Page 116 - JSOM Spring 2023

Evacuation of Non-ST Elevation Myocardial Infarction in West Africa

19 Hours of Lessons Learned in
Prolonged Casualty Care and En Route Care

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Matthew V. Speicher, USN *; Joel McGowan, USN ; Sean Pruett, USAF ;
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Jaimie Shurden, USN Medical ; William Bianchi, USN ; Aaron Kibler, USAF 4
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ABSTRACT
Trauma casualty care has historically been the cornerstone of therapeutic services, such as angiography, interventional cardi-
special operations military medical training. A recent case of ology, and cardiothoracic surgery. NSTEMI patients in austere
myocardial infarction at a remote base of operations in Africa locations can require lengthy transport times to obtain tertiary
highlights the importance of foundational medical knowledge care, creating a unique type of Prolonged Casualty Care (PCC)
and training. A 54-year-old government contractor support- scenario for the medical providers. Managing resources during
ing operations in the AFRICOM area of responsibility (AOR) PCC of a cardiac patient requires knowledge of cardiac and
presented to the Role 1 medic with substernal chest pain with respiratory physiology, as well as a thorough understanding
onset during exercise. Abnormal rhythm strips concerning for of resource management specific to the evacuation platform
ischemia were obtained from his monitors. A MEDEVAC to and timeline.
a Role 2 facility was arranged and executed. At the Role 2
a non-ST-elevation myocardial infarction (NSTEMI) was di- We present the case of a 54-year-old man who suffered an
agnosed. The patient was emergently evacuated on a lengthy acute NSTEMI in a remote location in Africa. His case, from
flight to a civilian Role 4 treatment facility for definitive care. presentation to the Role 1 to definitive management at a Role
He was found to have a 99% occlusion of the left anterior 4 in Europe, demonstrates the need for vigilance for the un-
descending (LAD) coronary artery, as well as a 75% occlusion expected medical emergency in the austere environment and
of the posterior coronary artery and a chronic 100% occlusion underscores the significance of preparedness to care for these
of the circumflex artery. The LAD and posterior arteries were patients for an extended period of time on the ground and in
stented, and the patient made a favorable recovery. This case the air.
highlights the importance of preparedness for medical emer-
gencies and care of medically critical patients in remote and Case Report
austere locations.
A 54-year-old man with no past medical history presented to
a Role 1 medical facility in a remote area in the AFRICOM
Background
AOR complaining of chest pain and shortness of breath. The
Non-ST-elevation myocardial infarction (NSTEMI) is a subset pain was substernal and described as a pressure-like sensation.
of acute coronary syndrome (ACS) characterized by athero- Initial vital signs included a heart rate of 84 beats per minute,
sclerotic plaque rupture or erosion without persistent ST seg- blood pressure of 148/70 mmHg, respiratory rate of 18, tem-
ment elevation but with elevation of cardiac enzymes, such as perature of 98.8°F, and SpO of 92% on room air. The patient
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troponin. In addition to NSTEMI, ACS also includes ST-eleva- received 324mg aspirin and sublingual nitroglycerin tablets,
tion myocardial infarction (STEMI) and unstable angina (UA). which moderately improved his pain. There was no capabil-
The annual incidence of ACS in the US population stands at ity to obtain a full 12 lead electrocardiogram (ECG), however
more than 780,000, but the incidence in the deployed setting the Role 1 provider was able to transmit individual rhythm
is not as well documented. One study from a Role 3 facility in strips to the Role 2 physician. The rhythm strips demonstrated
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Afghanistan diagnosed approximately 19 cases of ACS over a 2–3mm ST segment depressions in lead II (Figure 1) and sim-
two-year period, making it the sixth most frequent admission ilar depressions in lead III, concerning for inferior ischemia.
diagnosis at the facility. Because of this concern, further doses of nitroglycerin were
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withheld due to the potential for preload dependent cardiac
While initial treatment of NSTEMI focuses on relieving the pathophysiology. Anticoagulation was not available at the
ischemia through platelet inhibition and anticoagulation, Role 1.
management of respiratory status and hemodynamics is para-
mount. In the austere environment, medications may be avail- Evacuation to the nearest Role 2 facility was arranged, and a
able, but in limited quantity. Furthermore, definitive treatment medical evacuation (MEDEVAC) platform was dispatched to
of patients with NSTEMI requires specialized evaluation in recover the patient. Upon turnover to the MEDEVAC team,
a tertiary facility that can provide advanced diagnostic and the patient’s vital signs included a heart rate of 94, blood
*Correspondence to matthew.v.speicher.mil@mail.mil
1 LCDR Matthew V. Speicher, LT Joel McGowan, and LCDR William Bianchi are from the Department of Emergency Medicine, Naval Medical
Center, San Diego, CA. Capt Sean Pruett is from the Department of Critical Care, David Grant USAF Medical Center, Fairfield, CA 94533.
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3 LT Jaimie Shurden is from the Naval Hospital Camp Pendleton, Oceanside, CA. LtCol Aaron Kibler is from the 10th Medical Group, USAF
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Academy Hospital, US Air Force Academy, CO.
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