• Marm Assistance

Operational & Medical Considerations in a commercial wing to wing Medevac:

A Case Review of a Turkey-Germany Repatriation


The patient a 77 years old male had sustained multiple traumas after his car crashed into another car on 17.09.2022, at southwest Turkey. He was diagnosed with a comminuted left femur diaphysis fracture and a linear fracture of ischium, with 2.5 CM of separation and displacement. He had also trauma to right shoulder, thorax, and had frequent lacerations on abdomen, and lower extremities.


He had undergone intramedullary nailing for left femur shaft fracture with external fixation for pubic fracture at same side, at the state hospital, and had been followed at İCU post-op for 10 days, then he was followed at orthopedic service.


marm medical department was in charge of medical follow up of the patient at state hospital, which receiving any information related to patient can be challenging due to GDPR. It was an obstacle to obtain a detailed medical report from Hospital.


After patient’s transfer from İCU to orthopedics service, his general condition, was reported as desirable, not mobilized yet, on oral nutrition, receiving iv fluids, antibiotics, analgesics and Enoxaparin with prophylactic dose.


In this stage marm’s partner assistance company requested marm to plan a MEDEVAC with a commercial Aircraft, due to patient’s limited policy.


marm medical operations and marm travel departments collaborated to schedule the patient’s Bed to Bed Medevac from state hospital at southwest Turkey, to Hospital in Berlin by marm’s experienced inhouse flight nurse and flight doctor.


All steps of this Wing to Wing and Bed to Bed Medevac, including the ground ambulance transfer from hospital to closest airport, İzmir airport (120 km), İzmir-İstanbul and İstanbul- Berlin flights with aircrafts with availability of stretcher configuration (wide body air crafts;Boeing 777 and A330) at best flying times with least waiting time between two flights, Oxygen tubes on board planned by close collaboration and detailed work of marm medical operations, and marm travel.





Pre-Flight & in-Flight Medical Considerations:


Overview:

Patient’s past medical history had no significant finding, except single medication treatment for Diabetes Melitus. According to the information received from treating team earlier, the patient was followed with close Hb follow up, since his Hb had dropped to as low as 8 post-op, and transfusion of total of 8 units of pack cell and 2 units of FFP was carried out on different dates post-op. Last Hb value reported after transfusion was 8.8 and marm medical team was informed that additional transfusion is planned for the patient. His Oxygen saturations were reported to be 95-96% at room temperature without oxygen.


marm medical escorts responsible to transfer the patient, decided to reserve on board oxygen for the patient with minimum of 3 lit/min during cruising altitude, considering the patient’s age, low Hb values and possibility of existence of lacking information due to the limits in receiving medical information from state hospital .

Marm medical escort team visited the patient at his bed at state hospital one day before flight, discussed medical details with treating team, carried out the necessary examinations.

Patient’s last Hb value was 11.4 , with O2 Sat: 91 % without supplementary oxygen at room temperature. It was obvious that having already reserved the oxygen on board, was a right and necessary decision.

marm medical team were informed by the treating Doctor that the Contramal (Tramadol) ampule used for pain control has caused rashes and itching on skin so the patient refuses its administration.


Pre-flight and in-flight values of the patient was recorded as below:

04.10.2022 - 22:30 –State Hospital: // BP: 110/60 PR:F81 SatO2:95% T:36.3 C

05.10.2022 - 3:40 - During Take Off://BP:145/86 PR:71 SatO2:91% (2 lit/min O2 with face mask was started to be given)

05.10.2022- 08:30-Cruising Altitude 32,000 ft //BP:135/78 PR:71 O2Sat:85% (without oxygen, so the Oxygen inhalation with 3 lit/min with mask was started)

05.10.2022- 10:30- Landing to Germany// BP:135/78 PR:78 O2Sat: 96% (with Oxygen 3 lit/min)





Discussion:

In many countries receiving medical information may be an obstacle to patient’s medical follow up, even with an authorization from the patient or insurance, due to GDPR, and it may cause problems in evaluation of patient’s status specially in case of repatriation plannings. Early visits prior to repatriation day at patient’s bed, and discussing the patient with treating team may lead to have a better image of patient and less complicated transfer process. In this case, escort team considered the low Hb values post-op and probability of lacking information and reserved oxygen on board despite normal range of oxygen saturations reported verbally, and while the saturation dropped to as low as 85% during the flight and the oxygen was quite useful.

It can be beneficial to discuss your probable on-board treatment or pain management plan with treating doctor, and inform patient or his relatives about medication to get information about any adverse reaction, cause as in this case the patient was allergic to one of the medications of choice in orthopedic and trauma patient’s pain control, Contramal (Tramadol), and the pain control during the flight was carried out with Nsaids.


Marjan Basmenji, MD Çiğdem Özek Yazar

Flight Doctor Flight Nurse