A few months ago, one of our clients, International SOS, requested an urgent evacuation of a 33-year-old lady from a military hospital in an active war zone in the Middle East, to a place where medical care is more closely aligned with international standards for intensive care.
The patient was at high risk of acute haemorrhage because of deep coagulation disorders, with a need for comprehensive ICU medical management and a potential liver graft
Patient’s medical condition
This young patient had no special past medical history but had over a few days developed a fever with sore throat, odynophagia, abdominal pain, and jaundice that was not improving after six days of treatment of azithromycine and paracetamol. She was initially assessed locally and transferred to the ICU of a military hospital in good clinical condition. Her subsequent blood work up showed severe liver and kidney failure with fulminant hepatitis complicated by acute coagulopathy, thrombocytopenia and metabolic acidosis. A CT scan of her abdomen further revealed mild anasarca made of pleural effusion, pericardial effusion, ascitis with hepatomegaly, splenomegaly and lymphadenopathy. The final diagnosis was an acute Epstein Barr Virus infection with liver and kidney failure, which was complicated by acute coagulopathy, thrombocytopenia and metabolic acidosis, with a possibility for a hematophagocytic lymphohistiocytosis. The patient was at high risk of acute haemorrhage because of deep coagulation disorders, with a need for comprehensive ICU medical management and a potential liver graft.
The team had only 120 minutes allowed on site by specific insurance policy extension
Considerations and complexities
To make this flight possible, and beyond dealing with the critical medical condition, Airlec Ambulance faced many operational challenges:
Because of the extremely high confidentiality in regards to the military airport details, it was nearly impossible for our pilots to obtain any precise airport approach plate.
The team had only 120 minutes allowed on site by specific insurance policy extension.
This area is strictly forbidden to French air operators, so Airlec Ambulance had to obtain a mandatory special waiver from the French Ministry of Foreign Affairs.
Because of the location of the patient, Airlec Ambulance actively sought security information from various stakeholders in order to evaluate the risks/benefits ratio of the mission.
For safe overflight-approach-landing-take off conditions in a war zone country/airport there was a complicated necessity to liaise with many different parties: French authorities; military airport authorities; and civilian authorities in the country.
Although Airlec Ambulance anticipated this option, no military plane was sent to escort our aircraft from the air to the airport.
The patient’s haemodynamic and ventilation remained stable throughout the flight, with only one acute episode of nasal bleeding which was stopped with intravenous tranexamic acid (the decision not to perform any anterior/posterior packing was made by the medical team due to the severe coagulopathy). The patient was finally safely handed over to the receiving medical team.
Paul Tiba, Chief Executive of Airlec Ambulance, told AirMed&Rescue: “It was a big challenge to implement a single civilian air ambulance in a complex military war zone system. It necessitated huge efforts and commitments from our operations team and ground handling agent to ensure the safety of the patient, medical team and pilots by securing overflight-approach-landing-take off in an active war country/airport. This included timely analysis of the situation and medical/operational capabilities; timely delivery of Labile Blood Products thanks to our agreement with French Blood Institute, and timely transfusion of the patient upon arrival of the team.”
About the author
Dr Yann Rouaud is an emergency physician with specialisation in Emergency and Disaster Medicine. After working for many years in public hospitals' A&E departments, he joined Inter Mutuelles Assistance in 2007 as a Medical Director. In 2012 he was recruited by International SOS. In his current role of AIRLEC Group Medical Director, his daily commitment is to ensure that quality of delivery will fully match patients' and clients' expectations as well as meet the true spirit of AIRLEC Group: always go above and beyond.
This article appears in the March 2019 print edition.