Medical

Being in aeromedicine was one of the most cognitively challenging yet fulfilling medical specialties. It tests one’s clinical acumen, temperament and physical agility simultaneously. You often work alongside people for hours who are strangers, be it your ground crew, flight nurse and two pilots. Therefore, working efficiently as a team player is essential.

On this occasion, my day started at 4.30 a.m. on a Sunday. I was yearning to be up and away when suddenly I was awoken by my on-call phone. 

The aeromedical logistic coordinators informed me of a sick patient located off the coast of Australia. She needed to be repatriated to the mainland as she had suffered a heart attack.

The medical care she required was complex and would have overwhelmed the services of a small offshore hospital. She needed an angiogram, a procedure that would initially look at the state of her coronary arteries and further intervention.

Treatment Is Urgent Transport

One of the mantras in aeromedicine is that the patient needs to be taken from the wrong place to the right place. So, transporting her was a critical part of her treatment.

After donning my flight suit and driving to the airport, the pilots, flight nurse, and I congregated for a pre-departure briefing. Our necessary paperwork was completed, and our passports were sighted in front of Australian Border Force officials.

The climatic conditions made for safe flying that day. The patient at the destination was deemed stable enough for transfer at this stage. This meant the ‘mission’, as we call it, could proceed as governed by further reporting from the offshore doctor.

The pilots also completed the flight plan and deemed it sinto depart. Given all our lives were in their hands, as is always the case, the final decision ultimately lay with them.

Complex logistical issues beyond our control render many tasks ‘mission impossible’. This could be due to several factors. There could have been an adverse change in weather. Or a patient who has deteriorated and needs further stabilisation before moving them anywhere.

They may have even died in the interim. So, despite any time-critical resuscitative efforts offered, they would have never survived any journey as their condition had become incompatible with survival.

A Favourable Forecast To Fly

With all life jackets sighted, our onboard safety brief was completed.

Our necessary medical equipment was safely stowed and secured into our tiny jet, like completing a 3-D Tetris puzzle. On this day, our ‘clinical’ environment was in the form of a Learjet 36A, a fixed-wing aircraft. Being only 15 metres long, they are dwarves compared with usual commercial airliners.

It sounds luxurious as it is often the transport of choice for the rich and famous. However, medical evacuation (medivac) jets have been heavily reconfigured.  With a large stretcher on board, movement is very restricted.

And as it lacks bathroom facilities, one always thinks twice about having that second cup of coffee.

Medivacs have runway priority ahead of all other air traffic, even at the busiest airports worldwide. We were bound on a two-hour flight to a place called Norfolk Island and took off just after sunrise.

Ascending to straight and level flight, I glanced at the iconic Sydney Harbour Bridge and Opera House below. Still, the views were soon left behind and become obliterated by early morning cloud cover. 

Pacific Paradise And Nature’s Nirvana

Before I ventured into aeromedicine, I had never even heard of such a place. It occupies a mere speck on maps depicting the vast Pacific.

Lying 1500km due east of Byron Bay, NSW and a mere 35² km in area, Norfolk Island is steeped in rich colonial history.

It dates back to the voyages of Captain James Cook and penal colonies. It is also the origin of the infamous Mutiny on the Bounty and Captain William Bligh stories dating back to the late eighteenth century.

With a stable population of around 2000, it is still considered part of Commonwealth Australia. It even boasts a New South Wales postcode (NSW 2899).

Only a couple of hours later, I was mesmerised by the sight of a tiny island appearing in the midst of the ocean. With my camera at hand, I once again fed my passion for aerial photography before our visual flight rule (VFR) approach to land.

Our Arrival

On clearing Border Force customs, we were met by one of the few heroic paramedics who work on a voluntary basis.

With our necessary equipment in tow, we made our way to the small hospital that contained only a handful of beds. The nurse and I were greeted by one of the most erudite ‘Fly-In-Fly-Out’ (FIFO) GP anaesthetists I had ever met.

Our patient had stable angina and, luckily was conscious and alert. Her initial heart tracing (ECG) looked sinister, confirming the heart attack she had suffered the previous night.

Being one of only two practitioners who serve the whole island, his scope of practice and clinical knowledge was beyond comprehension. For instance, he doubled up as a radiographer and an emergency dentist.

A Changing Of The Guards

Following the clinical handover, we found ourselves back at the airport after being handed the patient’s notes, including the chest X-ray that the GP had taken himself.

After loading the patient onto the aircraft, her vital signs were repeated as for every patient regardless of their illness. 

In the unlikely event of a medical emergency, defibrillator pads were placed on her chest. The adrenaline was also within close reach. As a crew, we are always prepared for the worst-case situation like cardiac arrest.

With full throttle, we bode farewell to the Norfolk Island pines. 

On taking off, I held my patient’s hand reassuringly as she had a fear of flying. The effects of air turbulence are always exaggerated in an aircraft you can barely stand up in.

The logistics coordinator back in Sydney was informed of our pending departure back to the mainland. 

En route, our rather loquacious patient, now comfortable, enlightened me with fascinating stories from this remote location. After all, the island had been her home for 65 years. 

Being educated first-hand by one of the permanent inhabitants is another privilege that this job brings. And what a raconteur she was, telling more island gossip than I cared to know!

