Evidence-based medicine and a race against time

Work-related life or limbthreatening injuries are frequently encountered in various industries across the world, with Africa being no exception. With the added challenge of limited medical infrastructure and delays in getting to defi nitive care, these injuries could lead to serious morbidity and mortality. We describe a case that involved a patient with a limb-threatening injury who needed to be evacuated from a central African country in a race against time. The way our air ambulance medical crew managed the case before and during transport demonstrated an approach centered around evidence-based medicine and patient comfort. At Air Rescue we strive to exceed expectations both in logistical capabilities as well as medical management. In some cases, like the one described, both these factors become paramount to the successful execution of the mission.

The patient’s injury

A middle-aged woman sustained an isolated crush injury to her left hand while operating a machine at work just before 1pm in the afternoon. It resulted in a severely compromised hand, which included an extensive degloving wound involving all digits as well as the dorsal and palmar surfaces of the hand. There was a partial amputation of the left thumb as well as numerous fractures to the other digits. The patient was taken to a local facility where temporary measures were undertaken which included a washout and debridement. Prompt assistance from an assistance company meant that the air ambulance could be activated at the earliest opportunity.

After all emergency clearances were obtained for the fl ight, our air ambulance took off from our base in Johannesburg shortly after midnight for a flight of just over two hours. Upon arrival of the medical crew, a thorough assessment of the patient followed, and it was concluded that the patient was a suitable candidate for regional anesthesia, which was offered to the patient. She consented to a supraclavicular brachial plexus block, which was performed ultrasound guided by the flight physician. Subsequently, the patient’s pain improved to the point where she was pain-free for the duration of the flight.

The patient arrived in Johannesburg in the early morning and was handed over to the trauma team at a well-known level 1 trauma center. The nerve block also allowed the receiving team to do an immediate detailed examination of the injured extremity without any additional analgesia or sedation.

Regional anesthesia

Logistically, this case necessitated a prompt response, and every effort was made to expedite the process. It is quite common to encounter logistical challenges when obtaining necessary clearances for flights on the continent, which can, in many instances, impact response time and require careful navigation for efficient operations.

From a clinical perspective, regional anesthesia has become an integral part of a multimodal approach to pain management. Not only does it provide analgesia that is superior to most other agents, but it is also not associated with the common side effects encountered when using high doses of opioids, often needed to manage severe injuries. With the ever-expanding use of point-of-care ultrasound, many therapeutic procedures previously deemed impossible outside of the confines of the hospital, are now well within the scope of the flight physician.

As was demonstrated in our case, ultrasound-guided regional anesthesia can be safely and effectively performed in the pre-hospital, retrieval, and transport settings and should form part of the armamentarium of any critical care retrieval team.