Aeromedical transfer of mental health patients in Western Australia

So you are working a locum in remote Western Australia and have a mental health patient requiring aeromedical transfer to a tertiary level psychiatric hospital. What are the issues you need to consider?

1. Be prepared for a delay in transfer – its unlikely there will be an available aircraft and crew waiting just for your request. Most likely it will be placed on a triage waiting list . The transfer request doesnt solve the acute mental health condition. It may in fact worsen it. You will need to regularly reassess your patient and provide ongoing care. That may mean at some point during the wait, the patient may no longer need to be transferred in fact. For example, an acute intoxication may resolve and the person is better and not needing higher level care. RFDS flights at night time for acute mental health patients tend to be avoided with aviation citing that its more difficult to undertake an emergency landing at night in case of acute agitation worsening in flight. I thought thats why they have a doctor and nurse on board and often a police escort as per the mental health laws? It is not uncommon for delays to stretch over 1-2 days. Here is one account from Kalgoorlie. Another from Port Hedland from 2007 no less ( refer pg 70)
2. Find and learn the state policies and guidelines for this situation. There are many and a lot of forms to know and fill. Better to try to learn the process beforehand. Here are some references : Sedation for Mental Health Patients Awaiting Aeromedical TransferGuideline. RFDS WA Clinical Manual ( refer to Chapter 7)
3. Consider drug withdrawal issues as risk for worsening agitation and try to mitigate for this. Nicotine withdrawal a major risk here so consider a nicotine patch early.
4. Try to keep patient fasted as much as possible, at least from solids. Aspiration is a real risk if parenteral sedation is used. Obviously if transfer delay is more than 12 hrs then you must reassess situation and the patient. Changing the clinical management plan to one not relying upon parenteral sedation may de-escalate situation and allow for transfer to be cancelled. Oral sedation is far safer option in all situations
5. If acute suicidality is the major issue to deal with then consider evidence based treatments like ketamine, not as a form of sedation but as a form of rapidly acting antidepressant with proven reduction in acute suicidal ideation. Here Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial. Note the major benefit in reduction of suicidal ideation in those with bipolar disorder. THis may help reduce the risk of absconding from hospital and increase safety whilst awaiting aeromedical transfer.
6. Endotracheal Intubation with general anaesthesia for acute primary mental health condition is a sentinel event and flagged for reporting to Chief Psychiatrist for mandatory review. If you feel it is justified then proceed but carefully document your reasons. If you have oversedated the patient and airway compromise has occurred its better to proceed with intubation and airway security than try to reverse the sedation or allow it to wear off and risk aspiration. Any emergency sedation must have a backup intubation plan with preparations made to do this emergently.
7. Document consent or lack thereof and attempts to gain it. Document under which law or principle you have acted under for the emergency care of a person who may not be able to give full consent. For example an agitated delirious person who has meningitis is being treated under duty of care for safety ( often referred to as Guardianship principle). A person with known psychotic disorder presenting with acute psychosis may be treated under involuntary section of mental health act for purposes of assessment, treatment and transfer for care.
8. Adequate staffing is a real issue in remote hospitals and one acutely agitated patient can easily overwhelm the staffing capacity. It can setup a dangerous imperative to try to manage the agitation with overreliance upon sedation and urgent transfer to another hospital. Police assistance may help here but it also may not and also cannot be always relied upon in remote areas where they have staffing issues as well. There are no simple answers here. My advice is to at least be aware of the risk of overreliance on sedation and that knowing that the transfer request doesnt solve anything immediately . You still need to manage the patient. Getting fixated on one strategy of keeping patient sedated and just waiting for the plane to take them away can be a dangerous trap. Trying to resolve the acute agitation state may be your best overall strategy and safer for all.