CASE STUDY: Repatriating a multiple trauma patient

The patient was a 72-year-old lady who sustained multiple trauma due to an accident while on a trip to Cappadocia, Central Turkey. She was found unconscious at the scene of the accident, and had difficulty in breathing, and stridor. She was haemodynamically unstable and immediately transferred to the closest well-equipped hospital. The patient was evaluated: she showed signs of shock, and was diagnosed with a left upper palpebral laceration; foreign bodies in her cornea; a comminuted fracture of the tympanic part of left temporal bone; tympanic membrane laceration in left ear; traumatic hemothorax in the right hemithorax; and lung contusion in the thorax.

Fracture lines were also detected at costas number 2, 3, 4, 5, 6, 7 and 8, bilaterally, while abdominal computed tomography (CT) scans revealed fluids in the abdominal fossa and findings suggestive of traumatic liver injury. Finally, the patient was diagnosed with displaced right femur shaft fracture; left humerus displaced diaphysis fracture; right clavicle fracture; and lumbar vertebrae transverse process fractures – bilateral at L1, L2, and L3, and unilateral at L4 and L5.

Ensuring the best medical provision

The patient was immediately taken to the operation room for a diagnostic laparoscopy. During the surgery, an aspiration of haemorrhagic fluids and repair of liver capsule laceration was carried out. The patient was transferred to an intensive care unit (ICU) postoperation, intubated, and ventilated with a high dose inotropic infusion. One day after admission, due to the patient’s severe condition, marm assistance medical team decided to transfer the patient to a better equipped hospital in Kayseri – 80 kilometres away. Upon approval by the insurance company and family, a medical doctor from marm assistance visited the patient and other victims of the tragic accident, supervised the transfer process, and evaluated clinical condition of all patients with treating teams in hospital.

Elective surgical operations for treatment of femur, humerus and tympanic segment of temporal bone fractures were carried out in the second hospital. A litre of haemorrhagic fluid was evacuated from the right hemithorax, via chest tube thoracostomy. The patient was followed in ICU and ventilated for one week, prior to weaning and non-invasive ventilation trial. Her general condition improved, while treatment for pan-resistant klebsiella growth on patient’s tracheal aspirations continued.

A sudden deterioration

Unfortunately, news that the patient’s condition had suddenly deteriorated complicated the situation, leading to re-intubation. A CT scan on the 13th day since admission revealed massive bilateral emboli, despite the fact the patient was receiving anti-thrombosis prophylaxis. Anti-thrombotic treatment was initiated. The patient was extubated after two days, and had spontaneous respiration – however, inotropic infusion and high flow nasal oxygen at 10 litre/minute continued.

Four days after pulmonary emboli diagnosis – on the 17th day of admission – the patient was discharged from İCU and was transferred to internal disease service, with spontaneous respiration and 6 litre/minute high flow oxygen support, with a saturation percentage of 97 per cent. During close follow-ups assessments, the marm assistance medical team evaluated the best time and means of repatriating the patient to her home country of Spain. Arrangements for readmission were carried out by the insurance company.

Careful consideration required

Considerations for the patient’s repatriation were both medical and logistical. Logistically, a direct transfer from Kayseri to Barcelona was only possible via air ambulance. Medically, the patient was stable, and her general condition was improving day by day – due to the complications of the massive bilateral pulmonary emboli, it was foreseen she may need a minimum 8 litre/minute of high-flow oxygen during the flight. Supplying this amount of oxygen on a plane, for the duration of a four-hour flight to Barcelona, could be problematic. The patient’s pain and delicate condition also favoured an air ambulance repatriation.

Considering the various factors, an air ambulance transfer from Kayseri to Barcelona was arranged, and the patient was successfully transported home on 23rd day of her admission, escorted by marm medical escorts.