Case study: FAI Air Ambulance on the value of in-flight ultrasound

Hospital evolution:

Typical course of such cases with the usual complications. Eventually stabilising, slow but steady recovery from multiorgan-dysfunction, however: 

• Patient did not ’wake up‘, weaning from mechanical ventilation was difficult, failed twice with re-intubation
• Weaning from haemodialysis and from inotropes/vasopressors was successful
• On tapering doses of Fentanyl and Midazolam
• Poor (almost no) neurological recovery, remained unresponsive, opening eyes occasionally, but no contact
• Labelled as ‘severe, post-anoxic brain lesion‘, aka minimal consciousness state. DNR policy was agreed
• EEG, SEPs/AEPs, brain MRI not done yet
• Limited, infrequent physiotherapy, no ‘early rehab‘ measures.

Handover at ICU was professional and friendly, but no recent chest X-ray available, and no explanation suggested why extubation failed. The son, who had arrived from the US, confirmed that he could not – despite all efforts and attempts – evoke any response from his father; had accepted a likely irreversible vegetative state and agreed to DNR.

Transport course:

• Routing: Wroclaw-Keflavik-Baltimore
• Aircraft: Challenger CL 604
• Crew: One Capt, one FO, one flight doctor (Intensivist), one ICU nurse

Once airborne, the remaining low-dose analgo-sedation with Fentanyl and Midazolam was completely withdrawn, ventilation mode was changed to Adaptive Support Ventilation (ASV). With tactile (foot massage) and verbal stimulation, patient became more alert (but not restless or combative), showing what appeared to be targeted movements with his arms and hand. We performed abdominal and thoracic ultrasound, which disclosed extended bilateral pleural effusions and reduced myocardial contractility. But more important than the interesting sonography results, when the patient was warned (as is routinely done with individuals in a ‘coma‘) that the ultrasound gel will feel a bit cold, he opened his eyes, nodded and gave the hint of a smile!

The rest of the flight was uneventful. We alternated phases when we let the patient sleep with intermittent simple basal stimulation techniques, and by the end of the flight the patient was reproducibly able to follow simple commands.

Epicrisis:

The patient‘s family informed us later that the colleagues in the receiving hospital confirmed our ultrasound findings, cautiously drained the effusions over the next days, added diuretics, stopped all benzodiazepine medication for good and were able to extubate the patient only 36hrs after our arrival without any problems. In the further course, the patient became fully alert, orientated, cooperative, and was mobilised to sitting in a wheelchair with good balance, while eating and drinking with little assistance.

Lessons learned:

• While decreasing sedation effects have certainly been the main reason for the unexpected neurological recovery, we are inclined to believe that it was also the change in environment (the flight-situation itself, close contact with the son and our intensive multimodal ‘input‘ in the form of basal stimulation, massages) that have significantly contributed
• The so far unknown, or at least undisclosed, pleural effusions, with subsequent compression atelectasis of both lower lung lobes, explained at least partially the previous weaning failures
• The modifications we applied to the mechanical ventilation (increased PEEP, ‘Adaptive Support‘ ventilation) were aimed to improve lung mechanics and recruit atelectatis lung areas, hopefully adding momentum to the weaning process
• Last, but not least, we saw once again, that in-flight ultrasound can offer valuable support for clinical considerations and decision-making.