Flying Doctor Service Research Articles

Community-Based Advanced Practice Nursing (APN): The Road to Vision 2020

Malaysia is a heterogenous, multi-ethnic society with a population of 30 million, of which 74% reside in urban areas. Since gaining independence, the main priority of health policy makers is to provide and enhance the delivery of health care for the disadvantaged communities, namely the rural populations: women, children and the disabled. The Ministry of Health is the main healthcare provider in Malaysia. There has been much development in the healthcare system of Malaysia from the time of independence; starting from the development of the two-tier system and its subsequent transformation to a three-tier system, as well as the extension of healthcare delivery into rural areas in Sabah and Sarawak through the implementation of mobile teams and the Flying Doctor Service (FDS). The improvement in health status of the general population, particularly in rural settings is remarkable and in line with the Tenth Malaysian Plan on the road to Vision 2020. However, the current shift in disease burden from communicable to chronic non-communicable conditions continues to undermine these efforts. As a result, deficiencies in healthcare delivery and the health status of populations still exist, albeit more rampant in rural populations. We propose the implementation of Advanced Practice Nursing (APN) in the community as a solution to bridge gaps in health care provision in rural areas in line with Vision 2020. An advanced practice nurse is a specialty-specific registered nurse with an expert knowledge base and clinical competencies for extended practice. Modelled on Australian and Norwegian systems, advanced practice nurses are recruited directly from rural communities, with a better understanding of the population, and access to the local cultural norms, such as traditional healers. APN training is still in its infancy in many developing countries. Evidence from other similar models has proven that the care provided by specialised nurses results in higher patient satisfaction, greater access to health care, improved outcomes and cost effectiveness. APN compliment the care provided by physicians; reducing doctors’ workload, patient waiting times and providing care in the convenience of the patients’ homes. To succeed in improving health care outcomes by APN, the utilisation of evidence based practice, audits, guidelines, and escalation of specialist care at hospitals and continuous medical education are essential.

The Leading Edge: Innovation, Technology and People in Australia's Royal Flying Doctor Service

Health & History, 2016. 18/2 121 Book Reviews Stephen Langford. The Leading Edge: Innovation, Technology and People in Australia’s Royal Flying Doctor Service (Crawley: UWA Publishing, 2015). ISBN: 9781742588148. 414 pp. All too often, accounts of Australia’s Royal Flying Doctor Service (RFDS) are dominated by the first letter of the alphabet: angels and apostles, adventure and adversity, aeroplanes and airwaves. I’m therefore pleased to report that although The Leading Edge is punctuated by humour and humility, it flies in the face of the populist ‘heart-warming’ genre. The text itself is a curious but valuable hybrid. Stephen Langford joined the Western Australian (WA) RFDS as a recently qualified doctor in 1983, and has risen through its ranks over the ensuing decades. Although it could be loosely described as his memoir, this book is more akin to an extended and carefully structured oral history than an autobiography. There is no doubt that Langford is central to each of the numerous short chapters, citing where appropriate his role in implementing changes in policy or practice. However, rather than focusing on his personal or clinical experiences, the author foregrounds technological developments within Australia’s aeromedical evacuation services over the past thirty-five years. The book’s title is therefore doubly apt: The Leading Edge indicates both the forward part of an aeroplane’s wing and innovation in a broader sense. As such it outlines interlinked developments in aviation, communications, information technology, education, and medical devices; as well as their corollaries in clinical care, servicing remote communities, staff development, and bureaucratic benchmarking. Each chapter is concise, generally spanning two to ten pages, and often illustrated by short narrative episodes detailing an event, case study or shift in practice. The book is engagingly written and can enjoyably be read over several sittings. Moreover, it will continue to serve as a concise reference regarding changes to inflight cardiac care, for instance, or the transition from wireless radio to smartphones in remotely assessing medical emergencies. Focused on WA operations and equipment, but standing in more broadly for Australia-wide developments, The Leading Edge has value beyond its primary subject. Certainly the text details the specifics of aeromedical evacuation, be it time-distance-weatherfatigue calculations or the clinical impact of altitude on pneumothorax 122 BOOK REVIEWS cases. What historians will particularly value, moreover, is the book’s pragmatic assessment of new technologies upon medical practice, from pulse oximetry to humidicribs. Regarding the latter, for instance, Langford remarks wryly that ‘Further monitoring was added as it became fashionable and then replaced when something new arose’ (p. 177). Ever open to ‘leading edge’ ideas, he is equally quick to admit their limitations or redundancy. Indeed, precisely because aerial ambulances are so tightly constrained by space, weight, and ergonomics, RFDS practitioners carefully evaluate the cost-benefit ratios of numerous emergency care innovations. Their choices may help us consider wider priorities in acute care, ambulance services, military medicine, obstetrics and neonatology—or even regional health screening and immunisation programmes. In this vein, I would have welcomed an appendix outlining the range of carefully numbered pharmaceuticals provided in remote-area medical chests. It’s not unusual, for instance, that a casualty with a broken limb will be advised during an RFDS teleconsult to self administer opiates while an aircraft is despatched. Allowing for shelf life and temperature sensitivity, this carefully structured pharmacopoeia could reveal much about how efficacy has been balanced against predictability in selecting essential medicines for non-prescriber administration. The Leading Edge is neither a technical manual nor an encyclopaedia, and is generally the better for it. One downside is that although nurses, midwives and Aboriginal people all appear within the narrative, their perspectives are largely marginalised. Conversely, Langford is quite specific about the choice, cost, and use of medical devices, aeroplanes, satellite phones, and software packages, including their operational idiosyncrasies. Such details can help us—both now and in the future—to reconstruct the embodied practices of late twentieth-century flying doctors and, to a lesser extent, the experiences of their patients. Likewise, sections on training, accreditation, record-keeping, and fundraising are important in understanding the wider systems necessary to sustain a complex health care entity such...

