Medical team saves life with 'cool' procedure

  • Published
  • By Senior Airman Tong Duong
  • 332nd Air Expeditionary Wing Public Affairs
JOINT BASE BALAD, Iraq (AFNS) --  Members of the Air Force Theater Hospital emergency staff here recently performed an unconventional medical procedure to help save a Soldier's life.

The 332nd Expeditionary Medical Group staff used therapeutic hypothermia to ensure the patient, who had suffered cardiac arrest, would fully recover.

Ramadi, Iraq (0-1 hour)
The incident started March 29 at a forward operating base outside of Ramadi, Iraq, when a Soldier attempted to discharge a large extinguisher. According to Capt. (Dr.) Will Porr, the 703rd Brigade Support Battalion, Ramadi Battalion Level II surgeon, when the victim discharged the bottle, the built-up pressure may have kicked the bottle into his chest. The blunt force trauma likely caused his heart to stop.

Dr. Porr said there were no witnesses and estimated the patient may have stopped breathing for approximately three minutes before first responders arrived. The Soldier didn't have a pulse, but medics who performed cardiopulmonary resuscitation were able to restart his heart. Within an hour he was medically evacuated by helicopter from Ramadi Battalion Level II center to Joint Base Balad's Air Force Theater Hospital, 63 miles to the northeast.

According to the American Heart Association, more than 95 percent of cardiac arrest victims die before reaching the hospital. A victim's chances of survival are reduced by seven to 10 percent with every minute without CPR and defibrillation. Brain death and permanent death start to occur in just four to six minutes after someone experiences cardiac arrest.

Air Force Theater Hospital (1-13 hours)
When the patient arrived, the emergency medical staff started its initial assessment.

Capt. (Dr.) Paul Haggerty, the 332nd Expeditionary Medical Operations Squadron Intensive Care Unit flight commander, notified Army Maj. (Dr.) Daniel Carlson, the 332nd Expeditionary Medical Group cardiology consultant, about the trauma patient. During Dr. Haggerty's assessment, Dr. Carlson volunteered his thoughts regarding the potential management of the patient's case.

"The patient was comatose upon arrival but was promptly resuscitated, which made him an ideal candidate for therapeutic hypothermia to improve his chances for a good neurologic outcome and return to full function," said Dr. Carlson, who is deployed from Walter Reed Army Medical Center, Washington, D.C.

According to Dr. Haggerty, therapeutic hypothermia is a process in which the body of a patient who was successfully resuscitated after sudden cardiac arrest is cooled to 89-93 degrees. By cooling the body, the brain's metabolic requirements are reduced and, in turn, this helps patients to recover neurologic function. Also, reducing the body temperature decreases tissue swelling and damage to the brain from interrupted blood flow during cardiac arrest.

"There have been several studies which show that patients cooled for a period of 24 hours have improved neurologic outcomes and improved mortality," Dr. Haggerty said. "This procedure is becoming more widely instituted in the U.S. as part of resuscitative care for patients who have survived cardiac arrests."

Although they had never before been a part of this procedure, medical staff members here were receptive to the idea. Dr. Haggerty, who is deployed from Wright-Patterson Air Force Base, Ohio, turned to appropriate medical sites on the internet for solutions.

After referring to the University of Pennsylvania's website for post-cardiac resuscitation care, Dr. Haggerty quickly implemented the protocol and directed the majority of the medical care.

"We didn't have cooling blankets or the high-tech equipment the stateside hospitals have," said Col. Paul Gourley, the 332nd EMDOS commander. "Our medical technicians were running around looking for coolers, while the third-country national dining facility workers were getting ice from wherever they could to cool this person."

Capt. Matthew Ockander, the 332nd EMDOS operation room anesthesiologist, who is deployed from Travis Air Force Base, Calif., performed the initial sedation and paralysis of the patient. This prevented the patient from shivering, which would inhibit the cooling process.

Army Maj. Robert Bejnarowicz, the 332nd EMDOS operation room neurosurgeon, who is deployed from Tripler Army Medical Center, Hawaii, then drilled a hole in the patient's head so a tool could be inserted to monitor his intracranial pressure for swelling of the brain.

Members pitched in wherever they could. Colonel Gourley, who is deployed from MacDill Air Force Base, Fla., took to blending ice so the medical staff could flush the patient's stomach and bladder with chilled fluids, while others filled baggies to pack around the body. Along with chilled intravenous fluids, the patient's core temperature was monitored with an intranasal thermometer. Senior Airman Casey Wilson, a 332nd EMDOS medical technician, who is deployed from Lackland Air Force Base, Texas, carried a 50-pound fan from the basement gym to the intensive care unit to assist the evaporative cooling process.

