Medical coordination and air emergency evacuation – a complex oncologic case

A 33-year-old insured female was admitted at Hospital Vivian Pellas, Nicaragua, with a highly complex medical history. She had longstanding hypertension (Aprovel 150 mg/ day since age 25), prediabetes (XigDuo 10/1000 mg/day), and recently diagnosed hypothyroidism (Eutirox 100 mcg/day).

The patient was also born with oculofaciocardiodental (OFCD) syndrome, requiring multiple past interventions including bilateral cataract surgery, glaucoma management, several corrective foot surgeries, and partial toe amputation. Family history was significant for cancer: her maternal grandfather had prostate cancer, and her paternal aunt had thyroid cancer.

Initial diagnosis and treatment

In early 2025, during a routine nutrition consultation, elevated TSH levels were identified. A subsequent neck ultrasound revealed bilateral thyroid abnormalities (TIRADS 5 on the left, TIRADS 4 on the right), along with a thyroglossal duct cyst. Fine-needle aspiration confirmed papillary thyroid carcinoma on 19 February 2025. The patient underwent a total thyroidectomy in March 2025, which included resection of the thyroglossal duct cyst and removal of ectopic thyroid tissue.

Clinical deterioration

Following surgery, clinical suspicion arose for multiple endocrine neoplasia syndrome. The patient developed severe right-sided pain (rated 9–10/10), rigidity, sialorrhea, ocular deviation, partial weakness, and syncopal episodes when lying supine. Imaging studies further revealed a pancreatic mass under investigation, as well as widespread metastases affecting the cerebellum, parietal lobe, mediastinum, bilateral lungs, and left adrenal gland.

Diagnostics and findings

• Ultrasound (7 Jul 2025): Marked hepatic steatosis, heterogeneous pancreatic body, probable mass at pancreatic tail or retroperitoneum

• Tumor markers: Elevated CEA at 114.5 ng/mL, CA 19-9 at 601.2 U/mL; AFP normal; prolactin mildly increased

• CT/MRI (10 Jul 2025): Multiple brain metastases (cerebellum and parietal regions) with vasogenic oedema and mild midline shift

• EEG: Abnormal, showing righthemisphere asymmetry and diffuse slow-wave activity

• Adrenal biopsy: Metastatic adenocarcinoma; immunohistochemistry positive for CK7, CK20, CDX-2; negative for TTF1

• Follow-up CT (15 Jul 2025): Confirmed parietal and cerebellar deposits with increased oedema and 2 millimetre midline displacement.

Management in Nicaragua

The patient was hospitalised for cerebral oedema management. Urgent cranial radiotherapy was strongly recommended. However, while radiotherapy is technically available within Nicaragua’s public health system, access is severely constrained, with average waiting times of six months or more. No private institutions in the country had the necessary facilities.

A request was then initiated for transfer to Sylvester Cancer Center in Miami, but the facility did not accept the transfer, citing the lack of a confirmed treatment plan and absence of patient enrolment in their system. This prevented immediate air ambulance activation and created additional delays in care planning.

Assistance coordination

The medical assistance team assumed an active coordination role. Communication was maintained between treating physicians in Nicaragua, the insurer, and multiple oncology centres in the US. The University of Miami oncology department was engaged for telemedicine consultation to review the case and determine feasible therapeutic strategies. Once a treatment plan was agreed upon and the patient’s condition stabilised sufficiently for travel, logistical arrangements were finalised.

The patient was transferred via commercial flight under medical coordination and is now receiving specialised oncologic care in Miami.

Outcome and lessons learned

This case highlights the challenges of managing advanced cancer when local infrastructure cannot provide timely interventions. Critical lessons include:

• Verify acceptance in advance: Destination hospitals must confirm patient enrolment and treatment plans before authorising costly repatriation.

• Utilise telemedicine: Virtual consultations can connect local providers with international experts, bridging clinical gaps.

• Plan around local limitations: Long wait times for radiotherapy in Nicaragua – often six months or longer – must be factored into medical and logistical decision-making.

• Prioritise transparent communication: Continuous dialogue among local hospitals, insurers, international providers, and family members is essential to preserve trust and ensure safe decision-making.

Through diligent coordination, the medical coordination team balanced clinical urgency with logistical feasibility, securing specialised care for the patient while minimising risks and costs.