A Ketamine Protocol and Intubation Rates for Psychiatric Air Medical Retrieval

ObjectiveThe air medical transfer of psychiatric patients with acute agitation is a regular requirement in only a few countries, with ours (Australia) being one of them. The optimal strategy has yet to be well described, ranging from physical restraints to general anesthesia with endotracheal intubation. In an Australian air medical service, Royal Flying Doctor Service (Queensland Section) rates of endotracheal intubation required for patient management were retrospectively compared before and after implementation of a ketamine sedation protocol for this patient population. MethodsA systematic retrospective review was performed using 9 years of data included in the Royal Flying Doctor Service (Queensland Section) electronic database (2004-2013). Coding for mental health as the primary diagnosis and intubation were the search criteria. ResultsA total of 1,478 patients were transferred during the study period, with 44 requiring intubation. This equates to intubation rates of 3.5% before protocol use compared with 2.3% after protocol implementation. ConclusionIn an Australian air medical service, the implementation of a ketamine sedation protocol for the management of the acutely agitated patient requiring air transfer has reduced the number of intubations in this patient group.

People living in remote communities can have best-practice diabetes care

S Kirby, M Moore, T McGarron, P Johnstone, D Perkins, D Lyle Broken Hill University Department of Rural Health, Broken Hill, New South Wales, Australia Broken Hill Base, Royal Flying Doctor Service, Broken Hill Airport, New South Wales, Australia Tibooburra Health Service, Tibooburra, New South Wales, Australia Centre for Rural and Remote Mental Health, University of Newcastle, Bloomfield Campus, Orange, New South Wales, Australia

TRAUMA CARE: HIGHLY DEMANDING, TREMENDOUS BENEFITS

TRAUMA CARE: HIGHLY DEMANDING, TREMENDOUS BENEFITS

The impacts of withdrawal and replacement of general practitioner services on aeromedical service trends: a 13-year interrupted time-series study in Tennant Creek, Northern Territory

