Transport of Critically Ill Patients – Dr Forbes Bennett

Joyce Barry: Welcome, everyone. First I want to introduce Doctor Forbes Bennett who’s been in this area pushing fifty years now, and it’s a great pleasure to have him tonight. Having the right vehicle with the right equipment, with the right people with the right time, heading to the right facility has to be a logistic[s] challenge for anyone dealing with very sick patients. That is what Forbes will be covering tonight and it’s a fascinating story.

So, a wee bit about Forbes … he’s not local, he was born in Wellington, but he did the clever thing and married a Hawke’s Bay girl, so he is legit [legitimate]. [Chuckles] And from there he graduated Otago Medical School in 1968, and then he did his Houseman and Registrar years in Wellington and then Hamilton; and then he headed to start his post-grad [post-graduate] anaesthetic training in and around the Auckland hospitals. He carried on with post-grad anaesthesia in intensive care medicine in Denmark, in England, and Sweden. So he came back to Hawke’s Bay to work under the Hawke’s Bay Hospital Board as a specialist anaesthetist and intensive care medicine specialist, so he’s been here since 1977, and in that time he was closely involved with the transport of patients, be it ambulance, be it helicopter – you name it. And of course it can cover trauma patients, and it can cover both medical and surgical patients; and it’s my great pleasure to hand over to Forbes. Thank you.

[Applause]

Forbes Bennett: Thank you very much, Joyce. I’ve written here, ‘Thank you, Joyce, for the kind words’, because I hoped you’d say something polite. [Laughter]

Firstly, to start it off, the fiftieth anniversary on April 10th was Wahine Day. How many people were in Wellington on that day? Hands up? I’ve got my hand up. Yes, quite a few, isn’t it? And we had a storm of some sort today, too; at least it wasn’t as bad as that. This talk really, if you thought it was going to be about medical … what was it? Hidden side of medicine, yes – the bit you don’t see. So you’ve been got [brought] here under false pretences because I’m going to talk about the transport of the critically ill patient. The talk covers the time – to get the historical bit – from 1977 to 2016, roughly.

My story started when I arrived, as Joyce said, for the Hawke’s Bay Hospital Board at Napier and Hastings hospitals, which are two hospitals fourteen kilometres apart, with anaesthesia and ICU cover and care in both. And I realised it was actually one hospital with a fourteen-kilometre corridor, [chuckles] and we treated it like that and did our best to make it work. Two emergency departments, two operating theatres, one paediatric department which was based in Hastings, two x-ray departments.

Now anaesthesia, which is an integral part of transporting a critically-ill patient, means that you’re put off to sleep by an anaesthetist; you have a tube put down your throat (usually, not always) to protect your airway; you’re sedated with various medications; you’re given other drugs to relax your muscles; and you’re attached to a ventilator which breathes in and breathes out in a controlled manner. Anaesthetists periodically – very rarely – make mistakes and need to ventilate their patients for some time after the procedure, so they started Intensive Care Units and they encouraged a lot of nursing staff to provide nursing care ‘cause they couldn’t be there all the time, so they trained nursing staff. (Stop laughing, Di Taylor!) [Chuckles] And this is really about the teamwork of the whole business.

Transporting somebody who’s ill takes the immediate team in the ambulance or in the aircraft around the patient; but there’s also the team at each end of the line – the people who look after all the other patients; the people who work the patient up and prepare them before and after the transfer. So there’s a whole lot of people involved and it’s very hard to cover everybody, so I’ll probably annoy somebody by not mentioning their input.

We had ventilated patients in both Napier and Hastings, but the longer-term ventilated patients were concentrated – for a whole host of political reasons, and nursing staff reasons, and paediatric reasons – concentrated in Hastings. So if you were going to be an intensive-care patient for a long time you had to be shifted from Napier to Hastings. And traditionally, anaesthetists were moving patients from the operating theatre to the Intensive Care Unit on ventilators, but they often used them in … they were hand-driven, self-inflating hand ventilator … and that doesn’t do a particularly good job. It doesn’t have the sophisticated wave form for the ins and the outs that mechanical ventilators have. So it was tried to use these mechanical ventilators to move from one place to another.

