In some repatriation or evacuation cases, it is impossible to obtain reliable information about the patient’s condition from the treating doctors. In such cases, besides waiting for more information, one should also consider scouting for information and/or sending out a medical crew to ensure the patient is stabilised for transportation. The medical crew could either be sent to the patient by commercial flight or by the air ambulance scheduled to repatriate the patient, depending on the location of the patient and how severe their medical situation, as it can be understood. In cases requiring an immediate takeoff, however, experience is essential – for the dispatcher as well as for the medcrew – as medical problems may occur at any time.
In this case, the insurance company requested the repatriation of a 51-year-old lady with sepsis from Gabes, Tunisia, to Germany. The only further information received was photographs of a severely infected leg from the pelvis to ankle, lab results showing a leukopenia (2800/mm3), thrombocytopenia (60000/mm3), massively elevated CRP 286 mg/l (cutout 7 mg/dl) and elevated creatinine (30 mg/l). All interpreted as a severe sepsis with renal failure.
The patient’s husband also sent a photo of a monitor showing an oxygen saturation of 99 per cent and a heart rate of 110 bpm. He was very concerned about his wife’s situation because the local doctors had told him that an amputation of the limb might be necessary. The doctors would not give us any further information.
We discussed this case with the insurance company and decided to start the mission without a full medical report, as we acknowledged that the patient’s life, or at least her limb, was in immediate danger.
Reaching the patient
The mission was initiated, and take-off was at 8:30 pm the same evening, with a flight crew and medical crew. Unfortunately, the local airport could not open for us at nighttime without more notice, so we flew into the island of Djerba, landing at 10:15 pm. The local provider could not supply us with a suitable road ambulance in time to meet us from the airport but got one to us at 1:00 am for the transfer of the medical crew to the hospital.
The medcrew, consisting of a critical care specialised anaesthesiologist and an experienced paramedic, was carrying medical equipment suitable for invasive monitoring, ventilation and resuscitation. The transport time, including ferry transport to Tunisia, lasted three hours and the medical crew arrived at the clinic at 4:30 am the next morning.
Surprisingly, the hospital was rather new, so were the rooms and the equipment. Indeed, a monitor was found standing on a chair in the corner of the room – just not connected to the patient.
The patient was conscious but sleepy and suffered extreme pain when moving her left leg. It was swollen, with extensive cellulitis from pubic bone to the ankle. There was a significant amount of exudate, the skin was red and, to some extent, showed necrotic parts.
The patient also complained of paraesthesia of her right leg and her mouth. She had difficulties talking and swallowing due to pharyngospasms.
All things considered
The patient and her husband explained that they had visited her husband’s Tunisian family for celebrations. She had been bitten by a mosquito four days ago, which immediately began to swell, causing her concern. She entered the hospital two days ago. The couple also informed us about an incident at a chemical factory close to a bathing place they had visited with the whole family. There was no other reliable information about this incident and the other family members were without any symptoms.
A nurse enabled the flight doctor to see the patient’s file and transfusion of three units of thrombocyte concentrate were documented the day before. There were no new lab results found. The patient was connected via peripheral line to a syringe-pump with norepinephrine. This was labeled with 16 mg/50 ml and the rate was 2.3 ml/h. The nurse confirmed the unusual high concentration and the absence of monitoring for the last eight hours. She stated that the anaesthesiologist came to visit the patient once a day and gave the order for the rate.
In addition, the file showed that the patient received multiple antibiotics at the same time: Ciprofloxacin, Gentamycin, Teicoplanin, Metronidazol, Pristinamycin and Imipenem.
The husband further reported that they had encountered problems with the hospital’s administration and that the hospital was still waiting for a guarantee of payment (GOP). The insurance company was contacted by the medcrew and confirmed that a GOP had already been given. Finally, the flight doctor had to talk to the hospital CEO himself to convince him that the payment was guaranteed, so that the patient was eventually allowed to leave the hospital.
The medcrew installed a monitor via the establishment of an arterial line into the patient. Analgesia and fluids were given, and the norepinephrine dosage was switched to an appropriate concentration of 5 mg/50 ml via suitable peripheral venous lines. Fluid management with Ringer’s solution with 500 ml/h was initiated. The patient was informed about the repatriation plans and possible risks of the transport such as life-threatening destabilisation with the potential need for medical or mechanical resuscitation and intubation in case of septic shock.
After two hours, the patient’s condition was stable, with constant respiration, and the transport to Djerba via road ambulance began at 6:30 am; this time the journey was much quicker due to better ferry connections. After a long security and border check, take-off with the patient took place at 10:30 am. By that time, the norepinephrine infusion was reduced to 2 ml/h and good diuresis started. The patient’s pain level was down and the patient slept most of the time but rejected any attempt at new positioning. Blood gases showed no concerning numbers despite slight hyperventilation.
In Stuttgart, Germany, the flight doctor escorted the stabilised patient to the hospital. At the time of handover to ICU (2:15 pm), the norepinephrine infusion was terminated and the patient was stable.
The follow-up phone call revealed the need for extended debridements from groin to ankle and specific wound management for a number of weeks. The microbiological investigation only showed a sensible streptococcus. An amputation was not necessary. The pharyngospasms ended spontaneously after stopping the unreasonable amount of antibiotics.
The origin of this severe cellulitis with septic reaction was ultimately unknown but a massive reaction to the mosquito bite is not considered unlikely.