Extreme psychiatric patient Case 2
By Dr Minh Le Cong, RFDS Cairns, July 2011-07-02
Hi there folks. This case is from a couple of years ago but I use it to illustrate the controversies surrounding aeromedical transport of psychiatric patients, what is or should be best practice and some unique logistical challenges facing remote Australian practitioners. It follows on from the theme Casey set with his extreme psychiatric patient case that tragically had a fatal ending. This story is not so gloomy but is a near miss in my view. Some of my colleagues in retrieval medicine argue it is not a near miss and in fact the best practice we can do in Australia given the challenges. I beg to differ and have some recent followup from the same patient in regard to the same situation but with a very different strategy utilised.
Lets set the scene for the story. Thursday Island hospital is on a remote island in the Torres Strait, about 2hrs flying from Cairns which is where I am based. This is a nice map image of the region and locations from Google Earth.
In Queensland, placing a patient under the involuntary section of the Mental Health act requires they be assessed in an authorised mental health service. For our local region this is only in Cairns. Legally the psychiatrists cannot assess a patient via videoconference or teleconference under the involuntary section of the act, although there is some wording in the section to allow some flexibility for remote patients. In general the psychiatrists are reluctant to assess remotely and so once a patient is placed under involuntary detention for psychiatric assessment then they must be transported to an authorised service for assessment within 24 hrs of a doctor completing the order.
In Thursday Island hospital there are 3-4 rural GPs and nurses who run outpatients, ED and inpatients as well as an obstetric ward and elective surgery list usually for visiting specialists. They have no secure ward or beds but do have police and security officers available
Now when you fly to Thursday Island to pick up a patient believe it or not you do not land on Thursday Island but a nearby island called Horn Island. This graphic nicely illustrates the relationship.
Guess how you get the patient from Thursday Island to Horn Island air strip? By boat or helicopter! Yes helicopter! Here is a video of the Customs Bell 412 helicopter that often takes us over!
So yes its weird. Fly up from Cairns in a twin engine Super King Air (pictured below)
Land on Horn Island then chopper over in the 412 to get the patient and back to load up into the KingAir! Confused yet? This happens on a daily basis! Why not boat them over you say? Well occasionally we do but its a regular ferry schedule not on demand so not very helpful afterhours!
Anyway back to the case. Lets introduce the patient. We will call him Jerry. Jerry is a 43yo Torres Strait Islander man with chronic schizophrenia. He is supposed to be on depot injection risperidone under a community treatment order as well as some oral benzodiazepines. He has been known in the past whilst psychotic to have assaulted police. He has become unwell again on a nearby island ( not Horn Island ) and the remote nurse has asked for help to get him to Thursday Island hospital for assessment and further management. Its arranged by our statewide clinical coordination service for a GP anaesthetist to go over assess the patient and bring him back to the hospital on Thursday Island via chopper. She promptly does so and returns with him intubated and ventilated. Its about 9pm local time at this point. Her reasons to do this are that he is a big man and she is small. They did not bring any police officer or security personnel. And they are in the back of a chopper where the patient can easily reach the door and open it. Its now, RFDS get the call to move him to Cairns. For those who have read my transport resources for mental health retrievals would be familiar with the fact that in Queensland RFDS we use a risk assessment tool to decide on management strategy for “disturbed patients”. This is the original risk assessment done for this man by our flight doctor with some personal details deleted
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You should note he is judged as high risk and the indication is for intubation as method of restraint. Fair enough you say, right? I should point out this risk assessment form here is now old and no longer in use. Nowadays we apply the stipulation that all high risk patients are subject to “an adequate trial of preflight sedation” before resort to intubation as restraint. This very case was one of the reasons why we changed the protocol.
The logistical problem that night was that it was cyclone season and the weather was crap. Our night pilot promptly told the flight doctor all aeromedical operations were on hold, pending improvement in weather. How soon would that be, is the question posed? Maybe first light tomorrow morning, about 8 hrs. Dilemma? What to do with this involuntary psychiatric patient ,intubated in a island hospital without any ICU facilities for the next 8+hours?
To be continued in the next instalment!