vehicle used to provide health clinics in remote and very remote areas. Photo courtesy Royal Flying Doctor Service

 

The Future

Within mainland Australia and the offshore islands and facilities covered by the RFDS, the demand for aeromedical services is growing. Increased mining, oil, gas, agriculture and tourism are bringing a larger population to what will remain remote and very remote locations for the foreseeable future.

The growth in demand for the RDFS is leading to the development of valuable new equipment and medical techniques, and to the evolution of existing equipment and clinical procedures. Of particular importance are advances in aeronautical technology that allow jets the capability to land on bush airstrips.

The RFDS will be acquiring these aircraft in 2017 to increase the speed with which medical care can be brought to patients and the speed with which patients can be retrieved to definitive care.

Advances in telehealth will also likely see the traditional radio, phone and satellite phones replaced with reliable audiovisual media and computerized apps, and easily transportable devices that will be able to provide valuable clinical information to a medical advisor over long distances. There’s also the promise of nanotechnology.

These advances, plus the wealth of experience gained by the RDFS over its 86-year history, will allow this advanced aeromedical service and many others around the world to better implement aeromedical and healthcare response plans to better serve rural and remote populations.

References

  1. Isakov A. Urgent air-medical transport: Right patient, place and time. CMAJ. 2009;181(9):569–570.
  2. Australian Institute of Health and Welfare. (2013.) Remoteness classifications. Retrieved Nov. 11, 2014, from www.aihw.gov.au/rural-health-remoteness-classifications.
  3. The Royal Flying Doctor Service of Australia. Brit Med J. 1961;1(5229):897–898.
  4. Thomas F, Wisham J, Clemmer TP, et al. Outcome, transport times, and costs of patients evacuated by helicopter versus fixed-wing aircraft. West J Med. 1990;153(1):40–43.
  5. Valenzuela TD, Criss EA, Copass MK, et al. Critical care air transportation of the severely injured: Does long distance transport adversely affect survival? Ann Emerg Med. 1990;19(2):169–172.
  6. Fatovitch D, Phillips M, Langford S, et al. A comparison of metropolitan vs. rural major trauma in Western Australia. Resuscitation. 2011;82(7):886–890.
  7. Langford SA. The first medical jet aircraft for the Royal Flying Doctor Service. Med J Aust. 2009;191(11–12):609–610.
  8. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. New Engl J Med. 2006;354(4):366–378.
  9. Duchateau FX, Verner L, Cha O, et al. Decision criteria of immediate aeromedical evacuation. J Travel Med. 2009;16(6):391–394.
  10. Royal Flying Doctor Service. (2014.) RFDS statistics 2013/2014. Retrieved Nov. 5, 2014, from www.flyingdoctor.org.au/About-Us/Facts–Figures.