Yukon coroner makes recommendations
The chief coroner of Yukon has set out a number of recommendations aimed at improving the quality of care given during aeromedical transfer missions.
The chief coroner of Yukon in northwest Canada has set out a number of recommendations to the provincial government aimed at improving the quality of care given during aeromedical transfer missions. The advice is included in Kirsten Macdonald’s report into the death of Cynthia Blackjack, a 31-year-old woman who passed away during an air ambulance flight on 7 November 2013.
The patient was being flown from Carmacks to Whitehorse, having presented with severe dental pain. The medevac team consisted of two paramedics and a physician.
The cause of death was reported as ‘multi-organ failure secondary to hyperacute liver failure of unknown cause’. Investigations also showed that the patient was suffering from multiple tooth abscesses and severe tooth decay. However, the coroner’s report also highlights a number of problems that occurred during the mission, including the fact that a blood transfusion was delayed at Carmacks as the wrong type of IV tubing had been brought by the transport team. An investigation revealed that this was because an incorrect size of tubing had been stocked together with the proper size for transfusion at a storage area in Whitehorse. Also, there was no working suction apparatus at the Carmacks health centre, says the report, and a manual suction device had to be used in order to intubate the patient. This delayed, and could have compromised, the airway management of the patient, notes Macdonald.
During the flight, vital signs were lost and CPR was started. The coroner notes: “The noise of the aircraft inhibited the ability of the medevac team to confirm proper ventilation, so the endotracheal tube was removed and replaced with a supraglottic airway.” A pathologist determined that the endotracheal tube was placed within the gullet, but this misplacement was thought to be of ‘unlikely significance’ as related to the cause of death.
Macdonald recommended that health centres must have functional suction devices at all times, and that a review should be conducted of the policies and procedures for transferring patients from community health centres to Whitehorse. Medevac transport teams and persons re-stocking supply cabinets should ensure that items are stocked properly, she said, and prior to departure transport teams should check to ensure that they have the proper equipment. Additionally, she added, transport teams should receive in-service education to ensure they are completely familiar with the equipment they carry, and monitoring devices must be capable of assessing blood pressure, pulse and oxygen saturation at all times, despite aircraft noise and vibration.