This is exact­ly what CRANAplus Edu­ca­tion is designed to do: deliv­er edu­ca­tion right to the heart of remote area nurs­ing. And I know every­one was excit­ed about this assign­ment. A vis­it to these beau­ti­ful islands had noth­ing to do with it, of course. 

It was not all plane sail­ing (see what I did?) as Leanne Lau­rie, Remote Clin­i­cal Edu­ca­tor, shares her diary entry dat­ed 5^th August: 

Our day was final­ly here. Excite­ment was pal­pa­ble, bags packed, and we were ready to go! Here we are 18 months on from the float­ing of our PEC/PALS course deliv­ery to board­ing the plane to deliv­er 10 CRANAplus cours­es over 12 days. A huge under­tak­ing for Indi­an Ocean Ter­ri­to­ries Health Ser­vice (IOTHS), par­tic­i­pants and facilitators/​educators.

We arrived at the air­port three hours ear­ly. At secu­ri­ty, we embar­rass­ing­ly had all our food and drink sup­plies con­fis­cat­ed because we failed to realise we were going Inter­na­tion­al. After restock­ing on the oth­er side, we board­ed to set­tle into our four-hour flight to Christ­mas Island.

All was going well. We excit­ed­ly chat­ted about the day final­ly arriv­ing, and we real­ly couldn’t believe it was final­ly hap­pen­ing. As we com­menced our descent, we were advised that the clouds were very low and that we would cir­cle around until they lift­ed so we could land.

Still, with high opti­mism, we gazed out of the win­dow, catch­ing glimpses of the par­adise we were so close to yet so far from. We could see the white beach­es and turquoise waters sur­round­ed by lush green foliage; it was call­ing our names.

And then, like a rock­et, we soared back high in the sky. Our hearts were like stone as the cap­tain announced we could not safe­ly land. We were off to Java to refuel.

That’s OK. We would refu­el and head back. The clouds would have lift­ed, the weath­er would have cleared, and we will just be a few hours delayed. But to our dis­may, as we sat like a strand­ed whale on the tar­mac refu­elling, we were told ​“No, you are head­ed back to Perth”. The silence was deaf­en­ing, the shock set­tled in, and our hopes were dashed.

That was a very long, mys­tery flight to nowhere. We all sat with our heavy hearts and hoped we would find anoth­er way to get where we need­ed to be.

We arrived back in Perth only to be absolute­ly drenched by tor­ren­tial rain, with a two hour wait for accom­mo­da­tion and trans­fers to be sort­ed, with no word on any recov­ery flight in sight. By 2am, we were right back where we had start­ed that morning.

The good news is that we did make it, albeit 48 hours lat­er. One thing remote area nurs­es are good at is adapt­ing under pres­sure. Plan D was hasti­ly devel­oped and activated. 

The Indi­an Ocean Ter­ri­to­ries (IOT) is a unique place to work. Both islands are clos­er to Indone­sia than Aus­tralia and house a melt­ing pot of dif­fer­ent cul­tures. Christ­mas Island is pre­dom­i­nant­ly of Chi­nese descent and has a large Malay population. 

The hos­pi­tal here has a small emer­gency depart­ment and gen­er­al ward and serves a pop­u­la­tion of approx­i­mate­ly 1,700 peo­ple. Cocos (Keel­ing) has a total of 27 islands cov­er­ing a land mass of 14 km². Only two islands are inhab­it­ed and have a small health­care clin­ic. They have a total of one nurse unit man­ag­er, five reg­is­tered nurs­es, one doc­tor and three health work­ers cov­er­ing both clin­ics, serv­ing a pop­u­la­tion of approx­i­mate­ly 600 people. 

The islands did not dis­ap­point. On arrival, we were met with a unique land of rugged land­scapes, ancient forests, abun­dant marine life, soar­ing sea birds, wild coast­lines, remote, pic­turesque trop­i­cal beach­es… and lots of crabs.