[Showing slides throughout] This is a lovely picture of Napier, and that’s one of Hastings. You’ll see that it’s historical, ‘cause you can see the cars. That’s what it started out like – it was a picture I found, I think it’s 1948. It’s early Hastings Hospital – that’s the block that you just saw; ‘The Memorial Hospital Hastings’ is written up there. There’s the house that [Doctor] Dave Barry lived in when he arrived back; that was the Nursing Home; that was the paediatric ward. The helipad’s now over here – fortunately that chimney’s not there. We’ve got an adjacent, very useful component of the hospital … [Laughter] Thank goodness it’s changed. That’s what it’s like now. Where the memorial logo is, the nursing home’s … you notice the helipad’s gone, it’s been shifted out [the] back. There’s more building here; the paediatric ward’s gone – shifted to where the ICU was. It’s changed quite a lot. There’s other stories there.

Now, the transport of the critically ill really started … that’s a patient in an ICU with a ventilator that’s got a very good name but it wasn’t a particularly good ventilator – it’s called a Bennett ventilator. [Laughter] And what was that one called? For some reason the patient’s got two ventilators – I think we were probably changing over and I snatched the photograph. But that’s the bit that you don’t get to see unless you’ve got relatives in there – tube down the person’s nose – we used to do them; we now do tracheostomies through here … through the neck … bit of rubber tubing goes over to the ventilator and that’s what brings you the air.

[New slide] I’ve got that in; it’s a balloon festival in Masterton, but I put it in because the first transport of critically ill patients was in the Franco-Prussian War when Paris was surrounded by Germans and the French wanted to get injured soldiers out to hospitals that they had outside the German lines – they put them into balloons. They must have known what they were [doing]; I mean we put people in balloons and they finish up in Chile. [Laughter]

Fixed wing planes were first used in 1917 for shifting sick patients. There was a British soldier injured in Turkey and he was flown in forty-five minutes – a trip that would normally take three days – and it probably saved his life.

In 1928 in Australia they started the Royal Flying Doctor Service, but they weren’t transporting critically ill patients; they were transporting sick patients.

In the Spanish Civil War [cough] they flew patients by plane to Germany, ‘cause Germany was on one side in the Spanish Civil War. They also used trains which were very nice. And Graham Masterton, who’s a retired General Practitioner, let me know that we used trains here for transporting patients. He described sedating psychiatric patients and cuffing them into Guards’ van [chuckles] in Hastings, and the train would stop at Porirua so they could unload the patients. Now you think we’ve progressed; [chuckles] ‘bout five or six years ago I had to organise the transfer of a patient back from Palmerston. [New Plymouth] We didn’t feel an anaesthetic was justified but she finished up being handcuffed into the back of an ambulance and brought over from New Plymouth – five-and-a-half-hour drive …

Audience member: Oh, God!

… on a mattress in the back of an ambulance. So there’s some things we haven’t really got right yet, but on the positive side we don’t handcuff our patients physically any more, we handcuff them pharmacologically, by using clever medication so they relax, and behave themselves in particular. [Chuckle] It’s a lot easier.

There were some planes used in 1939-’41; not much, but in the Korean War, you’ve all heard of M*A*S*H, and the helicopter usage in there. You couldn’t really get at the patient in the M*A*S*H helicopter because they were slung on the skids on the outside, so if they started to deteriorate on the trip there’s nothing you could do.

That’s the ambulance as it was in the 1970s. So we’d take a bed from the hospital like this, put some bits on it with a patient too, load that into the ambulance and drive from Napier to Hastings or Hastings to Napier. And while we were doing that I was aided by [Doctor] Ted Ward, who really got the Intensive Care Service going and had all the bright ideas – I just swum [swam] in his slipstream – we realised that we could actually move [cough] the ventilators and all the monitoring equipment because of the advances in the equipment that were occurring.

