Case Study 13: Melbourne to Dublin
A 19 year-old- male from Ireland arrived on a working holiday during October 2012 while traveling on an unsealed road around the farm he was involved in a motor vehicle accident. Travelling in the middle seat of the utility vehicle he leaned out of the car and was hit by a tree branch extracting him from the vehicle.
He was found at the scene with a Glasgow Coma Scale of 3/15, due to the facial injuries he was unable to be intubated and he was airlifted to Royal Melbourne Hospital (RMH).
Computer Tomography (CT) scans of the brain, chest and spine showed a left extradural haematoma, contusion, basal ganglia haemorrhage, temporal bone fracture, multiple facial Le Forte Type 1 fractures including, bilateral mid facial, zygoma and mandible fracture. His chest injuries included bilateral hemopneumothorax, pulmonary and pneumomediastinum contusion, right lower lobe laceration of the right main branch, right 3-4th ribs fracture, right mid shaft clavicle fracture and spinal disc bulge of L5-S1 causing mild central canal stenosis.
After the initial surgery and intensive care at RMH the patient’s condition was stable with a GCS of 8-10/15 and he was transferred with tracheostomy to the brain injury unit at Epworth Hospital Richmond.
From November to January the patient’s neurologically status slowly improved and by late January he was alert enough for his tracheostomy to be decannulated, however, the neurological improvement came with increased confusion and he transitioned into Post Traumatic Amnesia (PTA) with short term memory of 5 minutes, confused to his surrounding and occasionally agitated.
At the beginning of March Medical Connect reviewed the patient for aeromedical repatriation back to Ireland. The initial assessment highlighted the issues of ongoing PTA with agitation, unable to spatially orientate and unable to redirect the patient, posing significant clinical risks for the repatriation.
To overcome these difficulties our proposal included increased sedation and increased allied health therapy, after three weeks there had been significant improvement in his behaviour and spatial orientation evident by a rise in the Westmead PTA score.
Over a further two-week period Medical Connect conducted daily onsite assessments of the patient. Increase activities, stimulus, noise and light during physiotherapy, behavioral therapy as well as increased exposure to the public including coffee shops, shopping centers and road trips out to the airport. This stimulus assisted to tested the patient’s stress response and the controls in place to manage these behaviors.
Over time his condition had stabilised and the view emerged this was less reflective of PTA and more consistent with chronic amnestic state associated with an extreme traumatic brain injury and underlying hypoxic brain injury.
After six months of hospitalisation in Australia Medical Connect successfully repatriated the patient to Beaumont Hospital Dublin Ireland for ongoing long-term brain injury rehabilitation, behavioural management and cognitive recovery. His family and the community were thrilled to see his improvement and safe return home.
