Medical Publications

In the last decade and a half, CareFlight medical staff have published more articles (in both peer reviewed scientific and general interest medical journals, plus textbooks) related to air medical and critical care transport (retrieval) than every other Australian air medical service combined.

The CareFlight staff amongst the authors of each paper are underlined. For those unused to journal citations, these are listed as: Title of Journal; Year; Volume (& issue) number; page number(s).

1. Munford BJ & Smith FE. How Far Is Too Far? (letter). Aeromedical Journal 1989 4(1):6. A response to a published case report of a long distance trauma transport by a flight nurse staffed helicopter. The letter argues that the patient suffered unnecessary risk & morbidity from a prolonged transport with a team with limited skills and therapeutic options, and outlines the improvements that could be expected in such cases by using a more clinically capable (i.e. medically based) team. more (PDF, 138KB).
2. Munford BJ. Formulating a Medical Blueprint on Retrieval. Australian Dr Weekly 1990 Feb 9: 37 8. A descriptive article on the principles of operation of a medical retrieval service, targeted at rural doctors working in small district hospitals. The article outlines that retrieval is not merely air transport (and sometimes not air transport at all) but a complete system incorporating communication, clinical teams, critical care equipment, & transport vehicles. The processes involved in activation, selection of level of care, mode of transport, and preparation of patients for transport are outlined. more (PDF, 171KB).
3. Wishaw KJ, Munford BJ & Roby HP. The CareFlight Stretcher Bridge – a compact mobile intensive care module. Anaesthesia & Intensive Care 1990 18 (2):234-45 . A landmark paper, describing the first truly portable intensive care module. Designed to attach to a stretcher across the patient’s legs, the unit incorporates a ventilator, oxygen and suction capability, monitors and infusion pumps. The development of this concept has shaped and simplified the cabin fit of subsequent air medical craft, both rotary and fixed wing. At last count, over a dozen air medical services throughout Australia & NZ were using the CareFlight bridge system or developments of it. more (PDF, 316KB).
4. Munford BJ & Wishaw KJ. Critical Incidents with Nonrebreathing Valves. Anaesthesia & Intensive Care 1990 18 (4):560-74 . A report of four cases, three of which occurred during retrievals, of problems with the valves used on most emergency department and transport ventilators. Both human errors and equipment failures were identified. The discussion suggested the mandatory use of automated pressure monitors with low pressure alarms, and capnographs (carbon dioxide monitors) for transport of all ventilated patients. These suggestions were subsequently incorporated into the ANZCA/ACEM minimum standards for transport of the critically ill. more (PDF, 4MB).
5. Ferguson D, Deen B, Fraser S, Lees C & Munford BJ. CareFlight – taking the hospital to the patient. Ambulance World 1991(2). A descriptive article by several of the original paramedics seconded to CareFlight and one of the medical staff on the value of the combined medical/ paramedical team for scene and interhospital transport. more (PDF, 455KB).
6. Munford BJ. Medical Helicopters for Motorsport – the Case for Minimum Standards. Motor Sport & Safety 1992 (January) pp13-14. An invited review article for the motor sport medicine association’s journal, following several incidents of unsuitable or under-specified helicopters being supplied as air ambulances for major motorsport events such as the various Grand Prix. Such events are now predominantly covered by full time air medical services rather than ad hoc. more (PDF, 213KB).
7. Nocera A & Dalton AM. Disaster Alert! The role of physician staffed helicopter emergency medical services. Medical Journal of Australia 1994, 161(Dec):689-92. A case report of the actual and potential role of air medical services to major trauma incidents, following the activation of CareFlight and Lifesaver by the CAA for the DC3 crash into Botany Bay at Mascot Airport. Presented the case for the wider utilisation of these services in major incidents, both for their transport capability (enabling the critical patients to be spread over a wider number of receiving hospitals) and advanced medical teams offering enhanced triage and treatment capabilities. more (PDF, 500KB).
