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Our research program aims to continuously explore ways we can enhance our patient care and transport.

Over the past 37 years, CareFlight medical staff have published numerous articles related to air medical and critical care transport (retrieval). These articles have appeared in peer-reviewed scientific and general interest medical journals, as well as in textbooks.

CareFlight medical staff regularly present papers at local, national and international air medical and critical care medical conferences.

Papers are listed as follows: Authors who are CareFlight staff; 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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  9. 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.
  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.
  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.
  12. Nocera A. A flexible solution for emergency intubation difficulties. (Case Report) Annals of Emergency Medicine1996, 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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  23. Nocera A & Garner A. An Australian Mass Casualty Incident Triage System for the Future Based on Mistakes of the Past: The Homebush Triage 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.
  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.
  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.
  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.
  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).
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  55. Garner A, Harrison K. Early Post Tsunami Disaster Medical Assistance to Banda Aceh: A Personal Account. Emergency Med Australasia 2006 18 (1): 93-6. The south Asian tsunami on 26 December 2004 saw Australia deploy civilian teams to an international disaster in large numbers for the first time. The logistics of supporting such teams in both a self sustainability capacity and medical equipment had not previously been planned for or tested. For the first Australian team deployed to Banda Aceh, the New South Wales Fire Brigades Urban Search and Rescue (US&R) cache supplied all food, water, tents, generators and sleeping equipment. The medical equipment was largely sourced from the CareFlight US&R medical cache.
  56. Flabouris A, Runciman WB, Levings B. Incidents during out-of-hospital patient transportation. Anaesthesia Intensive Care 2006 Apr; 34(2):228-36. Out-of-hospital patient transportation (retrieval) of critically ill patients occurs within highly complex environments. Adverse events are not uncommon. Incident monitoring provides a means to better understand such events. The aim of this study was to characterize incidents occurring during retrieval to provide a basis for developing corrective strategies. Four organizations contributed 125 reports, documenting 272 incidents; 91% of forms documented incidents as preventable. Incidents related to equipment (37%), patient care (26%), transport operations (11%), interpersonal communication (9%), planning or preparation (9%), retrieval staff (7%) and tasking (2%). Incidents occurred during patient transport to the receiving facility (26%), at patient origin (26%), during patient loading (20%), at the retrieval service base (18%) and receiving facility (9%). Contributing factors were system-based for 54% and human-based for 42%. Haste (7.5%), equipment malfunctioning (7.2%) or missing (5.5%), failure to check (5.8%) and pressure to proceed (5.2%) were the most frequent contributing factors. Harm was documented in 59% of incidents with one death. Minimizing factors were good crew skills/teamwork (42%), checking equipment (17%) and patient (8%), patient monitors (15%), good luck (14%) and good interpersonal communication (4%). Incident monitoring provides sufficient insight into retrieval incidents to be a useful quality improvement tool for retrieval services. Information gathered suggested improvements in retrieval equipment design and use of alternative power sources, the use of pro formae for equipment checking, patient assessment, preparation for transportation and information transfer Lessons from incidents in other areas applicable to retrieval should be linked for analysis with retrieval incidents.
  57. Gibson J, Flabouris A. Awareness in Retrieval Medicine. Anaesthesia and Intensive Care Oct 2006; 34;678-682. Awareness is the spontaneous recall of an event(s) that occurred during general anaesthesia and surgery. The incidence of awareness is approximately 0.2% of cases where neuromuscular blockers are used and half that where they are omitted. The majority of data relating to awareness is from anaesthetic practice. We report a case of awareness associated with an out-of-hospital transportation of a critically ill patient requiring a medical escort (retrieval). We discuss the risk factors associated with awareness during retrieval, in particular the trend toward excessive administration of neuromuscular blockers, and the unique challenges for the prevention of awareness within the retrieval environment.
  58. 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.
  59. McMonagle MP, Flabouris A, Parr MJ, Sugrue M. Reducing Time to Urgent Surgery by Transporting Resources to the Trauma Patient. Australian and New Zealand Journal of Surgery. 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 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.
