PHARM podcast Episode 230 Queensland retrieval medicine in the 1980s with Dr Tony Harrington

 

Dr Paul Peake & Dr Tony Harrington ( on winch harness)


Hi folks! . In this episode I have a good chat to Dr Tony Harrington, a retired emergency physician, on the 1980s era in Queensland and evolution of retrieval medicine & emergency medicine.

Show notes:

Dr Tony Harrington MBBS, FRACGP, DA,RCS (Eng) FACEM, OAM (Retired)

It is interesting to reflect and see how far we have come since those early pioneering days. The collective and cooperative work of an extremely enthusiastic and passionate group of Queensland Emergency Physicians built the strong foundations of the seamless retrieval system we see today.

INTRODUCTION

To discuss emergency medical care in the 1980s in Queensland it is important to understand the the political and health care environment during this embryonic period in the development of Emergency and Retrieval Medicine.

BRIEF BIO

Tony became passionate about becoming involved in Emergency Medicine and Retrieval Medicine while working as rural and remote GP in WA and Qld. He had 8 years of general and acute medical experience including 18 months of Anaesthetics and Intensive Care. He had experienced the trials and tribulations of being the a solo practitioner looking after a critical patient and then trying to get help and transfer them within a system that often blocked and delayed urgent and critical transfers.

During his career Tony contributed to multiple and significant advances in Emergency Medicine and Education of emergency personnel. His achievements include pioneering development of helicopter emergency retrieval services in Brisbane and on the Sunshine Coast. He was passionate about effective pain management in ED implementing pain scoring in the ED and QAS and also developed nurse initiated analgesia. He wrote a procedural sedation Monograph and lectured regularly on this topic. He was also involved in ground breaking research using a non invasive nasal spray(Intranasal fentanyl) to deliver opioid analgesia for children and adults.  He became a senior educator with the Australasian College of Surgeons for the Early Management of Severe Trauma (EMST) . He was a regular lecturer at Toxinology, Trauma and Procedural Sedation workshops. He was the first to report bites and treatment of the Sunshine Coast and Fraser Island Funnel web spider. He helped write the Queensland  Medical Disaster Plan in the early 1990s and was a trained disaster commander. He helped manage and be medical commander at several multi victim incidents. He was a keen advocate for the advanced training of paramedics and the implementation of advanced skills. Tony was a member of over 50 health committees and was the chair of several of these committees. He was awarded eminent and pre eminent status for his contribution to Queensland Health. He was a keen educator of QAS, Heli crew, Police, Fire, SES. Emergency medical and nursing personnel. He achieved an Australian first by training Australian Professional Lifeguards APOLA to defribillate on the beach which has saved about three lives each year on the Sunshine Coast. With the help of community funding he built a innovative Senario Based learning Center for team training with all emergency service personnel on the Sunshine Coast. He travelled extensively and studied EMS in USA, Canada, UK, IRELAND, Germany, France, Italy, Switzerland, NZ and Australia bringing back and implementing the best ideas and systems from each of these countries. He has published multiple peer reviewed scientific papers, a book chapter on paediatric analgesia and procedural sedation and multiple monographs. He was the convenor and presenter at numerous local, national and international conferences. He was heavily involved in convening the first meeting of the Australasian chapter of ISAS (now Aeromedical Society of Australasia) in Brisbane to discuss the development of national standards for aeromedical services. This group was closely connected to  International AIRMED conferences and we convened the first Australian one in Brisbane in 1993. He worked closely with community charities Lions, Rotrary, Variety Club, Jaycees and Wishlist raising money for essential emergency equipment and services. He directed three Christmas shows and four Rock concerts again raising funds for equipment and emergency projects. In recognition of his contribution to EMS, a relaxation garden he designed for Emergency staff was given his name, “Harrington’s Haven.” The “Tony Harrington’s Honours Board” was unveiled in July 2019 at the new Sunshine Coast University Hospital.  In 2015 he was Invested with the Order of Australia Medal (OAM)for services to the community and Emergency Medicine.

Health complications from diabetes IDDM over 45 years forced Tony to retire in 2014.