8. Munford BJ & Manning R. Paramedic Helicopter Retrieval of Trauma Patients (letter). Australian & NZ Journal of Surgery 1994, 64: 640. Letter offering a critique of a paper in the previous issue by Cameron et al which described the treatment and outcomes of trauma patients transported by the paramedic staffed Air 495 helicopter in Victoria. The letter pointed out that over half the patients were transported without essential resuscitative measures that could and would have been performed by medical teams; and that this presumably related to the mortality being some 30% worse than that for similar studies where medical teams were deployed. more (PDF, 158KB).
9. Roby HP, Bentley L & Munford BJ. Considerations in International Air Medical Transport. Part VI Chapter 1 (In) Air Medical Physician Handbook, AMPA/Chicago Univ Press 1994. A chapter looking at the medical, equipment, practical, legal, and financial issues in international air transport of patients by both air ambulance and aboard airliners; in the first physician level scientific text on air medical transport, written & published by members of the (US based) Air Medical Physician Association. more (PDF, 1MB).
10. Munford BJ & Hanrahan BJ. The Scope of Air Medicine in Australia: More than Just Patient Transport. Part VI Chapter 5 (In) Air Medical Physician Handbook 1994, AMPA/Chicago Univ Press. Another chapter in the text described above, looking at the role of air medical services in the delivery of different types of health care services in different regions. The chapter outlined how the use of air medical services within Australia could be described by a population model incorporating three categories: remote, rural and para-urban, and how the requirement for air medical services differed in each region using examples such as the RFDS, CareFlight, and NSW Air Ambulance. more (PDF, 408KB).
11. Lee A, Lum ME, Beehan SJ & Hillman KM. An evaluation of an education program in the use of interhospital transfer guidelines. (Abstract) Anaesthesia & Intensive Care 1995, 23: 399-. Evaluated the use of an education program in using the retrieval triage tool developed by the authors (see below). The paper showed that medical and nursing staff completing the education package were able to reliably select the correct level of escort as determined by a panel of experts and the ANZCA/ACEM guidelines. more (PDF, 834KB).
12. Nocera A. A flexible solution for emergency intubation difficulties. (Case Report) Annals of Emergency Medicine 1996, 27(5): 665-7. Written in response to case reports of difficult intubations in earlier issues of this journal, the letter outlined CareFlight’s experiences in successfully using a long silicone bougie with multiple difficult prehospital intubations, with description of a typical case and suggested that emergency medicine physicians should receive more training in its use. more (PDF, 133KB).
13. Lee A, Lum ME, Beehan SJ & Hillman KM. Interhospital Transfers: decision making analysis in critical care areas. Critical Care Medicine 1996, 24: 618-22. Described a triage tool developed to determine the level of medical escort (paramedic, nurse escort or medical retrieval team) required for interhospital transports, using a tabular format of diagnosis, treatment and physiology plotted against airway, breathing, circulation and disability, with a “sieve” principle for patient selection. This tool was introduced and is still used in the SW Sydney Area Health Service, and was later copied by the NSW Ambulance Service for use in its Guidelines for Medical Retrieval poster. more (PDF, 454KB).
14. Hanrahan BJ & Munford BJ. Air Medical Scene Response to the Entrapped Trauma Patient. ADAC/International Society of Aeromedical Services AIRMED 96 Congress Report. 1997:375-8. ADAC Luftrettung GmbH. A transcript of the paper given by Dr Hanrahan at the AIRMED 96 congress in Munich, this paper included four case reports which outlined the approach to the trapped multitrauma patient as developed and practiced by CareFlight medical teams; an approach that stresses early employment of anaesthetic techniques for extrication, and aggressive crush injury syndrome prophylaxis. more (PDF, 617KB).
15. Munford BJ & Beehan SJ. Development of a Model for Air Medical Services. (In) ADAC/International Society of Aeromedical Services AIRMED 96 Congress Report. 1997: 597-602. ADAC Luftrettung GmbH. This is the text of an invited keynote address by Dr Munford, who was the sole Southern Hemisphere representative on the scientific faculty of the AIRMED 96 conference. It reviews the existing scientific models of air medical services (including the population density model developed by Drs Munford, Beehan and Bishop as part of CareFlight’s submission to the Australian Health Minister’s Advisory Council (AHMAC) review of Australian air medical services). A combined model incorporating aspects of several previous models was presented and the role of such a model in predicting the utilisation and efficacy of air medical services outlined more (PDF, 308KB).
