Advice / Opinions

[Ken Lawson-Williams <Macgyver@FlightMedicMail.com>]

SITUATION: 300# 39y/o native, some prenatal care, EDC/LMP unknown. No ultrasound
done this pregnancy. P3G7 @34 wks (est from fundal height). Active labour since
0300, presented to hospital 0900, PV=frank bleeding from cervix, unable to assess
dilation as entire vaginal vault filled by intact membranes/fluid, bulging and
tense. Transverse lie. Previous PROM/Prem labour at 27 weeks (didn't survive).
Obese and pendulous abdomen. 25 bed community hospital calls at 1009 for fixed
wing Medevac (45 response and 45 min flight each way, add 10 min ground time at
destination and 5 at sending) to semi-regional 100 bed center (GP-anethestethist,
general surgeon, GP who does lots of OB, pediatrician) with available OR. Closest
NICU/level 1 trauma centre 2 hours flight time away with 20 min ground. NICU team
response to sending 4 hours and won't come pre-delivery. GP attending to come with
patient.

ON ARRIVAL AT 1145: "Crowning"-like bulging membranes, dilation not
assessable. MgSO4 running at 2.5G/hr. N/S via 16 at TKVO. Foley and high flow O2
in situ. EFM reassuring with Q20 mild contractions Fetal tones good. VS stable.
Dexamethasone IM on board. L lateral Trendelenberg with feet 30 degrees elevation
(40" above head) GP attending adamnant that position be maintained "if
we lie her down wthe membranes will rupture and we will lose the baby and then the
mother".

AVAILABLE RESOURCES: Flight medical crew = GP from sending and solo CCEMT-P/final
semester RN with ALSO/ATLS/NRP/PALS and instructor level ACLS/AMLS/PHTLS/BTLS
certifications. Off-line protocols very liberal and comprehensive. Medical
director unavailable at the time. No transport coordination medical director.
Recieving MD = surgeon and unfamiliar with flight issues / unwilling to get
involved untill patient is in his facility. Ohio transport incubator with opaque
heat retention cover (the old style incubators). BLS ground crews at both ends. 3
seats on BE-B200C. FERNO #9 and 25yr old medevac sled (brand unknown, not Spectrum
or Lifeport). single channel MTP pump, Zoll PD1400 with pacing. Bird Avian III.
Minimed 911 NIBP/SPO2/ETCO2 monitor, doppler, Jackson-reese (anesthesia style flow
through bag) with manometer, pressure infuser bags and standard ACLS meds
including MgSO4 x 50mg, oxytocin x 100mg, no Ergot or Hemabate or indocid, RSI
meds=sux/pavulon/versed/morphine. Flight crew advise only room for 2 attendants
due to weight/balance issues. FD has FERNO basket and cargo straps available.

OTHER INFO: Trauma center / teaching hospital has never sent out a surgical team
to a small community hospital, would take 4 to 6 hours minimum to set up.
Sat-phone U/S. Cell coverage minimal (25 min dead spot mid-flight). Ambient temp
-25 Celcius at sending with 8 knot wind, outside ambulance bay, no hanger
available. -30 Celcius at receiving with no hanger available, 4 knot winds,
enclosed EMS bay. 4 units 0- available (entire supply) at sending. Altitude
sending/recieving 800' and maintainable throughout flight. MD remains ABSOLUTELY
INSISTANT on maintaining trendellenberg at minimum of 25 degrees (30")
despite explanations of risks during both ground and air transport of trying to
secure patient in that position "She's my patient, your job is to get me, and
her, to an OR where we can deliver surgically. How you do it is not my concern.
I'm responsible for her care, you for the mechanics of the transport. Find a way
and make it happen".
 
Suggestions? Alternatives to flight? Packaging hints? Sympathies?

Will followup with outcomes / trip report later
KLW

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