ACE Air & Ambulance reports on an urgent medevac from a game reserve, where the patient’s critical condition meant last-minute changes to the transfer plan
Running an air ambulance in Zimbabwe that specialises in remote rescue inevitably means that the majority of our workload is for primary calls and trauma. It will come as no surprise, then, that wild animals feature in a significant number of these calls. Elephants top the list of offenders – there are high numbers of them in the region, and their unpredictability, coupled with their immense size and strength, mean they present a real danger to locals and visitors alike.
Call for help
Just before 10 a.m., the call centre received a notification requesting the evacuation of a patient from a remote game park across the border in Malawi. The request was ‘to activate as soon as possible’ and medical details provided were that the patient had been injured by an elephant around 7 a.m., that he had a deep laceration to the upper abdomen, an open fracture to his leg and a puncture wound to his thigh. His blood pressure was reported as 76/69 mmHg with a pulse rate of 122, indicating to our team that he was in severe hypovolaemic shock.
The patient had been taken from the scene to a local clinic adjacent to a dirt airstrip. Our records showed that the dirt airstrip was not suitable for anything other than light single engine aircraft and would not accommodate our King Air fleet. Our dispatchers quickly established that the nearest serviceable airport suitable for our aircraft was some 80 kilometres from the clinic, and the journey from clinic to airport – on dirt roads in very poor condition – was estimated at two hours.
In many of these cases, the biggest delay to take off is due to difficulties in obtaining flight clearance, either into the country or for onward clearance, which can sometimes take many hours. In certain African countries, the clearance can only be given by the military and will only be granted with a letter from a local doctor (a problem when the patient is in a remote safari area with no doctors!). Fortunately, in this instance, we had developed a good relationship with the relevant authorities and within an hour of receiving the call, clearance was granted to fly our aircraft into the serviceable airport.
Once the King Air had cleared customs, our flight medical team and its equipment were loaded onto a helicopter based at the serviceable airport and flown to the patient’s side. Simultaneously, a ground ambulance was dispatched by our local service provider that would (in theory!) conduct the two-hour road trip to transfer the stabilised patient to the air ambulance with our medical crew.
ACE’s air ambulance took off from Harare 90 minutes after the initial call, landing at the serviceable airport just over an hour later. The air ambulance crew carries jump bags containing essential medical equipment which were taken with them on the helicopter, as it was not configured for air ambulance work. In addition, the crew took an oxygen cylinder and portable ventilator and were then on their way to the patient.
During this time, our dispatch centre had established which hospital in South Africa (the selected patient destination) would be best suited to receive the patient and arranged for a ground ambulance to meet the aircraft when it landed. Importantly, it had obtained Port Health Clearance from the authorities, allowing us to bring the patient into the country.
The medical flight team arrived at the clinic at 1.30 p.m., some six hours after the injury had occurred. The ‘clinic’ turned out to be nothing more than a mud and thatch hut alongside the airstrip. Details of how the incident happened then unravelled. At around 7 a.m. that morning, an elephant had attacked a safari vehicle and overturned it. The occupants had all jumped out of the vehicle and run away from the scene, but the patient had stopped at some point to take a photograph of the incident and this caused the elephant to attack them. Although there was a doctor and nurse in attendance, no start had been made at resuscitation and they didn’t have any equipment to set up an intravenous drip, nor did they have any painkillers. This is a common scenario in remote clinics in Southern Africa.
Examination by the medical team showed quickly that the patient’s injuries were more severe than had been previously described. There was a degloving injury to the chest on the left. This exposed a number of fractured ribs and a contused, collapsed lung. Through this hole in the chest wall the heart was visible. The injury to the thigh was very extensive, exposing the bone around the hip and there was a severe open fracture of the leg. In addition to the patient’s very low blood pressure and high pulse rate which indicated hypovolaemic shock, the patient had a dangerously low oxygen saturation level.
The medical team started the patient on oxygen and established intravenous infusions before closing the chest wound and inserting a chest drain. This resulted in a normal oxygen saturation level and improvement in the patient’s blood pressure. After an hour had passed, the team felt that the patient’s condition was stable enough for them to be moved. At this point, however, it was deduced that the journey by road was not a reasonable option. The patient was still critically ill and in considerable pain when moved, despite intravenous pain relief. If a road trip was to be undertaken, it would have had to be done at a very slow speed, which would result in a significant delay in getting the patient to the air ambulance and the oxygen cylinder may not have lasted for the full duration.
Enquiries were made with contacts in the area and a local safari operator made a Cessna 208 available (the helicopter that had transferred the medical crew was not suitable for patient transport). Prior to this short flight, insurance, indemnity and consent forms had to be completed. The patient’s weight was at the upper limit of the air ambulance stretcher, which, along with the bulky vacuum mattress used to support the patient’s fractures, made loading and managing the chest drain in-flight difficult, but the process was accomplished nonetheless.
Once the patient was successfully transferred into ACE’s air ambulance at the airport, the patient’s vital signs continued to improve and the team had a relatively uneventful flight to South Africa before finally handing over the patient to the waiting trauma team in Milpark Trauma Unit, Johannesburg, at 9 p.m. that night. The patient survived surgery and has recovered substantially.
Dr Charles Crawshaw is Medical Director for ACE Air & Ambulance (Pty) Ltd in Zimbabwe. He is a founder member of the British Association of Spinal Surgeons and is a consultant in medico-legal cases for the UK’s NHS litigation authority and the Medical Defence Union.