Long-range mission for a complex patient

We received a quote request to fly an 84-year-old gentleman from Denpasar, Bali, back to Amsterdam, the Netherlands. . He had received immune-suppressive therapy for a former diagnosis and then developed pneumonia. We received medical reports from the date of admission in BIMC (Bali International Medical Clinic) to date. He suffered from hypoxia, but performing intubation and mechanical ventilation in such an elderly patient often leads to death. BIMC managed to handle the situation with a non-rebreather mask and high oxygen flow. Unfortunately, on his way to hospital, he had a non-ST-elevation myocardial infarction, which reduced his cardiac function.

Evaluation of mission

In his current condition, he could not be flown all the way back to Amsterdam. ICU treatment always aims to support the body’s own reserves and responses. The reduced heart function from the myocardial infarction, plus the diagnosed valve stenosis, put him at risk for accumulating fluids in his lungs (pulmonary edema) and pleural effusion, pressure on the liver with leakage of protein rich fluids into the abdomen. The chances of improvement were small for this patient. But over several weeks on ICU with a very small range of equilibrium, he was showing signs of improvement. The non-rebreather mask could be exchanged for a normal mask and lower oxygen flow. Following this positive development, we were able to start making a plan to fly him back home.

Flying patients means increasing their risk!

Expertise can diminish that risk Going up to altitude means that air pressure will decrease, and so does oxygen pressure. The patient will need about 30 per cent more oxygen during flight, and eventually more. We calculated that the long-range flight in our Challenger 604, would take around 19 hours including fuel stops – for which one needs a significant amount of oxygen cylinders on the plane. Additionally, third spacing will happen – a fluid exchange from within the blood vessels to the tissues. On inner-continental flights, this may not be a severe problem, but on ultra-long-range missions, this affects every person in the aircraft. Blood pressure decreases, heart rate increases, and worsening oxygenation of tissues are all results of this effect. With our patient, who already was prone to accumulating fluids, we might have to add more fluids to keep a steady equilibrium. The questions we had to answer were, how much more did we need, and when would it be too much? Luckily, we always carry a handheld ultrasound device on our missions. The Butterfly probe shows structures from superficial to 25 cm deep. We were able to do sonography of the vena cava inferior, a superb blood vessel to show fluid overload of a human being. With the need of increase of oxygen flow calculated and the ultrasound-controlled body-fluid status confirmed, we were able to fly him back home without complications.

Crew considerations

We had a three-person medical crew on this flight, and organised a 22-hour rest stop on Bali before the transfer. Pilot duty time regulations are one part of the mission, but in the end the patient must be treated safely from takeover till handover, and this is a medical responsibility. Well-rested medical crew will always act better. Our patient was ‘stable’ throughout the flight – a so-called uneventful transfer. However, without the correct medical devices and without decades of experience, this flight might have turned out very differently!