Case Studies

Sunshine Hospital Melbourne to Moruya NSW.

 A 76-year-old female travelling around Australia was admitted to Sunshine Hospital on July 5, 2012after falling in the shower resulting in a fracture Neck of Femur (NOF).

She was taken to theatre for repair to the left pertrokmanteric fracture with subtroch extension. This required a 8-hole 135-degree dynamic hip screw to secure the fracture.

The post-operative period was unremarkable requiring non-weight bearing for the next six weeks. With a history of oesterperosis, osterarthritis and obesity rehabilitation would have required significant time and may have prolonged time away from family.

With a shortage of acute clinical beds it was advantageous to assist in repatriating the patient to her local regional hospital for rehabilitation.

On July 20, 2012 15 days after her initial injury the client was flown by Medical Connect from Melbourne to Canberra and driven by vehicle to Moruya.

 “I wish to thank you for all your wonderful care and attention you gave me. I couldn’t have had a better person to take care of me. The details of your efforts were great.”

 Client.

The Alfred Hospital Melbourne to Royal Perth Hospital Perth

 A 47-year-old male from Perth was working on a construction project as a rigger, building oil and gas platforms in the Bass Strait Victoria.

On the March 3, 2012 while working on a barge, a metal hatch with a mass of approximately 350kg gave way, falling across his legs resulting in bilateral crush injuries to his tibia and fibula and he was airlifted by helicopter to The Alfred Trauma Centre.

At the Alfred Hospital he was treated for bilateral tibial fractures, left tibial plateau fractures and left fibula closed fractures, right fibula comminuted compound grade 3 fractures, tight compartments of the left leg and soft tissue defect of the right pretibial.

He underwent a number of orthopedic and plastic surgical procedures including – bilateral open reduction internal fixation of tibia with unreamed nail, fasciotomy of the left leg, closure of the fasciotomy to left leg wound, split skin graft and debridement and local muscle flap to right leg.

After three weeks the muscle flap had taken and there was no evidence of infection, he remained non-weight bearing for another four weeks and commenced leg dangle for 10 min at a time.

As he had completed the acute surgical phase he was repatriated back to Perth on March 21, 2012 by Medical Connect to commence rehabilitation and for family support.

The Alfred Hospital Melbourne to Toowoomba Queensland

A 27-year-old male working in the transportation industry on February 22, 2012 was involved in a high-speed motor vehicle accident resulting with the truck running off road, rolling and bursting into fire.

The patient was ejected out of the cabin and found at the scene with an altered glasgow coma scale and multiple lacerations and was airlifted to The Alfred Trauma Centre. A CT-brain, spine, chest and abdominal scans, showed a large left frontal subgaleal hematoma with a complex scalp laceration, C5 kyphosis, mild atelectasis at lunge base blunting of costophrenic angles, small pleural effusion, fractures to ribs 5-9 of left anterior. Other injuries included left deep lateral leg wounds and multiple bruising and graze to trunk and limbs.

Other significantly comorbidities contributed to medical recovery including morbid obesity with a mass of 188kg, type two respiratory failure on nocturnal CPAP and warfarinised for previous pulmonary embolism.

His high anesthetic risk precluded theater resulting in delays to wash out his wounds, debridement and closure.  He was admitted to intensive care type with type two respiratory failure.

On March 3, his left leg laceration was debrided, however, at this point it had became infected with pseudomonas. On March 8, he underwent further debridement and split skin graft from left upper thigh to left lower leg to close the wound.

An aeromedical risk assessment was completed and on March 15, 2012  and he was successfully repatriated back by Medical Connect to Toowoomba Queensland, by air and road.

Sir Charles Gairdner Hospital Perth to Kuala Lumpur Hospital Malaysia.

A 30-year-old male from Malaysia on holiday in Australia presented to a General Practitioner with a 1-month history of blurred vision and vomiting. He was referred to an ophthalmologist and underwent A CT-Brain scan on the January 27, 2013.

This scan showed crainocaudal heterogeneously enhanced mass in the pineal region measuring 3.2 x 2.9 x 3.1 cm with evidence of moderate to severe hydrocephalus and seeding into the forth ventricle was noted.