  60. Vassiliadis J, Mallett R, O’Regan S, Harrison K, Neuhaus SJ. Simulation Training for ADF Surgical and Intensive Care Teams: a Pilot Study. ADF Health, Journal of the Australasian Defence Health Service 2009 10;(1), 14-18. This paper describes a pilot program to develop pre deployment simulation training for health personnel including surgeons, intensivists, nurses and medics. The initiative was prompted by the need to provide realistic wartime surgical experiences and to develop pre-deployment teamwork. Success was measured in terms of participants’ satisfaction and the observations of team performance by the training faculty.
  61. Walker S, Mattox K, Wigle RL, Crippen D. So you want to help? British Medical Journal 2010 340: c562. Pictures of the aftermath of the earthquake in Haiti have led to questions about the humanitarian effort. This paper offers some advice for prospective volunteers, including likely conditions and problems that will be encountered, how to become part of the organised response, what training is available for prospective medical volunteers and suggestions for personal equipment.
  62. Jones C, Tzannes A, Reid C. A prehospital paediatric tension viscerothorax presenting as a tension pneumothorax: A diagnostic dilemma. Emergency Medicine Journal 2010. This article reports a case of a paediatric pre-hospital tension viscerothorax, and its subsequent management. It also discusses the difficulty in diagnosing this condition in the pre-hospital arena.
  63. Jones C, Hommers C, Burns B, Forest P. ECMO retrieval in NSW and beyond. Current Anaesthesia & Critical Care 2010 21: 282-286. This article discusses the background, logistics and safety of ECMO retrieval in New South Wales, Australia. We look at the experiences of a well established, high volume medical retrieval service and the challenges presented during the recent H1N1 swine flu pandemic. In outlining the referral and retrieval process utilised in NSW we hope that other retrieval services can gain from our experience.
  64. Murphy D, Garner A, Bishop R. Respiratory function in hoist rescue: comparing slings, stretcher and rescue basket. Aviation & Space Environment Medicine 2011 82: 123-7. This paper compares respiratory function during four commonly used hoist rescue techniques: single strop, double strop, stretcher and US Coast Guard rescue basket (CGRB). All modalities impaired respiration due to either direct chest compression or posture, with the exception of the CGRB. The CGRB where available is the preferred option for hoist rescue of patients with respiratory compromise.
  65. Milligan JE, Jones CN, Helm DR, Munford, BJ. The principles of aeromedical retrieval of the critically ill. Trends in Anaesthesia and Critical Care 2011 1: 22-26. This article discusses the physiology of aeromedical transport and its effects on certain clinical conditions and the equipment used. The article also offers some practical advice on personnel, equipment and how to carry out a tasking in both fixed wing and rotary wing aircraft.
  66. Weatherall A, Skowno J, Lansdown A, Lupton T, Garner A. Feasibility of cerebral near-infrared spectroscopy monitoring in the pre-hospital environment. Acta Anaesthesiol Scandinavia 2012 56: 172-177. This study evaluated the feasibility of the use of the new generation of absolute cerebral tissue oxygenation monitors in the prehospital environment. Quality of recordings in both road ambulances and helicopters were evaluated in healthy volunteers. Adequate bilateral signals were available more than 705 of the time.
  67. Garner A, Lee A, Weatherall A. Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew – case identification rates and effect on the Sydney paediatric trauma system. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012 20: 82. Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC. Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.
  68. Barker CL. Practical Management of the Shocked Neonate. Emergency Medicine Australasia 2013 25: 83–86. The shocked neonate often causes anxiety in the ED. This article aims to provide a systematic, practical approach to recognition and initial management of these patients. Their resuscitation should follow a pattern of provision of oxygen, fluid resuscitation, blood glucose correction, inotropic support and ventilation. Practical tips for intravenous access and the rationale behind choice of inotrope and anaesthetic induction agent are discussed. The major underlying causes – sepsis, cardiac disease, metabolic disease and non-accidental injury – along with their investigation and management are considered.
  69. Marland S, Ellerton J, Andolfatto G, Strapazzon G, Thomassen O, Brandner B, Weatherall A, Paal P. Ketamine: Use in Anaesthesia. CNS Neuroscience & Therapeutics (2013) 1–9. doi: 10.1111/cns.12072. The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.
