When a Critically Ill Child is Oceans Away From a PICU: A Military Pediatric CCAT Mission

A 4-year-old former 26-week premature male presented to the U.S. Naval Hospital Guam emergency department in respiratory failure secondary to human metapneumovirus requiring urgent intubation. His condition was complicated by a bradycardic arrest requiring 15 minutes of resuscitation before the return of circulation. He was admitted to the adult intensive care unit and was managed via pediatric telecritical care from San Diego. He developed acute respiratory distress syndrome, acute renal failure, hypotension requiring multiple pressors, and fluid overload necessitating bilateral chest tubes and two peritoneal drains. A pediatric critical care air transport team departed San Antonio within 36 hours of activation and transported the patient via C-17 to Hawaii, performing a tail swap to a KC-135. Before takeoff, mechanical delays caused prolonged ground time and lack of temperature control resulted in patient's hyperthermia to reach 104.2°F despite the ice packing. The ambient temperature caused equipment malfunction (suction, handheld blood analyzer, and ventilator), necessitating manual bagging. Despite initial temperature challenges, the team removed 700 mL of peritoneal fluid and substantially reduced the patient's ventilator settings. After 22 hours of care, the team arrived with the patient to a civilian pediatric intensive care unit in CA, USA. Over several weeks, the patient made a full recovery. This pediatric critical care air transport mission highlights the complications intrinsic to air transport. Missions of this severity and length benefit from utilization of pediatric specialists to minimize morbidity and mortality. Highlighting the challenges related to preparation, air frame, and equipment malfunction should help others prepare for future pediatric air transports.