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Guide to Medical Evacuations

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Introduction

Medical evacuations (medivac) are by definition, unplanned, unexpected and urgent. They result from an equally unexpected event such as illness or injury which has happened to a patient far from quality medical care. The medical problem sets the timetable for transportation of the patient and determines the mode, route and destination for the patient.

Most people derive their knowledge, or perhaps it is more accurate to say their expectations, of medical evacuation procedures from the media, often from highly publicized i.e. highly romanticized television shows or so-called "docudramas". The same people though, working in their chosen profession - be it journalism, mining, oil exploration, or high finance - would not expect their clients in turn to be anticipating "standards" of performance and modes of implementation modeled on, respectively, Sharon Stone, John Wayne, Tom Cruise and Michael Douglas movies ... (would they?).

But when a medical evacuation has become necessary, and people are worried, anxious, scared and in pain, the time is not appropriate to explain sensible reasons for the differences between cherished myths and an assistance company's performance. For this reason the background planning and achievements that go into supplying our clients with a careful and professional medical evacuation service are worth looking at in detail.

The main elements in a rapid and secure medical evacuation are careful medicine and safe transportation. To support these a large number of actions have to be taken after the go-ahead for the medivac has been given,
including checking that:

*The medical director or manager of the patient's company agrees to the evacuation
*The patient's full name, nationality, and birth date are known
*The patient's medical problem and medical history are known
*The passengers' (if any) names are known
*The location of the patient is precisely known
*The patient's passport is available, and it and the patient's exit permit are valid
* The destination country will allow the patient in
The destination hospital is appropriately chosen and has a bed, and doctor available
If the patient is a child, the destination hospital has a companion bed available
The treating doctor is aware that the patient will be evacuated and will release the patient
* The patient's hospital / medical expenses will be paid so the patient will be released
The charter aircraft used is suitable for the patient, the route, the airport, and the weather
The charter company have provided a fixed-price quotation
A flight plan has been filed
The medical crew are available
The medical crew have been briefed on the patient's condition
Appropriate medical equipment is listed, checked, and packed
*The evacuation costs are covered by us, OR another party guarantees the cost
* Money to cover the cost of airport and fiscal taxes is available
Transportation is available for medical crew and patient to and from airports
The plan of action takes into account delays and changes in time zones
* Family members have hotel bookings available after arrival at evacuation destination
Local agents are available for ground assistance
The flight plan is approved
The destination airports are open

Checking and preparing those marked * above can take a lot less time if companies and individuals make an effort to plan in advance for an emergency.

Points to remember

Medical escort staff are specialists

Care of the patient in the air and on the ground while travelling is far different - and far harder - than care of the same patient in a hospital, clinic, or home. The operating platforms are noisy, unstable, and cramped; privacy is impossible; the environment is often dirty, hot, and without facilities such as power and water, let alone a flat area to carry out sterile procedures; trained personnel are lacking and the untrained are often panicking; even basic medical investigations such as blood tests, X-rays and ultrasound for the early detection of worsening disease are quite impossible; and in the case of air and sea transportation, the environments induce particular physiological changes in even healthy people, which are frequently magnified by and themselves magnify the physiological changes that accompany disease. Also, the patient needs to be escorted by at least one staff member than can speak his language. So we cannot - and we do not - pick our medical escorts from just anywhere. Being a "friend of the family" even if medically qualified is not a valid reason to escort a patient - indeed the reverse may be true.

Medical escort staff have to be called in at short notice

Doctors are needed who are experienced in preparing and executing medical evacuations. A medical escort should not be a doctor or nurse used only to working in hospital, and unaware of the logistic and medical difficulties associated with the transport of sick patients. Trained professionals are in short supply and cannot be waiting on call for an "instant" response when a medical evacuation is required; almost the only way this is feasible is when a large urban hospital in a highly-developed country, supported by the taxpayer and / or private donations, is prepared to release its medical staff on a rostered basis for such work; even then these medical flights are almost universally limited to under 30-40 minutes from base. (The "Flying Doctor" service in Australia is actually no exception; while medical teams cover a very wide area they are solely employed in this service, and funding is again secured from both private and public sources). There is a consequent short and unavoidable delay; medical staff cannot simply abandon their patients and their work, they - or we - have to find substitutes for them.

Medical equipment needs are far from ordinary

Medical equipment specialized for use in the medical evacuation environments is also needed. Requirements are for light, compact, robust, and battery-operated equipment, all specifications which mean that medical monitoring equipment suitable for mobile use is double or triple the cost of its hospital-based cousins. As it frequently happens that two or more patients - or indeed two or more medivacs - need to be supplied at the same time, such equipment must be expensively duplicated - and then more sets bought and kept ready serviced as backups; in a tropical environment, breakdowns are more common, and equipment has to be sent overseas for servicing increasing down-time. And then before each evacuation all medical equipment needs to be checked - you can't send out for spares en route.