  70. Barker CL, Costello C, Clarke PT. Obstetric Air Medical Retrievals in the Australian Outback. Air Medical Journal 2013, 32(6): 329-33. Within our 200 relatively high-risk obstetric patient cohort, there was only one maternal patient who required intervention beyond the scope of midwife practice. The newborn neonates we transport frequently require specialist neonatal care. If the neonate is born before the request for transport, decisions on team composition are relatively simple. With limited clinical information and long retrieval distances, the challenge is deciding when to request external neonatal specialist support for high-risk in utero patients. Individual transport services need to determine how they manage the unexpected delivery of a preterm or sick newborn during the transport of labouring women. Options include a neonatal specialist on all transports or increasing the skill levels of midwives or flight doctors to include specialist neonatal procedures and care.
  71. Barker CL, Weatherall AD. Prehospital paediatric emergencies treated by an Australian helicopter emergency medical service. Journal of Emergency Medicine 2013 DOI: 10.1097/MEJ.0b013e328362dffa. The study is a retrospective cohort analysis of 349 patients under the age of 16 treated by CareFlight in Sydney, Australia, between April 2007 and April 2012. Falls (33%), motor vehicle incidents (30%), sport injury (14%) and immersion injury (12%) were the most common mechanisms. A total of 27 children died within 30 days; nontrauma cases were proportionally overrepresented in the deaths. With respect to tasking, 59% cases involved a severely or significantly injured child. Among the children, 97% with a traumatic mechanism were transferred directly to a paediatric trauma centre. In addition, 81% of children had at least one intervention by the helicopter emergency medical services team at the incident scene, most commonly intravenous cannulation (61%), crystalloid bolus (29%), intubation (21%) and intravenous analgesia administration (15%).Paediatric prehospital patients can be of high dependency, requiring urgent critical care procedures. Training in prehospital medicine should include paediatrics. It is essential that practitioners maintain skills in venous access, airway management and provision of adequate analgesia in children.
  72. Garner AA, Fearnside M, Gebski V. The study protocol for the Head Injury Retrieval Trial (HIRT): a single centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:69. This paper describes the design and protocol of the Head Injury Retrieval Trial (HIRT) which is a randomised controlled single centre trial of physician prehospital care (delivering advanced interventions such as rapid sequence intubation and blood transfusion) in addition to paramedic care for severe blunt TBI compared with paramedic care alone. Primary endpoint is Glasgow Outcome Scale score at six months post injury. Issues with trial integrity resulting from drop ins from standard care to the treatment arm as the result of policy changes by the local ambulance system are discussed.
  73. Barker CL, Ross M. Paediatric aeromedical retrievals in the ‘Top End’ of the Northern Territory. Australian Journal of Rural Health (2014) 22, 29-32. The primary objective of this study was to describe the remote paediatric aeromedical population of the ‘Top End’ of the Northern Territory. The secondary objective was to identify children requiring high dependency care by the transport team. The majority of paediatric aeromedical patients have an infective cause for their illness. Respiratory disease is the most common indication for aeromedical transport. The majority of patients are transferred by a flight nurse and do not require high dependency care. The main risk factor identified for requiring high-dependency care during transport is respiratory distress in a newborn infant.
  74. Weatherall A, Garner A, Lovell N, Redmond S, Lee A, Skowno J and Egan J. Study protocol for the PHANTOM study: prehospital assessment of noninvasive tissue oximetry monitoring. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014; 22:57. This prospective cohort study will demonstrate associations evident from the earliest stages of prehospital treatment between near-infrared spectroscopy tissue oximetry values and both acute and long-term outcomes of patients suffering traumatic injuries. This may provide the basis for future interventional studies utilising near-infrared spectroscopy tissue oximetry to guide prehospital trauma care.
  75. McNeilly S, Coward A, Currie B, Collins S, Stephens D, Clark P. Meropenem use in the pre-hospital setting in the Top End. The Northern Territory Disease Control Bulletin March 2014; 21(1):8-11. Meropenem is recommended in the CareFlight Northern Territory Top End Antibiotic Policy as pre-hospital treatment in critically unwell septic adults or children being evacuated to Royal Darwin Hospital (RDH), specifically to cover the possibility of melioidosis. A 12 month audit of the 3126 patients retrieved by CareFlight to RDH from Community Health Clinics, Katherine and Gove District Hospitals showed that 40 patients were given meropenem for presumptive severe sepsis and of these 17 (42.5%) were admitted to RDH Intensive Care Unit and 6 (15%) were confirmed to have melioidosis. Meropenem is an important drug carried by CareFlight and it is being used appropriately in evacuated patients who have severe sepsis.