MRI on January 28, 2013 showed diffusion abnormal hyperintensity, involving the midbrain and thalami bilaterally and extending into the left cerebellar peduncle. There are 4 nodules of the fourth ependymal in the fourth ventricle with the largest measuring 6×5 mm and the remaining less than 2mm or less.

On the January 28 he underwent an endoscopy ventriculostomy and biopsy of pineal tumour and insertion of Extra Ventricular Drain. On the February 1, he underwent and Ventriculo-Peritoneal shunt.

The patient was neurologically stable, however, his prognosis was considered poor and required further surgical intervention to debulk the mass. On February 13, 2013 Medical Connect successfully repatriated him home to Malaysia for further treatment and family support.

Royal Melbourne Hospital to Military Hospital Vientiane Laos

A 26-year-old male from Laos was on an exchange program from the Laos Army with the Royal Australian Air Force Defence International Training Centre (DITC), Laverton Victoria.

He presented to Royal Melbourne Hospital with a headache, nausea and with a Glasgow Coma Scale (GCS) of 14/15. A Computer Tomography (CT) scan of the brain followed by a Cerebral Angiography revealed a right frontal lobe Mid Cerebral Aneurysm  (MCA) in the setting of multiple mycotic vascular aneurysms in the parietal region. Following the Angiography he rapidly dropped his conscious state to a GCS of 6/15 and was taken to theatre for decompression and evacuation of blood clots.

After surviving the initial cerebral bleed he was woken from his induced coma to assess his underlying neurological condition. At this time some purposeful bodily movement and eye opening was noted and a decision was made to continue medical treatment for possible rehabilitation, however, after two weeks no improvement was noted and the expert medical opinions concluded that his long term prognosis was poor and risk of vascular re-bleed was likely. As predicted, further CT-brain scans revealed new small basal ganglia hemorrhage and he remained at GCS 3/15.

A tailored risk assessment was conducted to premeditate transfer hazards and possible controls implemented to minimise adverse medical risks to the patient.

The patient showed improvement on arrival at Laos.  He was able to open his eyes, obey commands, squeeze his left hand and move his left foot within days. The patient continued to show improvement over the next twelve months and is now a highly functionally individual and plans to return to Australia to complete his military course.

Medical Connect was recognised for this retrieval with awards for outstanding work from the Laos Department of Foreign Affairs and Defence International Training Centre Laverton.

“Our accompanying officer on the flight has reported that at every point during the flight and transfers your meticulous pre-planning professionalism and attention to detail ensured a totally smooth trip that concluded with the Captain’s safe return to his family in Laos. At all times the service provided by you during this difficult transfer was exceptional and that the successful outcome could not have been achieved without the care, kindness, and outstanding professionalism.”

S.A. UNWIN

Wing Commander

Commanding Officer

Defence International Training Centre Laverton Vic Australia.

Royal Brisbane & Women’s Hospital to China Rehabilitation Research Centre Beijing

A 30-year-old male from China fell from a three-story building and landed in the adjacent carpark. He was taken to Royal Brisbane Hospital where a Computed Tomography (CT) brain scan revealed a right partial Extra-Dural Haematoma (EDH), a burst L1-L3 anterior crush fractures with multiple large retropulsed fragments resulting in an incomplete spinal cord injury, T12 fracture and right foot fracture. He was taken to theatre for right frontal craniotomy, evacuation of the EDH.

The patient underwent L1-L3 Corpectomy and internal fixation, however, his neurology remains unchanged with limited sensation and no power to his lower limbs.

His post operative recovery was unremarkable and with no family in Australia a decision was made to Aero-Medically Evacuate him back to his family in China.

At twelve months and with stem cell therapy the patient has made a remarkable recovery and is walking short distances with a frame.

“All of the families are quite moved by your professional manners and caring last night. Again we need to express our most sincere appreciation to you and to all the kind people [that] helped out in this tragedy.”

Patient’s niece.

Royal Prince Alfred Hospital Sydney to Auckland Hospital New Zealand

A 78-year-old male admitted with headache, parasthesis to all limbs. A CT-brain scan showed WFNS scale grade-1 and Fisher grade-3 Subarachnoid hematoma. Shortly after he decreased his level of conscious and found to be in Ictus and was transferred to ICU and intubated. CT-brain scan on day 1 showed increased ventriculomegaly and blood loading so a CT-angiography was performed which showed A-comm aneurysm which was secured by coiling.