That, Jan, you’ll recognise; there’s a Bird ventilator, and that was our first easily-portable ventilator. It’s a tube that runs through there and a series of holes in the middle with leakages controlled by these knobs, so that the tube is able to flick backwards and forwards. There’s two magnetic discs; the tension between those discs gives you a flip-flop device. You run compressed air in one end and you get intermittent compressed air out the other end, and it ventilates the patient. It can be adjusted and set up to do it really very well, and it’s small and wonderfully reliable. So with that and an oxygen cylinder we could move people very easily around the hospital, and put them in an ambulance and move them easily from one site to the other. We also thought, ‘Maybe we could shift them by air’. Now I don’t think we were the first, and one of the things in preparing this talk I was trying to find out who actually was doing the critically-ill air transports first, and I couldn’t put my finger on that. I think it was an idea that developed … occurred to a lot of people at the same time, ‘cause in presenting what we were doing to a lot of people at conferences, other people would say, “Oh yes, we’re doing that too.” So I would presume that because people were using the equipment, that’s sort of what happened.

So there’s a patient in an ambulance; the Bird ventilator’s tucked on the side and there’s tubing … goes to the tracheostomy. Pretty primitive blood-pressure measuring by intensive care standards, because the monitoring that we developed meant we could put a needle or a canula into an artery and display that on a screen so we got instant readouts. That was pretty standard at the time for cardio-thoracic surgery, but it wasn’t used very often in ambulances shifting people around. There’s a dedicated nurse – the slide’s a wee bit cropped – she’s got a look of some anxiety on her face; she’s really being very watchful, which one’s immensely grateful for.

And another picture of the inside of an ambulance; ambulance monitors, our monitors displaying the patient’s vital signs, intubated; the spare ventilator set up there, that’s that hand ventilator; watchful nurse and oxygen supplies.

The other group of people we found were very helpful were anaesthetic technicians, because they work with [coughing] anaesthetic registrars in the operating theatre. They know one another’s behaviours and patterns and what has to be done, and they work very well together as a team. But I couldn’t really sell that concept elsewhere in New Zealand; nobody else really took on to that. We’ve had a really good run from our anaesthetic techs who greatly appreciated it – the chance to get out and fly somewhere – but it didn’t really catch on as much as I would’ve liked. It’s quite interesting watching an anaesthetic technician give a nursing handover at another hospital. That led to quite a lot of entertainment … quiet entertainment on my side.

It was crowded inside the aircraft ‘cause they’re all small. That’s a syringe pump. You can see how things are getting smaller – a syringe pump to control the infusion rate; bits of the ventilator; the patient’s head up near the controls, so you don’t really want an awake psychiatric patient sitting in that position. [Chuckles] They’re sedated.

And that’s the sort of aircraft that we were initially using – small, twin-engined, and they’re waiting to load an oxygen cylinder. And that’s on the tarmac at Bridge Pa. We did a lot of our flights taking patients to Auckland and Wellington and Christchurch, sometimes flying initially out of Bridge Pa and then in later days we were flying out of Napier airport.

We got bigger planes; this is a pressurised one. You can imagine fitting a two-hundred-kilogram patient through that door. [Chuckles] You have to strap them into the stretcher so that when you tilt it on one side they don’t fall out [chuckles] which we anticipated; it never actually happened. We tended to have a lot of gear going with us too, bits and pieces, planning ahead and anticipating problems.

Loading another plane – the ever-present oxygen cylinder; that cumbersome ventilator – I’ve no idea why we were using that. It was a big thing to push round and lift up on the wings and carry, but for some reason we wanted to use that.

And we had an affiliation with a Chinese university in Hong Kong; this gentleman’s called Gavin Joynt, and I put this on to show that while we were travelling we had to measure what was going on as well. This device has a screen that puts up the heart rate, the blood pressure – it’s all coloured too, so you can recognise which one you’re looking at – the oxygen saturation, that’d be carbon dioxide from the respiration, oxygen, a ventilator – see how small that’s got compared with that box that you saw before? And that’s a mannequin there, a non-Chinese speaking mannequin. [Laughter] They wear masks because they had a really good dose of SARS and they were worried about that. But they had different masks when they got the SARS epidemic.