16. Nocera A. Notable Cases: The St Mary’s fragmentation grenade explosion. Medical Journal of Australia 1997, 166(May): 545-8. A case report of the CareFlight response to multiple trauma patients from an explosion at an ordinance factory, incorporating a discussion of management priorities and the role of air medical services in penetrating trauma cases and multiple patient incidents. more (PDF, 437KB).
17. Nocera A, Gallagher J & White J. Severe tiger snake envenomation in a wilderness environment. Medical Journal of Australia 1998, 168(Jan):69-71. A case report on the prehospital management and winch rescue of a critically ill snakebite victim, with discussion of the place of prehospital antivenene and the role of air medical services in the delivery of this and advanced life support measures. more (PDF, 249KB).
18. Munford BJ. Practical Pharmacology of Neuromuscular Blockade. Air Medical Journal 1998, 17(4):149-56. A review of the pharmacology of paralysing drugs, the use of which has recently increased in many air medical programs, and practical guidelines for their use based on the author’s own twelve year and CareFlight’s somewhat longer collective experience with these agents in the air medical setting. more (PDF, 574KB).
19. Harrison KR & Munford BJ. Retrieval of the Trauma Patient: A User’s Guide. Australasian Emergency Nursing Journal 1998, 1(5): 14-15. A review of the role of retrieval services in the integrated care of the trauma patient, focussing on education of peripheral hospital staff who are the principle “consumers” of these services. Includes a guide for preparation of patients for transport. more (PDF, 373KB).
20. Bartolacci RA, Munford BJ, Lee A & McDougall PA. Air medical scene response to blunt trauma: effect on early survival. Medical Journal of Australia, 1998, 169 (Dec):612-616. A retrospective review of eight year’s experience with a physician staffed helicopter service for prehospital response to trauma. The paper showed that 215 out of 270 patients had received additional therapy from the medical team (beyond that able to be provided by general or paramedic ambulance officers). Patients taken to one hospital (Westmead) which collected Trauma Research Injury Severity Scoring (TRISS) data were further studied. Air medical team (AMT) patients required significantly less interventions than a matched group of patients brought in by ground paramedic, and were 40% less likely to die in the first 48 hrs. When AMT patients were compared against the survival norms established by the Major Trauma Outcome Study (MTOS), there was a 50% improvement in survival. more (PDF, 459KB).
21. Garner A & Bartolacci RA. Massive Prehospital Blood Transfusion in Blunt Multiple Trauma: A First Report. Medical Journal of Australia 1999, 170 (Jan): 23-25. A report of a 15 year old trapped in a motor vehicle for less than two hours with multiple injuries and massive blood loss who received a transfusion of 15 units of blood over the period it took to release him. This is the highest published figure for prehospital use.) Despite a survival probability of only 16% according to MTOS (see above), which was probably worsened further by his entrapment (not taken into account by MTOS), this patient made an almost complete (albeit protracted) recovery. The authors discussed the indications for & problems with massive transfusion in the prehospital setting. more (PDF, 252KB).
22. Nocera A & Garner A. Australian Disaster Triage: A Colour Maze in the Tower of Babel. Australian & NZ Journal of Surgery 1999 69: 598-602. A survey of different systems used for casualty triage & “tagging” at mass casualty incidents. There were five different triage methods, six different triaging methods and five different systems of coding. None complied with the National Triage Scale used in Australian hospitals. The authors recommend a nationally standardised system. more (PDF, 330KB).
23. Nocera A & Garner A. An Australian Mass Casualty Incident Triage System for the Future Based on Mistakes of the Past: The HomebushTriage Standard. Australian & NZ Journal of Surgery 1999 69: 603-8. Accompanying the above paper, the authors present a new suggested standard system for Australia, based on previously described Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) methods. Geographic triage is suggested as a better alternative than tagging, as is the use of familiar ambulance/medical routines where possible. more (PDF, 406KB).
