The key to success in aeromedical missions is detailed planning and preparation, but unforeseen logistical or medical complications can potentially throw everything off course in a matter of moments. A mid-air medical emergency threatened to do just that on a recent European Air Ambulance (EAA) mission, during the repatriation of a 23-year-old from Bangkok to Paris.
Setting the scene
The patient had been knocked from her motorbike by a truck in Vietnam some weeks earlier, sustaining massive soft tissue damage, liver and pulmonary contusions, and multiple rib and pelvis fractures. After transfer to an intensive care unit in Bangkok, Thailand, she received weeks of treatment in isolation due to drug-resistant bacterial infections. But with her condition improving, the decision was taken to repatriate her to France for the next stage of her treatment; permanent wound closure.
EAA’s Mission Control Centre in Luxembourg began planning the transport, having been satisfied by information from the hospital that the patient was fit to fly. The necessary medical equipment was prepared, and the flight and medical crew set off.
The handover in Bangkok was carried out utilising EAA’s checklist-type transfer sheet. This guarantees that no pertinent issues – such as current medication, allergies, lab results, CD copies of imaging – are left behind. It also ensures that all medication required during repatriation is available and given at correct times. The Thai nurse in charge confirmed that all medications up to the time of handover were administered, including an adequate dose of low molecular weight heparin.
The patient was then transferred via road to EAA’s dedicated air ambulance at Bangkok’s Don Mueang International airport, where the flight to Paris commenced. Non-invasive monitoring was carried out continuously, with oxygen administered via nasal cannula, a continuous morphine infusion via syringe pump, and all other medication as required.
A sudden downturn
The patient remained stable for six hours, including a fuel stop in Hyderabad, India – but suddenly developed severe shortness of breath, nausea and vomiting. These symptoms were extremely worrying and indicated either a pulmonary embolism or pneumothorax (potentially caused by the multiple rib fractures she had suffered). As standard lung auscultation is futile at cruising altitude with two engines blasting 7,000 pounds of thrust, an arterial blood gas (ABG) analysis was performed immediately with the point of care analyser onboard. The ABG confirmed severe hypoxaemia.
The oxygen supply was changed to a non-rebreathing mask and the flow was increased to the maximum of 15l/min. Thereafter, oxygen saturation levels increased from 75 per cent to 92 per cent. Fortunately, the patient remained haemodynamically stable under these conditions. However, as there was no possibility to confirm either of the two suspected diagnoses, the medical crew declared a medical emergency.
A 12-lead ECG raised concerns about some right ventricular stress. When the patient, who was awake and alert at all times, denied having received any subcutaneous injection in the morning, the medical crew suspected a pulmonary embolism caused by insufficient treatment with blood thinners. Immediately, 5,000 units of heparin were injected intravenously. Gradually things improved on board. Nevertheless, prompt hospital admission was imperative to obtain a final diagnosis of what caused the severe deterioration.
With the support of EAA’s Mission Control Centre, who secured the necessary permissions, an ambulance was summoned to the tarmac at Dubai airport – which, although 15 minutes farther than Muscat, is significantly closer to hospital facilities.
The patient was admitted to the Al Quasimi Hospital, where an emergency chest X-ray showed a bilateral ventilated lung, but blood tests disclosed elevated D-Dimers and Troponin, therefore confirming the EAA medical team’s primary diagnosis of a pulmonary embolism.
Taking into account treatment times, the patient’s now-stabilised condition, the opinion of the EAA medical crew, ED doctor and the patient herself, and the fact that the best treatment options could effectively be carried out while in transit, it was decided to continue with the repatriation.
The patient remained stable for the rest of the journey to Paris, where she was taken by ground ambulance to the receiving hospital.
Dr David Sinclair, Medical Supervisor at EAA, said of the flight: “This mission presented unexpected challenges, both medical and logistical. But thanks to the quick actions of EAA’s expert team – in the air and on the ground – we were able to adapt our flight and medical plans immediately. I’m pleased to say that the mission was successfully completed, and the patient returned to her home country safely and in a stable condition.”
Dr David Sinclair graduated from medical school in 1998 having studied at University of Tübingen (Germany), Dartmouth Medical School (NH, USA) and UC San Diego (CA, USA). He finished his specialisation in anaesthesiology in 2004 and sub specialised in critical care medicine and emergency medicine. He is also certified in ATLS and travel medicine. He began working for Luxembourg Air Rescue* (LAR) in 2002 and was nominated medical supervisor in 2007. Dr Sinclair is board certified in Germany, France and Luxembourg.
*European Air Ambulance (EAA) is an initiative of Luxembourg Air Rescue.
-- this article has appeared originally on ITIJ on September 2018