That was one of our monitors that we used a lot, turned off and charging; ICU palliative care pump – don’t know why it was called that, we didn’t do much palliative care in the ICU. We’ll move on quickly then. [Chuckles] And a printout that we use to record what we did during the trip, and the monitors and cables that clip onto people.

[Showing more slides] Neuron monitors; monitors are getting more and more function; there’s more and more monitors. These things are … how much? They’re $15-20,000 each; they’re not cheap – you could buy a good car for one of those. The Chinese university; banks of syringe pumps waiting to be used. Once they’ve been used they get cleaned and put in to charge, so you’ve always got them ready to pick up and go. Our bank of equipment; things plugged in to charge and waiting to go.

This is a tube and ventilator – it’s the tubing on a little baby. How old would that be – three months? Tube down the nose into the lungs, ventilating; the cardiologist examining the patient.

[I] put this one on to show the size of an echo machine. And there’s the legendary [Doctor] Michael Bostock, and the legendary [Doctor] David Barry, with different coloured hair. [Laughter] But this machine now we don’t actually use them in transport, but I put it there to show how the technology’s advanced, which has made our job possible. This machine is now available in about the size of this thing [demonstrates] and the current cardiologist, Richard Luke’s got one with a probe that comes off it. So it’s gone from being a big box into something that runs for hours on batteries and is the size of a small box … that size. So it makes fitting it inside an aeroplane ever so much easier. [Chuckles]

We developed training programmes with medical and nursing training and for the anaesthetic technicians; we had support from Colleges – the College of Anaesthetists and the developing Intensive Care fraternity – ’cause the faculty didn’t [?] then – brought out standards for guidelines in transporting the critically ill. And the College produces standards in relation to activity that they are undertaking, and we’re part of an Australasian College. And I was intrigued with the politics of this. The Australians wanted New Zealand to be in on it, so it’s the Australian and New Zealand College, like most of the Colleges; I don’t think any of them aren’t. And the reason for that is that the politicians can’t fiddle with a multinational body as easily as they can legislate if it was a national body. So by having your policy documents authorised, understood and agreed upon in two countries, you’ve got a much better chance of getting things done properly than telling the politicians to get on and spend some more money; which seems to me the state we’re in at the moment. I mean, look at Middlemore Hospital – you wonder what on earth is going on up there. We need to have a bit more money spent there, I think.

We inherited the Chathams [Chatham Islands] somehow or other; why on earth the Chathams, which is equidistant from Napier, Wellington and Christchurch – why it should come here is anybody’s idea, and it was the Hawke’s Bay District Health Board’s responsibility. To make it more simple, Wellington made the fire capacity for the Chathams – that was organised from Christchurch; the Police was organised from Wellington, and the Health was organised from Hawke’s Bay. We certainly didn’t object to having to go out to the Chathams but it was most interesting. Going out there was a little bit like going back into the fifties; this was a pinky … faint pink colour. [Showing slide] Modern equipment, but it was just a prefabricated hut. And it was warm and dry; the roof didn’t leak, unlike Auckland, so it was really …[Chuckles]

That’s coming in to land at the airport in the Chathams. And they told me that the sheep had to tack to move upwind. [Chuckles] They had their priorities right; you see the sign here – bottle store, Catholic Church, and hospital. [Laughter] There’s a lot of stories about the Chathams, but I don’t think … [Chuckles]

As you can see, a lot of these photographs are taken from the air, with a helipad there at the front of the hospital, on that side. And we did use air quite a lot to go longer distances.

It started relatively early in New Zealand because we are quite spread out. British graduates who come and work here are a bit surprised you can’t drive down the road to the nearest neuro-surgical hospital. In our case it’s either Christchurch or Auckland; if you drive to either Christchurch or Auckland it takes a little bit longer than the time you’ve got available, so using air was an obvious option. And we had the history of the Royal Flying Doctor Service, and a lot of support from the aviation industry as well. There was [were] people like Mike Toogood, who was a very skilful businessman who kept us from spending too much money in the helicopter by running a tight business; Peter Kidd is an aviation person who – I was quite happy to sit on an oxygen cylinder and get the flight done – and he said, “No, no, no – you’ve got to put these in the plane properly.” So they got one aircraft and fitted it up with a secure oxygen cylinder that wouldn’t move round in turbulence, or if you stopped; suddenly you had something that wouldn’t fly around [??], ‘cause it was much safer than [??] to transfer oxygen. So [it] was a pretty [?step-wise?] progression; we had a lot of people pushing in the right direction.

