U.S. Air Force-Army-civilian team makes medical history

  • Published
  • By Nadine Leavitt Siak
  • HQ PACAF Public Affairs
Living in Hawaii leads people to use a lot of superlatives. People in Hawaii often say they have "the best weather," "perfect beaches" and the "most amazing waves." More objectively, they can point out that Hawaii is the world's longest island chain, and that Hawaii Volcanoes National Park contains two of the world's most active and accessible volcanoes. Now they can report that, in an unprecedented Air Force, Army, and civilian medical move, the longest recorded adult ECMO transport to date was conducted from Hawaii.

ECMO stands for "Extracorporeal Membrane Oxygenation" -- a medical treatment that provides both cardiac and respiratory support to patients whose heart and lungs are so severely diseased or damaged that they can no longer function. ECMO is most commonly used in neonatal intensive-care units, for newborns in pulmonary distress. According to Lt. Col. (Dr.) Melissa Tyree, staff neonatologist and neonatal/pediatric ECMO specialist at Tripler Army Medical Center, only a handful of the approximately 130 ECMO programs worldwide are set up to handle adult patients.

In November 2010, a 56-year-old woman from Chicago developed a fever and cough while vacationing on Oahu, Hawaii. She was diagnosed with a viral infection and admitted to Straub Hospital in Honolulu. Although she was treated with antibiotics and then put on a ventilator, the woman's condition continued to deteriorate to the point where she was in severe respiratory failure and unresponsive to all advanced pulmonary support available. She needed ECMO to survive.

Her Straub doctors tried to find for her an adult ECMO transport team on the continental United States, but none were available.

There is no formal adult ECMO program -- or even one physician specializing in adult ECMO -- anywhere in Hawaii.

But there was a sliver of hope for the patient: In 2007, Kapiolani Medical Center, Kaiser Permanente and Tripler Army Medical Center pooled resources to create The Hanuola ("Healing Breath") Neonatal and Pediatric ECMO Consortium. The consortium has a network of 15 military and civilian doctors; and since Tripler has both Army and Air Force personnel, the consortium is also joint-service.

Straub staff contacted Colonel Tyree, who acts as the medical director of Hanuola, for assistance. Although she and her consortium associates were only experienced with administering ECMO treatment to youngsters, it became clear that their expertise was the only thing that could save the woman who was, Colonel Tyree recalls, "quickly approaching 0% survival."

"[We knew] the concept exists, the technology exists," Colonel Tyree says, and "we were not going to let anything stop us, including red tape."

Colonel Tyree was joined on the case by Lt. Col. (Dr.) Erik Osborn, a U.S. Army pulmonologist and adult critical care specialist at Tripler Army Medical Center. They both received permission from Brig. Gen. Keith W. Gallagher, commanding general of the Pacific Regional Medical Command and Tripler, to provide medical care to the woman at Straub and they began to work on saving her life.

The patient was placed on ECMO the afternoon of Nov. 13, 2010. Over the course of the next several days, it unfortunately became apparent that her lung disease was not going to be quickly resolved. She required transportation to an established adult ECMO center for extended ECMO care and a possible lung transplant. After an adult ECMO center in Iowa agreed to accept the patient, Straub administrators coordinated extensively with the woman's insurance company while the transport team arranged for air travel there.

"This is where the magic came in," Dr. Tyree said.

In less than 24 hours, the medical team was organized, a civilian plane secured, and multi-institutional equipment and supplies all coordinated. In addition, a special ECMO stretcher, chock-full of tubes, wires and medical devices, was even constructed from scratch.

The core medical transport team included Colonel Tyree; Colonel Osborn; Kris Costales, a civilian perfusionist (specialized health professional who operates the heart-lung machine); and Melody Kilcommons, a civilian registered nurse. Also on the Gulfstream III jet were two adult critical care transport nurses (provided by the civilian medical jet company), a civilian safety officer, two pilots -- and the patient.

Air Force Col. Sean Murphy, PACAF command surgeon, calls the composition of the medical team "very unique."

"It was a joint effort combined with a civilian team," he writes in an e-mail interview. "Hawaii is truly an island, and with the challenges of resourcing medically complicated and expensive efforts such as ECMO, it makes sense to partner where we can as this patient could just as easily been a military beneficiary as a civilian. This was big time special!"

In the early afternoon of Nov. 19, the patient was transported more than 4,051 miles - a total transport time of approximately 12 hours from her Hawaii hospital bed to her Iowa hospital bed (including 8 hours of in-flight time). The transport was a complete success and the patient underwent additional ECMO treatment in Iowa. Unfortunately, the patient eventually died of complications, but she had been given an additional month to say goodbye to her loved ones. In addition, she was able to partake in a private family ceremony that included water brought from the Ganges River in India. As Hindus, she and her family consider such water sacred and essential for a good death/funeral.

Colonel Tyree, who previously worked in the neonatal/pediatric ECMO program at Lackland Air Force Base, Texas, says even when a patient dies despite the best efforts of a military medical team, "what gives families the greatest sense of peace is that the government cares - it's as if the President himself has reached out to them."

In this case, she says, the woman's family felt, "the whole island rose to [their] mother's need."