  76. Sheils M, Ross M, Eatough N, Caputo ND. Intraosseous Accesss in Trauma by Air Medical Retrieval Teams. Air Medical Journal 2014; 33(4):161-164. When adequate peripheral access is impossible for hypotensive trauma patients, current evidence suggests that the use of IO devices offers rapid access with a high success rate. The IO device allows a bridge to initiate resuscitation while minimizing on-scene delays. These factors, combined with the complication profile of IO devices, offer benefit over the insertion of CVCs for prehospital air medical teams. In trauma, if access is required, we recommend the use of the IO device after 2 failed attempts at peripheral cannulation. Concerns over flow rates can be overcome using pressure bags and multiple sites in the short-term. Long-term access will be required for ongoing resuscitation once the patient arrives at the hospital.
  77. Caputo ND, Auld M. Placement of a Central Venous Catheter in the Antecubital Vein Using a Modified Seldinger Technique. Air Medical Journal 2014;  33(6): 280-282. We describe a case of a patient requiring inotropic support without central venous access in which the central venous catheter (CVC) was placed in the antecubital vein using a modified seldinger technique. The technique offers a novel technique as a temporizing solution until appropriate CVC access can be gained.
  78. Soomaroo L, Mills JA, Ross MA. Air Medical Retrieval of Acute Psychiatric Patients. Air Medical Journal 2014; 33(6):304-308. This review shows the characteristics of psychiatric patients retrieved by an air medical service in the NT of Australia. Most patients received sedation before team arrival with approximately one third of patients requiring further in-flight sedation. Only 3% of patients required intubation. A critical care flight doctor was tasked on most retrievals. The complication rate was minimal, showing that such patients can be transported safely with an appropriately skilled flight crew. Further analysis of patient history and characteristics of violence could lead to a risk assessment tool for the retrieval of such patients.
  79. Garner AA, Mann K, Fearnside M, Poynter E, Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician pre-hospital management of severe blunt head injury compared with management by paramedics only. Emergency Medicine Journal 2015; doi:10.1136/emermed-2014-204390. Advanced prehospital interventions for severe brain injury remains controversial. No previous randomised trial has been conducted to evaluate additional physician intervention compared with paramedic only care. This trial suggests a potential mortality reduction in patients with blunt trauma with GCS<9 receiving additional physician care. Confirmatory studies which also address noncompliance issues are needed.
  80. Garner AA, Mann KP, Poynter E, Weatherall A, Dashey S, Puntis M, Gebski V. Prehospital response model and time to CT scan in blunt trauma patients; an exploratory analysis of data from the head injury retrieval trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:28 DOI 10.1186/s13049-015-0107-1. https://sjtrem.biomedcentral.com/articles/10.1186/s13049-015-0107-1 It has been suggested that prehospital care teams that can provide advanced prehospital interventions may decrease the transit time through the ED to CT scan and subsequent surgery. This study is an exploratory analysis of data from the Head Injury Retrieval Trial (HIRT) examining the relationship between prehospital team type and time intervals during the prehospital and ED phases of management. This study suggests that well-rehearsed and efficient interventions carried out on-scene, by a highly trained physician and paramedic team can allow earlier critical care treatment of severely injured patients without increasing the time elapsed between injury and hospital-based intervention. There is also indication that role specialisation improves time intervals in physician staffed HEMS which should be confirmed with purpose designed trials.
  81. Garner A, Barker C, Weatherall A. Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2015, 23:92 DOI: 10.1186/s13049-015-0177-0 http://sjtrem.biomedcentral.com/articles/10.1186/s13049-015-0177-0 .P-HEMS played a significant role in the management of severe paediatric drowning in this case series. Requirement for P-HEMS only interventions were high and all identified cases were transferred directly to a paediatric specialist centre. Discontinuation of the P-HEMS direct case identification system that operated during the majority of the study period resulted in deterioration in system performance with some paediatric drowning cases subsequently not identified for P-HEMS response being transported to adult hospitals.
