AAGBI Travel Grant report Flying Doctors, AMREF (African Medical & Research Foundation) February-March 2013Nairobi, Kenya

Dr Melissa Dransfield

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“Eating Geography” was how one of the mechanics described my time in AMREF. I flew to ten countries on 31 flights transferring 21 nationalities over a 2 month period.

AMREF provides free healthcare and education within Africa. The Flying Doctors Service (FDS) donates all profit to this cause. It generates income from medical evacuations (for insurance companies) and paid membership of the Flying Doctors’ association. By participating in the Volunteer Physician program, I was able to make a small contribution to this profit. The FDS also undertakes charity evacuations where individuals are evacuated free of charge from areas with limited healthcare resources to a place with better capabilities, usually Jomo Kenyatta Government Hospital in Nairobi.

Each flight had an experienced nurse trained in intensive care, emergency medicine and midwifery and a volunteer physician, like myself. We often had only brief or inaccurate clinical information prior to an aeromedical transfer and so we equipped ourselves for the

worst case scenario. On several occasions we were asked to evacuate multiple casualties simultaneously, particularly from military bases. The equipment and drugs available were of a high standard and regularly serviced and checked.

The areas to which we flew were at times unstable or remote and inhospitable, for example Kismayo (Somalia) or Dadaab refugee centre (Kenya). This meant that the time spent on the ground at the retrieval location needed to be short, with clear communication between the medical team, pilots and control room. There were rare times when all forms of communication were impossible e.g. Bangui (Central African Republic) during the rebel coup of March 2013, when we were unable to contact our base using radio, mobile or satellite phone.

A diagram of missions undertaken over 2 months

There was a variety of reasons for air evacuation, however some patterns emerged such as traumatic injuries from military bases and cardiovascular events and infectious diseases from Western visitors to remote East African locations.

During the 2 month period I delivered teaching sessions to the clinical team of flight nurses based on interesting cases and incorporated recent evidence and learning points. Intraosseus access devices were added to the FDS equipment during our placement and I conducted a clinical skills session on their use and management. February was the busiest month in the history of the FDS at AMREF and so a huge proportion of the time was spent preparing for and flying missions.

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Clinical conditions of evacuated patients n=37

Every case required different skills and in some ways I felt that my experience as a senior house officer in the Brighton Emergency Department helped me most. One case that really stands out was a medical evacuation from Uganda for a patient with severe malaria. The e-mail briefing us was extremely worrying; GCS of 4, a respiratory rate of 50 (after aspirating) and deteriorating renal and liver function. The clinic we arrived at had a depleting oxygen supply and no anaesthetic agents so had held off intubating until there was no alternative. His blood pressure was only 60 mmHg systolic when we arrived and he had a severe metabolic acidosis, with no urine output.

The time available to stabilise the patient was limited by our oxygen supply as we also needed it for the hot and dusty hour-long journey by road back to the airport. Despite ventilation strategies and maximum inspired oxygen concentration his pulse oximetry readings peaked at 89%. The road ambulance struggled to fit him on the stretcher due to his size. The uncomfortable bumpy ambulance journey felt interminable as we struggled

Trauma& Cardiac&

Surgical& Infec2ve&

Stroke& Misc&

with lines, intravenous fluid, inotropic infusions and oxygen levels. The frustrations grew as the airport officials insisted we wait for visa and passport checks before getting to the relative safety and supplies of the Citation Bravo. Fortunately the experience and communication skills of the pilots helped to expedite this process.

We visited him a week later after he had been discharged from ICU - his brain function intact and he had a great sense of humour. I felt like we had used every resource and capability to transfer him safely to Nairobi and it was such a sense of achievement to find out that he had recovered so well.

I learnt a great deal during the 2 month placement. Most of the skills I developed were related to communication, team work and crisis resource management. The daily control room meetings enabled reflective practise and discussion of the learning points based on completed missions. The volunteer physician programme enables Flying Doctors to minimise overheads due to medical staff, and therefore, increases its donations to AMREF’s medical and research divisions. Doctors from a wide variety of countries bring new skills and ideas to the flight crew and enhance its recognition world wide. I would highly recommend this experience to anyone interested in transfer medicine or pre-hospital care. The challenges and experiences I encountered were unique and served to broaden my view of the world.

I am very grateful to the International Relations Committee of the AAGBI for providing me with a travel grant of £500. I used this towards my flights to Nairobi and for my temporary Kenyan medical licence.