24. Munford BJ & Hanrahan BJ. Medical Scene Response to the Entrapped Trauma Patient. RESCUE Australia 1999 Autumn: 5-7 & 66-7. A review article for non medical personnel (ambulance, police, fire, rescue, etc) outlining the pathophysiology and special medical problems of entrapment, and the basis of the medical team approach to such patients. Includes discussion of elective and sequential airway management, crush injury syndrome prophylaxsis and treatment, blood transfusion, and general and regional anaesthesia for extrication. more (PDF, 1MB).
25. Bishop RO. Emergency Sedation Intubation. (letter) Emergency Medicine (Australasia) 1999, 11 (3): 200-1. A critique of a recent paper (Sams & Kelly, Emergency Medicine 11:84) on the use of high dose sedatives by paramedics to facilitate intubation in air medical transport, as an alternative to the combination sedative paralytic approach used by medical teams. The letter outlines the significant risks and problems of this approach, and suggests the best solution to be the addition of an appropriate physician to the flight team. more (PDF, 2MB).
26. Garner A, Rashford S, Lee A & Bartolacci R. Addition of Physicians to Paramedic Helicopter Services Decreases Blunt Trauma Mortality. Australian & NZ Journal of Surgery 1999, 69: 697-701. A comparison of severe blunt trauma patients taken by two different helicopter services, one doctor/paramedic staffed and one paramedics only to three different hospitals. Air medical team patients had significantly more interventions performed prehospital and were more stable on admission than paramedic helicopter patients. Direct comparison of groups calculated an expected 13 extra survivors per 100 patients from the use of a medical/paramedic team compared to paramedics alone. The authors contend that the enhanced procedural capabilities of a medically based team can more than compensate for the increased prehospital time in blunt trauma patients who require helicopter transport, whereas a paramedic only team cannot. more (PDF, 362KB).
27. Garner A & Nocera A. Should New South Wales Hospital Disaster Teams Be Sent To Major Incident Sites? Australian & NZ Journal of Surgery 1999, 69: 702-6. A review of the experience, currency, level of personal protective & safety equipment, and familiarity with medical equipment amongst medical staff sent to the 1997 Thredbo landslide disaster. None of the doctors without medical retrieval experience met the criteria in these areas, compared to much higher levels of compliance amongst staff either provided by medical retrieval services or with prior medical retrieval experience. It is suggested that medical teams to work at disaster sites should be provided by medical retrieval services (such as CareFlight). more (PDF, 1MB).
28. Munford BJ. Backbearings: Air Medicine into the Third Millenium. (Guest editorial) Air Medical Journal 1999, 18 (4): 134-5. The author (an editorial board member for the journal) reviews the developments of the past 25 years in air medical transport and identifies priorities for the future. These include appropriate utilisation, safety, excellence in clinical care and timely, cost effective provision of service. The need for a fluid approach to balance these sometimes conflicting priorities is emphasised. more (PDF, 111KB).
29. Munford BJ & Garner A. Paramedic Advanced Life Support – Rapid Sequence Intubation? (Letter). Australasian Journal of Emergency Care 2000, 7 (2): 7-8. A critique of an editorial in the previous edition of this journal, which argued that paramedics should be certified to use muscle relaxant drugs to perform rapid sequence induction. The letter addresses the implications of this contention in the light of the additional training, equipment and ongoing recertification required compared to the actual need for the procedure in the urban setting where the majority of paramedics practice. The letter argues that it is unrealistic to expect staff working purely prehospital to be able to perform any procedure purely because it is done in a hospital – or prehospital by a hospital based team. more (PDF, 2MB).
30. Nocera A & Newton AM. Bogus Doctor Deceptions during Multi-Casualty Events and Disasters. Prehospital & Disaster Medicine 2000, 15(3): 125-127. A review of five incidents where non medical individuals impersonated doctors at disasters including the 1995 Oklahoma City bombing, for reasons including journalistic, psychiatric and criminal. The implications and possible strategies to protect the community from bogus doctors during disasters are discussed. more (PDF, 641KB).
