Page 117 - JSOM Spring 2023

anterior descending artery demonstrated a 99% stenosis and
was treated with two stents. The circumflex artery demon-
FIGURE 1 Lead II.
strated 75% stenosis, and the right coronary artery had mod-
erate to severe chronic stenosis. These lesions were not treated
during the initial procedure.
pressure of 152/90, respiratory rate of 16, and an SpO of
2
97% on a non-rebreather at 15 liters per minute. A 12 lead The patient recovered for 24 hours in the intensive care unit
EKG was performed, which demonstrated depressions in lead and was transferred to the cardiology floor of the hospital. He
II. After 8mg of morphine, the patient reported mild residual was started on dual antiplatelet therapy and a statin. His inpa-
chest pain of 3/10. In order to maintain adequate preload, the tient course was notable for a brief acute kidney injury, which
patient had received approximately 1.5L of crystalloid by the was successfully treated with fluids. On hospital day seven, the
time of handover to the MEDEVAC team. His vital signs and patient was taken back-to-back to the catheterization lab for
chest pain remained stable during transport, and no changes stenting of the circumflex. Repeat diagnostic angiography af-
were noted on telemetry. Ultimately, due to distance, it would ter stent placement demonstrated an ejection fraction of 50%.
take 7 hours from symptom onset to reach the Role 2. The patient was discharged on hospital day eight and returned
to the United States for continued outpatient management.
At the Role 2, a physical exam revealed a patient in mild dis-
tress with absence of jugular venous distention, murmur, or
lower extremity edema. A brief history confirmed that the Discussion
patient had no prior medical history, no surgeries, and took While stabilization and management of traumatic injuries are
no medications. A 12-lead EKG was performed and demon- the cornerstone of deployed special operations medicine, this
strated ST depressions in the precordial leads indicating pos- case serves as an important reminder that critical patients can
terior ischemia (Figure 2). A chest x-ray was significant for present anywhere at any time. Over 19 hours elapsed between
cardiomegaly. A cardiac point of care ultrasound revealed car- presentation and definitive management in the catheterization
diomegaly, septal wall hypokinesis, and a decreased ejection lab, with more than 11 of those hours in the air. The successful
fraction. A single non-high sensitivity troponin I was signifi- management of this patient required thorough medical train-
cantly elevated to 14.41ng/mL. Time at the Role 2 facility was ing, coordination with several contract, active component, and
limited due to aircraft and operational constraints; therefore, a civilian entities, and optimal resource utilization for delivery
posterior ECG was not obtained. Cardiology at a Role 4 facil- of effective PCC by the medical team.
ity was consulted via telehealth. After reviewing the ECG, the
diagnosis of non-ST segment elevation myocardial infarction The initial diagnostic and treatment modalities for NSTEMI
(NSTEMI) was made. A heparin bolus and drip were given, are present at most Role 1 facilities. However, forward de-
and the decision was made to MEDEVAC the patient to a ployed medical provider must remain prepared for the possibil-
higher level of care immediately. ity of a complicated cardiac patient and plan for the according
treatment. Per the 2014 American Heart Association and
American College of Cardiologists (AHA/ACC) guidelines for
NSTEMI, treatment begins with the administration of aspirin,
a P2Y inhibitor (clopidogrel or ticagrelor), and anticoagula-
FIGURE 2 Role 2 12
12-lead ECG. tion (unfractionated heparin, low molecular weight heparin,
1
fondaparinux, or bivalirudin). The AHA/ACC guidelines for
STEMI recommends against the routine use of P2Y inhibi-
12
tors in patients before catheterization who may require coro-
nary artery bypass graft (CABG) in the following 5 to 7 days.
2
Less than one hour from arrival to the Role 4 facility, the pa- Nitroglycerin should be given if chest pain is present, but used
tient was loaded onto a MEDEVAC-capable accompanied by with caution in the setting of suspected right ventricular isch-
an emergency physician and a nurse anesthetist. The patient emia. In our case, ST depressions in leads II and III were con-
was transferred onto the aircraft in supine position, which cerning for right ventricular compromise, and nitroglycerin
resulted in the development of moderate dyspnea and an in- was used judiciously. Importantly, clopidogrel was withheld
creased oxygen requirement. This acute change was suspected in the event the patient might require CABG. Beta blockers
to be related to the development of moderate pulmonary and statins may be beneficial within the first 24–48 hours, but
edema. The patient was repositioned to a 90° seated position. not necessarily at the first point of contact. Notably, this case
Diuretics were considered, but held due to the concern for was prior to the release of the updated 2020 AHA guidelines;
an inferior, or right ventricular, infarction. CPAP and BiPAP therefore, the 2014 AHA guidelines were used as a reference.
were not available on the MEDEVAC platform. The upright
positioning improved the patient’s dyspnea, and he remained The MEDEVAC from Role 1 to Role 2 was a positive exam-
stable throughout the remainder of the flight. Total en route ple of a contract MEDEVAC platform with a contract medic,
care, which including one refueling stop, was approximately as well as an integrated active-duty component critical care
9 hours. nurse. The presence of an experienced nurse familiar with the
complicated physiology of myocardial infarction and the po-
At the destination airfield, the patient was transferred to an tential for significant heart failure proved invaluable for the
ambulance and transported to the hospital. The patient was patient’s fluid resuscitation and symptom management.
taken for emergent cardiac catheterization within 30 minutes
of arrival. Diagnostic angiography revealed severe three ves- During the MEDEVAC from Role 2 to Role 4, the patient
sel disease and a reduced ejection fraction of 31%. The left began to deteriorate with increased shortness of breath and

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