Neil Silverwood

Meet the doctors preparing for our worst-case scenario

Medical care across New Zealand works on the following principle: get to the nearest hospital as fast as possible. But what if storms, flooding, landslides or earthquakes make that impossible? One emergency doctor is determined to equip medical students for our increasingly unpredictable future.

Written by       Photographed by Neil Silverwood

In July 2020, Robin Barraclough found himself the sole doctor in charge of Kaitaia hospital as a 500-year storm turned farmland into lakes and cut off Northland’s main highways.

He had 20 patients on the ward and 10 patients in the emergency department, including two very sick people. One had just had a heart attack; only the third jolt of electricity revived him. Normally, that patient would be sent straight to hospital in Auckland. Not tonight. “There was no air travel, no choppers or anything, because the weather was so bad.”

Barraclough found himself in a situation the health system, with its focus on efficiency over resilience, wasn’t set up for.

“Often what happens in rural hospitals is that you stabilise patients,” he says. “You might give them antibiotics or fluids. Patients with severe problems get helicoptered out pretty quick. But that was never going to happen that night. It left me with a sinking feeling in the pit of my stomach.”

“It doesn’t matter how sick anybody in the hospital gets. They’re going nowhere. The buck stops here. The weight of that kind of responsibility—it’s pretty heavy.”

After emigrating to New Zealand in 2012, Barraclough worked as a GP in a number of places around the country, including at Franz Josef, where he learned that the towns along the West Coast would likely become utterly isolated when the Alpine Fault ruptures. “I don’t think I’d fully understood where I was living,” he says.

Barraclough, a strong, jovial northern Englander with a lifetime love of mountaineering, is an intriguing mix of physical capability and deep thought. He strikes me as the kind of person who takes the world’s problems deeply to heart, and is not content to sit around waiting for someone else to solve them.

New Zealand, he says, needs to do more to prepare for the risks it’s exposed to—not only geological threats, but the impacts of climate change, too. And he sees an enormous gap in doctors’ ability to deal with emergencies before a patient reaches a hospital.

Many rural hospitals and general practices, he says, rely on a ‘just in time’ model of medicine, where sick patients are picked up by a helicopter or airplane and taken to the nearest hospital. “That model’s great when the weather’s fine, the roads are working, and when there’s not an emergency somewhere else. But when the system gets overwhelmed for some reason, that all falls to bits. And in many parts of New Zealand, it’s already falling to bits.”

[chapter break]

Winter-hardened snow breaks beneath my boots as I walk into the Pisa Range, crunching along a ski trail that leads me to a hut at the back of Cardrona’s Snow Farm.

When I get there, a group of 15 medical students are clustered at the hut entrance, discussing how to prepare a severely injured patient for a long walk out. I listen, fascinated by the talk of managing the patient’s “pain journey” with high-powered drugs. This is not your typical first aid course.

Medical student Jemima Gillingham is “rescued” by fellow students at Treble Cone ski field. Poised as we are on a major tectonic boundary, New Zealanders live with an extraordinary amount of environmental risk. We also have one of the largest search and rescue areas in the world. The course aims to help prepare students, physically and mentally, to manage some of what they might encounter during a natural disaster.

The students are working their way through a course that Barraclough co-designed—a six-week elective involving a combination of outdoor skills with casualty management in what’s known as an “austere” environment.

In the context of a natural disaster, an austere environment is what you get when the proverbial hits the fan. This kind of messy situation is something scientists say we should prepare for—climate change is predicted to bring more severe weather to our part of the world.

“I think some of the skills that you can access through mountain medicine directly train people for some of that future,” says Barraclough.

The course, which he and colleague Malin Zachau put together with the New Zealand Society for Mountain Medicine and the University of Otago, is about being “resourceful, self-reliant, and resilient”, about having “some personal confidence around being able to look after yourself”, and gaining “an overview of the things that will kill people within minutes to hours, and knowing simple life-saving interventions you can do to change some of those things”.

Medical students, led by instructor and top mountaineer Lydia Brady, learn basic mountaineering skills in the Remarkables near Queenstown. With climate change predicted to bring more extreme weather events to our shores, course organiser Robin Barraclough believes skills gained in the outdoors will help prepare students for an uncertain future.

