Critical in the Congo

I’ve had about 36 hours of extremes mostly involving the Congo. I’m amazed how I seem to end up doing evacuations from one country for a few days then don’t go there again for ages. For example I’ve not been back to Somalia for two weeks. Well the latest theme country has been another hotbed of discontent and political exasperation, the Democratic Republic of the Congo.

This series of patients had a theme of miscommunication. Assumption really is the mother of all f*£k ups, and hence why we prepare for the worst case scenario. Even with that modus operandi, our time in Congo took the biscuit for surprises.

My first flight at 0700 took me into the airstrip of Goma in the Congo, on the Rwandan border. It's yet another interesting African town with links to the Rwandan genocide and still rather bubbly with political violence. Only last year it was seized by rebel forces and hence why we do not retrieve patients from the hospital, no matter their condition. We were going to retrieve a man who had been involved in a RTA on a motorbike and had was supposed to have sustained nasty facial fractures and suspected other injuries. With that information we were expecting a patient with multitrauma and a swollen difficult airway so we prepared for a critical patient with all the toppings.

After about an hour of wrangling with self-important airport officials in French, we were approached by another two men. I asked if the patient was on his way, in my best pigeon French to be told by one of the men, with a hearty handshake and a smile, that he was the patient. It seemed he sustained ‘suspected’ facial fractures after bumping his face into his friend’s motorcycle helmet when they fell off at low speed a week ago. He had even driven himself from home! So not exactly requiring of a critical care transfer. Oh well I had some work to do on my laptop anyway.

Nyiragongo simmers in the background

The most striking thing about Goma is the Nyiragongo volcano and cleared piles of volcanic rock alongside the airstrip. I am told that about 10 years ago the volcano erupted spewing lava straight through the surrounding town destroying about half of it and right along the runway down to the Lake Kivu. It killed many people through asphyxiation and rendered the airport completely incapacitated. It took a long time to clear enough of the rubble to get the airport operating again but it still only functions with about 2/3rds of its original length runway. It also has a reputation of being phenomenally dangerous with a way-over-average number of aircrashes with a plane overshooting the runway in 2008 smashing through a market and another nasty one in March of this year!

After this unexciting medical case we were called out to a little dirt airstrip out in the sticks of Tanzania to pick up a member of Raleigh International. I am currently trying to persuade my little cousin to do something useful with her gap year and Raleigh are one of the organisations I’m looking into for her.  It was interesting to hear more about what they are up to from the horse’s mouth. I particularly like their ability to focus on the personal development of young people from all sorts of backgrounds in the UK and combine that with sustainable projects for these rural populations.  Crucially they have a good reputation for safety with excellent logistics and medical support. So the information we had from these guys about the casualty was exemplary. The casevac went extremely smoothly with a beautiful low level flight across the plains and hills in the Cessna Caravan.

Just when we thought the medevacs had wound up for the day we received word of an urgent case needing transport from Kinshasa in the DRC going to Johannesburg. ‘Malaria and bronchopneumonia. Condition deteriorating.’ was all the information we had prior to take off. I tried to get more but nothing was forthcoming. Flying all night across the Congo in a small aircraft is not something you want to do unless it is absolutely necessary. One of the reasons for this is that this area is known for some of the most aggressive and tallest cumulonimbus storm clouds on the planet some climbing up to 60,000 ft. Radar is a great help but the pilots really want to see what is going on around them. These clouds can tear planes apart. Added to which, there are few alternates on that route that you can safely land a jet at night.

We set off about 2230 and flew towards the jungles of the Congo and the unknown. We requested the patient be brought to the airport in time for us to quickly land, fuel, package up the patient and head south for the 4 hour trip to SA. Upon arrival, however, we were told that the ambulance crew would not leave the hospital until we had touched down. This does happen from time to time and it is rather frustrating. We are left waiting airside at the airport twiddling our thumbs when we could be sorting and settling the patient. For some reason this time it made me uneasy. Why would they want an absolute guarantee that we were here and waiting before setting off? I asked our liaison about the state of the patient and he assured us she was stable but requiring oxygen pointing to his nose implying nasal prongs. So we relaxed and I sat back watching the aerobatics above us as bats pursued bugs around the floodlights.

