Wednesday morning Derby Hospital doctors, and DAHS doctors met with the Royal Flying Doctor Service (RFDS) doctors for our monthly case review. This month we discussed the care and transport of victims of a rollover accident 40 km outside of Derby. The RFDS doctors were particularly interested in talking to us about patient transport from their perspective, so we may better understand what to expect when we call for a "Miracle Flight".

First, let me say again that Western Australia is BIG. It is hard to convey how big it is in words. This map may help (click on it for better resolution):
It is about 2300 Kilometers from Derby to Perth. This is about the same distance as from Chicago to Phoenix, AZ in the U.S. From takeoff in Broome, on a jet, it is a good 2+ hour flight time (and we always have an in-flight movie!)

Now the RFDS does not have jets. (I'll get to that below). They fly twin prop Beechcraft Kingairs or similar planes. The planes are fitted to take one very high needs patients (e.g. unstable, ICU level, ventilated, etc.) or sometimes two stretchers stacked up if both patients are lower care level.

The facts about evacuation from Derby:
• Best in-air time from Derby to Perth is 4.5 hours.
• However, at least ONE refueling takeoff and landing is required.
• With load-up and offload times at each end, minimum evacuation time door to door from Derby Regional Hospital to Perth hospitals is thus 8.5 hours.
• However, if the patient must be transported at "sea level" cabin pressures, this means the pilot must follow the coast, because inland airstrips are over 1000 metres altitude. Low level flights have much lower airspeeds and a longer route. This means up to 3 to 5 refueling stops. These flights may take from 12 to 15 hours.
• BUT the CASA rules (based on sound science) only allow pilots to fly up to 12 hours (14 hours if in the middle of a "mercy flight"), then they need a 12 hour rest break.
• There are only two pilots and two planes at Derby base right now.
• Often they try to coordinate a swap of pilots or planes by having a crew fly up from the south and meet them halfway, usually at Meekathera, which is about 1000 km from Derby. This can only happen if there is another crew available from one of the other RFDS bases.
• Thus, if an evacuation leaves the Kimberly, the doctor and crew are usually gone for 30 hours.
• Right now there are only two RFDS doctors at the Derby base.

In the case of the local rollover accident, there were 7 injured persons. One was very minor, 3 required hospitalization here in Derby, and 3 ultimately required evacuation to Perth for a variety of serious injuries. One of those patients was hemodynamically unstable (i.e. could not maintain blood pressure and circulation well). As you can imagine, this presented a serious triage and transport problem.

The situation would not be so serious if the Kimberly hospitals were not so under-resourced. Despite the name, "Derby Regional Hospital", the designated regional hospital for the area is in Broome, 220 km away. Derby is supposed to have a full-time surgeon on site, and a full-time OB/Gyn. Since I have been here we have had neither, and I understand this is not unusual. The gap has been plugged by hiring locums surgeons who come for 2-3 days every month. Clearly this is OK for booking elective procedures like tubal ligations or circumcisions; but it does nothing to help deal with trauma, which is quite common in the Kimberly. So the local GPs do the best they can. (We do have 2 "GP-OBs" who can do C-sections, assisted by the 2 "GP-anesthetists".) But if someone comes in bleeding internally, there is only one surgeon in the Kimberly, and he is in Broome and quite overworked as you can imagine. With 27,000 people in the West Kimberly, one surgeon is hardly sufficient.

There may be many reasons why there are no surgeons based in this remote town. Lack of amenities, schooling opportunities for kids, family distances, lack of career opportunities for spouses- in fact, all the factors that make it hard for any rural community to attract doctors are all in play here. But one factor is fixable and that is reimbursement. I heard on arrival here that the Hospital lost the opportunity to hire a 1-year locums OB/Gyn over a difference of a few thousand dollars. This type of funding problem has a measurable impact on access to services for the community. The current referral wait time for a colposcopy (follow-up test) for a pap smear showing pre-cancer cells is over 4 months. A general surgeon here in Derby would be quite busy with not only elective surgery, but regular cases of wound care, abscesses, orthopedics and fractures, appendectomies, and could provide some roster coverage for Cesareans, spreading the load out and making it easier to recruit GPs.

Our discussion with RFDS was originally supposed to be a review of the decision to evacuate the unstable patient to Broome first for stabilization, before moving on to Perth. But is developed into a wide-ranging discussion among the doctors about everything from communications problems, to triage, to community barriers to seat belt use (its hard to buckle up when you are riding in an overloaded 1970s vintage ute that barely has seats). We discussed RFDS needing jets, but that is really not the answer. For one thing, it does not solve the pilot rest problems very well. But the bigger problem is that it requires a quantum leap in support staff and services, including technicians who can maintain jet engines. This is a big issue in country with severe labor shortages, and especially a problem in the Kimberly. For example, there is only 1 licensed plumber for Derby and the West Kimberly, and great concern over his upcoming retirement.

I have suggested that we doctors as a group compose a letter to the Minister of Health for Western Australia, expressing our concerns over the lack of manpower in the area hospitals. Certainly the more things we could handle locally, the easier triage and transport would become for RFDS. And this would be a better use of current infrastructure and local funds. (Maintaining a trained surgery support staff costs money no matter how often they are used.) We will see what becomes of it.

For myself, I am going to be very careful not to hit anymore cows.