BackgroundThe Royal Flying Doctor Service (RFDS) provides aeromedical care to patients during fixed-wing transport over vast distances to healthcare unavailable in rural or remote communities. This study examined the relationship between changes in local accessibility to primary healthcare services and rates of aeromedical service use over time.MethodsThis was a 13-year interrupted time-series study (1999–2012) in Tennant Creek, Northern Territory. Quarterly aeromedical service use for primary care sensitive conditions were calculated and exposure to general practice (GP) services was characterised over time with events modelled as intervention variables: (a) GP service withdrawal (Nov-2004); and (b) GP service replacement (Dec-2006). Intervention effects were estimated using PROC ARIMA in SAS after examination of the time-series structure.ResultsGP withdrawal resulted in an immediate and sustained doubling in quarterly aeromedical service use (+11.8 services per quarter) and GP service replacement had no significant effect.DiscussionLarge and immediate increases in aeromedical service use result from the loss of local GPservices yet, in this case, replacement with a new GP service, 2-years hence, did not ameliorate that effect after six years.ConclusionsThese findings demonstrate the immediate impact of GP-service loss on the rates ofaeromedical transfer of patients from this remote community and lend caution to expectations about thetimeline over which newly implemented primary health care services in such contexts can mitigate the impact of such a loss.

Nursing Tales – Personal Reminiscences of Sexual Health Nursing in the Twentieth Century Ward Madelaine Nursing Tales – Personal Reminiscences of Sexual Health Nursing in the Twentieth Century 143pp £10 Bound Biographies 978 1 9051 7868 1 1905178689

Author Madelaine Ward qualified in London in 1968 and was a staff nurse before joining the Zambian Flying Doctor Service and later working for a time in Texas.

E-Health readiness in outback communities: an exploratory study

E-health has been a recurrent topic in health reform, yet its implementation, ultimate role and feasibility are yet to be clearly defined. Organisations such as the Royal Flying Doctor Service South East Section (RFDS SE) are in a position to utilise technology to enhance the effectiveness of existing clinical services for remote communities. The study aim was to explore the readiness of the remote population of far-west New South Wales, Australia, and RFDS SE as a monopoly service provider to take up e-health innovations. A convenience sample of patients sequentially attending 15 remote fly-in clinics conducted by RFDS SE medical officers were invited to participate in a semi-structured telephone survey using an established survey tool to gather quantitative and qualitative data. RFDS SE health staff and managers were also surveyed. The overall core-readiness to embrace new e-health technologies was at a moderate level; barriers were mainly technical competence and technology availability. Enablers were willingness to learn and engage. The majority of patients did not feel isolated and had their health needs met; albeit there was interest in change if this improved outcomes. Video consultations for mental health and access to specialists were particularly welcome, although responses also indicated concern that video links might replace existing face-to-face services. Health staff saw the need for new technology to assist in healthcare provision but technology availability and support were flagged as key points. Organisational views as elicited from managers identified internal needs for workplace readiness to assist with adoption of new technology. Patients, healthcare providers and RFDS SE as an organisation are interested in engaging in e-health to improve the level of healthcare delivery. There are challenges around the technical capacity and the structural and organisational support for an e-health venture in an outback setting. Specific patient, healthcare provider and organisational needs have been identified and allow for the development of a tailor-made implementation strategy particularly to overcome technical challenges.

Effect of telestroke on emergent stroke care and stroke outcomes.

The delivery of medical care through telecommunication has been available in one form or another for ≈100 years. In the early 1900s, people living in remote areas of Australia used 2-way radios (powered by dynamos and bicycle pedals) to communicate with the Australian Royal Flying Doctor Service. The first direct reference to telemedicine in the literature was in the 1950s, with the transmission of radiological images by telephone in Philadelphia, closely followed by the teleradiology system established in Montreal, Canada.1 Telemedicine by video communication was first implemented by the University of Nebraska in the 1960s to allow clinicians to service remote populations.1 Jumping forward to the 21st century, there are now ≥55 telestroke programs in 27 states of the United States that deliver stroke services to ≥350 spoke hospitals.2 To justify the use of telestroke, there is a need for evidence of benefit. However, evaluating the outcomes of a telestroke program is complex because clinical outcomes from treating patients with acute stroke and wider health system and financial metrics need to be captured. The purpose of this review is to provide an overview of the various outcomes of stroke telemedicine and to outline the new paradigms evolving for systems of care, research, and education, as well as financial considerations. Stroke telemedicine (or telestroke) is the practice of clinical stroke care via telecommunication and came into its own with the era of stroke thrombolysis in the late 1990s. A key driver was to ensure better equity for patients in accessing this time-critical therapy in metropolitan and rural hospitals. Our knowledge base on the benefits of stroke thrombolysis continues to develop. The totality of evidence through pooled data analysis indicates that the therapeutic benefit of recombinant tissue-type plasminogen activator (tPA) is time dependent and is greatest when given early …