Soon the ambulance arrived and sped towards the plane. That was also odd, normally it’s a rather sedate affair. The ambulance backed towards us and the back doors swung open to reveal a rather big surprise. Three medical staff removed themselves from the back and were dressed head to foot in masks and infectious disease protective equipment. Maurice the flight nurse and I looked at each other. Then back into the ambulance where we could the familiar waveforms of an Oxylog 3000 ventilator. This woman needed more than a bit of oxygen! She was a critical care patient with maximal oxygen requirements and circulatory drug support. My eyes widened even further as her medical discharge note was handed to me. In French of course. Now my French was good enough to translate the gist of the case. It looked like she had been given a diagnosis of malaria with a high parasite load and then in hospital became increasingly short of breath. A CT scan of her chest showed that some process was obliterating her lungs and she was intubated. Despite maximal ventilator pressure settings, to the point of risking popping her lungs, they were unable to adequately oxygenate her. Hence why they were transferring her to South Africa intensive care to see if things like Nitrous Oxide might help her. NO is a lighter gas reducing the work of breathing but last I read on it, it has very little evidence of benefit in such cases. Nevertheless how they thought a long duration, high-risk transfer in the middle of the night was in her best interests is beyond me but that’s what the doctors and family wanted.

To go or not to go?

At that point one of pilots came around from checking the fueling and said “What the f*£k are they wearing those masks for? There is no way that patient is getting in my plane with some freaky disease that we are all gonna catch. No way!” I asked the medical team to explain the barrier protection and failed to get a decent explanation. It seemed that this was just their standard practice for any patient who was short of breath. There was nothing they were specifically worried about but for a time I felt like I was in the introductory scenes of some Hollywood apocalyptic outbreak movie. Conversations between the concerned pilot and one of the medical team became more heated (despite the fact neither could understand the other) as I pawed through the medical notes and the CT scan to work out what the hell was going on. I couldn’t believe I was standing there in the middle of the Congo in the dark surrounded by bats, bugs, masked medics, irate pilots and concerned relatives trying to make this decision about a woman who could take no part in it.

The case seemed like a pneumonia with probable ARDS (Acute Respiratory Distress Syndrome) complicating malaria with profound anaemia. I explained to our team that if she was breathing for herself, coughing away on the plane with ‘some freaky disease’ then yes we would be at risk. But she was already on a ventilator with a filter and a closed circuit so we were about as safe as we could get. In fact if I was significantly concerned about communicable disease in a conscious breathless patient, ventilating them for the flight might be reasonable to protect myself and the crew from whatever they had caught.

While all this was going on Maurice had been beavering about setting up our ventilator, pumps, drugs and stretcher. Having an experienced unflappable ICU flight nurse like Maurice was absolutely vital and there’s no way I could have done it without him. In addition the medics there had made some weird decisions about the drugs they were using and there was a virtual Christmas tree of infusion pumps going into this poor woman. It was all pretty complex in English, let alone trying to work it out in French!

We managed eventually to sort it out and started lifting her and all her bits and pieces into the plane. Of course then as we were about to lift her, a massive ugly flying bug landed on the patient’s chest. Three of my assistants jumped and nearly dropped her!

Every time you transfer a ventilated patient there is a risk of displacing the tube in their throat. For her that would have probably have been fatal. This ladies oxygenation was so critical that, when we had to detach her from the ventilator for less than 20 seconds to change a cylinder for example, her saturations plummeted down to the mid 60s. To explain how bad this is, if you give a normal adult pure oxygen to breathe and then stop them breathing, a drop in saturations won’t happen for several minutes. Pop a probe on your finger and try to get your oxygen saturations down to 60% by holding your breath. I’m sure it will take longer than you can tolerate. So if her tube had come out from an accidental tug I doubt there wouldn’t have been enough time to ventilate her via a mask effectively or intubate her again before her oxygenation dropped to the point she would have had a cardiac arrest.

After about half an hour of fiddling in the plane we had sorted the spaghetti of wires and were ready to get the hell out of there. On the flight she was a classic ‘spinning plate’ critical care patient. No sooner had you sorted one thing out, something else started going wrong; the kind of ICU patient you spend all night tinkering to try to stop their spiral around the plughole. I’d like to claim that normally I’m pretty good at being proactive rather than reactive but that night I felt like I was chasing my tail.

At one point I took the opportunity to look out the window as the sun started to rise. In the midst of the
stress and exhaustion (we were close to 24 hours solid flying by that point) it was one of the most beautiful scenes I’ve ever seen. In amongst a perfect panorama of stars, the moon hung directly above the spreading orange and blue glow of the breaking dawn with a bright thin crescent marking its lower rim. (My camera was dead but I think someone managed to get a shot with their iPhone.)

After what seemed like an age we arrived in South Africa and managed to get the patient to their resuscitation bay in one piece. We handed over as much as we knew about the case, advising them that a French translator might not be a bad idea. We stepped out of the hospital into the sunshine finally free after 30 hours of solid flights. We got to our hotel, ate our fill and slept like the dead.