  82. Joynes EL, Martin J, Ross M. Management of Septic Shock in the Remote Prehospital Setting. Air Medical Journal 2016.  www.airmedicaljournal.com /article/S1067-991X(16)30007-4/abstract. This study aims to assess the management of septic shock by air medical retrieval teams in the remote setting. A retrospective observational study was performed over 36 months. Sixty-seven adult patients who met the criteria for septic shock were included. Respiratory sepsis was the working diagnosis for 53% of patients; this was confirmed on intensive care unit (ICU) discharge in 39% of patients. Intravenous antibiotics and oxygen were delivered in over 90% of patients. Central and arterial line insertions were performed in 48% and 40% of patients, respectively, and 79% of patients were catheterized. Thirty-three percent of patients required intubation, and 80% of patients received an initial crystalloid fluid bolus of 20 mL/kg. Vasopressors were started in 89% of patients. Upon reaching definitive care, 91% of patients were admitted to a high-dependency or ICU setting, with a median length of ICU stay of 4 days and a 30-day mortality of 13%. Of those admitted to the ICU, intubation was required in 48%, new renal support in 20%, and blood pressure support in 84% of patients, respectively. Septic shock was recognized early and managed aggressively by remote retrieval teams, which may have contributed to the low mortality rate observed.
  83. Milligan J, Lee A, Gill M, Weatherall A, Tetlow C, Garner A. Performance comparison of improvised prehospital blood warming techniques and a commercial blood warmer. Injury 2016. DOI: www.injuryjournal.com/article/S0020-1383(16)30209-1/abstract. Prehospital transfusion of packed red blood cells (PRBC) may be life saving for hypovolaemic trauma patients. PRBCs should preferably be warmed prior to administration but practical prehospital devices have only recently become available. The effectiveness of purpose designed prehospital warmers compared with previously used improvised methods of warming has not previously been described. All of the warming methods significantly warmed the blood but only the Buddy Lite reliably warmed the blood to a near normal physiological level. Improvised warming methods therefore cannot be recommended.
  84. Garner AA, Lee A, Weatherall A, Langcake M, Balogh Z. Physician staffed helicopter emergency medical service case identification – a before and after study in children. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2016, 24:92. DOI: 10.1186/s13049-016-0284-6. A case identification system using the crew of a physician staffed helicopter emergency medical service (P-HEMS) that identified severely injured children for P-HEMS dispatch was previously associated with high rates of direct transfer to a paediatric trauma centre (PTC). It was theorised that discontinuation of this system may have resulted in deterioration of system performance. After cessation of the P-HEMS system the rate of case identification fell from 62 to 31 % (P<0.001), identification of fatal cases fell from 100 to 47 % (P<0.001), the rate of direct transfer to a PTC fell from 66 to 53 % (P=0.076) and the time to arrival in a PTC increased from a median 69 (interquartile range 52 – 104) mins to 97 (interquartile range 56 – 305) mins (P=0.003). The parallel identification system improves case identification rates and decreases time to arrival at the PTC, whilst requiring RLTC authorisation preserves the safety and efficiency benefits of centralised dispatch. The model could be extended to adult patients with similar benefits.
  85. Biles J, Garner AA. Loss of consciousness during single sling helicopter hoist rescue resulting in a fatal fall. Aerospace Medicine and Human Performance. 2016; 87(9):821-824. https://www.ncbi.nlm.nih.gov/pubmed/27634704 We report an adult male falling 80 ft to his death while being hoisted into a rescue helicopter for a likely fractured ankle. A single rescue sling harness technique was used, but the patient became unconscious, slipped out of the harness, and fell. He had significant comorbidities, including cardiomyopathy, obstructive sleep apnea, morbid obesity, and diabetes. A decrease in cardiac output secondary to thoracic compression was the presumed cause for his loss of consciousness and the potential physiological mechanisms and modifying factors are discussed. Further research into harness suspension trauma is required. Stretcher, double point harnesses, or rescue baskets are likely safer methods of hoisting, especially in a medically compromised patient.
  86. Shipway T, Johnson E, Bell S, Martin J, Clark P. A Case Review: In-Flight Births Over a 4-Year Period in the Northern Territory, Australia. Air Medical Journal 2016; 35:317-320. https://www.ncbi.nlm.nih.gov/pubmed/27637445 This case series reviews several cases of in-flight birth and immediate maternal and neonatal outcomes from air medical retrievals in the Northern Territory of Australia over a 3-year period. In-flight deliveries are rare events in air medical medicine. This case series includes patients of variable preterm gestation and correlates poor outcomes to prematurity of neonates. Close communication between remote clinics, obstetric centres, and air medical teams plus up-to-date early labour guidelines are essential for safe practice and to limit the risk of in-flight births.
