Pre-Hospital and Retrieval Medicine (PHRM)
“Because Critical Illness has no respect for Geography”
The term retrieval medicine can mean different things in different parts of the world. In North America if you told someone you work in retrieval they would think you are flying around the country with kidneys in ice boxes. In the Australasian setting PHRM is practiced by medical, nursing and paramedic staff with specific training to work in this unique environment. Gone are the days of the “enthusiastic amateur” where the most junior doctor who was working in an Emergency Department was thrown in the back of an ambulance or helicopter to take a patient from A to B. In the UK there is now a Faculty of Prehospital Care with the College of Surgeons and there is discussion amongst the critical care colleges in Australasia of establishing a similar faculty. There are post-graduate qualifications in prehospital care that can be attained from a number of Universities.
The mantra of retrieval is “to get the right patient to the right place with the right team, in the right time, first time.” This means that an understanding of what the patient needs to remedy their condition needs to be understood, for example a patient with a STEMI should go directly to a PCI centre, trauma is better to go directly to a major trauma centre and there is no point taking an aortic dissection to a hospital that doesn’t have a cardiothoracic service. This may mean you overfly some hospitals.
Retrievals can be defined as primary, where there has been little or no medical care prior to the team’s arrival such as attending the scene of an RTC; secondary, where a patient will have had some level of care in a smaller facility and is now being transferred to a larger centre for definitive care; or a modified primary where the only real difference from a primary is that there is a roof over your head and some bright lights. Further sub classifications such and “land-on primary” and “winch primary” are also used.
A number of transport platforms can be utilised including road ambulance, rotary and fixed wing aircraft and occasionally boats. Each of these has specific benefits and limitations to use. Depending on terrain inside 50 km it is usually faster to respond by road. Road ambulance also offers more space and has the advantage of being able to stop if required, and does not have the same weather limitations as aircraft. Rotary wing aircraft are typically faster for distances from 50 to 250 km. They have the advantage of being able to land directly at the hospital and do not require a landing strip so they can typically get closer to the site of an incident. Over larger distances fixed wing aircraft are more efficient due to their faster airspeed, however are limited by requiring a landing strip or airport to land at. This usually necessitates and ambulance trip at each end, which can add significantly to transfer time. Fixed wing aircraft may be pressurised which is useful for some medical conditions and also allows them to fly higher, at faster speeds, for greater distances and in less turbulence.
When a patient becomes critically unwell or injured, the thing they are most concerned about is how quickly will they be back to their normal daily activities. They don’t care about whereabouts they receive the care that will start them on the road to recovery. In this respect, the inhospital/prehospital divide can be counterproductive to patients and the thought that “it will all happen in the ED” is not necessarily true. By taking the hospital to the patient the dying process or critical illness process can be interrupted much earlier and 10 minutes extra on scene can save an hour or two in the hospital later. This highlights the importance of understanding what the patient needs – you can’t do a laparotomy on the side of the road to fix the bleeding splenic injury so any care provided should not delay transport to an operating theatre, but you can provide definitive care to the person who has taken a large quetiapine overdose by intubating and ventilating them with transfer to an ICU to continue the care you have established. You can also make sure the patient receives adequate analgesia which may prevent later PTSD; you can prevent further blood loss and pain by adequate splinting; you can ensure that the trauma team is ready to continue a massive transfusion by a high quality sitrep (situation report).
PHRM occurs in a unique often austere environment where resources such as equipment and human resources are limited (you don’t have to worry about running out of oxygen or suction in your RSI in hospital but this is a very real consideration in PHRM). Challenges include: too hot, too cold, too rainy, too dark, too sunny, limited access, noise, vibration, multiple patients and many more. There is also a need to consider scene safety for you personally, your team and the survivors. Despite these factors it is not acceptable to accept less in a more challenging environment, so a procedure should be performed to the same standard it would be in hospital, for example, if you would normally use EtCO2 to intubate in hospital you have to do it prehospital; if you would normally give pain relief in hospital you have to give it prehospital. Attention to detail and doing the simple things well are core aspects of making a retrieval team highly functional.
Rewarding aspects of the job include working with highly motivated and skilled paramedic and nursing staff as well as the non-medical staff including the aircrew, fire and rescue, police, SES and members of the public. The team you would normally have around you in hospital has to be formed often at short notice from these people and at times you can achieve incredible things with this small team.
Photography by Dr Luke Wheatley