As our Learjet 45 touched down on a sunny and calm landing strip in Morocco, we transferred ourselves and our intensive care kit into an ambulance and drove to a small district general governmental hospital. The information that we had received described a young man who had fallen from a three-storey building four days earlier and sustained a large extradural bleed. This had been drained in theatre and the CT report at that time stated that there were no further spinal injuries and a fracture of the ischium.
Waiting outside the intensive care department we were met by some concerned family members and the grave face of the resident ICU doctor. Apparently run ragged as the sole doctor covering a busy 10-bed ICU department, he was trying his best to keep control of his patients and had clearly been up all night. He had minimal nursing support and resources were scarce. He informed us that the patient had deteriorated overnight. He had become septic, spiking temperatures of 38.5oC and a lumbar puncture had returned positive for bacteria, indicating a meningitis – an infection inside the brain cavity as a result of either the previous brain surgery or frontal skull fractures allowing the entry of bacteria. He was already on appropriate broad spectrum antibiotics to cover the meningitis.
His routine bloods from that morning had also returned and had showed a massive acute drop in his haemoglobin level from 12 to 6.1g/dL – he was bleeding from somewhere internally and he was critically unwell and unstable.
Before doing anything else we arranged for an urgent blood transfusion. Blood in many countries globally is a scarce resource, but with the support of the hospital manager, authorisation was given to allow for blood to be retrieved from the blood bank. The only intravenous access in-situ was a very thin bore femoral line, which allowed for only the very slow administration of fluids, so we placed two wide bore peripheral cannulae to allow for the rapid transfusion of four units of blood and tranexamic acid. We also placed an arterial line for closer monitoring of his cardiovascular parameters and to take off blood samples.
He very quickly pinked up following the transfusion and his cardiovascular parameters stabilised, albeit perhaps temporarily. His ventilation was also problematic – he had severe bilateral atelectasis – probably from a lack of re-positioning and suctioning. Despite efforts to re-recruit he had poor lung function and was requiring 70 per cent oxygen.
The next problem was to work out where the bleeding was coming from. To have dropped his haemoglobin level so acutely he must have lost several litres of blood. There was no bleeding visible. The cranial cavity would not be able to conceal such a large quantity of blood. His respiration on the ventilator and oxygen requirements had not worsened and examination did not show any signs of a haemothorax. There were no signs of obvious lower limb injury which could be concealing blood loss, which left the abdominal and pelvic regions as the potential sources of bleeding.
In order to differentiate between these sites, we organised an urgent CT scan. This presented many logistical hurdles which we had to overcome, as the hospital did not have any portable ventilators or oxygen cylinders, so we transferred the patient over onto our portable equipment. This also required a lot of co-ordination with the local staff in order to make this happen. The CT was not up to the level of a usual trauma scan, but we were able to ascertain that the bleeding was coming from the pelvis due to fractures of both the ischium and trochanter and that an unstable pelvic fracture had been missed on his initial assessment.
A pelvic binder, which provides pressure to squeeze the pelvis inwards in order to prevent further blood loss, was not available, so prior to transfer to CT we folded a bed sheet and wrapped this around the hips, maintaining tension with an arterial clamp, an act which has much the same effect. We transferred him onto our vacuum mattress with the intention that this would also provide a degree of pressure on his pelvis to prevent further blood loss. The hospital did not have the facility to run blood gases, so we used our bedside iStat machine to test his haemoglobin level, which had now increased to 9.9g/dL following transfusion. His sodium was increased at 159mmol/L, suggesting that he was still very dehydrated and that his true haemoglobin if he was normovolaemic would in fact be lower than this.
At this point we had replaced the critical blood loss, ascertained the source of bleeding and hopefully temporarily controlled the bleeding. This was however, only a stop gap prior to definitive treatment, which would require an operation to fixate his pelvis and thus prevent further catastrophic blood loss.
A conference call was rapidly arranged between our team on the ground, our senior medical team back at base and senior medical representatives from the insurance company organising the repatriation. Amidst the din of the hectic ICU unit, we managed to relay the necessary information as to the current situation and a concerted decision was agreed upon.
Much of medical repatriation is based upon the decision to transfer a patient to the most appropriate place of safety. It was clear that despite the best intentions of the team in Morocco, they did not have the ability in their resource-poor environment to provide the best level of care to the patient. There was a general surgeon on call, but he did not have the capabilities to perform complex pelvic surgery. They had limited blood products available in their blood bank if he were to continue bleeding. Despite his instability, it was not an option to leave him where he was.
On the other hand, if we were to fly him in our air ambulance, we would also have no access to blood products during the transfer, which would take several hours. The flight would also involve flying over multiple safe places of care – trauma referral centres which did have the ability to stabilise his pelvis and provide a high level of intensive care management.
We decided, therefore, to fly to the closest hospital that could provide an optimal level of care. We received military permission to fly to Gibraltar and from there a Spanish ambulance met us on the tarmac and we made the short drive to a Spanish hospital, where around 10 experienced trauma team members were waiting gloved and gowned up with open arms ready to accept our patient. Within minutes they had whisked him off for a full body trauma CT scan, from where he was directly admitted to ICU and that night was operated on to stabilise his pelvis as well as providing optimal neurological treatment for the meningitis.
Two weeks later he was stable enough to allow for his safe transfer back to the UK.
Closest appropriate care
This case demonstrates the utmost importance within the field of aeromedicine to make appropriate decisions as to the safest place of care for patients, a decision which must take into account many variables and is relative to the current situation of the patient. As so often is the case, this decision comes down in a large part to the ability to communicate effectively within a supportive team environment. This makes the difference between a potentially stressful situation running out of control, to an immense amount of job satisfaction and allowing for a management plan which is the best available option for the patient.