Medical equipment needs to be installed in the aircraft chartered for the purpose

In our area of operations there are no public-owned air ambulances available as governments and health authorities do not consider these a funding priority. The cost of us providing such an aircraft on permanent standby in Singapore is huge; not only the fixed costs associated with hangerage, crewing, maintenance and apron fees, but also the lost "opportunity cost" when the aircraft on standby at short notice is then unavailable for other operations. Should companies wish to reduce the delay in launching a medivac to an absolute minimum, the answer is to put an aircraft with flight and medical crew on permanent standby and absorb the cost... otherwise the medivac, if not done by our Singapore-based air ambulance, will be carried out in another aircraft chartered for the mission. This necessitates reliance on the outside air operator's crew availability and speed of response; and also builds in additional and unavoidable delays while medical equipment is transported and stowed safely on board. When the aircraft hits a patch of CAT (Clear Air Turbulence) or encounters tropical squalls or even icing conditions (entirely possible even on the Equator when the OAT - Outside Air Temperature - is below 4 degrees) is no time to share an aircraft cabin with loose steel oxygen cylinders or a wayward electrocardiograph.

Aircraft, like medical crew, need to be chosen appropriately for the mission

A smaller aircraft is cheaper, and will burn less fuel; but its engines are less efficient and can carry less weight, and therefore less fuel; so it will fly more slowly and need to refuel more often. A major part of all fuel burnt is consumed getting up to an efficient flying altitude where the air is thinner and air friction less; and a smaller aircraft will need to climb more often and cannot reach as high a cruising altitude. A smaller aircraft that is slower and has to refuel more often may actually be more expensive over a longer flight.

A jet will travel faster than a turboprop aircraft, but will require greater runway length for take-off and landing, as well as a much better standard of runway surface. An unpressurized aircraft makes loading easier as preserving the pressure integrity of door and hatch seals is not as critical and larger emergency exit doors may be brought into service; but such an aircraft is noisier, slower, and a poor choice medically for illnesses or injuries where the effects of altitude - reduced partial pressure of oxygen, and expansion of trapped air - can be dangerous or lethal; as in heart attacks, head injuries, chest injuries, abdominal injuries, blood loss, immature lungs (of new-born babies), damaged lungs (in chest injuries), respiratory insufficiency (in asthma and pneumonia), and decompression illness.

More expensive aircraft also carry weather radar and can avoid much bad weather; this is essential as none of the commercially-available "business" jets that are the backbone of the small civil aviation fleet can match the "ceiling" - maximum altitude - attainable by the big Boeings and Airbuses (and military aircraft) which allows the larger airlines to give you a more comfortable ride across the continents.

Aircraft and helicopters cannot go where they should not go

All aircraft have minimum take-off, flight and landing requirements, and the pilot-in-command and IATA rules govern these. Wise clients of charter companies do not do any of the following:

tell the pilot to fly into bad weather when he is reluctant to do so
hurry up pre-flight checks
insist on take-off before the co-pilot has arrived
persuade or bully a tired pilot to fly again rather than wait for his replacement
insist on take-off when a warning light indicates a possible malfunction
insist on takeoff before the tanks are topped up
ask for a night flight when the landing area is unlit and / or the approach is unfamiliar
ask a non-instrument rated pilot to fly IFR (Instrument Flight Rules) when VFR (Visual Flight Rules) flying is no longer possible, rather than to turn back
tell the pilot to "try and get it down" on a too-short runway
tell the pilot "I'll get some cars with headlights on and oil drums with petrol-soaked sand to outline the runway..."

... yet I have personally witnessed over many years people trying to do one or more of the above.

Patients, passengers and crew must still abide by the rules of law on a medivac flight

The most important law is that of gravity. Time spent checking the aircraft pre-departure is not time wasted; if the engines stop, gravity cannot bereasoned with. Additional "along for the ride" passengers and unnecessary luggage (as opposed to medical equipment) increase fuel burn and flying time. However man-made laws apply equally.