We got hold of a helicopter which the Lowe Corporation funded for us. I really like this one. It’s a training exercise but you’ll notice there’s no pilot in the helicopter. [Chuckles] We got the only auto-piloted self-driving helicopter. [Laughter] He popped out to take the photograph.

We also moved on to getting a bigger helicopter; cost more to run, and this is part of the problem the company’s going through at the moment. These things are horribly expensive beasts – makes owning a car a pleasure when you look at the repair bills for helicopters. But there’s obviously going to be some rationalising at some point, I think. The pilot’s not trying to push-start it, he’s doing some more unloading; and that’s obviously Auckland and the Sky Tower.

We sometimes had to fly from Hawke’s Bay [chuckles] here, to Christchurch down here; we didn’t ever get this high. [Laughter] This is what – two hundred and forty kilometres up? We only went about three, four kilometres up. [Chuckles] Isn’t it a wonderful photograph? There’s the Sounds, there’s Farewell Spit, Nelson’s here, Wellington hidden behind the mast, and Hawke’s Bay’s just out of sight.

The reality of the transport – there’s a young lady going for a cardiac valve into surgery. She’d been [?compensated?] in Hastings; she was put on a ventilator that’s tucked round the back. She needed lots of infusions to keep her blood pressure up. She had a dedicated technician looking after [her] who did not want to be photographed. [Laughter] Don’t know where the ventilator is in that – usually somewhere around the back; and [?] recording what was happening. And we had this tie-up also with the Chinese University in Hong Kong; it was just problems in relation to moving people round. [More slides]

Those are bits on the ventilator – these are all taken from the teaching lecture that appears. I was talking about how to set up the various wave-forms that you want on a ventilator. That’s a filter and humidifier; that’s a expiration control valve. And when they were doing it – I don’t know what they’re doing now, but this is fifteen, twenty years ago, it’s historical – the oxygen and the attachments for the ventilator, and the settings.

We’ve moved on to a rather more sophisticated ventilator that can imitate the wave forms of the big ventilators within the ICU and reproduce them to maintain the ventilator. All these things have a host of alarm systems on them, ‘cause they tell you if it’s running out of oxygen, or electricity. And sometimes when you’re setting up to go for a transport, part of your work up is trying to work through the alarm system to work out what’s going wrong; but they’re very, very necessary alarm systems. It’s just lying on its workbench with oxygen – we’ve probably been playing with it with an artificial lung.

Different plane; bits fold out to make it easier to get into. Skyline Aviation, which you see when you drive past Napier; think it’s called Hawke’s Bay Air Ambulance Service now. And one of our pilots; loading ramps; more space, easier to get into; can take bigger patients which, funnily enough, seems to be the fashion. Another reason for liking [a] big entrance.

And storage of gear that can be picked up. We’ve got a list of where the various packs are; you could run three transports at one time – then. I don’t know what’s happening now; there’s quite a lot of money attached to this. Hawke’s Bay, when I was part of it, was doing about a thousand transports a year. We were doing about a hundred ICU transports a year. The total amount of income generated from that’s around about five and a half million dollars. If we do it, it stays in Hawke’s Bay, but Auckland and Wellington are looking with big eyes at that little bit of money; they’d like to get their hands on it, too, so I’d say, “Watch this spot”. But I’m not a part of it any more – I’m history, so … whatever happens. I can talk about it, though.

That’s the back of the BK … the loading area. The patient goes in on the stretcher and is slid in. The staff looking after them sit in there, there and there, and there’s gear added into it. The configuration’s changed somewhat ‘cause these slides were taken about four years ago and it is quite a fast-developing industry.