  87. Martin J, Mills J, Stanley D.  Is Nifedipine as a Tocolytic Effective in Facilitating In Utero Transfer? Air Medical Journal 2017; DOI: http://dx.doi.org/10.1016/j.amj.2017.01.010 Previous studies have reported that air medical transfer of women in preterm labor can be safely accomplished, without preterm birth occurring; in fact, many women were later discharged without preterm birth occurring. The purpose of this study was to determine if nifedipine, when used as a tocolytic, is effective at facilitating in utero transfer of women in preterm labor in the Top End of the Northern Territory of Australia.  In this study, nifedipine was used successfully to facilitate in utero transfer in many cases. Nearly half of the women referred were discharged without preterm birth occurring. Findings compare favorably with other published studies.
  88. Alan A. Garner, Jeremy Hsu, Anne McShane, Adam Sroor.  Hemodynamic Deterioration in Lateral Compression Pelvic Fracture After Prehospital Pelvic Circumferential Compression Device Application.  Air Medical Journal 2017. DOI: http://dx.doi.org/10.1016/j.amj.2017.05.006  Increased fracture displacement has previously been described with the application of pelvic circumferential compression devices (PCCDs) in patients with lateral compression–type pelvic fracture. We describe the first reported case of hemodynamic deterioration temporally associated with the prehospital application of a PCCD in a patient with a complex acetabular fracture with medial displacement of the femoral head. Active heamorrhage from a site adjacent to the acetabular fracture was subsequently demonstrated on angiography. Caution in the application of PCCDs to patients with lateral compression–type fractures is warranted.
  89. Torgrim Soeyland, Alan Garner, Sam Vidler, Cristian Humberto Gutierrez, Arnold Foster, Jane Kitcher. Predrawn prehospital medications are microbiologically safe for up to 48 hours. Emerg Med J 2018. DOI: https://emj.bmj.com/content/35/12/743 Prehospital medical teams are commonly required to administer a range of medications for urgent stabilisation and treatment. The safe preparation of medications during resuscitation requires attention,time and resources, and can be a source of medication error. In our two road and HEMS (Helicopter Emergency Medical Service) prehospital services, medication errors are mitigated by predrawing commonly used medications to set concentrations daily (Hunter Retrieval Service, HRS) or second-daily (CareFlight Sydney, CFS). However, there are no published data confirming that such practice is microbiologically safe. None of the 299 cultured samples yielded significant micro-organisms. Predrawing of the eight studied medications for urgent prehospital procedures appears to be a microbiologically safe practice with syringe dwell times up to 48 hours.
  90. P Hanley, J Holden, A Garner, A Weatherall, T Johnson. Two cases of penetrating left ventricular cardiac trauma:  Pre-hospital ultrasound and direct to theatre. Trauma Case Reports, Volume 21, June 2019. DOI: https://www.ncbi.nlm.nih.gov/pubmed/31011613 Left ventricular (LV) Cardiac penetrating trauma is a rare and grave injury. In cases of penetrating cardiac trauma, pre-hospital Ultrasound by flight doctors can assist identify specific pathology. This pre-hospital triage has now been linked to a change in both prehospital and in-hospital management. There are minimal cases reported where Pre-Hospital ultrasound provided definitive diagnosis and, while providing Pre-Hospital blood transfusion, informed a direct to theatre approach. In 2017 in New South Wales, Australia, a new protocol “Code Crimson” has been introduced to formalise a system wide process where Pre-Hospital medical teams can expedite a straight to theatre approach.
  91. A Garner, Nicholas Bennett, Andrew Weatherall, Anna Lee . Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis. Critical Care, Volume 24, April 2020. DOl: https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02865-y .Clinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team. Methods: We searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions.
  92. Urquhart C, Martin J, Ross M. Outcomes following out-of-hospital cardiac arrest in the aeromedical retrieval population of the remote Top End of the Northern Territory, Australia. Aust J Rural Health. 2021;00:1–8. https://doi.org/10.1111/ajr.12812.  Out-of-hospital cardiac arrest is an event with an extremely poor
    prognosis. There is limited literature on the outcomes for regional Australia, with none specifically addressing remote populations. We aimed to assess outof-hospital cardiac arrest outcomes in the aeromedical retrieval population of the
    Top End Medical Retrieval Service.