HELP FROM ABOVE

MATT SHAND, JOURNALIST

The last rescue mission flown by emergency medicine specialist Gary Payinda highlights an opportunity for specialist doctors to become part of the prehospital and retrieval medicine (PHRM) response process across the country.

Three Australian tourists met Cyclone Gabrielle’s fury as a massive landslide knocked their Ōrua Bay rental bach off its foundations and dragged them down a 15-metre cliff on to the beach.

One of the family managed to get free of the collapsing debris, but a man was critically injured, and an elderly woman was left trapped underneath the overturned and crushed house.

A Fire and Emergency New Zealand truck carrying heavy rescue equipment and crew was on its way when it became delayed by another slip. There was no road access to the site and the tide was rising. The beach where the wreckage and the patient lay would be underwater in a couple of hours.

Rescue crews were requested by hovercraft and helicopter. Neighbours and volunteers pitched in.

Specialist Doctor Gary Payinda and Critical Care Paramedic Ross Aitken were on duty that day, working with the Auckland Westpac Rescue Helicopter’s PHRM service. The pair were among the first responders to what would become a complex rescue scene.

“There was no safe helicopter landing site, so we were lowered down by winch,” Payinda said. “One patient had a serious injury, while a second patient was still trapped. We were unsure of their condition, and access to the collapsed structure was unsafe.

“While we were down there trying to assess and stabilise patients, our helicopter pilot and air crew officer became a resource for the fire service, conducting aerial reconnaissance of the hillside.

“A second Westpac Rescue Auckland team helped stabilise the wounded male while we focused on safely extricating the trapped elderly female patient. Thanks to the quick response from a variety of rescue teams, we managed to get her out without any rescuers being harmed. It was a big day and a perfect example of inter-agency teamwork.”

Gary Payinda

Auckland is unique in New Zealand as it operates a physician and critical care paramedic staffed PHRM model of care. This makes it the only city in New Zealand to have specialist pre-hospital and retrieval medicine doctors ready to fly 24/7.

Payinda says his last mission highlighted the importance that this level of service is rolled out across more remote and isolated parts of New Zealand.

“Critical care flight paramedics are immensely skilled. When you add the experience and knowledge of a pre-hospital and retrieval medicine doctor, you end up with an unbeatable team that can provide hospital-level care to patients regardless of location,” he said.

“We try to bring ED and ICU-level care to the site of the emergency. Our doctor and critical care paramedic teams travel with ultrasound, ventilators and blood. If you’re a patient with life-threatening bleeding, you can get a diagnosis and a transfusion before you even reach the hospital. In some cases, this can be the difference between life and death, especially if you are trapped or require a long transport time.

“With the right gear and the right staff, the helicopter becomes a mobile intensive care unit. The doctor and critical care paramedic PHRM model is innovative as it brings a critical care team to the side of the road, a paddock, the deck of a sailboat or any remote location,” Payinda says.

“The ability to deliver an ED, ICU, or anaesthetic specialist to the patient’s side, and the ability to do procedures such as echocardiograms in the field, means they can sometimes obtain a diagnosis before arriving at hospital.

“Treatment with the right medications or surgical procedures can start in the field. This reduces time delays to critical interventions, improves survival rates and reduces morbidity.”

His last rescue employed this model to great effect.

“We got in there and did our job,” he said. “Both patients survived, and no rescuers were hurt. The last I heard, they were doing well in recovery.

“It was really gratifying to see the teams come together. The system worked, from neighbours and bystanders to volunteer and professional firefighters, heavy rescue, ambulance and helicopter crews. All the time, resource and training paid off.”

Unfortunately, the doctor and critical care paramedic PHRM model is not yet available in other parts of New Zealand.

“I’d like to see this service available across the entire country, not just the Auckland region,” Payinda said.

“For reasons of equity, it is important to have this sort of service available in places like Northland, where I live.

“Places that are poor, isolated or remote benefit the most from services like this one.

“Māori and rural communities especially stand to benefit. We can reduce treatment times for some of our sickest or most injured patients in these under-serviced areas.

“We’ve got the doctors willing to do this work, even willing to staff it for free in a 3-month trial, to prove it can bring better outcomes to our rural communities.

“My hope in driving down to Auckland each month from Northland for the past three years was that one day we’d be able to transition the doctor and critical care paramedic PHRM model up to Northland. The dream was that one day the most critically ill patients anywhere in Northland could have a critical care doctor delivered to their side within 30 minutes.

“Those of us who’ve seen this system work want to see it expand to underserved parts of New Zealand.”

Payinda says there is much education and innovation that comes from having specialist doctors in the pre-hospital space.

“There is a real sense of constantly trying to improve the service, to bring more advanced techniques, medications and procedures out into the community to help patients. To do things faster, better and more effectively.

“Quite simply: to bring the best of the ED and ICU to the patient’s side, no matter where they might be.”

Kate St Louis

Kate St Louis

Giving people access to critical care outside of the hospital setting was a key factor in Kate St Louis signing up to work on rescue helicopters, and it encouraged her to stay there for the past three years.

St Louis came to New Zealand from the UK and worked in Hawke’s Bay, Christchurch and Auckland in emergency medicine.

“I am interested in the pre-hospital aspect of health care,” she said.

“Approaching a patient in their home or in a field is very different from the patient being brought to you in the hospital, and it has a whole new set of challenges.

“Every day is different, and you never know what to expect.”

St Louis has seen the benefit of having critical care and specialist intervention first-hand.

“The reality is people living in New Zealand are actually quite remote.

“Our priority is trying to get the patient to hospital as quickly as possible, but we can bring a lot of the things you will see in the emergency department, including the doctors and specialist equipment, and you can receive a blood transfusion en route.

“For someone suffering a life-threatening haemorrhage, that starts their treatment much sooner and leads to a better outcome.”

Her specialist skills have been critical on many occasions, and she encourages others to think about careers in pre-hospital medicine.

“One example we had was a young patient in cardiac arrest,” she said.

“He had the automated CPR device performing compressions. We were able to perform an echocardiogram to guide our ongoing therapy and decisions around resuscitation.

“We can also provide drug infusions and provide critical care interventions in-flight through the Auckland Westpac Rescue Helicopter service.”

St Louis also enjoys splitting her time with the public health system.

“There are a lot of pressures working in the hospital environment at the moment,” she said.

“Working in pre-hospital and retrieval medicine is energising and makes emergency medicine a sustainable career choice for me.”

St Louis says there are some preconceptions to what pre-hospital medicine or what helicopter-based doctors are like.

“There is an expectation you are a certain type of person,” she said.

“We are changing that. We have got more females in positions on aircraft, and sometimes we have a predominantly female operational crew. Our challenge is how do we improve equity of access across Aotearoa? I think if the PHRM model was rolled out around the country, we would have the people and the life-saving ability to help a lot of people.”