POLITICS and QUEENSLAND HEALTH in the 1080s

Former PM Kevin Rudd’s father died after a MVA and in his biography he blamed poor Queensland Health QH services and systems  for his fathers death. He described QH services as “third world”. When I started Emergency Medicine in 1984 Queensland Health had been suffering  for nearly 20 years under the yoke of ultra conservative Premier Joh Bjelke-Pietersen 1968-1987 nicknamed the “Hillbilly Dictator.”  In many of his press releases “feeding the chooks” as he described it, he expounded “Queensland has the best health system in the world.” FAKE NEWS! I had worked  for eight years in Western Australia, England and NZ and it was my opinion that QH wasn’t quite “third world”  but it was 10-15 years behind the services I had experienced in Australia and overseas. Bjelke-Petersen demanded total loyalty of the media and was unforgiving and vindictive if reporting was not to his satisfaction. Does this remind you of anyone today? To my mind his only redeeming quality was that he loved aircraft and purchased a Twin Squirrel Helicopter for the SES but principally to fly him around SE Qld. Could it be used for retrievals? Absolutely!

HOSPITAL CULTURE

Not having experienced a closed and negative work culture it was quite a shock starting as the first training registrar at RBH. Each specialty department was of a silo mentality and interaction with other departments  especially with ED was  usually of an obstructive and combative nature. Patients were often almost treated as the enemy. To rectify this toxic culture Directors and ED personnel spent much time and effort brings the threads together to achieve patient advocacy and a friendly team of clinicians within their hospitals.These founding pioneers have been responsible for development of a healthy culture change in QH.

THE BACKGROUND

INTERNATIONAL EMERGENCY MEDICINE ORGANIZATIONS

The state of play when I joined as the first training Registrar was that care in ED was still old school “CAS” with junior staffing and minimal supervision. Dr Frank Garlick RBH and Dr Noel Stevenson had formed the Qld Casualty Surgeons Association in 1977 and a group of enthusiastic “CAS” Supervisors were meeting regularly and pushing for the foundation of the specialty. USA was leading the way with ACEP incorporated in 1968 and the first hospital based helicopter retrieval service with a Alouette 111 single engine helicopter which became operational operational in 1972 at St Anthony’s Hospital Denver Colorado. Noel Stevenson had trained and received board certification in USA. Germany beat them to the punch with a hospital based BO105, Christoph 1 in Munich sponsored by ADAC( German automobile association)  Having just completed a diploma of Anaesthetics in Devon England the standard there was on a par with Australasia. In the UK the BAEM was only formed in 1990 and the faculty FAEM in 1993. In Australia ACEM was founded in  July 1983 and incorporated In July 1984

RETRIEVAL SERVICES available in the early 1970s and 1980s

Retrieval services in Queensland during this period had been long provided by RFDS for remote and rural emergencies. For SE Queensland the QATB was servicing the Burnett and North Coast Region with a fixed wing aircraft providing interhospital transfers and return of less sick to their regional hospitals. Armed forces aircraft looked after their own personnel and carried out SAR missions. We carried out joint SAREX exercises with them. The first SLSA helicopter was a Bell 206 Jetranger which became operational from the BIG COW Yandina Sunshine Coast in 1979.  This was set up by local businessman and entrepreneur Des Scanlan together with Jim Campbell DFC a decorated Vietnam War Veteran helicopter pilot. They helped set up the SLSA Gold Coast helicopter with Ashley Van de Velde in 1981. These helicopters were offered to all emergency service agencies for search and rescue. Their principal function was surf and shark patrols but they carried out an occasional medical mission. They were crewed by volunteer lifesavers with the addition of an occasional doctor for a medical task. Interhospital transfers were usually by road QATB with a “ambulance bearer” as was their designation during this period. Sometimes they were accompanied by a junior nurse or doctor who invariably had little or no training for these difficult and often hair raising missions. Critical patients would often arrive unannounced in the back of an ambulance with no attendant suffering aspiration of vomit, hypoxia, hypercarbia, hyperthermia and pressure areas from a five hour trip in the back of a hot ambulance.

THERE MUST BE A BETTER WAY

THE BEGINNING

“The journey of a thousand miles begins with the first step.” Old Chinese Proverb

EARLY PRIMARY and SECONDARY INTERHOSPITAL TRANSFERS

Being concerned about the level of care provided and inspired by American and German aeromedical services the RBH and Gold Coast Hospitals began offering road flying squads using police vehicles and helicopter primary and secondary retrieval services in 1985. Dr Keith Little  visited in 1986 extolling his experience with flying squads and a specially equipped road ambulance MEDIC 1 at the Edinburgh Royal Infirmary. Other EDs in SE Queensland provided road retrieval services. Skills and equipment ideas were shared between services and tasking was carried out by the Qld Police Operations Center.