We carry quite a lot of drugs for various things; we really hardly ever use these – that’d be fair, wouldn’t it? Very rarely use these drugs; occasionally, but they’re there in case something starts to happen. The secret to it is really getting the patient as stable as possible before you move him. See, I’m starting to give away secrets of Intensive Care medicine. [Chuckles]

It’s a bit of a barrow bag to find what you’re after, but once you get used to working with that you work very well. And this is a flight from Wairoa down to Hastings; [the] nurse is monitoring and keeping a track of what goes on. Patient wearing earphones because we suspect that even though inside a helicopter’s noisy, so we put earphones even on unconscious patients so hopefully we won’t damage their hearing. He’s sedated; he wouldn’t hear it anyway. The ventilator, monitors, syringe pumps, pressure bag, controlled wave form on the ventilator, and a sedated patient. We could play music on it but if you’re asleep … [Chuckles]

That’s the sort of team on a training weekend … a display weekend. We’ve got a degree of recognition getting uniforms so that the people were identifiable, and as you can see they’re all happy hard workers. [Chuckles]

And what we’ve tried to do is get a continuation of what was happening to the patient in ICU, not to get any diminishing in care in the transport. I was thinking it’s difficult, but it’s what we had to do with these unstable, quite ill people. When I say ‘unstable’ – you’d stabilise as best you could, but the stability we can’t always guarantee, and so if the syringe pump fails, you’d have to find some way around to keep the fluids that we’re using in the syringe pump running in some other way.

And the object of the central safe transport of critically ill is a faculty that could provide better care or diagnostic facilities, and better management. And the simple definition of critical illness is really somebody who’s on a ventilator, ‘cause you’re dependent on machinery, and machinery’s just a touch less reliable than humans are. Humans make funny decisions, but machinery’s a bit prone to stop working when you least expect it. So anybody who’s dependent on that is called critically ill.

Not all the transports involve critically ill, and of a thousand patients who are transported by the Board, a good number are people who’ve had a heart attack and have to go to Wellington for stenting, ‘cause we’re not big enough to do the cardiac-thoracic surgery and the stenting here.

There’s a number of requirements, who should go; and we started with doctors doing it ‘cause it seemed it was our responsibility to do it. Some countries use just nursing staff, no doctors; some use ambulance people, no doctors; some contract it out almost completely. What you actually need are people who are happy working in an aviation environment or in the back of an ambulance, who’ve got the mental flexibility to work away from supervision and away from rules, which is one of the things I like – you’re getting every colleague looking over your shoulder and telling you what to do. You’ve got to have equipment … you work out what you need; it’s got to work properly; you’ve got to anticipate particular problems; you need a plan to transport and then you need to document what you’re doing.

When we were starting up it was usual to have an [cough] escort, but that’s not necessary – you want a system that works more than anything else. It’s quite interesting [coughing] watching them at the moment grappling with “Should we take away Taupō and Rotorua’s Rescue helicopters?” And one of the arguments advanced by an Auckland clinician this morning is that you get better doctors from the big hospital in Auckland. He didn’t say it this way; this is the intent of what he meant – you get these really good doctors from Auckland and they are what sick patients really, really need. [It] just crossed my mind – I bet that the Taupō rescue helicopter people are a damned sight better at rope work to get patients out of difficult mountain places than the Auckland ones are. Remember it snows more. [Chuckles] I do remember going up skiing; you could always tell the cars that had come from Auckland, ‘cause they wouldn’t have their chains on; they’d be off the side of the road. So there’s a place for … [I] guess there’s a place for rationalising, but I watch that with interest [coughing] to see what we’ll finally move around.

You’ve got what I consider a base hospital, although we’re only a District General Hospital; we’re second tier, not tertiary tier.

We did have one patient from the Chathams who collapsed on Pitt Island and was found unconscious. He was brought on a very rough day from Pitt Island, which is off-shore Chathams, back to the Chathams. We flew out to the Chathams to get him. He was intubated in the Chathams, brought back to Hawke’s Bay, had a CT scan; we landed in Napier; [sneeze] CT scan was in Hastings. He had a thing called an ependymoma, which is a tumour in the inner ear. He was taken to Wellington and the tumour was excised and he survived without any damage. You could say it’s hard to bring down people from the Chathams. [Laughter]

So when it works it goes wonderfully well – all depending … there’s four steps there, five steps. Chathams is now not a Hawke’s Bay District Health Board responsibility; I think it’s gone to Christchurch, and that’s really a better deal because Christchurch has neurosurgical, and … big hospital specialties which is what the people in the Chathams need.