Flying doctor service in East Malaysia

Issue/problem Health services in Malaysia are delivered through a network of static and mobile health facilities which provides promotive, preventive, curative and rehabilitative care. Sabah and Sarawak are states in East Malaysia with difficult and rugged terrain and pockets of population in remote villages that are not accessible by land and river. Mobile health services which include the Flying Doctor Service (FDS) provide …

A 3-Year Retrospective Audit of the Use of Noninvasive Positive Pressure Ventilation via the Oxylog 3000 Transport Ventilator During Air Medical Retrievals

IntroductionThe purpose of this study was to describe the safety profile of noninvasive positive pressure ventilation (NIPPV) using the Oxylog 3000 transport ventilator (Drager Medical, Lübeck, Germany) by air medical retrieval teams from the Queensland Section of the Royal Flying Doctor Service of Australia. MethodsOver a 3-year period, patients identified in clinical transport records to have NIPPV via the Oxylog 3000 transport ventilator during air medical transfer were systematically reviewed on the clinical indication and adverse effects. ResultsA total of 29 patients were identified to have had treatment with NIPPV during air medical retrieval. Three patients suffered serious adverse effects of cardiorespiratory arrest during treatment. The main reported adverse event was intolerance of the facemask. There were no documented episodes of vomiting or hypotension. ConclusionThe use of NIPPV via the Oxylog 3000 transport ventilator during air medical retrieval requires careful patient selection. The application and management do not differ from standard hospital-based practice.

Endotracheal Tube Cuff Pressure before, during, and after Fixed-Wing Air Medical Retrieval

Background. Increased endotracheal tube (ETT) cuff pressure is associated with compromised tracheal mucosal perfusion and injuries. No published data are available for Australia on pressures in the fixed-wing air medical retrieval setting. Objective. After introduction of a cuff pressure manometer (Mallinckrodt, Hennef, Germany) at the Royal Flying Doctor Service (RFDS) Base in Dubbo, New South Wales (NSW), Australia, we assessed the prevalence of increased cuff pressures before, during, and after air medical retrieval. Methods. This was a retrospective audit in 35 ventilated patients during fixed-wing retrievals by the RFDS in NSW, Australia. Explicit chart review of ventilated patients was performed for cuff pressures and changes during medical retrievals with pressurized aircrafts. Pearson correlation was calculated to determine the relation of ascent and ETT cuff pressure change from ground to flight level. Results. The mean (± standard deviation) of the first ETT cuff pressure measurement on the ground was 44 ± 20 cmH2O. Prior to retrieval in 11 patients, the ETT cuff pressure was >30 cmH2O and in 11 patients >50 cmH2O. After ascent to cruising altitude, the cuff pressure was >30 cmH2O in 22 patients and >50 cmH2O in eight patients. The cuff pressure was reduced 1) in 72% of cases prior to take off and 2) in 85% of cases during flight, and 3) after landing, the cuff pressure increased in 85% of cases. The correlation between ascent in cabin altitude and ETT cuff pressure was r = 0.3901, p = 0.0205. Conclusions. The high prevalence of excessive cuff pressures during air medical retrieval can be avoided by the use of cuff pressure manometers. Key words: cuff pressure; air medical retrieval; prehospital

Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: Why are there no births in flight?

