Spotlight Series: When the Coordination Plan Meets the Simpson Desert

Dr. Mardi Steere on Remote Retrieval, Improvisation Under Pressure, and What Technology Providers Still Don't Understand

Part 3 of the Medora Advisors Spotlight Series

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Most healthcare technology providers have never designed a system for a team of two, flying at altitude, with no connectivity, caring for a critically ill patient they've never met.

Most retrieval physicians have never been asked to advise on the technology that is supposed to support them.

Dr. Mardi Steere has done both.

As Executive General Manager of Medical and Retrieval Services at the Royal Flying Doctor Service SA/NT, Associate Professor at Charles Darwin University, and a practising retrieval physician with decades of experience across emergency care, Dr. Steere operates at the sharp end of remote medicine — where the gap between a coordination plan and operational reality is not a design flaw. It is a feature of the environment.

She has led hospitals, expanded retrieval systems, and managed clinical operations across some of the most geographically and logistically complex settings in the world. She has also watched the digital health industry repeatedly build tools that fail the moment connectivity drops — which, in remote Australia, is not an edge case. It is the baseline.

We asked Dr. Steere four questions about remote retrieval, crisis improvisation, technology design, and innovation. Her answers are a masterclass in what the digital health industry still gets wrong about designing for the field.

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Q1: From your experience, what aspect of emergency evacuation and retrieval appears manageable on a coordination plan, but becomes significantly more complex once you're in the air or operating in a remote setting?

Dr. Steere:

One thing that comes to mind is a lack of complete information — that's really what adds to uncertainty in our environment. In the remote retrieval setting, what you often find is that patients who are calling for help from a remote cattle station or the roadside do not have any clinical care around them. So you don’t have the quality of information you’d receive from a regional hospital GP calling for a transfer, or a remote nurse calling for a retrieval — it's a lay person calling for emergency help, with poorly audible verbal information and interrupted reception depending on their location and environmental conditions.

A great example of this is that we received a call one night from the middle of the Simpson Desert from a tourist who had a sat phone that could only communicate by SMS. This tourist's sat phone SMS relay went to the Netherlands, where an operator had to call us and read out the English translation of the sat phone SMS. And so you can imagine the complexities of getting a clinical history from someone who is in the desert in the middle of the night with intermittent sat phone messaging connectivity — to not just get their location to send an emergency response to them, but to also figure out how sick they are, to give them advice and to remotely stabilise them for the next two hours until our plane arrives.

One of the unique things about Australia is its austerity and its lack of connectivity – this is something that people just take for granted in high income and geographically compact countries. The lack of information, distances away from help, are huge challenges for us. If a city ambulance service gets a call from someone with chest pain, they can send a couple of paramedics - if they arrive and the patient is critically unwell, they seek assistance from an intensive care paramedic or a full retrieval team by road or HEMS. In Australia, in the remote setting, we have to send a full retrieval team most of the time, as we assume that we don't have all the information when we launch. We may need to send a high degree of skill set for something that sounds pretty basic, because we have to assume that not only could that chest pain be angina, but it could be a dissecting aneurysm that needs blood on board and a critical care doctor. So in the end we hyper-prepare and may potentially over-service the most remote patients, because the risk and consequence to the patient of a “basic” response without the right team or right equipment on board could be higher than what it appears at initial face value.

What most people don't understand about retrieval medicine is that the doctor/nurse team doesn't sit in the plane looking out the window and reading a book waiting to get to the patient. There's so much work that goes on with mission planning en route to the patient. We've got strict checklists and standardized systems to make sure that everything is always on board and ready to use just in case. If our team is en route to a patient with chest pain, en route they will consider — what do we think this is most likely to be? And then - what are three other things this could be? What will we assess when we get there to ensure we have de-anchored ourselves from our assumptions to make sure that we are not missing anything, what equipment and drugs should we pre-prepare now and have ready? Then when we arrive, we can ensure we have fully stabilised them appropriately, based on that additional diagnostic information, so that there are no surprises on the trip home.