Oh, I did want to talk about safety around helicopters. If any of you have ever had the experience of travelling in a helicopter, you never approach from this end. So the door has to be reinforced ‘cause you can hear this rotor, but you can’t hear that one. And it makes a hell of a mess if it touches you. [Laughter] So you walk in it from the front, and it may be acceptable to come in from [the] sides.

Another problem with flying is radiation; this is the amount of radiation you get when you go up. So if you fly to Britain at an altitude of four kilometres – what’s that? Four thousand metres. You get higher than that you get even more radiation. The radiation levels there are in millisieverts, which is a measure of radiation per year. A chest x-ray is .01 millisieverts per second, so if you’re flying at twelve thousand feet, you’re getting the equivalent of a couple of x-rays as you’re flying to Britain. If you do it often enough it would mean that you’re being exposed to significant radiation. But there’s debate about how much it actually matters; nuclear plant workers are allowed a hundred millisieverts a year, which’d be a lot of chest x-rays. And in Fukushima when it was hot they were getting a hundred millisieverts an hour, but most of the people who got that [have] currently died of various sorts of malignancies.

Background radiation – Finland’s got nearly eight millisieverts a year. The fascinating thing with all of this is that despite … this is from granite, the radon gas-carrying radiation. New Zealand’s not mentioned, but Australia gets a bit of radiation from gamma radiation which I think is sunshine – correct me, Joyce? [Is] that right? Probably sunshine, because Australia has a lot of sunshine. But the incidence of malignancy – it doesn’t go up in relation … it isn’t higher in Finland than anywhere else, so there’s obviously unknowns about the effect of that radiation. What it boils down is, you just don’t worry about it. [Chuckles]

I think that’s about it. We have training programmes developed; we’ve got support from colleagues, particularly Ted [Ward] – he was very, very helpful in this. We’ve developed at the same time a rescue facility that worked in with the ambulance, and the Waimarama Surf Lifesaving Club contributed an enormous amount [of] enthusiasm to get things going in the early days. They didn’t do any of the transport of the critically ill, but their background and enthusiasm in getting the helicopter up and running was very, very helpful. There’s Sky Aviation, now Hawke’s Bay Air Ambulance, who are providing the bulk of the service; and Lowe Corporation’s still funding it, and it’s working well with St John Ambulance who work with Lowe itself – a real going concern.

And that’s about it. I have to swear you all to secrecy because you’ve seen photographs of patients and other confidential data so you can’t discuss this. [Chuckles]

I was about to mention too, that Forbes is a great fan of the outdoors and for years in his off-time he was a medic on the slopes of Ruapehu with the ski patrol. And I’m sure that’s worthy perhaps of another talk sometime, Forbes, ‘cause there must be quite a few stories from that. I want questions, please.

Question: Yes, just a couple, and they’re both to do with air; and the first one is the air pressure, you know, how high can you fly with these people? ‘Cause pressurised planes are still fairly low pressure, aren’t they?

