Dangers & Distance Cautionary Tales 1994-2019 - PowerPoint Presentation

1. Dangers & DistanceCautionary Tales 1994-2019Dr Christina Steffen AMGeneral & Vascular Surgeon,Cairns

2. Case Study 153 year old diabetic indigenous man – Lockhart RiverSevere ischaemic heart disease, peripheral arterial disease; still smoking.R BKA 2016, L femoro-popliteal bypass and forefoot amputation Dec 2018.Back in Lockhart River - non healing residual wound, recurrent infection ? osteomyelitis Transferred to Cairns for foot debridement.29/5 Arrived at night. Antibiotics.30/5 Emergency list bookingNo time during day, surgery postponed to 31/5.31/5 Chest pain - myocardial infarction with cardiogenic shock, renal and respiratory failureICU support, coronary angiography and stents, dialysed1/6 – operation - necrosis of deep tissues in foot – below knee amputationSubsequent cardiac arrest and demise

3. AnalysisIn retrospect an unsurprising outcome.Transfer late in clinical course. Could have been flagged earlier but,Patient factors – non-attendance at clinicHealth facility factors – limited pathology, no X ray etc, Telehealth not necessarily utilised, practitioner limitations.Delay to surgery at receiving hospital (which probably made no difference)No ARP ……. Extent of intervention could have been modified by ARP

4. Case Study 225 year old woman, working in Port MoresbySeveral month history intermittent upper abdominal pain – thought she would have to pay for all treatment in Australia, so postponed trip. Developed proximal small bowel obstructionAdmitted to Port Moresby hospital, N-G tube and intravenous fluidsTransferred to Cairns HospitalLaparotomy – small bowel obstruction from soft tissue mass proximal jejunum, small bowel resectionBlack patches noted in skin on admission by ICU consultant and biopsy taken.Inexplicable post-operative deterioration.Biopsy – torulaDied – torula fungaemia, likely source the intravenous fluids prior to transfer.

5. AnalysisThe patient was an Australian citizen.Unaware she could access medical services under Medicare in Australia.Avoidable death.

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7. Case 324 year old man, missionary in PNG highlandsShot in back of leg by “rascals”.Significant bleeding, no tourniquet, long travel to Cairns.Jehovah’s Witness; iv crystalloid onlyLong transfer - arrived Cairns 0300 ~ 15 hours post-injuryHb 3, moribund.SUMMARY –Potentially salvageable – tourniquet.

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9. Case 463 year old man translating Bible in PNG2003 Infrarenal aortic aneurysm repair Cairns, complicated by graft infection treated successfully with Rifampicin.20 Aug 2013 - Sudden onset severe epigastric and chest pain.Saw mission doctor (same one as in 2003) who diagnosed a leaking thoracic aneurysmHe contacted me per phone at Innisfail Hospital at 1200 requesting transfer to Cairns. Insisted on Cairns not Townsville.Logistics: Entry visa for Australia : arranged per phone, flights1400 – visa finalised, flight organised, ambulance transfer to hospitalArrived Cairns Hospital 19.24 20/8, CT scan performed, discharged 22.29 pmArrived Townsville 00.29 21/8. Replacement AVR, ascending aorta 22/8.Discharged Townsville General Hospital 2/9/13Post-op reviews in Cairns – last review 2018 – well, no sac enlargement.

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11. Analysis : What went right Communication - contactsSmooth logistics – knowing the system & accessing itPathology that could wear the delayLuck? Divine intervention?

12. Salient Points People have to be aware of health and other risks and be prepared – especially when going to remote/dangerous placesEarly definitive management crucialEarly communication between sending and accepting teamsSmooth logistics – patient status (immigration), transport etcFavorable pathologyEVEN THEN, CAN’T SAVE THEM ALL

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