Q2: Can you share an example where a communications failure, system outage, or unexpected clinical complexity during a retrieval required rapid improvisation? What was the outcome, and what did it reinforce for you operationally?

Dr. Steere: 

A good example of this is when I worked for our paediatric state retrieval service in South Australia several years ago, which is before we had electronic health records in the pre-hospital space. I was tasked to respond by air to a newborn baby in a regional hospital, and the information we were given is that we were retrieving a term baby who had been expected to be healthy, but was cyanotic soon after birth. Based on the information that the coordinating doctor had received, we thought that this could be a transient tachypnea of the newborn or respiratory distress syndrome - but we were also quite concerned it could be congenital heart disease. If a baby has congenital heart disease, there's a suite of medications that we take and give to keep certain blood vessels open to maintain blood circulation to  the lungs. So our mission planning was very much focussed on this — we think this is likely to be a heart issue, let’s do all of our weight-based calculations, we’ll draw up our medications in advance, and we will arrive ready to stabilise this baby.  Our tasking records  were purely on paper, we didn't have internet connectivity or any on-board messaging available, so we developed our plan based on what we knew.

The plane flight was about an hour long.  When we landed, there were transport constraints that meant myself, the nurses and all of our equipment couldn’t all fit in the same vehicle. I thought: we are pretty sure of the clinical situation, I'll go in as the doctor with these heart medications, and you as the nurse take the next car with all of the rest of our gear, and we'll there. Now, this is a no-no in retrieval medicine - you try to keep the team and the equipment together at all times.

So I arrived at the hospital before the nurse, and without my equipment. The regional doctor said to me as I walked in — this isn't heart disease. An x-ray was up on the screen, and it showed a tension pneumothorax. And so suddenly I had to change my mental model — this baby now has an unexpected, urgent condition that needs immediate intervention. I didn't have my chest tube equipment with me, so I did what you need to do, which is you take a needle from the local clinic and you decompress the chest and you buy yourself some time. But I also couldn't communicate with that nurse who was bringing my equipment - so she walked in expecting one thing, to find me over the baby with a needle in the chest saying “I need you to get out the chest tube equipment”. So she also had to pivot incredibly quickly, and come up with a completely new plan with me immediately, despite our on-board planning.

I think, that's just a really excellent example of how digital connection for us is so powerful now. With the electronic health record that we now use, we could have received a digital note from the referring or coordinating doctor saying they're now concerned about pneumothorax, and we could have seen an image of that chest x-ray before we arrived. And on the plane, we would have prepared and reviewed in our minds what we needed for placing a chest tube — which in a neonate is honestly a high acuity, low occurrence procedure that it helps to have a little bit of refreshing over — instead of pivoting on the fly. And that for me, I think, is a perfect example of how connectivity changes safety and quality in terms of your team being fully prepared to do what they need to do without unnecessary additional cognitive burden.

Q3: If you could offer one piece of advice to a health system or technology provider designing tools for emergency evacuation and retrieval medicine, what would it be?

Dr. Steere:

I'm going to be cheeky and give you two pieces of advice. I think they're equally important.

The first one is: your technology must be intuitive. In the retrieval environment you have highly expert pilots, clinicians, and operators. They're smart people, they know their workflows, they know what to do. So you need to make your technology intuitive, because no one wants to use their brain space on a full day of teaching on how to learn new workflows to use your piece of software, with an annual refresher when your software changes. Every clinician in retrieval has been doing medical documentation for years and years and years – so make your technology align with the way they currently already do this as much as possible.  If you ask clinicians to change their workflow, and interrupt their actual patient care, they simply will not adopt it. So that's the top thing I would say. You need to design with a deep understanding of how clinicians actually work, now.  Make your tech like an iPhone app - as a clinician, I want to be able to open this thing at 3am for the first time, and be able to figure it out with no training whatsoever.