31. Nocera A. Helicopter Emergency Medical Services. Lancet 2000, 356 Perspectives: s2. A review of the “state of the art” in helicopter emergency medical services (HEMS) and their role in the wider delivery of health care in providing equity of access to emergency and critical care encompassing both interhospital and scene responses, the latter including hoist rescue and disaster response. Safety and economic issues are also reviewed. more (PDF, 1MB).
32. Mellor AJ. Helicopter Medical Retrieval in Sydney, New South Wales. Journal of the Royal Naval Medical Service 2000. 86 (3): 167 - 169. The author, a Royal Navy medical officer, outlines the NSW system for critical care transport and his experiences during a 6 month secondment to CareFlight in the first half of 2000. Secondment to an air medical & retrieval service such as CareFlight is suggested as an ideal opportunity for naval/military medical officers to acquire experience in patient transport. more (PDF, 304KB).
33. Flabouris A & Seppelt I. Optimal Interhospital Transport Systems for the Critically Ill. In: Vincent JL (ed). 2001 Yearbook of Intensive Care and Emergency Medicine Berlin-Heidelberg, Springer Verlag, (2001): 647-660. A review of clinical and organisational aspects of interhospital retrieval/critical care transport systems. Aspects covered include: organisational structure; medical crew selection & training; mode of transport selection; patient selection, referral & stabilisation for transport; developments in monitoring and oxygen supply; quality assurance; economic issues; and future trends. A process for developing a critical care transportation system as part of regionalisation of health care is outlined. more (PDF, 1MB).
34. Munford BJ & Garner A. The Role of Air Medical Services in Envenomation: An International Perspective. Air Medical Journal 2001 20 (2): 34-35. An editorial commentary accompanying a case report on the use of air medical transport in a paediatric rattlesnake bite victim in the USA. Differences in the pathophysiology of snakebite between US pit vipers and the elapids (cobra type) of Africa, Asia & Australia are outlined and the implications for first aid and definitive management discussed. A blueprint is outlined for the role of air medical response in envenomation that includes the need to carry and administer antivenene as required, as well as other resuscitative and support measures. more (PDF, 1MB).
35. Garner A, Crooks J, Lee A & Bishop R. Efficacy of Prehospital Critical Care Teams for Severe Blunt Head injury in the Australian Setting. Injury 2001; 32: 455-460. A retrospective comparison of outcomes in patients with severe blunt head injury treated by either a physician staffed prehospital service or paramedics. Patients were similar in all regards except that the physician treated patients spent more than twice as long to reach hospital due to differences in dispatch criteria. Despite this, physician treated patients had significantly lower mortality and better functional outcomes than the paramedic treated group. The authors conclude that the “package” of advanced interventions and enhanced judgement of a physician staffed prehospital team results in improved outcome for patients with severe head injury but were unable to determine the individual factors responsible. more (PDF, 376KB).
36. Garner A, Lee A, Harrison K & Bishop R. Comparative Analysis of Multiple Casualty Incident Triage Algorithms. Annals of Emergency Medicine 2001 38 (5): 541-8. Several algorithms have been recommended as quick ways of rapidly identifying critically injured casualties at major incidents and disasters. As disasters occur infrequently and documentation is usually poor, comparison of these algorithms during an actual disaster is not possible. Instead the authors have retrospectively compared the accuracy of the algorithms in patients transported to two trauma centres during routine prehospital care with the assumption that they will perform similarly in a disaster. Simple Triage and Rapid Treatment (START) and CareFlight Triage had similar sensitivity but CareFlight Triage had significantly better specificity. Triage Sieve was a significantly poorer indicator of severe injury than either of the other two algorithms. more (PDF, 502KB).
37. Flabouris A. Clinical features, patterns of referral and out of hospital transport events for patients with suspected isolated spinal injury. Injury 2001 32: 569-75. Retrospective evaluation of 196 patients transferred for suspected isolated spinal injury, half of which were interhospital transfers. Signs at the scene correlated poorly with subsequently documented injury corresponding in only 31% of cases. Cervical injuries as part of mixed injuries were the most commonly missed. Road transport was associated with a significantly higher rate of critical incidents but none of these resulted in neurological deterioration. The routine use of helicopter transport for all suspected spinal injuries is thus questionable. more (PDF, 456KB).
