I recently completed twelve months as a retrieval registrar in Far North Queensland. As part of the LifeFlight retrievals team I was privileged to work with a number of talented individuals from diverse backgrounds in one of the most beautiful landscapes on the planet. The job required me to adapt the skills learnt in the hospital to a number of unique pre-hospital situations. It was a challenging year in many ways, but an enormously formative experience for me, both personally and professionally.

In order to get to this point I had completed terms in paediatrics, intensive care, anaesthetics, and emergency medicine. I’d been working towards this job for a while. Most retrieval registrars come from critical care backgrounds and usually complete this term late in their training. The registrars I trained with came from all around the globe and from various specialties. I was humbled by how much experience they all had and the fact many perform such complex tasks using English as their second language.

Training week for retrieval registrars

We arrived at training week full of excitement and expectation. We were given new flight suits and were thrown in the deep end, quite literally. As part of safety orientation, we completed the HUET training platform which simulated a helicopter ditching attempt in water. A large crane carried us out in a mock aircraft before turning us upside down and dunking us in the pool. As someone who enjoys diving it wasn’t an altogether unpleasant experience although it’s always sobering to consider the risks we take every time we fly. We were trained in winching from the helicopter and run through a number of simulations which forced us to adapt the skills we learnt in the hospital to the pre-hospital environment.

After completing our training week, it was time to meet our local team and receive base induction. The best part of working pre-hospital in my opinion is the opportunity to work with a highly skilled and well-drilled team. Everybody knows their role and has a part to play to get each job done efficiently. The team at my local base was made up of a pilot, aircrewman, rescue crewman, paramedic, and doctor. The team had worked together for many years and had developed a great working relationship prior to my arrival. Despite that they were incredibly welcoming and were only too happy to teach me about the helicopter, our equipment and our procedures.

The start of each day began with equipment checks for both medical gear and for the aircraft. The paramedic and doctor drilled difficult airway simulations and ensured all equipment was functional and in good working order. It was also the opportunity to audit challenging cases and reflect on positives and negatives to look at possible improvements for the future.

The first job

There was a lot of nervous excitement about “the first job”. I was really keen to get off the ground and get to work. The opening shift did not disappoint. It was my first experience on-call and I don’t think I had been sleeping long when the phone rang. A child had fallen from a rock and had an altered level of consciousness. They were six years old and I was tasked to assess them in a rural facility west of Cairns prior to transfer.

The retrievals service I worked for required us to service both adults and paediatric patients, but suffice it to say I was hoping my first case would be an adult. On arrival the patient had evidence of a base of skull fracture after falling two metres onto their head. They were not responding appropriately, and we rapidly made the decision to intubate and transfer to the nearest neurosurgical facility in Townsville (around an hour flight from Cairns).

Having just completed my anaesthetics rotation I felt comfortable to perform a rapid sequence induction. However, this was the first time I would do this outside of the comfort of my larger hospital and without the possibility of senior oversight. The experience of my paramedic colleague put me at ease and fortunately the tube went in the right place and we were shortly off to deliver them to the neurosurgical team. I felt an enormous sense of relief to hand over care, and I’ll admit I was pretty sapped because I fell asleep on the flight home.

Primary retrieval tasks

After finishing a number of similar inter-hospital transfers it wasn’t long before the first primary retrieval task arrived. A “primary” is a tasking to a pre-hospital event, often a car accident, snake bite, or farm injury. These require us to adapt the skills we learn in the hospital to many environments. On this particular afternoon we were tasked to a primary at a local waterfall. A tourist had slipped and fallen from the waterfall. It wasn’t possible to get them to hospital due to the isolated location of the falls. We suited up for a winch retrieval and our pilot and aircrew expertly positioned us to be winched down over the site to attend to the injured.

I seem to remember being afraid of heights at one point in my life, but as I was lowered from around thirty metres through the rainforest and onto the rocks I was more consumed with the clinical challenge of getting the patient out. They had fallen quite a long way and had clear evidence of a significant head injury but were otherwise haemodynamically stable. We made the decision to intubate and rapidly extricate to hospital. As we performed the intubation it was clear how different this was compared to the relative safety and security of the hospital.

The waterfall sprayed water in my face and as I looked up to intubate the sun was directly in my eyes. The noise of local tourists eager to provide assistance was a distraction as were the distressed relatives and friends of the injured and the noise of the helicopter circling overhead. Police held up a blanket to shield the glare and the patient was successfully intubated. But this was only step one. The next part was getting the ventilated patient to the helicopter.

The spins

The paramedic had vast experience with this task and hand ventilated the patient, whilst being winched into the aircraft (it was impressive). I was winched separately holding the gear and I got to experience what I now know as “the spins”.

Winching in a confined space generates air currents that circulate from the helicopter and cause the person on a long “string” to rotate rapidly. As I held the bag and watched the world go by like a blur, I remember thinking to myself if I pass-out I don’t think I’ll ever live this down. I felt a firm hand grab my collar and pull me into the aircraft as I rapidly tried to regain my senses. After delivering the patient to hospital we debriefed as a team and watched the retrieval on the local news (fortunately minus the hapless spinning doctor).

Conclusions

I honestly loved going to work every morning. Each day had a unique challenge and also offered the opportunity to see some locations from the air that I could otherwise only dream of. I remember flying low over a pod of whales, watching cane fires in the evening, and watching the sun rise on an early morning flight over the water. I am so grateful for the experience pre-hospital medicine has given me and I hope to continue this work in the future.