Learning about the threat of the Alpine Fault rupturing, the international students on the course are astonished at the level of risk New Zealanders live with. Meanwhile, local students tell me they signed up for the course because it’s their only opportunity in medical school to learn these sorts of skills.

“It’s difficult to get any of that pre-hospital trauma training early in your medical degree,” says Gemima Gillingham, from Wellington. “Unless you go into rural training or ED training, but that’s always towards the end of your training. So it would be ten years before you could get that sort of experience.”

Keeping warm on a break are students Alex Sinclair, Lewis Halpin, Heather Croghan-Miksch and Jemima Gillingham. Students came from all over the world to participate in the mountain medicine course, and indeed, one of the course’s aims was to help forge an international network of first responders to share knowledge and skills in the future.

After the break, we head back out into the snow. There are bodies everywhere. An “avalanche” has swept down the hillside while we were drinking tea in the hut. The students don’t blink an eye — after three weeks of this training, they’re used to mass calamities striking unannounced. Six or eight people are lying “injured” among the schist and tussock, and one person is screaming.

The students have to make fast decisions about which of the patients to treat first, and how.

The patient that’s screaming for help is left till last—it’s the silent ones that need the most urgent attention.

The air is bitterly cold. As the students work through their triage and start attending to the patients, I feel concerned for the actors lying in the snow, freezing in wet clothing. It makes me realise that in an emergency, every second is crucial, and death moves swiftly.

[chapter break]

New Zealand’s climate change wake-up call arrived in February 2023, when Cyclone Gabrielle tore through the northern part of the country. Days after the storm, Barraclough flew to Tairāwhiti to help out at Wairoa hospital. The drive from Gisborne to Wairoa took twice as long as usual. “The road was strewn with debris and dirt,” he says. “It was quite eye-opening—this is what natural disasters look like in real time.”

On the Coromandel Peninsula, problems remain a year later. “The roads are still wrecked up here,” says Coromandel GP Bryan Macleod. “It really shocked us, seeing how fragile those roads are. That concept that we’ve got an ability to get from A to B is being put into question.”

The vulnerability this presents, in the sense of people’s ability to seek treatment, is set against a backdrop of a medical system already struggling to meet the needs of rural communities on a day-to-day basis.

[sidebar-1]

McLeod says a nationwide shift over the last century towards centralised urban healthcare has seen many regional hospitals shut down or having their capability reduced. It’s left rural communities more dependent on travel.

A 2018 study by Rebbecca Lilley and others found that 16 per cent of New Zealanders, or around 700,000 people, would not be able to access advanced healthcare within an hour, by either road or air, if they needed it. Māori, older New Zealanders and people living in the lower South Island were particularly disadvantaged in this regard.

The situation is exacerbated by a chronic shortage of rural doctors, a situation that is projected to worsen as the current cohort of rural GPs age and retire. A 2022 survey conducted by the Royal New Zealand College of General Practitioners, found that four out of five rural doctors suffered from burnout. A third of the rural medical professionals surveyed intended to retire within the next five years, and half within 10 years.

Students Will Goodrum and Josh Canton (left) check out the medical equipment onboard a HeliOtago chopper in Queenstown. In New Zealand, the helicopter is a crucial tool in managing emergencies. HeliOtago maintains a fleet of eight fitted out for this purpose. But what happens when, in a major disaster, every medical helicopter in the country is overwhelmed?

The extent of many rural doctors’ and nurses’ emergency training is a five-day course run by St John called PRIME. But large areas of the country don’t have any staff who’ve undergone the training, or don’t have them available around the clock, says Mark Eager, who used to chair PRIME. In some places, he says, “it’s literally a flip of a coin whether you’re going to get help or not”.

At the time of writing, Twizel, for example, has no ambulance service after 6pm. If a mass casualty event took place—an avalanche at Ōhau, for instance—there might only be one person on call for the whole area, says local GP Gemma Hutton.

“I think it’s very obvious that rural areas will be under a huge amount of pressure when something like that happens. You have such a small team, anyway, in a rural setting.

“You’re going to be severely under-resourced. Even if you have the best skills in the world, it’s going to be really limited by transport and communications.”