The cours­es

Remote Emer­gency Care (REC), and Pae­di­atric Emer­gency Care and Pae­di­atric Advance Life Sup­port (PEC+PALS) com­bined
Anna Heaton, Remote Clin­i­cal Edu­ca­tor, Emer­gency Stream

Resources, includ­ing pre­cious health­care staff, are lim­it­ed in such a remote envi­ron­ment. This left us with only a short time to deliv­er the best emer­gency care edu­ca­tion that we could. We com­bined our lead­ing cours­es by pro­vid­ing all the the­o­ry online. 

The work­shops then focused sole­ly on devel­op­ing skills and putting the­o­ry into prac­tice. The sce­nar­ios were writ­ten to fit the clin­i­cal envi­ron­ment, and a tech­ni­cal debrief/​discussion includ­ed the dif­fer­ent con­sid­er­a­tions and skills required across the lifes­pan. This enabled the learn­ing out­comes of both the adult and pae­di­atric cours­es to be ful­ly covered. 

Cocos (Keel­ing) Islands had request­ed an Advanced Remote Emer­gency Care course, which was again adapt­ed to be appro­pri­ate to the envi­ron­ment. This course includ­ed advanced skills, includ­ing front-of-neck access and chest drains. 

The sce­nar­ios were devel­oped to include advanced crit­i­cal care con­sid­er­a­tions when deal­ing with acute­ly unwell emer­gen­cies such as sep­sis and burns in such a remote envi­ron­ment. The high­light of this course was run­ning a mass casu­al­ty sce­nario that includ­ed the Aus­tralian Fed­er­al Police (AFP) and all clin­i­cal staff.

The sce­nario com­menced on the AFP boat and involved three casu­al­ties, includ­ing a 45-year-old male hav­ing had a car­diac arrest and upturned the boat. His 37-year-old wife was thrown over­board, sus­tain­ing major injuries includ­ing C‑Spine pre­cau­tions, frac­tured pelvis, frac­tured femur, mul­ti­ple lac­er­a­tions and an embed­ded pro­pel­lor blade. The couple’s child, an 18-month-old, was also thrown into the water, sus­tain­ing a sub­mer­sion injury and lat­er dete­ri­o­rat­ed and arrest­ed. The sce­nario involved four AFP staff, six local nurs­ing and med­ical staff, along with numer­ous keen bystanders will­ing to help.

After patients were sta­bilised on the boat and the jet­ty, they were trans­ferred by mule (not the four-legged one) back to the clin­ic for fur­ther treat­ment, man­age­ment and evac­u­a­tion.
There were lots of chal­lenges with lim­it­ed resources, much impro­vis­ing, and a whole lot of skill demon­strat­ed in treat­ing and man­ag­ing the casu­al­ties suc­cess­ful­ly. The team pro­vid­ed out­stand­ing emer­gency health care. This was a fan­tas­tic exer­cise in team col­lab­o­ra­tion, com­mu­ni­ca­tion and best use of resources. I think we left Cocos (Keel­ing) with some food for thought.

Prac­ti­cal Skills course

We con­clud­ed the Emer­gency Stream cours­es with four fun ses­sions: plas­ter­ing, sutur­ing, emer­gency eye care and ear pre­sen­ta­tions. The day was all about lots of hands-on prac­tice while learn­ing valu­able skills. We saw some ter­rif­ic sutur­ing tech­niques. The emer­gency stream cours­es end­ed with every­one acquir­ing at least one plas­tered limb. It was great fun all around.

Mid­wifery Emer­gency Care (MEC) course
Aman­da For­ti, Remote Clin­i­cal Edu­ca­tor, Mid­wifery Stream 

The MEC cours­es were busy and fun, filled with Leonie and I teach­ing in tan­dem to deliv­er a trun­cat­ed pro­gram. Both doc­tors and nurs­es well received the pro­gram. Deliv­er­ing MEC in 12 hours or less was an exem­plar of what can be achieved in a lim­it­ed time­frame with a small team of health pro­fes­sion­als who usu­al­ly work together. 

Hav­ing min­i­mal equip­ment to teach with (only that which we could car­ry) pro­vid­ed some chal­lenges, and the odd raised eye­brow from cus­toms offi­cers as they not­ed the repli­ca human pelvis in my hand lug­gage as I went through secu­ri­ty. For­tu­nate­ly, the pae­di­atric man­nikin, preg­nant bel­ly, mod­el pla­cen­ta and birth instru­ments were all checked in. 

