Case Study: End-of-life repatriation, long transfer, high oxygen needs

Acute Air Ambulance and Aitheras Aviation Group share details of an end-of-life repatriation that needed careful patient management

This transfer was conducted in March of 2020, prior to any Covid-related travel restrictions. Although not clinically or logistically complex compared to many international transfers that occurred throughout 2020, this particular transfer was considered as such by Acute Air Ambulance and Aitheras Aviation Group.

Clinical background

Acute Air Ambulance was contacted by the family of a 54-year-old patient undergoing treatment for metastatic thyroid cancer (bone, liver and lungs) at MD Anderson in Houston, Texas. The family wished to transport their loved one home to Brazil for end-of-life care.

A full medical report was obtained by our Clinical Supervisor and the patient was deemed fit-to-fly after review by our medical director. Of note, the nurse caring for the patient reported the patient disliked the BiPap mask and had increased anxiety. Given the transport time and patient’s high oxygen needs, a Cessna Sovereign operated by Aitheras Aviation was utilised for the transfer.

Logistics

The three-captain aviation team and critical care medical team were positioned to Houston, Texas ahead of the transfer and three technical stops were arranged. Although only two stops were required, an additional one was arranged to allow for the refilling of the onboard oxygen system, if needed. The patient was receiving BiPap therapy with 60 per cent oxygen and an average of 11.2 litre minute volume. Given the flight time, combined with anticipated ground time during technical stops, liberal estimates for oxygen usage would deplete our fixed onboard supply.

Detailed pre-flight briefing leads to better outcomes

With a total of 9,900 litres of oxygen on board, not inclusive of portable E tanks, we activated our critical care team consisting of a registered respiratory therapist with nearly 20 years of flight experience and a dual-licensed registered nurse/paramedic with current adult emergency department and neonatal intensive care unit.

A verbal pre-flight briefing was provided to the transport team by the Clinical Supervisor to discuss current and anticipated oxygen needs. Avoiding intubation in this particular patient was of utmost importance. A detailed discussion regarding the consideration of anxiolytics and pain medication to manage increased anxiety related to the flight took place. Increased anxiety could lead to an increased respiratory rate, which will increase oxygen consumption on an already very long transport.

Flying time

The first leg of the transport (KHOU-SKRG) was four hours, 10 minutes. This leg was particularly challenging for the patient as he required a combination of narcotic pain medication, anxiolytics and a small dose of an antipsychotic, all within a period of three hours. Ground time was just over one hour.

The second leg of the transport (SKRG-SGAS) was six hours. The patient required an additional dose of anxiolytics, as well as a small IV dose of a non-steroidal anti-inflammatory medication for a low-grade temperature and patient-reported pain, all within a period of two hours. Ground time was 40 minutes.

The third and final leg (SGAS-SBPA) of the transport was just one hour, 10 minutes.

Patient management benefits from diligent planning

Due to diligent planning and forward thinking, the transport was uneventful and the patient required between 30 per cent and 40 per cent oxygen. Anxiolytics and pain medication were administered for patient comfort, leading to minute volumes ranging from six litres 10.4 litres. The patient was safely transported to his home hospital to be with family during end of life care.

About Acute Air Ambulance and Aitheras Aviation

Acute Air Ambulance’s critical care transport team has been accredited by NAAMTA since 2018.

Aitheras Aviation is one of the only fixed-wing operators to attain the ‘SMS Active Conformance’ title from the Federal Aviation Administration. Additionally, Aitheras Aviation is ARGUS Platinum Rated.

Aitheras Aviation recognized Acute Air’s clinical excellence and the opportunity to expand operations in Fort Lauderdale. This is demonstrated by Aitheras’ acquisition of Acute Air Ambulance in 2019.

This transport was unique to both Aitheras and Acute Air Ambulance for several reasons. Acute Air Ambulance, based in Fort Lauderdale, Florida, has been in operation since 2011. Utilizing a fleet of short-range jets (Citation Ultra, Lear 35), Acute Air Ambulance offers services to northern South America, Central America, the Caribbean and north through the continental United States and Canada. Transfers to and from these locations are routinely within the range of the respective aircraft.

Aitheras Aviation, based in Cleveland, Ohio, and operating since 2005, conducts domestic and worldwide transports for the Cleveland Clinic Critical Care Transport Team as well as organ procurement teams. These transfers are typically less than two hours. With a fleet of nine aircraft, routinely available jets in Ohio include Citation Ultra, Citation Excel, Citation Sovereign. Aircraft are rotated between Fort Lauderdale and Cleveland.
Medical charters are also available in air ambulance configuration or charter configuration. All aircraft in air ambulance configuration carry three fixed ‘M’ tanks of oxygen, totaling 9,900 litres. Additional portable ‘D’ and ‘E’ tanks are utilised for ground transport.

Acute Air Ambulance and Aitheras Aviation Group are able to provide same-day rapid PCR testing to meet international requirements, as well as rapid antigen testing for entry into the United States.