A medivac is NOT a "mercy dash" and authorities do NOT condone associated illegalities... so the fact that an aircraft is on a medical evacuation flight does not allow the patient, pilot and crew to ignore the laws of the country. There is NO regulation or agreement that allows visa- and passport-free entry into a country simply because there is a patient on board that aircraft. There IS a regulation that allows a pilot to declare a medical emergency and land in a country for which the plane and crew did not previously file a flight plan or carry visas - but ONLY if this emergency occurs and is declared in-flight. If before take-off the patient or passengers do not have valid passports and exit / entry permits; at the very least there will be delay. In some cases the medivac may be cancelled by the authorities and / or the aircraft and crew impounded. For this reason passports should be scrupulously checked; for this reason we request copies or originals of passports be available as early as possible in an evacuation. Furthermore, observation of customs regulations requires that all medical equipment leaving and entering a country be declared to the appropriate authorities.

Arrival times of aircraft are flexible; departure times are absolutely not guaranteed

Our medical teams always aim to arrive at the aircraft before the aircraft is ready; but for the logical and cogent reasons outlined above we do not "hurry up" professional air crew doing their job, both before and during flight. Flight times vary widely for any number of reasons; head winds, tail winds, the need to go around weather, the need to avoid restricted air space especially for military reasons, the need to refuel, and ATC (Air Traffic Control) restrictions on sharing airspace with large military / civilian aircraft both to lessen mid-air collision risk and to avoid wake turbulence (which behind a 747 can trail for 4 miles...).

Furthermore, an aircraft is not allowed to take off until it is known that the aircraft's destination and / or alternate airports are available for the aircraft to land. If the destination airport is only serving one scheduled flight per day, it usually closes - and is literally deserted - after that flight departs. To use the airport, we then needs to track down the airport operator, get his permission to re-open the airport, and liaise with the charter operator and confirm the destination airport open. This may sound straightforward; but in countries where in some areas the military also exercise control over airports for strategic reasons, where few people have telephones, and many people have more than one job, this can be an extremely difficult and complex process.

Time spent after arrival with the patient, even if it delays expected take-off time, is never wasted. The medical crew need - even beyond the requirements of simple courtesy in saying "hello" to the patient(s) - to check the patient's history, examination and clinical course; to carry out needed medical procedures for the safety and comfort and medical stabilisation of the patient; to set up monitoring equipment, to load the patient safely, and lastly to report back to us with a medical update, in case the destination and mode of delivery from the airport to the receiving hospital need to be changed. The "paperwork" for patient(s) and companions needs to be processed; again, international law requires every aircraft to fly with a passenger list, and if we do not have passengers' details before initial dispatch of the aircraft this requirement adds delay at the retrieval site.

We try to fly as soon as we can; but we do need to wait for approval

In our company's operations, clinical staff personally supervise all evacuations. We like to get the job done fast for the patient's benefit - we take that personally. But when we are not the insurer, i.e. when we are spending someone else's money, we need to wait for their approval. Delays in securing approval are a lot more likely if you do not have a written agreement with our company; if you delay in supplying us with your confirmation; or if your company's senior staff or your insurer's representatives cannot be located in an emergency. Are all your authorized staff listed with us? Are their names, office and telephone numbers current? Do we have addresses of your senior staff on file in case we need to send someone around with papers to sign or to retrieve passports or luggage? Do you know the address and contact details of your immigration consultant? Your insurance policy / broker? Do you ever have all your senior staff out of the country simultaneously?

"OK, what does this all mean?"

There is a great deal of "behind the scenes" activity and preparation going on before the aircraft and crew arrive on the scene; and an equal amount of unseen and possibly unrealised effort takes place during and after the retrieval flight. Our evacuation co-ordinates are experts, the best in the business, and if it can be done we will do it; but we reserve the right to do it carefully, the best way it can be done, the most professional way within the constraints of our operating environment, and we will not take unnecessary risks with your and our safety.

In summary, we urge you to act to both reduce your risk of needing an evacuation, and increase your chances of getting a rapid and safe evacuation, by making sure that:

people with medical conditions likely to deteriorate are not brought to the site
medical symptoms are taken seriously enough early on
preventative medical treatment (such as malaria prophylaxis) is taken as recommended
annual medical check-ups are done to reduce the risk of unexpected illness
sensible driving, recreational and social behaviour reduce the risk of unexpected injury
all employees know how to mobilize the evacuation response
passports and exit permits are kept current and accessible at all times
unnecessary passengers and luggage on evacuation flights are kept to a minimum
if employees in remote sites or on long journeys are overdue, an early alert is raised

The ultimate safety blanket

If you want the option of an "instant" medical evacuation response, we can have an aircraft, pilot and medical crew on 24-hour standby on your site.

Our appreciation to Dr. Rene de Jongh of International SOS, An AEA Company who has contributed this article to help prepare expatries for medical evacuations from Indonesia.

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