I think the other thing that I would say is: do not assume digital connectivity is reliable, ever. You must build in at least two offline redundancies into your product – your online version, an offline resilient digital version, and then a paper version. If your product goes offline, or one of your host applications or data engines goes down due to a CrowdStrike update failure or DDoS attack, how does this team caring for a critical patient with no one to help them continue to use the tools that you've given them? The business continuity plan needs to be as intuitive and as easy to switch to as your bells and whistles online version, so that when there is an inevitable cyber blackout, the team can continue to do their job. That will win you clinical buy-in and business.

Q4: What innovation in remote emergency care or retrieval medicine are you most excited about — and what operational or logistical realities must be addressed for it to succeed at scale?

Dr. Steere:

To me, generative AI in the pre-hospital space is the most exciting. When you've got a team of one or two people who may very cognitively overloaded in a critical situation — how can we decrease the friction of their work by analysing images and converting them to text, pre-populating vital signs based on video and environmental analysis, or interpreting clinician audio cues about a STEMI with AI prepopulation of drug orders from endorsed clinical guidelines which just require human confirmation. There's so much paperwork in emergency medicine - taking some of that friction and burden away in the austere environment whilst keeping humans in the loop to confirm will really make the ability for us stay hands-on with our patients, watching them rather than a screen.

As I mentioned, one of our barriers is consistent internet connectivity. And so I think one of the huge opportunities for us is low earth orbit satellite networks continuing to mature and grow. Starlink is almost ubiquitous, but the costs for businesses to access Starlink — especially, for example, in the plane — can be astronomical. So watching Amazon and the Kuiper network, I'm really looking forward to some competition in the low earth orbit network space, so that we've got more consistent connectivity which will crack open better remote access to large language models supporting AI processes. Augmenting that with edge servers — to see how much information we can also get onto a plane in a disconnected state to be the foundation of basic AI algorithms — will build on AI being reliable and truly helpful in the pre-hospital space.

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Why This Matters

Dr. Steere's insights reveal a truth that most digital health vendors and system integrators have yet to fully reckon with:

Designing for retrieval and austere medicine is not a harder version of designing for a hospital. It is a fundamentally different problem.

In a hospital, connectivity is assumed. In the Simpson Desert, it is a luxury. In a hospital, you can escalate. In the air, you cannot. In a hospital, the team arrives together. In retrieval, they sometimes don't.

The implications for technology design are significant. A system that requires training to use is a system that will not be used under pressure. A system that assumes connectivity is a system that will fail at the worst possible moment. A system that doesn't account for the cognitive load of a two-person team managing a critically ill patient in a moving aircraft is a system that was designed for a boardroom, not a flight deck.

Dr. Steere's call to action is clear: design with the clinician's current workflow, not against it. Build offline resilience as a first-class feature, not an afterthought. And understand that in remote retrieval medicine, the margin for error is not measured in percentages. It is measured in lives.

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About Dr. Mardi Steere

Dr. Mardi Steere a highly experienced Australian voice in remote and retrieval medicine — a clinician, operational leader, and educator who has spent her career at the intersection of emergency medicine and the logistical realities of delivering care in some of the country's most challenging environments.

As Executive General Manager of Medical and Retrieval Services at the Royal Flying Doctor Service SA/NT, Dr. Steere oversees clinical operations across a service that covers vast stretches of remote South Australia and the Northern Territory. She has previously worked with the South Australian paediatric state retrieval service MedSTAR kids and has extensive experience in both emergency prehospital and hospital medicine.

Dr. Steere is also an Associate Professor at Charles Darwin University, where her academic work reflects her commitment to building the evidence base and clinical workforce for remote and retrieval medicine in Australia.

Her perspective on technology is grounded in operational experience: she has seen what happens when digital tools fail in the field, and she has a clear view of what it will take for the next generation of AI and connectivity innovations to actually serve the teams who need them most.

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The Medora Advisors Spotlight Series features healthcare executives who've actually led operations — not just consulted on them. If you've sat in the seat and want to share your story, connect with us at medoraadvisors.com.