Forbes: Yes. We worried about that quite a lot ‘cause there’s several problems with transporting a patient who’s at ambient pressure; you have to … you know, where you’re having to blow your nose when the plane’s coming down … an unconscious person can’t do that, so you get changes in air pressure in your ear, which hurt. [It’s a] problem. The tube that’s in your windpipe is full of air, normally – it expands as you go up and contracts as you come down. In expanding it can actually vent air out from the pressure that you set, and then it can leak so when it comes down you can under-ventilate the patient unless you’re watching it very closely and you’ve got it back up again. The arterial pressure measurements change a little bit, which is zero pressure reference point changes. When you go up … generally you’d stay under twelve thousand feet; it changes about half a millimetre. It’s not a significant change in terms of the human physiology, but it’s there, and you can see it if you move … we just used to ignore it, apart from the radiation, because it doesn’t affect the remarkably versatile human body that we’re blessed with having. The gas is supplied at two thousand pounds per square inch in the cylinders, reduced to about sixty pounds per square inch, is the ventilator supply, and that takes care of the pressure running the ventilator. More modern aircraft we pressurise – that’s pressurised. And the other advantage of that is you can get over the weather, so you can get high enough to get above the turbulence. It’s ever so much nicer going up and over the weather than having to fly through it and getting tossed around in it. So this pressures problem – there’s about seven different ways of expressing pressure in different measurement forms. Anaesthetists have to be conversant with all of them because cylinders come filled with one pressure; the people who are repairing your equipment work at another pressure; car tyre pressures are pressured in another pressure. Potentially we refer you back to your tables to see which pressure you’re working with. In practice, it doesn’t make a major difference. The other pressure you have too, is quite interesting; you have the air in your gut. And you see this in Ruapehu on Friday nights when you’re driving up the Bruce Road from three thousand feet by The Chateau to six thousand feet up by the carpark; the air in people’s guts expands, and guess what happens? [Laughter]

Question: Thanks. The other one’s to do with the helicopters. About eight or ten years ago we fought like hell to save our helicopter, and now they want to get rid of them in other parts of the country. And I really can’t see this, it will only be a cost probably, but I thought this one down there; must’ve had something to do with that really, instead of getting rid of the helicopters.

There’s a problem; the helicopters are expensive. And I mean, we cracked a tail rotor on the Squirrel, that white one that you saw, and Mike Toogood] was meticulous in his maintenance with helicopters; he said, “Replace it.” It was all of $10,000. You know, you do your clutch in your car and it’s about $1,000 or something like that, but little cracks in the helicopter … An engine overhaul is a quarter of a million dollars. Horribly expensive things and that’s why they want to rationalise it. But I agree with you; the golden hour – the concept of getting to somebody within an hour – and it’s just common sense that if you solve these problems quickly you’ll get a better result. But the problem is it costs, and the downstream costs really do mount up and mount up and mount up and become highly significant. So there’s a balance between those two and we’re working our way through that, like – with my awareness of what’s going on I can see that they would probably save quite a lot of money, but you wonder what the cost is going to be when somebody doesn’t get the care that could have been delivered in time. And it probably comes back to communities, a bit like talking about euthanasia – it’s got to go to the open community and be discussed in detail, rather than, as you do, change the name of your Memorial Centre and put ‘Conference’ in it. [Laughter] We don’t want to have that. So it’s a good question, and I don’t know which way it’s going to go. I don’t like the noises they’re making, ‘cause I’m a professional rotor head, or a skid rider; somebody who gets free rides on helicopters come hell or high water. I’m very much in favour of [inaudible].

Joyce: Di?

Di Taylor: What I want to say is, when Forbes arrived in 1977, there was nothing; there was nothing at all. And the worst thing of all was the X-ray Department was in Napier and the Intensive Care Unit developed in Hastings. So if we wanted any sort of sophisticated x-rays, which in those days weren’t very sophisticated at all, we had to put the patient in the ambulance and take them to Napier. And these were patients who were ventilated, and it was not easy. And when we got the CAT scan, it was in Wellington, so if a patient needed a CAT scan we had to fly them – it seems so primitive now, but it’s, what – fifty years ago?

Comment: It’s about thirty years ago.

Di: And there was nobody else; Ted [Ward] had his hands full with the Unit, and Forbes took the whole transport thing on, and he started it from nothing. And he taught all of us, and we all flew off;  the whole thing was a wonderful achievement, Doctor Bennett.

Forbes: Oh, thank you very much.

Joyce: Is there any more praise for Forbes here? Forbes, fantastic; I thought Di put her finger on it – I don’t think people realise what they’re looking at tonight, that actually it was a service started up from nothing. And I think Di touched on a point too, that when you did take a patient over to Napier for the scan, they had to pull in another whole team to cover what was left in the hospital here.  Forbes, fantastic; we’ve got a wonderful team in Hawke’s Bay; we’re very proud of them all.

[Applause]

And we thank your colleagues for coming tonight; it’s been wonderful.

[Applause]