Mission Review: Medevac impeded by patient’s potential criminal charge

One of MEDEVAC.FLIGHTS’ recent medevacs has been featured as a case study in International Travel and Health Insurance Journal’s latest Air Ambulance Review. Read how our medical team and operations personnel worked together to overcome an adverse situation to be able to medevac the patient home safely.

Visit: www.itij.com/current-issue or read the extracted article below.

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MEDEVAC.FLIGHTS’ experience in handling complex cases, both medically and operationally, was highlighted by one of the company’s recent missions repatriating a patient from China to New Zealand, where poor patient care and a potential criminal charge resulted from an altercation between the patient and nursing staff.

The case

The patient was a 78-year-old male from New Zealand, who was travelling in China with a tour group. He became unwell with respiratory failure and was admitted to a local hospital. The patient was being treated for pneumonia, but while in hospital had a mechanical fall and as a result suffered a fractured neck of his femur. A decision was made to not perform surgery by the orthopaedic surgeon in China, with the preferred option being an air-ambulance back to New Zealand prior to surgery.

The patient had a history of ischaemic heart disease and coronary bypass surgery, cardiomyopathy (likely ischaemic), chronic kidney disease, permanent pacemaker and/or internal defibrillator and an abdominal aortic aneurysm (previously repaired).

Hospital altercation

The team arrived in China and made their way to the hotel with the medical equipment. Shortly after, a call came through on the operations assistance line stating that the patient’s condition had deteriorated and he had become violent and aggressive, possibly attacking one of the staff members. The operations team quickly contacted the medical team in China and they attended the hospital immediately to get first-hand information regarding the situation.

They were met by some very distraught nurses, who immediately called the night doctor in to explain the situation. The flight nurse was shown a picture of a bleeding thumb and told that this was a ‘very bad man’, that he had caused this damage by biting a nurse and it might be an arterial bleed. This had occurred when the patient became distressed in bed and was not taking the advice of the nurses. Due to the altercation, the patient had been sedated. The flight nurse told the hospital’s medical staff that the patient would be medevaced the following morning and that he would be returning to collect the patient then. The hospital’s doctor and nurse repeatedly said that the patient was a ‘very bad man’, and that the police had been called to start criminal proceedings. It appeared that there was a high chance the patient was going to be detained in China while the incident was investigated. This was all relayed by the operations team to the insurance company, who were also advised that they should send a representative from their China office, as this was a serious incident where the patient may be detained and criminal charges could be laid.

Upon the medical team’s return in the morning there was a cast of many, with doctors, nurses, executives and police in attendance, including the MEDEVAC.FLIGHTS’ doctor and nurse team, as well as their interpreter. The medical team was initially denied access to the patient but was later granted access after extensive work by the operations team and a representative of the New Zealand Embassy.

The patient

Upon gaining access to the patient, they found him in a disheveled state in bed, still heavily sedated, with no monitoring or oxygen attached. This was concerning as the patient had presented with pneumonia and had continually been on 2L O₂ via nasal prongs – giving him SATS in the low 90s. After finding the patient very hard to rouse, the medical team queried the hospital medical team as to what sedation he had been given. No definitive answer was given, however, as the doctors were preoccupied with the police situation outside the room. Placing a SATS probe on the finger of the patient gave a reading of 78 per cent on room air. The patient was cyanotic and hypoxic with no supplemental oxygen. He was lying in soiled and wet bed linen, and his pants and underwear were around his knees. Clinically, he was dehydrated. Further assessment of the patient found that he was not catheterised, had no cannula and had extreme dry mucous membranes, with thick yellow phlegm in his mouth. He was in acute urinary retention, and later drained >800mls of urine once a urinary catheter was inserted. The MEDEVAC.FLIGHTS medical team immediately applied their own oxygen, catheterised and cannulated the gentleman and commenced IV fluid therapy. The patient’s aggression had clouded the management of this patient and so the basics of care had not been performed.

MEDEVAC.FLIGHTS reported all findings to the Ambassador from the New Zealand Embassy and advised that after this situation this patient could not continue to be cared, or not cared for in this case, in this facility. The same was communicated to the insurance company client and they were advised that if the patient was not allowed to depart China at this time, that an alternate hospital must be found as the patient was being neglected by the current facility.

Through extensive discussions with the insurer, the operations team and the medical team, it was determined the patient’s health and safety would be compromised if he remained in the hospital in China. Therefore, the patient was to be medevaced to New Zealand immediately without delay.  The medical team were worried about the patient’s age and low Glasgow Coma Score (GCS) following a night of hypoxia and were prepared that this patient may require intubation and ventilation for transfer home.

Evacuation underway

The medical team and the New Zealand Ambassador were able to liaise with the Chinese police and Government to secure the release of the patient, allowing him to be medevaced. The involvement of the member of the Embassy was invaluable, and without her, it would have been extremely difficult to secure the release of the patient and transport him back to New Zealand.

The medical team packaged the patient and placed him on their stretcher, at the protest of the local nursing staff. They were still adamant that this man had done wrong by them and should receive police punishment. The New Zealand Embassy managed to smooth over the situation and enabled passage to the waiting ambulance. The medical team proceeded with lights and sirens to the waiting Learjet 60 aircraft. The patient’s GCS started to improve, and he became more aware and lucid. He was able to communicate in simple sentences. The team cleared customs and loaded the patient onto the jet.

Due to the lengthy delay at the hospital, the flight schedule had to be pushed back and the cut off time for departure that would allow the team to make it all the way back to New Zealand on the single jet had passed. This situation had been communicated previously to the insurer and MEDEVAC.FLIGHTS had devised a solution to be able to transport the patient home – a second jet, a Falcon 50, was to meet the first aircraft for a wing-to-wing handover of the patient in Australia. This meant that the patient did not have to stay another night in China and did not need to be admitted into a hospital in Australia.

After the drama in China, it was an uneventful flight. The patient’s behaviour was not an issue, he was never aggressive or abusive, but rather pleasant and compliant. He had minimal to no pain and tolerated the transfer very well. He even asked whether he could buy some gin at duty-free when the jet arrived in New Zealand!

Post-mission analysis

It was surprising that only simple interventions were needed to improve the patient’s condition.  The flight medical team surmised that the patient could have been hypoxically delirious, which may have led to his fall in hospital. He then remained hypoxic and confused and was not catheterised so was potentially trying to get out of bed.  This led to an argument with the nursing staff, which was compounded by a language barrier and the patient’s frustration, resulting in a nurse’s thumb being bitten.

The success of this mission was due to the incredible medical and retrieval experience of the doctor and nurse team, as well as the operations team’s preemptive planning and strong communication between the numerous relevant parties.

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MEDEVAC.FLIGHTS, which is the first air-ambulance Accredited Service Provider for International Assistance Group on the East Coast of Australia, and has recently obtained ISO 9001:2015 Quality Management Systems Accreditation.