For more than three decades, women at imminent risk of preterm birth (PTB) in Western Australia have been transferred by small aircraft over long distances to the single tertiary level perinatal centre in Perth, with no known case of birth during the flight. We aimed to review recent experience to understand how aircraft travel may delay PTB. Retrospective observational study of 500 consecutive Royal Flying Doctor Service (RFDS) transfers of women at risk of preterm labour to the tertiary referral centre, from September 2007 to December 31, 2009. In-flight delivery, complications associated with transfer and factors associated with delay in preterm delivery. There were no in-flight deliveries or serious complications associated with the aeromedical transfer of these patients. In a multivariable Cox proportional hazards regression analysis, clinical factors in the presentation that were associated with a shorter time from landing to subsequent delivery included cervical dilatation ≥ 4 cm, ruptured membranes, gestational age > 32 weeks and nulliparity. The aircraft reaching an ambient altitude > 14,000 feet, or cabin altitude above zero (sea level), was associated with a delay in time from landing to delivery for women who were not in spontaneous preterm labour. Our findings add to a 30-year experience that women at risk of preterm labour do not deliver during aeromedical transfer. Ambient and cabin altitude of the aircraft were associated with an extension in the time to delivery after arrival. The mechanisms underpinning this effect warrant further investigation.

Women Lead in Adopting New Technologies

Women Lead in Adopting New Technologies

Major Trauma Patients Transferred From Rural and Remote Western Australia by the Royal Flying Doctor Service

The "golden hour" of trauma care is irrelevant in rural areas. We studied the effect of distance and remoteness on major trauma patients transferred by the Royal Flying Doctor Service from rural and remote Western Australia. The Royal Flying Doctor Service retrieval and Trauma Registry databases were linked for the period of July 1, 1997, to June 30, 2006. Major trauma was defined as Injury Severity Score (ISS) >15. Remoteness was quantified using the Accessibility/Remoteness Index of Australia (ARIA) classes: inner regional, outer regional, remote, and very remote. The primary outcome was death. Among 1328 major trauma transfers to Perth, mean age was 34.2 years ± 18.3 years (range, 0-87 years) and 979 (73.7%) were male. Over half were motor vehicle crashes. Mean transfer time was 11.6 hours (95% confidence interval [CI], 11.2-12.1). The median ISS was 25 (interquartile range [IQR], 18-29), and there were no differences within the ARIA classes for cause and injury patterns. After adjusting for ISS, age, and time, the risk of death increases as remoteness increases: outer regional odds ratio (OR), 2.25 (95% CI, 0.58-8.79); remote, 4.03 (95% CI 1.04-15.62); and very remote, 4.69 (95% CI, 1.23-17.84). Risk increases by 87% for each 1,000 km (OR, 1.87; 95% CI, 1.007-3.48; p = 0.05) flown. Despite long retrieval times, there were no deaths in flight. There is an excess of a fourfold increase in the risk of major trauma death in patients transferred to Perth from remote and very remote Western Australia. Remoteness, as measured by the ARIA, is more important than distance, in the risk of death.

Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval

ObjectiveAeromedical retrieval services face the difficult problem of appropriate levels of sedation for transport of acutely agitated patients to definitive care. This paper describes a technique using ketamine, which is...

Increasing alcohol restrictions and rates of serious injury in four remote Australian Indigenous communities

To document rates of serious injuries in relation to government alcohol restrictions in remote Australian Indigenous communities. An ecological study using Royal Flying Doctor Service injury retrieval data, before and after changes in legal access to alcohol in four remote Australian Indigenous communities, Queensland, 1 January 1996-31 July 2010. Changes in rates of aeromedical retrievals for serious injury, and proportion of retrievals for serious injury, before and after alcohol restrictions. After alcohol restrictions were introduced in 2002-2003, retrieval rates for serious injury dropped initially, and then increased in the 2 years before further restrictions in 2008 (average increase, 2.34 per 1000 per year). This trend reversed in the 2 years after the 2008 restrictions (average decrease, 7.97 per 1000 per year). There was a statistically significant decreasing time trend in serious-injury retrieval rates in each of the four communities for the period 2 years before the 2002-2003 restrictions, 2 years before the 2008 restrictions, and the final 2 years of observations (2009-2010) (P < 0.001 for all four communities combined). Overall, serious-injury retrieval rates dropped from 30 per 1000 in 2008 to 14 per 1000 in 2010, and the proportions of serious-injury retrievals decreased significantly for all four communities. The absolute and the proportional rates of serious-injury retrievals fell significantly as government restrictions on legal access to alcohol increased; they are now at their lowest recorded level in 15 years.