Two days later his Glasgow Coma Scale (GCS) improved from 9-13/15 as he started obeying commands, however, shortly after dropped his GCS. A further CT-brain scan the next day showed a large blood loading and an external ventricular drain was inserted to relieve this pressure.

While in ICU he developed multiple other medical issues including fast atrial fibrillation, bradycardia with asystolic events of 5-10 seconds requiring the insertion of a pacemaker. Post operatively he had facial seizures, hypernatremia, septic shock from infection. He was eventually transferred to the ward with fluctuating GCS of 10-13/15, however, again dropped to 7/15 and he was returned to ICU.

With occasional fluctuation in his GCS he continue to show improved and was repatriated back to Auckland Hospital New Zealand, for rehabilitation and family support.

At 12 months the patient can walk for 40-45 minutes duration and enjoys light gardening.

“I remember very well the care you took of me when you flew me back to New Zealand. I was particularly impressed that, although you had not been to Auckland before and had a day free to look around, you came to see me in the ward at Auckland Hospital to see how I was getting on after the flight.” Patient

Royal Prince Alfred Hospital Sydney to Larnaca General Cyprus

A 66-year-old female who arrived in Australian from Cyprus was, within 24-hours of arrival, found on the floor in a drowsy state, unable to move her left side and with slurred speech.

A CT-brain scan showed an established infarct in the right middle cerebral artery (MCA), with hypo-density of the anterior middle artery territory and right basal ganglia. CT-angiography showed the absence of flow in the right MCA. A repeat CT-brain showed evidence of hemorrhagic transformation in the initial period, and she was unable to be thrombolysis.

The stroke was thought to be cardioembolic as she was also found to be in atrial fibrillation. An echocardiogram showed hypertrophied left ventricle with moderate global hypokinesics but no intra-cardiac thrombolysis.

Over the next two weeks she showed clinical improvements with her level of conscious, however, she remained densely hemiplegic and her long-term prognosis was considered poor.

The family did not have health insurance cover for the situation (considered a pre-existing condition) and with limited family funds for rehabilitation in Australia a cost benefit analysis was conducted by Medical Connect to obtain funding.  Family contributions and a private donation made the repatriation possible and she was successfully returned home to family.

At twelve months the patient can mobilise with the aid of a walking stick and the family are pleased with her progress.

Western Hospital Melbourne to Maharaji Agrasen Hospital New Delhi India

A 25-year-old female suffered a severe hypoxic brain injury secondary to a cardiac arrest and post severe asthma attack. After 120 days her condition had not improved. In summary her conditions included:

Neurological

• Complex pain management neuropathy verses behavioral issues with extended periods of crying, grimacing, agitation and grinding of teeth, for which she required high dose sedation and analgesia.

Respiratory

• Biphasic stridor due to tracheostomy trauma clinically presenting with tracheal tug and nose flaring. A bronchoscopy showed airway oedema, collapse of supraglottic and glottis areas during inspiration with minimal vocal cord movement, however, no stenosis of laryngeal or tracheal was found.
• Asthma, bronchial spasm and breath holding treated with salbutamol and adrenaline nebulizers and benzodiazepine drug therapy.
• Apnea secondary to hypoxic brain injury.
• Sputum retention polling of salvia and poor swallowing.
• High dose dependency and resistance to benzodiazepine and narcotics, in a setting of asthma, hypoxic brain injury and compromised airway.

Medical Connect’s initially found the patient clinically not suitable for an Aero-Medical Repatriation (AMR) and was of the opinion that further consultation with the Respiratory Medicine, Ear Noise and Throat and Anesthetics specialists was required. A detail analysis of the patient was conducted to investigate the patient’s capacity for travel and the tests included: Computer Tomography, Bronchoscopy, new sedation and analgesic management. The hospital’s consultant’s academic opinions and Medical Connect’s specialist knowledge and practical experience in aviation allowed for the hazards to be identified and also enabled a detailed risk assessment to be conducted. Medical, business and legal risks were identified and discussed at length with the relevant stakeholders.

After two weeks of clinical reviews the patient was found to be suitable for an AMR.  Medical Connect anticipated that the AMR was going to be challenging and required specialized risk management strategies, however, a safe repatriation was anticipated and she was safely reunited with her family in India.

At 12 months the patient remains in the care of family and is responding to family who are grateful for her return.