It was won­der­ful get­ting to know the IOHT team, and we were extreme­ly grate­ful for the oppor­tu­ni­ty to expe­ri­ence the deliv­ery of mater­ni­ty care, work, and life in this very remote set­ting. We also had the oppor­tu­ni­ty to explore and spend time in a place of incred­i­ble nat­ur­al beau­ty (par­tic­u­lar­ly under­wa­ter), afford­ing us life­long memories.

First Line Triage (FLT) course
Leonie McLaugh­lin, Remote Clin­i­cal Edu­ca­tor, Mid­wifery Stream 

A First Line Triage (FLT) course was con­duct­ed on each island. This course focus­es on the triage of patients and appoint­ment man­age­ment in the pri­ma­ry health set­ting. The aim was to upskill the non-clin­i­cal pri­ma­ry health prac­ti­tion­er to con­fi­dent­ly assess patients whilst apply­ing the prin­ci­ples of triage to ensure patients receive appro­pri­ate care. Both were delight­ful, engaged groups made up of admin and some health work­er staff. Each half-day ses­sion involved lots of dis­cus­sion, rel­e­vant case stud­ies, and facil­i­ta­tion, enabling the group to tease out local issues and cre­ate poten­tial solu­tions togeth­er. The con­tent around the impor­tance of pos­i­tive and effec­tive com­mu­ni­ca­tion across all roles with­in the clin­ic was enjoyed and active­ly engaged with.

The par­tic­i­pants’ feed­back on the day was very pos­i­tive. They report­ed that the course had real­ly helped them under­stand their roles and respon­si­bil­i­ties. Pro­vid­ing a the­o­ret­i­cal frame­work rein­forced the need to fol­low an agreed-upon, con­sis­tent, and for­mal triage process in their pri­ma­ry care/​clinic set­tings. It even extend­ed to the request that the clin­i­cal staff be informed of their triage process as well.

A very reward­ing teach­ing and learn­ing expe­ri­ence for myself and these key mem­bers of the teams in the Pri­ma­ry Health clin­ics on the islands.

The great­est ben­e­fit for us as edu­ca­tors and for the staff, was not only deliv­er­ing the work­shop in the envi­ron­ment in which they work, but also work­ing with the whole of the team. It was fas­ci­nat­ing to see how every­one slipped into their nor­mal roles. They were incred­i­bly sup­port­ive of each oth­er and debrief­ing includ­ed some thought-pro­vok­ing dis­cus­sions on how they could improve their emer­gency care mov­ing forward.

Aman­da For­ti sums it up beautifully: 

The entire jour­ney was a career high­light for Leonie and myself. Shar­ing the expe­ri­ence with each oth­er, the emer­gency stream edu­ca­tors and our remote col­leagues was a rare expe­ri­ence of what work­ing as a Remote Area Nurse and Remote Clin­i­cal Edu­ca­tor (Nurse & Mid­wife) can look like. 

None of these cours­es could have gone ahead with­out the amaz­ing ded­i­ca­tion and sup­port of both the Nurse Man­agers and Clin­i­cal Edu­ca­tors, Vicky and Leah, on the islands. 

There were about a thou­sand emails and phone calls as we tried to gath­er infor­ma­tion about the diver­si­ty of the care they deliv­er, the emer­gen­cies that present and how these are man­aged in this unique envi­ron­ment. We were ded­i­cat­ed to tai­lor-mak­ing these cours­es to be of the best learn­ing ben­e­fit to all the staff. 

In addi­tion, huge thanks to our fab­u­lous vol­un­teer facil­i­ta­tor Steve Gust who just goes with the flow and his love­ly wife who made for an excel­lent Trau­ma patient. The mass casu­al­ty would not have been the same with­out you. 

I think I can hon­est­ly say, that whilst it was an exhaust­ing time for every­one involved, the expe­ri­ence was illu­mi­nat­ing, high­ly edu­ca­tion­al and a whole heap of fun! We look for­ward to vis­it­ing again. Thank you from every­one at CRANAplus Education.

Anna Heaton, Remote Clin­i­cal Edu­ca­tor, CRANAplus