A comparison of metropolitan vs rural major trauma in Western Australia

BackgroundMetropolitan and rural Western Australia (WA) major trauma transport times are extremely different. We compared outcomes from these different systems of care. MethodsMajor trauma (Injury Severity Score, ISS>15) data from the Royal Flying Doctor Service (RFDS) and Trauma Registries, 1 July 1997–30 June 2006. Two groups were studied: Metro (metropolitan major trauma transported directly to a tertiary hospital), and Rural (rural major trauma transferred by the RFDS to a tertiary hospital in Perth). The primary endpoint was death. We used logistic regression and multiple imputation. Results3333 major trauma patients were identified (mean age 40.1±22.6 yrs; Metro=2005, Rural=1328). The rural patients were younger, had a larger proportion of motor vehicle crashes, and higher median ISS (25 vs 24, p<0.001). Mean times to definitive care were 59min versus 11.6h, respectively (p<0.0001). After adjusting for age, injury severity and the effect of time with the initial rural deaths, there was a significantly increased risk of death (OR 2.60, 95% CI 1.05–6.53, p=0.039) in the Rural group. For those rural patients who reached Perth, the adjusted OR for death was 1.10 (95% CI 0.66–1.84, p=0.708). ConclusionThere is more than double the risk of major trauma death in rural and remote WA. However, if a major trauma patient survives to be retrieved to Perth by the RFDS, then mortality outcomes are equivalent to the metropolitan area.

H1N1 09 influenza—An aeromedical perspective

The Royal Flying Doctor Service, Queensland Section is the primary service provider for aeromedical retrieval and transfer within Queensland. During the recent H1N1 09 influenza pandemic the organisation was required to undertake substantial planning as well as revision of existing guidelines in light of a new strain of influenza of unknown transmissibility and virulence and potential increase in workload. This paper provides an overview of the experiences of the organisation during the H1N1 09 influenza pandemic including surge capacity planning, infection control measures unique to the aeromedical environment, caseload data and employee health impacts. The Royal Flying Doctor Service, Queensland Section is the primary service provider for aeromedical retrieval and transfer within Queensland. During the recent H1N1 09 influenza pandemic the organisation was required to undertake substantial planning as well as revision of existing guidelines in light of a new strain of influenza of unknown transmissibility and virulence and potential increase in workload. This paper provides an overview of the experiences of the organisation during the H1N1 09 influenza pandemic including surge capacity planning, infection control measures unique to the aeromedical environment, caseload data and employee health impacts.

The first medical jet aircraft for the Royal Flying Doctor Service

Medical Journal of AustraliaVolume 191, Issue 11-12 p. 609-610 Rural and Remote Health The first medical jet aircraft for the Royal Flying Doctor Service Stephen A Langford, Corresponding Author Stephen A Langford Medical Director stephen.langford@rfdswa.com.au Royal Flying Doctor Service Western Operations, Perth, WA.Correspondence: stephen.langford@rfdswa.com.auSearch for more papers by this author Stephen A Langford, Corresponding Author Stephen A Langford Medical Director stephen.langford@rfdswa.com.au Royal Flying Doctor Service Western Operations, Perth, WA.Correspondence: stephen.langford@rfdswa.com.auSearch for more papers by this author First published: 07 December 2009 https://doi.org/10.5694/j.1326-5377.2009.tb03346.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume191, Issue11-12Christmas issueDecember 2009Pages 609-610 RelatedInformation