THE CHALLENGES TO CHANGING THE SYSTEM

“Where there is no struggle there is no progress.”  Fredrick Douglas

As I have already outlined there were few funds in the system and resistance to change at all levels of QH. By using the media wisely the general public enthusiastically supported this new developing service thus negating the blocking of service delivery by administration. Equipment was often purchased by fund raising and all on call was done at no cost to the hospital. I remained on call 1:1 for 15 years give advice, crew or coordinate these early missions. Primary Response and Rescue training was carried out with senior SES ex military full time crew members.

THE PIONEER EMERGENCY PHYSICIANS IN QUEENSLAND

S E Queensland in the early 80s had a very talented and enthusiastic band of founding fellows of ACEM

FRANK GARLICK RBH was a surgeon who was passionate about surgical skills in ED and from a missionary background brought balance and spirituality to the department.

NOEL STEVENSON PAH was trained in Emergency Medicine in USA. He was an excellent clinician with a wise approach to all problems

PHIL KAY GCH was sharp, entrepreneurial, progressive and would never take a backward step He is now director of PAH and multiple private EDs

GERRY FITZGERALD IGH was passionate about prehospital care. His MD thesis was on our National Triage Scale now adopted throughout the world. He held several executive positions with ACEM and later became Commissioner of QAS

RICHARD ASHBY QE2H An excellent clinician with great administrative and political nous. He became director of RBH and President of ACEM and during this time helped gain recognition of ACEM as a principal specialty in 1993

IAN KNOX TGH Excellent clinician later to become the President of ACEM

PAUL FITZGERALD Brisbane Mater Lovable, sensible mature clinician

Mostly from a rural and remote generalist background these fellows knew the problems and challenges we faced. They worked closely as a team and were great mentors to the new emerging trainees. They had a keen understanding of problems in prehospital care and interhospital transfers. They were all great supporters of Retrieval Medicine.

THE RBH MEDIVAC PROJECT

Realising the desperate need for a retrieval service to one of the biggest tertiary facility in Australia Paul Peake RIP and myself set up a Primary response road and helicopter retrieval service in 1985. We carried out over 100 primaries in the first few years. We worked closely with the SES helicopter, QATB and Police. We placed ourselves on call 24/7 for no financial remuneration. I produced interhospital transfer guidelines and worked closely with referring hospitals especially Cliff Pollard at Redcliffe Hospital and Rob Stable at Nambour General Hospital. We set up an audit system for each transfer with feedback to the respective hospital. Transfer standards began to steadily improve. We refined our receiving service with a kind word and a cup of tea for the team regardless of how poorly the transfer team performed. The idea was to get everyone onside to enhance care through audit and positive feedback and training. I can recall the numerous times I was inappropriately abused by receiving ICU personnel who didn’t have a clue about the retrieval environment. Bad culture. There must be a better way!

PREHOSPITAL DEFIBRILLATION

As an intern during my first term in “CAS” I saved the life of the WA Police commissioner after his cardiac arrest at South Fremantle AFL match. I became passionate about early defibrillation. Seattle ambulance USA were having great results rapid early defibrillation. RBH CCU decided to run a flying squad mobile coronary care ambulance. I cooperated but immediately knew “There must be a better way” ie all Ambulances carry defibrillators. I presented a paper at a Mater Hospital symposium pushing this concept and they were finally introduced to prehospital care providers. Later Gerry Fitzgerald, Ambulance Commissioner, introduced  public access AEDs. He even used one to save his mother’s life when she arrested when he went to pick her up at the Brisbane airport. I achieved an Australian first when I introduced and trained Australian Professional Lifeguards APOLA to use AEDs on the Sunshine Coast. This was before SLSA introduced them for surf lifesavers.

ISAS and INTERNATIONAL RETRIEVAL SERVICES

I was heavily involved in convening in Brisbane the first meeting of the Australasian chapter of ISAS (now Aeromedical Society of Australasia) to discuss the development of national standards for aeromedical services. This group was closely connected to  International AIRMED conferences and we convened the first Australian one in Brisbane in 1993. This importantly allowed cross pollination of ideas and new ways of delivering services.

PERSONNEL

Most retrievals were done by training registrars and emergency nurses with the exception of consultant Phil Kay on the Gold Coast. Experience was variable but in most cases we did no harm.