38. Garner A & Nocera A. "Sieve", "Sort" or START. (Letter). Emergency Medicine 2001 13: 477. A reply to an article in the previous edition of the journal, which describes the Major Incident Medical Management and Support (MIMMS). The letter highlights some of the deficiencies in the Sieve and Sort triage system and suggests alternatives. more (PDF, 144KB).
39. Garner A & Schoettker P. Efficacy of prehospital interventions for the management of severe blunt head injury. Injury 2002 33: 329-37. A literature review including non-English language articles, which examines the evidence for the efficacy of prehospital interventions in severe head injury. Overall there is paucity of well-designed studies. Data on the relationship between prehospital intubation and outcome is conflicting. Some observational data supports correction of hypotension. There is some support from randomised trials for hypertonic saline in hypotensive patients but these studies were designed to test other hypotheses. All studies that examined prehospital advanced intervention teams found improved outcome and the issue is deserving of further evaluation in a randomised, controlled trial. more (PDF, 497KB).
40. Ruth MJ. Pressure changes in tracheal tube cuffs at altitude. (Letter) Anaesthesia 2002 57: 825-6. A letter written in response to article that developed an algorithm for predicting changes in tracheal cuff tube pressures with altitude changes. The author describes CareFlight’s routine way of monitoring cuff pressures during flight by use of a hand pressure gauge, eliminating the necessity to be able to predict the changes in tube pressure associated with altitude. more (PDF, 205KB).
41. Everest E & Munford BJ. Transport of the Critically Ill. (In) Oh's Intensive Care Manual, 5th Edition, Elsevier, 2003. An review of the issues involved in transport of the critically ill patient, focussing predominantly on interhospital transport, but also intra-hospital movements, as well as a brief overview of critical care teams in prehospital responses and international air medical transport. Subjects discussed include: communications and organisational aspects; modes of transport; medical equipment required; preparation for and monitoring during transport; selection of personnel; transport and aviation physiology; education and QA issues. more (PDF, 648KB).
42. Tran MD, Garner A, Morrison I, Sharley P, Griggs W & Xavier C. The Bali Bombing: Civilian Aeromedical Evacuation. Medical Journal of Australia 2003 179: 353-6. This paper describes the civilian aeromedical evacuation of patients from the Bali bombing to Australian burns centres. All the critical care transports from Denpasar to Darwin were conducted on C130 aircraft by the RAAF. However the secondary transports from Darwin to burns centres in other parts of Australia were conducted almost entirely by civilian retrieval teams. In addition medical teams accompanied Qantas flights and treated more than 60 less injured persons on direct flights from Denpasar to Sydney. more (PDF, 1MB).
43. Lee A, Garner A, Fearnside M & Harrison K. Level of prehospital care and risk of mortality in patients with and without severe blunt head injury. Injury 2003 34: 815-9. A retrospective review of 2010 blunt trauma patients to determine the association between mortality and the level of prehospital care in severely injured blunt trauma patients with or without severe head injury. The study failed to demonstrate that either physician level or paramedic level prehospital care was associated with an improvement in survival – which may reflect that such teams are dispatched to more severely injured or more remote patients. The need for a randomised study is suggested by this analysis more (PDF, 277KB).
44. Munford BJ. What is the right helicopter for air medical scene response? Injury 2003 34: 800-3. An invited letter, which is a precis of the author’s keynote presentation at the Injury 2001 conference in Auckland, N.Z. The article addresses the limitations of helicopters in trauma, and the erroneous tendency to regard them as intrinsically lifesaving, and every helicopter as a potential air ambulance. Minimum specifications for cabin space, configuration, and equipment are proposed. A classification of currently common EMS helicopters by cabin space is outlined, and the limitations and advantages of each category are summarised. The author concludes that above a certain minimum standard, careful selection of equipment and crew, with a strong safety theme, are more important than the type of aircraft in achieving a safe and effective helicopter EMS operation. more (PDF, 242KB).