From Island To Intervention

After landing in Sydney, our patient was transported by road ambulance to her destination hospital. Her care was handed over to a cardiologist and coronary care nurses. 

Any drugs administered in flight were cross-checked and documented. After all the paperwork was completed and signed, we hugged our patient, wishing her all the best for her ongoing care.

Today had been uneventful. But like every mission, it had brought its unique challenges as every patient is different.

With The Highs Come The Lows

On the other end of the spectrum, I have often flown much further afield. This included Australia to Europe at one point with a quadriplegic patient by a commercial A777-300 airliner with a brief stopover in the Middle East.

Aeromedical retrievals of this length notoriously take a massive strain on one’s body, regardless of the patient’s condition. 

The manual work involved in transferring an immobile patient, combined with the effects of working at altitude with relative hypoxia, can be exhausting.

Your body can be quickly drained of energy both physically and mentally. You’re often manoeuvring around tight spaces in a flight suit, breathing cabin air that can dehydrate you easily.

It is a fact that one hour of duty in the air is equivalent to two hour’s work on the ground.

As with pilots, our fatigue management is also paramount, especially when traversing multiple time zones. Transmeridian dyschronism, or jetlag, is your enemy, especially when trying to provide the best care for your patient.

Anyone who has flown long-haul will empathise. Symptoms can range from constant fatigue, poor concentration and irritability, and random physical symptoms such as headache and gastrointestinal disturbance.

Beware And Be Prepared

Aeromedicine is also dynamic, where clinical priorities can change rapidly in flight. A very sick patient can suddenly deteriorate, and the whole crew involved must maintain their composure, adapt accordingly, and think laterally.

Your ward bed is thousands of feet in the air, and all your equipment and fuel are limited. But it’s important not to get flustered. The pilots would have also been briefed on how sick your patient was and would have made a comprehensive flight plan accordingly.

At times of crisis, you often feel like you’re alone and without your highly skilled flight nurse to assist you, you will certainly come unstuck.

They are there to check everything you’re doing, including medication doses and troubleshoot any issues with you. And as a pair, you are ‘it’ as the resuscitation team.

But thanks to our intensive training on the ground, we simulate worst-case ‘horror’ scenarios that will prepare us for real life in the air.

I’ve also been stuck on the island overnight due to a freak thunderstorm. So, doing this work can sometimes hack into your personal life. So, think twice about accepting any pending dinner invitation.

As once happened on my birthday, you can never guarantee when you will be back on terra firma.

Complicated Cases To Consider

On other occasions, I have transported ventilated patients on life support late at night with multiple life-saving drug infusions running.

Alarms constantly bleep and it is easy to get entangled within the monitoring cables, tubing and hospital sheets in the dim light. All while you are keeping your patient alive. 

I’ve transported bariatric patients who barely fit onto the stretcher or are claustrophobic. Agitated patients requiring titrated sedation, those who are clinically deteriorating or complex trauma victims, can also pose potential logistic dilemmas.

Undoubtedly, these medivacs leave you pumped with adrenaline as you hone in on all your skills that test your patience.

The Journey Back To Base

It was now late Sunday evening. During a thorough debrief, the flight nurse and I returned to base at Sydney airport to re-stock the medical equipment.

This process facilitates open and honest discussion for clinical improvement if needed. It also prevents you from taking your work home. 

Many of our friends do not come from medical or nursing backgrounds. They may not understand the complexities of the work involved in transporting a patient by air, let alone the clinical jargon.

Our mission was now deemed complete. The nurse and I thanked one another and then parted company.

Feeling exhausted and finally back on Earth, I head home, reflecting on how I had seen a majestic sunrise and sunset from the air today. But more importantly, our patient remained alive.

Whilst driving, I contemplate as an ‘aeromedicophile’ that my passion for travel, aviation and managing the critically ill is perfectly integrated with this vocation.

Are Emergency Evacuations Endangered?

With the news on in my car, I am again reminded that we are amid a pandemic. At the time of writing, the future remains unpredictable. 

I am often saddened that the media focuses heavily on how COVID-19 has paralysed commercial aviation and tourism businesses worldwide.

But what about aeromedical services? Aren’t they also being slowly crippled? Biosecurity measures have been stepped up globally and continue to threaten all travel, regardless of purpose. 

The mandatory wearing of PPE has somehow mitigated the risk of spreading this deadly pathogen. Especially from countries where COVID-19 is still running rife in unvaccinated populations.

In any doubt, these services are indispensable. They rely heavily on charities and broader organisations for economic assistance and sustainability. To safeguard their future, they must continue nurturing partnerships with external agencies for extra support in any time of crisis.

After all, aeromedicine is at the helm of preserving the health and lives of displaced patients trapped overseas. I hope the specialty continues to put up a fight against the pandemic.

With this thought, my feet shall remain firmly on the ground and my head not in the clouds.

From dense bushland, adrift at sea, halfway up a mountain or a remote hospital in the middle of nowhere – it all happens in this world.

And after all, one day, it could be your life, your loved ones or even mine that needs rescuing at some point.

(NB: Consent was obtained to photograph the cockpit images from the aircraft captain)

About the author

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Dr Surrinder Singh is a medical doctor, blogger and freelance writer. He is passionate about healthcare, medicine and education and works professionally with B2B and B2C clients.