My first weekend in Nunavut started with a 3-am page.
“Are you the pediatrics resident? Are you free to go on a medevac? We have a mother in threatened preterm labour with 30-week twins in Igloolik.”
As I mentally rehearsed every worst-case scenario, the nurses at the Iqaluit hospital helped me assemble intubation medications and surfactant, which I stuffed into my backpack before taking a cab to the airport. The transport team wasn’t available, so I took a commercial plane with a family physician, who was trained in obstetrics.
Things happened quickly. The babies had been born an hour before we arrived. They were covered in bruises, after a perilous footling-breech extraction, which had been bravely performed by the Igloolik nurses. One twin in particular was in a great deal of distress, his skin sucking in under his ribs with each breath as the nurse hand-ventilated him.
I took over ventilation of the sicker twin as the nurses relayed the perinatal history and vital signs. The family physician checked on the mother, who was quietly watching everything unfold from the corner of the room, the father and grandmother at her side.
With over-the-phone guidance from a tertiary centre, the nurses prepared medications for intubation. I began laryngoscopy on the first twin as the family and nurses looked on expectantly. In my residency training, I had done this only a handful of times. As the tube passed between the infant’s vocal cords, we both breathed more easily.
The medevac team arrived from Rankin Inlet, and as the flight nurses moved the first twin from the resuscitation bed into the incubator, I popped my head outside for some fresh air (a bit of an understatement above the Arctic Circle). The sun was setting over Igloolik, casting a rose–gold glow over the snow-covered landscape. It was a chilling beauty. The glow was obscured abruptly as the shadow of a van backed into the health centre — this would be the first leg of our evacuation.
![Figure](https://www.cmaj.ca/content/cmaj/187/4/279/F1.medium.gif)
Image courtesy of DeVil79/iStock/Thinkstock
Back inside the nursing station, it was becoming more difficult to maintain the oxygen saturation of the first twin, so we administered surfactant on the advice of the receiving hospital. I silently thanked the nurse in Iqaluit who had helped me pack the equipment.
Watching the first twin, tucked into an incubator and primed with surfactant, a flight nurse attentively hand-ventilating him through an endotracheal tube, I was struck by the harsh reality of our circumstance. We had no mechanical ventilators, only self-inflating bags with no pressure gauges. Each squeeze of the bag threatened to blow a pneumothorax. Preflight X-rays would be a next-to-impossible prospect. We would only know for certain if there was an air leak once we had ascended in the plane, which creates a drop in cabin pressure. Ambient noise would render careful auscultation futile. Assessment of any clinical deterioration would be a challenge.
Just then, the second twin began desaturating, requiring intubation. This process did not go smoothly. We dealt with chest freeze, a tube that was too small, precipitous desaturations and bradycardia. The family physician stepped aside to update the family. I called the receiving hospital. We had to try intubating again; there was no other option.
As the endotracheal tube finally passed through the second twin’s airway, I cried. Then I stopped so that we could provide this twin with the same care we had given his brother.
I was finally given the thumbs-up to leave with the babies, who were now 10 hours old. The nurses gave us hugs. They had been happy to see us arrive, and they were even happier to see us leave.
I crouched in the back of the van, hand-ventilating the second twin through holes in the side of his incubator. A portable flashlight was propped up beside the baby. An oxygen saturation monitor that resembled an old FM radio sat precariously on top of the incubator, beeping reassurance. These would be our eyes and ears for the flight.
The first plane carried a flight nurse, the family physician, mom and the first twin. The second plane would take another flight nurse, me, the grandmother and the second twin.
We loaded up the plane on the tarmac. I took my hand out of the incubator briefly and my glove snapped in the –40-degree wind. We crawled over each other into the snug cabin.
The grandmother seemed to take it all in stride. She buckled me in as I continued to hand-ventilate her grandson. She was holding a teddy bear, a gift. She told me she had seen all of this in a dream, indicating the inside of the plane. I asked her how the dream ended. She said she didn’t know, she had only seen part of it.
Two-and-a-half hours later, we arrived in Iqaluit. I was so grateful to see the comparatively resource-laden hospital. A staff pediatrician had arrived, and we stabilized the babies before he took them on the last leg of their journey, to the tertiary centre. It was 2:30 am.
I tried to process the lessons I had learned in the past 24 hours; about trouble-shooting intubation, the invaluable support of an interdisciplinary team, resource needs begetting extraordinary resourcefulness in northern communities, the resilience of the Inuk spirit … but I was tired. I vowed to write it all down, at some point.
“Transport” by its most utilitarian definition means “to carry from one place to another,” but it also means “to move to strong emotion.” You can be transported by a melody or by a work of art, and as I learned that day — by transport itself.
I fell asleep, with a cramp in my hand from ventilating, recalling the image of the grandmother clutching a snow-white teddy bear.
Acknowledgements
The author thanks Dr. David Goldfarb, Dr. Stephanie Redpath and the Children’s Hospital of Eastern Ontario Neonatal Transport Team, Qikiqtani General Hospital, Igloolik Health Centre, Nunavut Lifeline, and the family that gave the author the honour of telling their story.
This submission is dedicated to the twins, one of whom passed away months later at the receiving hospital. His brother is living in Igloolik with his family.
Footnotes
This is a true story. The family has given consent for this story to be told.