45. Garner A. Documentation and Tagging of Casualties in Multiple Casualty Incidents. Emergency Medicine 2003 15: 475-479. Dr Garner reviews the rationale for the use of triage tags, and some of the problems with their use. He then looks at the evidence for alternative systems, particularly geographical triage – with separate areas for different categories of patients – and concludes that overall this method is superior to triage tagging, although he recommends retaining tagging for deceased casualties. more (PDF, 342KB).
46. Flabouris A. A Description Of Events Associated With Scene Response By Helicopter Based Medical Retrieval Team. Injury 2003, 34 (11): 847 - 852. A review of critical incidents and positive events from 1198 scene ('primary') responses over 11 years. There were 216 critical incidents and 41 documented positive events. Critical incidents occurred most commonly during at scene time, during tasking, and in transport respectively. The commonest critical incidents were equipment related, followed by communication problems, and then difficulty in performing indicated medical procedures. The commonest positive events reported were good interaction at scene with other emergency services, appropriateness of tasking, and positive organisational factors. Both critical incidents and positive events were most common during responses to multiple trauma patients. more (PDF, 351KB).
47. Flabouris A. Interhospital Patient Transport Systems for the Critically Ill. (Review article with 115 references) Netherlands Journal of Critical Care 2003 7 (6): 353-62. Interhospital patient transport systems (IHPTS) are a collaboration between clinical and transport/aviation resources. Utilisation of such services is driven by the need to maintain equity of specialist medical care delivery throughout regions. These factors vary – and service delivery must vary appropriately. Studies have identified clinical and process benefits of specialist transport services. For any IHPTS efficient communication between referring, receiving & transport teams is vital. It is this mixture of clinical and logistic skills and imperatives that define IHPTS as a unique & specialised field of medicine; however the best service models and utilisation are still yet to be validated in controlled studies. more (PDF, 2MB).
48. Flabouris A, Schoettker P, Garner A. ARDS with Severe Hypoxia – Aeromedical Transportation During Prone Ventilation. Anaesthesia & Intensive Care 2003 31: 675 - 678. Severe hypoxia, despite maximal conventional respiratory support, is one of the few remaining limitations to aeromedical transportation. A case is reported of a 35-year-old female with severe adult respiratory distress syndrome (ARDS) following major trauma, who was referred for transfer by air to a tertiary centre 36 hours post-injury. At the time of referral the PaO2/FiO2 ratio was 48. Usual manoeuvres to improve oxygenation had only minimal impact. The patient was turned and subsequently transported prone with resultant improvement in PaO2/FiO2 ration to 260. There were no patient or transport-related adverse events. The implications & suggested management of the prone patient during aeromedical transportation are discussed more (PDF, 2MB).
49. Trevithick S, Flabouris A, Tall G. & Webber C.F. International EMS Systems: New South Wales, Australia. Resuscitation 2003 59: 165-170. An overview of the emergency medical system in NSW. Dr Trevithick & co-authors describe the ambulance services; aeromedical and medical retrieval services including CareFlight; hospital emergency departments: and the State critical care and major medical incident plans in NSW. Their roles in the overall delivery of emergency medical care in the state, including the major role played by transport services, are outlined and discussed. more (PDF, 485KB).
50. Garner A. Practicality of performing Medical Procedures in Chemical Protective Ensembles. Emergency Medicine Australasia 2004 16: 108-13. Four levels of personal protective equipment are generally recognised, from fully encapsulated with positive pressurisation (level A) down to normal work overalls with gloves, eyeware & mask (level D). This study looked at whether certain vital medical procedures can be successfully performed wearing level A to C protection, within a clinically useful time frame. A significantly greater time was required to secure the airway and obtain intravenous access in Level A protection, but differences between other groups were not significant. It is recommended that medical teams’ protective equipment should be upgraded to Level B. more (PDF, 356KB).
