The rural doctor initiative closing the ‘trauma gap’

When a 40-tonne semi-trailer truck ploughed into the side of a passenger train at a level-crossing in rural Victoria in June 2007, causing 11 deaths and leaving 23 people with significant injuries, critical time was spent waiting for emergency services to arrive.
 
Local doctors based five minutes away in the next town were prevented from attending the scene because they were not part of the state-based emergency response, despite all having emergency care skills to augment care on scene.
 
Known as the Kerang rail disaster, this was the impetus for the Sandpiper Bag initiative, according to its Chair, Associate Professor Tim Leeuwenburg.
 
A rural generalist (RG) in Primary Care, Emergency Medicine, Anaesthetics, and Senior Specialist Retrieval and Medical Retrieval Consultant with the Central Australian Retrieval Service, Northern Territory, Associate Professor Leeuwenburg is based on Kangaroo Island in South Australia.
 
‘This rail incident sparked calls to better define the role of rural clinicians in providing emergency care in their community,’ he told newsGP.
 
‘This was traumatising for the doctors, emergency services, the patients, and the Victorian Coroner was quite scathing in her response, that we really do need to have systems to integrate rural doctors into state emergency responses.
 
‘So that’s why Sandpiper exists.’
 
Around 15 years ago, Associate Professor Leeuwenburg was involved in setting up a national state-based rural responder network.
 
This program saw rural doctors sent to farm accidents or car crash scenes to support ambulances and deliver early interventions in advance of the retrieval team arriving by air.
 
Noting there was no similar system in other states outside of SA, and frustrated with the ‘geographic narcissism’ of state-based trauma services, discussions began with both the RACGP and ACRRM, with a common theme that many rural doctors were being called to these accidents, but in an ‘ad-hoc manner’.
 
So, they began to look at models overseas.
 
Based on the Sandpiper model in Scotland, the initiative started in Australia in 2018 – providing rural doctors with a medical life-saving kit, targeted towards clinicians with an interest in emergency and disaster preparedness and rural resilience, used for roadside emergencies and retrievals to help improve outcomes and ‘close the trauma gap’.
 
Associate Professor Leeuwenburg says that while Australia has ‘excellent’ ambulance and retrieval services, they are mostly metro-focused and can take ‘considerable time’ to arrive on scene of a rural or remote incident.
 
‘Critical illness does not respect geography,’ he said.
 
‘One third of major trauma happens in MMM3–7 areas. Patients with time-critical needs often suffer protracted delays to receive timely care, due to the tyranny of distance. This is Australia’s trauma gap.
 
‘At the same time we’ve got RGs with skills to “value add” on scene, but who are not included in state-based emergency responses, with the exception of South Australia’s Rural Emergency Responder Network (RERN),’ he said.
 
‘By having a standardised kit, we can provide support for ambulance for a local incident such as a vehicle rollover, farm accidents, and other catastrophes that require urgent care, and ensure life-saving attention is given before the arrival of specialist retrieval teams.’
 
Dr Alex Sleeman is one of those RGs who carries a Sandpiper Bag in the back of his ute.
 
Based in regional Western Australia, while having only used it a handful of times for ‘not that serious’ incidents, Dr Sleeman said the bag was an ‘amazingly well-stocked handy piece of equipment’ for the one serious emergency road accident he was confronted with during a family road trip in rural Queensland in 2023.
 
‘I was travelling with my wife and kids and going into Townsville, and there was a car roll over,’ he told newsGP.
 
‘I wasn’t the first on scene, but I was there probably a minute after it happened. There were three people in the car in various states of disrepair, so the kids grabbed my Sandpiper Bag out of the back.’
 
One person had a broken arm, so Dr Sleeman administered pain relief, put their arm in a splint, and fitted a drip ready for when the ambulance arrived. Another person was showing signs of internal bleeding, so he also put a line in to prepare for the ambulance to load him up and take him away.
 
‘The ambulance took about half an hour to turn up, and they could see I’ve just used everything out of the bag, and the paramedics were like, “Holy shit, where’d you come from?”.
 
‘Having that equipment at the roadside was amazing … it’s a really handy piece of equipment.’
 
Inside each Sandpiper Bag is two backpacks and 13 colour-coded pouches, including for catastrophic haemorrhage, intravenous access, intraosseous, airway contamination, and chest compressions.
 

The contents of a Sandpiper Bag. (Image: supplied) 

RACGP Rural Chair Associate Professor Michael Clements supports the concept of the program and encourages rural and remote GPs to ‘engage with it where they can’.
 
‘It’s not just about equipping rural doctors so they can provide support for rural and remote patients when they’re injured, but it’s about raising awareness of the role and skills that our rural GPs have in responding to those around them,’ he told newsGP.
 
‘Being able to recognise and equip available responders with all the different skill sets in rural, remote communities is so important because it can be such a very, very long time between point of injury and point of entry into a tertiary hospital.
 
‘I certainly would encourage government and local authorities to engage with it and build up the network of people equipped and skilled and ready to do this.
 
‘But we must get that state government buy-in for the use of GPs if we’re going to help it grow further.’
 
The Sandpiper Bag supports a network of RGs embedded in community as a ‘go to’ source of expertise for larger state-based incidents such as bushfire, cyclone, earthquake or flood, according to Associate Professor Leeuwenburg.
 
‘Such work is entirely consistent with good primary care; we often know these patients before the accident, and us being there on scene is incredibly reassuring to patients,’ he said.
 
‘We mustn’t forget that we also walk the long road with these patients after the accident, helping them come to terms with often life-changing injuries, chronic pain, depression, PTSD, etc.
 
‘It’s part of good primary care.’
 
In addition to SA’s RERN, which has approximately 50 Sandpiper Bag clinicians integrated with the ambulance service, only around 250 bags are used across the rest of Australia. The program is encouraging those clinicians who have the bags to talk to their local ambulance and be advocates for change in their state.
 
Associate Professor Leeuwenburg said the bottom line is that incorporating RGs with skills in not just primary care, but also emergency response is ‘vital’ for rural Australia.
 
‘We have no real integration of the rural doctor workforce to actually value add on scene, and this is ludicrous,’ he said.
 
‘We have retrieval and ambulance services that cannot meet the capacity, they’re too far away because of the distance. So why not use those doctors?
 
‘In Australia, with tyranny of distance and the extra skillset of RGs, the trauma gap persists.’
 
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emergency medicine emergency response remote retrieval rural generalism rural medicine Sandpiper Bag