Case study: Commercial transfer of a TBI patient

Patient onboard flight

Nitin Yende of HI Flying discusses a case that centres on the transportation of a ventilated patient on a commercial flight

Background
Severe brain injuries, such as traumatic brain injury (TBI), intracranial haemorrhage or stroke, are a common cause of intensive care unit (ICU) admission and mechanical ventilation initiation. Mechanical ventilation is frequently applied to protect the airway from the risk of aspiration and to prevent both hypoxaemia and hypercapnia, which are two major systemic factors of secondary brain injury. Observational data suggests that brain injury patients are given higher tidal volume and lower positive end-expiratory pressure (PEEP) levels than non-neurological patients, and that they have longer mechanical ventilation duration and higher rates of hospital-acquired pneumonia, tracheostomy and mortality than non-neurological patients.

Case report
A young Filipino woman working in the UAE met with a road accident resulting in polytrauma and severe head injury. She was in the ICU on a ventilator for 15 days, with a tracheostomy performed a week before, after her injury and impaired consciousness and brain stem reflexes induced hypoventilation – she had aspiration and was on supportive medications, sedation and higher antibiotics.
HI Flying was contacted by the patient’s relatives and the Filipino embassy to co-ordinate a patient transfer, as they knew that her medical insurance would not last for more than a month. We were immediately put in close touch with the treating doctor at the hospital.
Our recommendation was for a dedicated air ambulance flight from the UAE to the Philippines. However, the cost was prohibitive, and the family could only afford a commercial flight stretcher option.

Pre-travel process
A detailed pre-travel assessment form was completed by the treating doctor in the hospital of origin, giving our team key information about the ventilator settings, the patient’s clinical status and an assessment of her 15-day stay in hospital. An improving patient status was a positive indication, allowing us to continue to plan for the patient to travel on a commercial flight.
We needed to know absolutely everything about the patient in terms of medical history, her course in hospital, any surgeries done, post-op recovery status, patient parameter charts, medications, tracheostomy status, nutrition supplements, oxygen, sedation needs and her ventilator settings.
A patient whose clinical parameters have deteriorated in recent days, freshly intubated patients on high FiO2 and PEEP, and patients on inotrope support, may not be the right candidate for a commercial stretcher transfer.
The following actions were then taken:

  • The Do Not Resuscitate (DNR) status of the patient was discussed with the family. 
  • Medical clearance procedure was initiated with airlines and obtained in 48 hours.
  • The patient’s oxygen requirement was carefully planned, including additional oxygen in case of flight delays/diversions.
  • Tarmac ground ambulance permissions were obtained in Dubai and Manila.
  • An intensivist physician and nurse team was planned to accompany the patient.

Keeping an eye on the patient

The transport
Our medical team reached the patient bedside four hours before flight departure.
A pre-travel assessment was done, which included checking the patient’s vital parameters, oxygen saturation and listening to breath sounds. In the case of a conscious patient, we would also typically note the patient’s anxiety levels and pain status during this process. Our team read the patient’s orders and obtained information about the patient’s current ventilator settings.
The patient was then transferred to our transport ventilator; vital parameters were checked, and oxygen saturation monitored. Current ventilator settings were confirmed to match with the settings in the order sheet. The team also checked vent alarms, to be prepared in case an alarm sounded. The location of the bag valve mask was confirmed in case the patient needed to be hyperventilated and hyper oxygenated.
Suction is vital for such patients. Key considerations for medics in this situation include:

  • Suction only as needed – not according to a schedule.
  • Hyperoxygenate the patient before and after suctioning to help prevent oxygen desaturation.
  • Not to instill normal saline solution into the endotracheal tube in an attempt to promote secretion removal.
  • Limit suctioning pressure to the lowest level needed to remove secretions.
  • Suction for the shortest duration possible.
  • If the patient has an endotracheal tube, our escorts will check for tube slippage into the right mainstem bronchus, as well as inadvertent extubation. They are alert to other complications of tracheostomy tubes, including tube dislodgment, bleeding and infection. They will assess the tube insertion site, breath sounds, vital parameters and PIP trends.

Once the ground ambulance team was ready, the patient was shifted to the ground ambulance using a vacuum stretcher, with one escort holding the endotracheal tube and the monitoring devices for a smooth transfer to the transport vehicle.
All patient parameters were closely monitored. Professional handling of the patient at this stage is essential, not least because it allows the relatives to feel assured that their loved one is in safe hands.
At Dubai Airport, the ambulance accessed the aircraft via a special gate that allowed them to get as close as possible to the aircraft. We always have a medical room booked on standby in case any additional help in terms of equipment or medications is needed during the airport transit; fortunately, it wasn’t needed on this transfer.
The patient was lifted into the aircraft with the help of an Ambulift and placed on the stretcher at the back of the aircraft, which was separated from regular passengers by a curtain. It was ensured that all equipment and oxygen were well placed and secured, and the patient was belted for a smooth takeoff.
Monitoring of the patient was done by multiparameter monitors placed on the patient side and suction carried out as needed.

In-flight intervention
As the flight took off, the patient’s parameters changed, and ventilator settings were adjusted as per her needs. During cruising, the patient’s parameters were monitored every half hour and standard ventilator management and monitoring were done throughout. Her parameters were stable for most of the journey.
At the destination, the patient was transferred to the waiting ground ambulance on the tarmac, with the medical team carrying the patient with the same commercial flight equipment but making use of oxygen cylinders from the ground transport.
Our team accompanied the patient to the destination hospital in Manila.
Overall, we completed a smooth, safe and economical transfer of a ventilator patient from UAE to the Philippines.

Conclusion 
When transporting a TBI patient on a ventilator, there is no clear advantage to using an air ambulance as opposed to a commercial flight. Financial factors such as a patient’s affordability and insurance coverage may be a determining factor. 
It is now clear that PEEP has minor effects on Cerebral Perfusion Pressure (CPP) in euvolaemic patients and could even have positive consequences on brain tissue oxygenation. Protective ventilation, with low tidal volumes (6-8 ml/kg of ideal body weight), can be safely performed during transport of a TBI patient.
Waiting for a patient’s full neurological recovery is not mandatory for a commercial flight transfer with an experienced medical team and the right airline, although it should be noted that an extubated patient on nasal oxygen has a higher chance of getting accepted by more commercial airlines, as many do not allow ventilated patients to travel.