Sudan is suffering from the cruelty of civil war. Clashes between the Sudanese army and the paramilitary Rapid Support Forces, due to their rivalry for power, have left dozens dead and hundreds injured. Hundreds of thousands of residents of the Sudanese capital, Khartoum, and other areas, including Greeks of the local diaspora, were under threat. Many countries have organized operations to release citizens from Sudan.

France implemented Operation Sagittarius to remove its diplomatic staff, French citizens, as well as Europeans from allied countries, including Greek residents of Sudan.

On Saturday 22 April, armored vehicles surrounded the metropolis where a service was taking place to mark the resurrection of Christ. When the churchgoers dispersed to go home, two of them were hit by a rocket that landed in the area. The churchgoers collected the victims and sheltered them inside the church.

A French Special Forces unit was engaged to release the entrapped citizens and evacuate the two wounded to the Hospital of Khartoum, where a forward surgical team (FST) was deployed.

The first wounded (Greek citizen, and 59-year-old man) had penetrating injuries to the abdomen and upper and lower extremities, causing profound bleeding, while the second suffered only minor injuries.

The FST attempted damage control surgery by controlling the external bleeding, especially in the lower extremities, but also performing exploratory laparotomy, where shrapnel was found in the peritoneal cavity, having penetrated the small bowel. They performed bowel resection and ligation with staplers. The abdomen was packed with gauzes and remained opened, covered with drapes. The lower extremities had multiple fractures and were splinted. The patient remained intubated and was hemodynamically unstable, needing five units of packed red blood cells (PRBCs) during the initial resuscitation.

An air medical evacuation operation was organized in the following hours, and he was transported to the Role 3 Military Hospital of Djibouti. Upon reception, he had a ‘second look’ abdominal exploration, and an external fixation was placed on his right tibia.

Prepared for takeoff

A distress call was made to the Hellenic Ministry of Foreign Affairs, asking for immediate patient evacuation for definite treatment. The Greek Prime Minister was informed about the critical condition of the Greek citizen and ordered his immediate repatriation.

Considering that all air medical evacuations of the public sector in Greece are performed by the Air Force and to avoid any conflicts, the operation was assigned to the air medical evacuations private company Life Line Aviation. The personnel were briefed earlier in the morning of Sunday 23 April about the patient’s condition and directed to proceed as soon as possible. It was a significant, low-profile mission that needed to be done with caution.

His abdomen was draped with sponges connected to a vacuum-assisted closure device

After preparing the aircraft (Cessna 650 Citation III) and all the necessary equipment tailored to the specific operation, the flight crew and the medical personnel consisting of a flight surgeon, a flight nurse, and a paramedic took off in the afternoon of the same day. Over Egypt, two Egyptian fighters provided a discreet escort up to Djibouti, and the aircraft landed at the Djibouti City Airport after midnight. A large multinational support team was deployed in the airport, and many airplanes were waiting to evacuate foreign citizens to Sudan.

Minutes after landing, a French ambulance carrying the patient approached. During the refueling procedure, the medical personnel got on the ambulance and were informed about the victim’s condition by the escorting doctors.

The patient was intubated, sedated, and paralyzed. Hemodynamically unstable with moderate doses of vasopressors, he was febrile (39°C) while on wide-spectrum antibiotics. His abdomen was draped with sponges connected to a vacuum-assisted closure device. He had a chest drain (Bülau) due to a burst lung caused by the explosion, nasogastric tube, and urinary catheter.

Lung expansion was confirmed by auscultation, and the good working order of the Bülau device was verified before takeoff

After a short assessment, the patient was connected to our ventilator and vital signs monitor including an invasive blood pressure monitoring module. The medical files and the available blood units for transfusion en route were handed over, and the patient was carried on the plane and secured on the stretcher.

All the infusions were labeled and checked for uncompromised dripping, proper endotracheal tube placement was ascertained, and the vital signs were recorded.

Finally, lung expansion was confirmed by auscultation, and the good working order of the Bülau device was verified before takeoff.

The flight home

During the flight, a fluid challenge was attempted, resulting in moderate hemodynamic stabilization and a reduction in the administered dose of noradrenaline. PRBC transfusion was continued, and the antibiotics were given at the prescribed timeframe.

The flight was uneventful, and the airplane landed at Athens International Airport in the early morning hours. The Army’s trauma ambulance unit was waiting on the apron, and the patient was finally transferred to the 401st Military Hospital – Army Trauma Center in Athens, Greece. After undergoing an entire body computed tomography (CT) scan and clinical assessment, he was admitted to the trauma intensive care unit (ICU).

During his ICU admission, which lasted five weeks, he had multiple redo operations until an end-to-end bowel anastomosis was performed. Although he developed ventilator-associated pneumonia, he was weaned successfully after 32 days. The patient was discharged after 52 days.