"By taking basically no actual resources to make this happen is a testament to the ingenuity of Airmen and the ability to adapt and overcome anything that was put in front of them," Colonel Gourley said. "There was easily more than 30 people involved to save one life."

Critical Care Air Transport Team (13-18 hours)
After stabilizing the patient's condition, 12 hours had passed since he arrived at Balad. At that point, emergency medical staff determined the patient needed to be transferred to Landstuhl Regional Medical Center in Germany.

The 332nd Operations Group critical care air transport team was activated. The CCATT's role is to transport critically ill or injured patients out of theater and to a higher level of care, as close to the time of injury as possible. They strive for 24 hours or less, and in this case, the patient was delivered in less than 18 hours.

The CCATT is deployed from Eglin Air Force Base, Fla., and is made up of, emergency medicine physician; Maj. Kirk Smith, critical care nurse and Master Sgt. Brandi French-Thomas, a respiratory therapist.

According to Capt. (Dr.) Jeff St. Amant, a CCATT emergency medical physician, transporting the patient presented some challenges. For one thing, the patient was transported with more than 500 pounds of life sustaining machines.

"He was on a ventilator, a cardiac monitor, invasive blood pressure monitoring, seven different continuous medication infusions and an intracranial pressure monitor," said Dr. St. Amant, who is deployed from Eglin Air Force Base, Fla.

The captain lauded the 332nd EMDG staff on using hypothermia to provide the patient the best chance of recovering and regaining normal function.

"This protocol is only used under very specific circumstances and he met the criteria," Dr. St. Amant said. "The Balad hospital did an outstanding job with this patient and had him cooled to 90 degrees Fahrenheit (normal body temperature is 98.6 Fahrenheit.)"

Air Power (13-18 hours)
To keep the patient's body temperature cooled, the CCATT used ice packs, refrigerated intravenous fluids and the help of the 729th Airlift Squadron C-17 Globemaster III loadmasters, who are deployed from March Air Reserve Base, Calif.

"We asked them to turn the heat off in the back of the aircraft to keep it cold," Dr. St. Amant said. "It made for a chilly flight, but all of the crew, passengers and other patients understood that it was necessary for the patient."

According to Lt. Col. Ben Hackworth, a 729th Airlift Squadron C-17 pilot, the longer a patient is in flight the more chances there are for complications. So when there are critical patients on board, it is not uncommon for them to operate at faster than normal airspeeds.

"Patients are prepped for the duration of the flight, but medical resources are limited," Colonel Hackworth said. "In this case, we were informed by medical personnel that any time saved would benefit the patient. So we expedited as best we could."

On a typical flight, pilots operate at speeds between Mach .74 (548 mph) and .76 (563 mph) which provide the greatest fuel savings when level at cruising altitude. On this particular mission, due to the expressed critical nature of the patient, the C-17 crew operated at Mach .80 or 593 mph, which saved about 30 minutes, Colonel Hackworth noted.

"We are permitted to request 'high speed' operations below 10,000 feet (mean sea level) in certain airspace," he said. "The German approach controllers approved high speed operations during the final phase of our arrival into Ramstein Air Base, Germany."

Marked with countless invisible barriers and international boundaries, pilots cannot fly in a straight line. With critical patients on board and to shave time, the C-17 crew continually pressed air traffic controllers for the most direct routing to Germany.

Landstuhl Regional Medical Center, Germany (March 30)
Once in Germany, the patient was handed over to the care of the Landstuhl medical team March 30.

Colonel Gourley's flight back to Iraq was delayed 24 hours, so he had the opportunity to witness the payoff of his medical team's efforts. The therapeutic hypothermia protocol required the patient to be cooled for a specific timeframe, then have his core temperature warmed up slowly.

"He was heavily sedated and not moving, but as they slowly brought his temperature up he started to wake up," Colonel Gourley said. "He even asked to use the 'commode.' When patients get ornery, that's a good thing."

The medical team at Landstuhl was ecstatic and considered this a great save, he noted.

"The fact that this guy was on death's door, looking horrible, to sitting up in bed and knowing his name ... therapeutic hypothermia has a lot of benefits," Colonel Gourley said.

Homestretch (April 2)
As the patient's condition improved, he was transported to and released from Brooke Army Medical Center, Texas, to recover with family members.

According to Dr. Haggerty, the patient's favorable outcome and success story can be attributed to everyone involved in his care.

"His care required enormous teamwork across a continuum of care, and his survival is a testament to the training and dedication of the men and women in the U.S. military," Dr. Haggerty said. "This is definitely one of the most rewarding patient cases in my career, and is something I will never forget and feel privileged to have been a part of."