Case Study: urgent air medical transport of electrical burns patient between Cyprus and Greece
Dr Ioannis Mamidakis, Medical Director of Gamma Air Medical, discusses an emergency air medical transport between Cyprus and Greece following an accident at an electrical substation
Despite significant advances in prevention and treatment, burns are among the most serious of injuries to the human body. Burns are tissue damage caused by the application of heat, chemicals, electricity, or radiation to the body. The extent of the damage – surface involved and depth of the burn – is a result of the intensity of the heat (or other exposure) and the duration of the exposure.
Burn disease does not cause only local lesions on the skin, but it is a generalized systemic reaction of the human physiology. In the first hours, hypovolemic shock, and airway obstruction are the most common fatal complications. The most common distant cause of death is sepsis. The age of the burn victim is another powerful factor that affects mortality.
However, throughout the most recent years of development, bio-culture of keratinocytes in patients with extensive burns has unlocked new possibilities of treatment in the early coverage of the burn surface and in effective treatment of the burn victim.
Critical burns at the Cyprus Electricity Authority substation
On 20 May 2021, two workers, aged 40 and 48, were critically injured in an accident at a Republic of Cyprus Electricity Authority substation during scheduled maintenance. The workers are believed to have been in contact with power lines inside the substation, which caught fire and set their clothes alight.
Burn disease is a generalized systemic reaction of the human physiology. In the first hours, hypovolemic shock, and airway obstruction are the most common fatal complications.
The workers sustained severe burns and were immediately transferred to Nicosia General Hospital, where intubation and resuscitation started. The older victim sustained a mixed electrical and flash burns that involved 90 per cent of his total body surface area (TBSA), and lesions were mostly full thickness. The second victim’s burns involved 50 percent of his TBSA and his condition was better manageable.
Given the severity of the injuries and the critical condition of the workers involved, the Ministry of Health approved the transfer of the workers abroad for treatment essential, specifically at a Burn Center that specialized in keratinocyte cultures and burn coverage. Gamma Air Medical undertook the organization and execution of the aeromedical transport of the most affected patient, whose clinical condition was worse, at the Burn Unit of Georgios Gennimatas Athens General Hospital, which specializes in the use of keratinocyte cultures, advanced level of plastic and reconstructive surgery procedures, and coverage of the burns with skin grafts.
The air-ground bridge between Athens and Larnaca
A medical “air-ground bridge” was immediately set up from Athens to Larnaca and back again with Gamma Air Medical’s Learjet 35A, ICU configuration medical equipment, and medical staff. The experienced pilots managed to complete the flight from Cyprus to Athens in 70 minutes.
The Gamma Air Learjet 35A is modified with a Spectrum Aeromed Stretcher Series 2200 with 3.500 liters of medical oxygen tank, air and vacuum pumps, and two medical oxygen supply outputs (one with high flow for ventilator connection and one with low flow for masks and 0-15 litres/min supply). The aircraft is also provided with a manual Patient Loading System for easy access to the aircraft cabin. The rest of the medical equipment is portable and installed just prior to departure.
As Head Doctor of the flight team, I contacted the Nicosia General Hospital of Cyprus prior to departure from Gamma’s base in Athens for updated medical information regarding the clinical condition of the patient, which was described as very serious and critical. A CT scan of his body was done and was clear and escharotomies – surgical incisions that allows necessary swelling without compressing the underlying blood vessels – were already performed as needed, as well as enclosing the burn wounds.
Burns treatment, sedation, and hydration
When the Gamma medical flying team reached the patient, he was on mechanical ventilation under deep sedation and antalgic treatment as well as hemodynamically supported with high doses of vasopressors. Sedation scheme included Propofol, Dormicum (midazolam) and Fentanyl, Esmeron (rocuronium) as a neuromuscular blocking agent to facilitate the mechanical ventilation and Levophed (norepinephrine) in order to support systemic blood pressure.
Hydration of the patient was another basic approach to patient’s support and this was done according to Parkland formula. Diuresis was also monitored. Ventilator settings were placed to CMV mode, 40 per cent mixture, RR 17 bpm, Vt 560ml, PEEP 6 cmH2O. After all necessary connections of the patient with the medical devices onboard including the ventilator, monitor, and infusion pumps, special blankets for burn victims have been used to wrap him integrally – around his full body
There was no stoppage, nor did Athens’ traditional traffic jams influence the fast transit of the patient
Transporting the patient
The patient’s blood circulation was continuously monitored, mechanically ventilated, and connected to infusion pumps for hydration and medicines administration, without any interruption throughout the air and road transfer. The task was significantly complex as the patient had to be transferred from bed-to-stretcher, from stretcher-to-stretcher, and from stretcher-to-bed multiple times, commencing from his departure from the hospital in Cyprus where he was initially treated and ending in the admitting hospital of Athens.
The patient’s critical condition required the use of advanced medical equipment including the Ventilator Hamilton T1, Zoll X Series Monitor-Defibrillator, BOSCAROL 0B3000 compact suction unit, and Kabi Injectomat MC Agilia infusion pumps, in addition to a host of portable medical supplies and consumables. The Gamma medical team did everything possible to transport the patient safely and promptly to the receiving hospital. Minimal changes of the ventilator settings were necessary, as well as flow rate adjustments of the sedation and vasoactive medicines, according to patient’s non-excessive blood pressure fluctuations and balancing air pressure in the cabin during flight.
Meanwhile, Gamma’s Operations Department had arranged for the ground ambulance vehicle that transported the patient from our touchdown at “Eleftherios Venizelos” Athens International Airport to be escorted by a patrol car of Hellenic Police. With the Police’s fundamental assistance, there was no stoppage, nor did Athens’ traditional traffic jams influence the fast transit of the patient to his final destination to “Georgios Gennimatas” General Hospital – the escort was so successful, the ground ambulance trip took only 10 minutes.
Our flight medical crew delivered the patient to the colleagues of the Burn Unit of the Athenian hospital, thoroughly detailed the case and handing full medical reports relevant to patient’s condition.
Gamma Air Medical would like to thank the Hellenic Police who assured a fast ground trip from “Eleftherios Venizelos” Athens International Airport to “Georgios Gennimatas” General Hospital and address our best wishes to the patient who fights for his life. A patient transfer with so many moving parts requires the utmost teamwork, precision, and professionalism. However, training and experiencing in taking decisions when every second counts really makes the difference.