EQUIPMENT

I distinctly remember the first helicopter job before we became organised and trained was to retrieve a patient from Moreton Island. Staff flipped a coin as to who would have the pleasure to fly over Moreton Bay on a nice sunny afternoon. A few bits of equipment were thrown in a pillow case and then off they went with no training and Inadequate equipment. There must be a better way! Gradually equipment was organised into fishing boxes then purpose built ADAC aluminium boxes and then Thomas Packs. The small orange Oxylog was the ventilator of choice. Review of each case using the CQI process saw rapid improvement and development of equipment standards. Monitoring equipment improved with the introduction of the Propac. Checking equipment and checking it twice then sealing it was implemented when I found myself on the beach with a near drowning case and no BVM! The stretcher bridge developed by Ken Wishaw and Blair Mumford of Sydney CareFlight was a great advance in keeping all monitoring equipment together on the one overarching bridge.

TRAINING and EDUCATION

Training in the early years was essentially DIY. There was no official program until 1986. I linked into all the other specialty programs. Surgeons Stuart Pegg and Darryl Wall were very kind and helpful educators. Director of RBH ICU Val Muir was supportive and helpful. There were regular presentations at QAEA (Queensland Accident and Emergency Association) monthly meetings. All the founding fellows were great mentors and enthusiastic educators. For retrieval education Phil Kay was the man. Paul and I trained regularly with the SES for vertical and offshore rescue. This training came to fruition when I did a retrieval to a large cargo vessel 30 nautical miles off the tip of Sandy Cape on Fraser Island. The Italian captain had suffered a massive heart attack with resulting pulmonary oedema. I got to deploy my vertical rescue skills, resuscitation skills as well as my Italian language skills ( I had just finished studying Italian at the University in Perugia Italy)

TRAUMA SERVICES

Trauma care when I started at RBH was a mixed bag of uncoordinated messy and untimely care. I set up three trauma bays with ergonomically placed equipment and developed trauma teams roles and positions for paired doctor/nurse teams with matching trauma protocols. Most of our primary response retrievals were for multi trauma victims. I later became a senior EMST instructor and this structured approach greatly improved care at a scene and in the Resuscitation Room.

VEHICLES

Primary road responses were carried out by Police vehicles returning with the patient in an ambulance. These were dangerous missions with lights and sirens all the way. Critical Interhospital transfers often had police escorts. Helicopter retrievals were carried out in the SES Squirrel and occasional fixed wing retrievals were usually done by ICU personnel.

POLICIES and PROCEDURES

Policies and procedures for retrieval and interhospital transfers were nutted out and gradually and regularly refined. We needed standardised methods for operation. The first meeting of ISAS in Brisbane helped develop national aeromedical standards. Most Australian aeromedical services were represented at this meeting.

COMMUNICATION SYSTEMS

The ED was linked by radio to Ambulance and Police communication centres. A combination of VHF and UHF were used on scene. Mobile phones were primitive and my first mobile was in a 6 kg briefcase and the extremely large heavy battery had a short time life needing constant recharging. Communication systems and algorithms were untimely and inefficient. It would sometimes take over an hour of calls back and forward before it reached the right person. Rural and remote doctors calling for help and retrieval might call anyone of 30 doctors in different specialities often to get palmed off by an obstructive junior registrar. It was only when Richard Ashby and Michael Cleary at RBH introduced single point contact did rapid communication and tasking improve. This put an end to the “Just send them down” with this being the only advice given by the multitude of receiving doctors.

DEVELOPMENT of QEMS

In 1984 when I started training coordination of the various Emergency Service agencies was still embryonic. All EDs were working to improve coordination and collaboration between services. Having close working relationships with Police, SES and Ambulance Paul and I convened the first Prehospital Care Committee to bring together these agencies in SE Qld. Following the formation of the Queensland Ambulance Service in 1991, a state EMS committee was formed. This committee led the development and approval of the cross portfolio QEMS policy framework that has resulted in dynamic policy development, system monitoring and evaluation. This framework was led by the Queensland Emergency Medical Services Advisory Committee. QEMS was formalised under the leadership of Gerry Fitzgerald.

AUDIT and REVIEW to CLINICAL GOVERNANCE

We set up audit and review of retrievals and interhospital transfers. Famous founding father of ACEP Peter Rosen once said “our best learning comes from our stuff ups.” Unless these are recognised and remedial action taken they keep occurring.  We put a stop to dangerous police escorts. Transferring personnel and other road users were being injured. Over the years clinical re-engineering, CQI and Clinical Governance has seen the development of an excellent retrieval service in the State of Queensland.

I did what I loved and they paid me for it!

“ Choose a job that you love and you will never have to work a day in your life” 

  Confucius

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