“The assumption with PRIME is there’s always help coming,” says Barraclough, who has received the training.

“There’s always a helicopter, there’s always an ambulance on its way. That’s not going to happen with some of the things I’m thinking about.”

Also attempting to plug the gap in emergency medical training is a non-profit called Kaitiaki Ora–New Zealand Tactical Medicine. Tactical medicine has its roots in the military and describes high-risk environments where the rescuer as well as the person being rescued is in danger. Its philosophy is that skills that save lives on a battlefield will be equally critical in the event of a natural disaster.

Kaitiaki Ora has teamed up with an American training provider called Ragged Edge Solutions to deliver a four-day course focused on fractures, pressure injuries and massive bleeds. The courses aim to give people tools to deal with these injuries without immediate backup, says Alex McDonald, Kaitiaki Ora’s president. “It’s about building that mindset of, ‘Okay, we are stuck. Now I need to look after this patient for two or three days. How do I do that? How do I think about critical care when I’m not a critical care provider? How do I identify someone that needs surgery when I don’t ordinarily have those tools to do it?’”

Will Paterson and Scott McKee check out an “injured” member of the New Zealand Defence Force.
Lucy Waldin sutures a chest tube on a mannikin.

Depending on the student’s level of experience and training, the course might train them to perform such interventions as inserting a chest drain or a surgical airway. I put it to McDonald that Ragged Edge, a private outfit, is meeting a need that the public health system should be providing.

“I think our emergency management system—the National Emergency Management Agency and Civil Defence are right there in thinking about these things,” he says. “They’ve got some good data, some good modelling around what could happen in some of these larger events. We just don’t have the capacity to rehearse it, because the health system is so under pressure.”

So far, 58 students have attended Ragged Edge courses.

As a fallback, Barraclough wants to see better investment in our rural healthcare systems, “because they’re the ones that are going to potentially bear more of the brunt of this”.

Government has a big role to play in encouraging this shift, says Fiona Bolden, a Whangamata GP and chair of Hauora Taiwhenua Rural Health Network. “It requires a whole lot more funding, but it’s also reviewing how you train people. You need to see the money shift towards general practice and community care, and away from hospital-type stuff.

“What you want are rural generalists—people who have a much broader scope of practice and are therefore more adept at dealing with a range of different conditions. You need people who are used to thinking outside the box.”

[chapter break]

Darkness falls on the Pisa Range and we’re all crammed into the hut, a fire blazing, after a long day out in the snow. The dishes are being cleaned away when Barraclough bangs the door open. He says that another instructor, Danny Freestone, has fallen into the stream outside the hut.

The students are out the door in seconds and hauling Freestone from the icy water. They wrap him up and get him inside in front of the fire.

His skin is pale and he shivers uncontrollably. His body is already starting to shut off blood supply to non-essential parts. He had just minutes to go before hypothermia—not simulated hypothermia, but the real, life-threatening deal—sets in.

The students layer him up in clothes and sleeping bags and give him something warm to sip. Gradually, the colour returns to his face. It’s a full 45 minutes before he says he is starting to feel himself again. It’s the closest I’ve ever been to seeing someone in a genuine state of hypothermia. Although I knew the exercise was planned, I can’t help but feel a little shocked at what I witnessed. There’s something deeply confronting about seeing that grayness, the precursor of death, in another human’s face.

As the students regroup, the rowdy chatter that filled the hut an hour ago has gone. They’ve seen plenty of simulated calamities. This the first time on the course they’ve had to put their training into action to properly save another person’s life.

The exercise has shattered the nonchalance that countless fake scenarios breed, exactly as Freestone and Barraclough intended. At any moment, the students have been reminded, the elements could take a life close at hand.

The students passed this test. But there were 15 of them and just one casualty.

The reality Barraclough hopes to prepare these students for would be infinitely more demanding. It could involve a rupture of the Alpine Fault, a scenario in which thousands of people could be injured and cut off from medical care. Or it could involve increasing cyclone events, like Gabrielle, as climate change starts to bite.

“This is the reality, this is the future for a lot of us,” says Barraclough. “You’re going to need clinicians who can manage it.”

More by

More by Neil Silverwood