CASE STUDY: Air transport of patient under ECMO support in Brazil
Pedro Augusto Gontijo Ramos, Critical Care Physician, reports an inspiring case of a 57-year-old Brazilian man transported under extracorporeal membrane oxygenation (ECMO) support from Campo Grande, MS, to São Paulo, SP.
The patient had a compromised immune system due to a kidney transplant 23 years ago and was diagnosed with lung failure due to a fungal infection followed by acute respiratory distress syndrome (ARDS). He arrived at a hospital in Campo Grande complaining of fever, cough and asthenia for five days. A positive test for galactomannan confirmed invasive aspergillosis. The patient was admitted to the ward for antibiotic therapy and clinical support, but despite these efforts, the patient’s clinical condition continued to deteriorate, and he was admitted to the intensive care unit on 5 May and started on mechanical ventilation four days later. He developed refractory hypoxemia despite optimised mechanical ventilation and without clinical progression after nine days.
The patient’s family contacted our team to arrange transportation from Campo Grande to São Paulo to receive ECMO support, but the patient’s clinical condition did not allow transportation. The solution was to bring the ECMO support to the patient for safe transport.
Thus on the evening of 18 May, after 10 days of mechanical ventilation, the cardiac surgery team was called in. The aircraft took off from Goiânia to São Paulo with an intensive care nurse and a physician specialised in aerospace medicine to meet the team with perfusionist, intensive care physician and two cardiac surgeons. With full team and equipment, the plane took off from São Paulo to Campo Grande to prepare the patient for aeromedical transport.
Upon arrival in Campo Grande, the team evaluated the patient, who was haemodynamically stable, with severe hypoxemia. The cardiac surgery team then began installation of ECMO support, while the rest of the team prepared and installed the transportation equipment. We decided to perform venovenous ECMO with femoro-jugular configuration, which was successful. With the patient in a stable clinical condition, sedated, on mechanical ventilation and ECMO support, we started transportation to São Paulo. We fired up the engines and covered the 900 kilometres that separate Campo Grande and São Paulo in one hour and 22 minutes. With a team with vast experience in air transportation and in managing critically ill patients, there were no complications in flight.
We landed in São Paulo at 8:00 a.m., after a total of 20 hours of mission. An ambulance adapted exclusively for transportation of patients with ECMO support was waiting for us to make our way to the destination hospital. The patient arrived at his destination in good clinical condition and the intensive care team took over.
While many patients need advanced technological density for their treatment, there is a great limitation of resources, and great distances to cover, in a country with continental dimensions like Brazil. Qualified transportation teams are the bridge between the patient who needs these technologies and the place where they are available. In many cases, such as this one, the equipment and the team trained to handle them are far from the patient, who does not have the clinical conditions for immediate transportation. The logistics, training and experience of aeromedical transportation make the difference, bringing hope to patients geographically distant from the necessary resources.