51. Garner A. The Role of Physician Staffing of Helicopter Emergency Medical Services in Prehospital Trauma Response. Emergency Medicine Australasia 2004 16: 318-323. The crewing of Helicopter Emergency Medical Service (HEMS) for scene response to trauma patients continues to be controversial, particularly regarding the role of the physicians. This review seeks to determine whether the literature supports using physicians in addition to paramedics in HEMS teams for prehospital trauma care. A literature search was conducted which identified 12 studies that compared physician & non-physician crewing of HEMS. 10 of the 12 studies, including the only randomised controlled trial, showed imporoved outcome with physician based crewing. The author contends that staffing of HEMS for pre-hospital response should conform to the same standards mandated for interhospital transport of patients with similar severity of injury. more (PDF, 778KB).
52. Flabouris A, Nocera A, Garner A. Efficacy of Critical Incident Monitoring for Evaluating Disaster Medical Readiness and Response During the Sydney 2000 Olympic Games. Prehospital and Disaster Medicine 2004 19 (2): 164-8. Because multiple casualty incidents (MCIs) are infrequent, audit and quality improvement (QI) of medical response to MCIs is difficult. The authors, who were seconded to the disaster medical response team for the 2000 Olympic Games in Sydney, studied the value of analysing incident reports as a tool for QI of medical team performance. A program of voluntary & confidential reporting identified 53 incidents. The authors conclude that incident monitoring is a potentially useful tool for systems evaluation but requires broader testing within a variety of disaster medical settings. As disasters occur infrequently, international collaboration is suggested. more (PDF, 2MB).
53. Garner A & Konemann J. Safety of Emergency Medical Service Helicopters. (Editorial). Medical Journal of Australia 2005 182 (1): 12. An editorial by CareFlight's Medical Director and Safety Pilot, that accompanied a study analysing the safety record of Australian HEMS operation. The article identifies single engine single pilot VFR helicopters flying at night as being most at risk, but the editorial authors highlight underlying systematic problems and the need for health systems to focus more on safety aspects of HEMS. The potential value of a collaborative aviation safety network as recently developed by several HEMS programs (including CareFlight) is outlined. more (PDF, 326KB).
54. Iedema R, Flabouris A, Grant S & Jorm C. Narrativizing errors of care: Critical incident reporting in clinical practice. Social Science & Medicine 2006 62: 134-44. This study examines the language, objectives and implications of the relatively new (to medicine) process of critical incident reporting (CIR), using a study of 124 retrieval medicine CIRs. Both the potential gains and also the risks to clinicians and systems are discussed. more (PDF, 686KB).
55. McMonagle MP, Xavier C, Garner A. Bilateral anterior cerebral infarcts from a depressed anterior base of skull fracture: Case report and review of the literature. Injury Extra 2007 38,, 175—178. This case report describes a fatal case of bilateral anterior cerebral infarction associated with an anterior base of skull fracture which was attended by CareFlight International. Although this is a rare complication of base of skull fracture, the possibility of vascular compromise should be considered with depressed base of skull fractures. more (PDF, 356KB).
56. McMonagle MP, Flabouris A, Parr MJ, Sugrue M. Reducing Time to Urgent Surgery by Transporting Resources to the Trauma Patient. ANZ J. Surg. 2007; 77: 241–246. Time to definitive trauma care directly influences patient survival. Patient transport (retrieval) services are essential for the transportation of remotely located trauma patients to a major trauma centre. Trauma surgical expertise can potentially be combined with the usual retrieval response (surgically supported response) and delivered to the patient before patient transportation. This paper identifies frequency and circumstances of such surgically supported retrievals performed by NRMA CareFlight from 1999 to 2003, identifying patients who had a surgically supported retrieval response and an urgent surgical procedure carried out before patient transportation to an major trauma centre. more (PDF, 75KB).

In addition CareFlight medical staff have presented over 70 papers at international, national and local air medical and critical care medical conferences, as well as providing articles and editorials for the newsletter of the Australasian chapter of the International Society of Aeromedical Services (ISAS).

CareFlight medical staff have also written over 50 papers in areas of medicine other than critical care transport.