Cross-Pacific ECMO transport for critically ill infants

A US Air Force (USAF) medical team from Wilford Hall Medical Center (WHMC), US rushed to Okinawa, Japan to save the lives of two critically ill babies in May.

A US Air Force (USAF) medical team from Wilford Hall Medical Center (WHMC), US rushed to Okinawa, Japan to save the lives of two critically ill babies in May. The infants – one nine months old and the other twenty days old – were moved from Kadena Air Base, Japan, to San Antonio, Texas, aboard a C-17 Globemaster III. Both are military dependents needing specialised care at medical facilities in US. They were reported to be in a stable condition following their arrival in the US. The first child, a nine-month-old, was suffering from congestive heart and severe lung failure at the US Naval Hospital in Okinawa. Despite the efforts of the medical team there, the infant required transfer to the US for immediate and long-term cardiac care. Doctors felt the child needed to be placed on extracorporeal membrane oxygenation (ECMO) to survive, a machine that provides cardiac and respiratory support to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function. The second child, a 20-day-old premature infant with respiratory distress, was also moved on the same aircraft and cared for by a USAF neonatal intensive care team, but did not require ECMO. According to Lt Col (Dr) Daniel Dirnberger, director of 59th Medical Wing's Neonatal Intensive Care Unit (NICU), the nine-month-old was not making any progress with conventional medical and ventilator therapy and needed immediate evacuation to the US for life-sustaining open-heart surgery. However, the baby was too unstable to be transported without a heart-lung bypass. He commented: “This was a massive undertaking, requiring complex co-ordination across multiple agencies throughout the Air Force, including personnel at Scott and Hickam Air Force Bases, Kadena Air Base, US Naval Hospital in Okinawa, Tripler Army Medical Center and Wilford Hall Medical Center.” The WHMC ECMO team travelled to Okinawa, placed the first baby on ECMO and transported him 26 hours later to Christus Santa Rosa Hospital in San Antonio with no complications. The second infant with respiratory distress had some instability during transport, but physicians said this was not uncommon for a baby his age. The ECMO team included two neonatologists, two neonatology fellows, a paediatric intensivist, a paediatric cardiologist, a team of neonatal and paediatric intensive care nurses, medical technicians and respiratory technicians. Because the WHMC paediatric surgeon was returning from deployment, an Army pediatric surgeon was flown urgently from Tripler Army Medical Center in Honolulu to meet the ECMO team in Okinawa to perform the surgery necessary to place the infant on ECMO. Dr Dirnberger added: “I’m extremely proud of our entire team. From technician through physician, every member gave 200 per cent of themselves to this mission.” Meantime, there were challenges. The C-17 had last-minute mechanical problems, while the lives of two critically ill infants on life support were waiting on the flight line. The clock was ticking while a new aircraft was quickly reallocated to assume the medical mission. As ground and aircrews worked feverishly, the ECMO and neonatal transport teams were running out of medical air and electrical power. The infants were taken to the Kadena Air Base Clinic, where they were able to use oxygen, medical air, and electricity while they awaited departure. Once the aircraft was loaded, the doctors, nurses and technicians rotated three shifts to ensure that fresh eyes and alert minds were on the patients at all times. An in-air refuelling mission significantly reduced the trans-oceanic transport time to 14 hours, which saved approximately four to five hours, with the aide of the 168th Air Refueling Wing, Eielson Air Force Base, Alaska, US. Dr Dirnberger commented: “The co-ordination across multiple military agencies, and the logistical and medical complexities accomplished to bring these babies safely home is a testament to the quality and character of our military healthcare system and the people in it.” The nine-month-old was able to successfully come off ECMO at Christa Santa Rosa Hospital and was scheduled for corrective open-heart a week later.