ITIJ Air Ambulance Review September 2019

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International Travel & Health Insurance Journal

AIR AMBULANCE

September 2019

R E V I E W

Getting your ducks in a row - P06

Case Study: MEDEVAC.FLIGHTS - P14

Mind your head - P18

ambulance flights to take place requires

repatriation from China to New Zealand

of decompressive craniectomy

The detailed planning that allows air skill and precision

MEDEVAC.FLIGHTS tells of a turbulent

The price is right – or is it? - P24

It’s good to talk - P28

obtain the appropriate insurance

debriefs

How difficult is it for operators to

policy for the risks they are taking?

The importance of mission

An insight into the considerations transports

+ More Inside




AIR AMBULANCE REVIEW

CONTENTS Getting your ducks in a row - 06 The detailed planning that allows air ambulance flights to take place is an area that takes skill and precision

Medevac impeded by potential criminal charge - 14 MEDEVAC.FLIGHTS tells of a turbulent repatriation from China to New Zealand

The price is right – or is it? - 24 How difficult is it for operators to obtain the appropriate insurance policy for the risks they are taking?

It’s good to talk - 28 The importance of mission debriefs

Overcoming logistical challenges - 36 CareJet describes a medical evacuation from Coron Island, Palawan to Manila Mind your head - 18 An insight into the considerations of decompressive craniectomy transports

The dangers of task fixation - 40 Capital Air Ambulance details a case where the ability to deal with a wide range of unexpected circumstances was vital

EDITORIAL COMMENT Putting together this second ITIJ Air Ambulance Review of 2019 has enabled some great opportunities for interaction with our readers, and our features have prompted a lot of discussion within the industry. The intricacies of flight planning and the lengths gone to by air ambulance firms to ensure contingency plans are in place to cope with the unexpected are under the microscope, and I’m sure these insights will provide reassurance to insurance professionals who rely on their air ambulance partners during time-critical repatriations. Insurance is also the topic at hand on p24, where operators around the world shed light on their access to insurance cover, premiums and specialist high-risk policies. Elsewhere, the importance of crew briefings are debated by industry professionals, with different approaches being taken by companies around the world. The ability of air medical professionals to transport critically ill patients who would previously have remained in hospital for some months is changing the way cases are being managed. In this issue, Dr Thomas Buchsein shares his insights and best practices for transporting a patient with a decompressive craniectomy. As ever in the ITIJ Air Ambulance Review, some of our esteemed air ambulance company readers have been generous enough to share their experiences through reporting on missions accomplished where they have overcome some particularly challenging conditions, either logistical or medical. Enjoy!

Editor-in-Chief: Ian Cameron Editor: Mandy Langfield Copy Editors: Sarah Watson, Stefan Mohamed, Lauren Haigh & Robyn Bainbridge Contributors: James Paul Wallis, Robin Gauldie Designers: Robbie Gray, Tommy Baker, Will McClelland Advertising sales: James Miller, Kathryn Zerboni, Marton Modis

The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned is hereby excluded. The views expressed do not necessarily reflect

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those of the publisher.

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Mandy Langfield Editor

Printed by Pensord Press Copyright © Voyageur Publishing 2019. Materials in this publication may not be reproduced in any form without permission INTERNATIONAL TRAVEL & HEALTH INSURANCE JOURNAL ISSN 2055-1215

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AIR AMBULANCE REVIEW

FEATURE

Proper preparation enables more successful missions. James Paul Wallis goes behind the hangar door with global air ambulance operators to find out more about the effort that goes into ensuring safe and high-quality repatriation flights go off without a hitch

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AIR AMBULANCE REVIEW

FEATURE

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he cabin door is closed, the crew take their seats, the plane taxis to the runway and, with a roar of the engines, the aircraft accelerates down the tarmac and takes off; the mission has started. In truth, of course, the mission started hours earlier. Long before the flight team reaches ‘wheels up’, the operations centre begins the painstaking work of getting everything in place so the mission will be a success. For AMREF Flying Doctors, planning begins with selecting an appropriate aircraft and crew members, explained Mike Black, COO and Accountable Manager. Next comes detailed route planning, along with a host of tasks such as obtaining flight permits, hotel accommodation, crew and patient transport, fuel releases, and arranging ground handling services.

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AIR AMBULANCE REVIEW

FEATURE

Border crossing

Despite the apparent freedom of soaring above the clouds, the need to obtain overflight and landing permits for the countries over which the plane will fly or land in adds time to the planning stage, as Glenn Salt, Operations Manager for Capital Air Ambulance, explained to ITIJ: “This process can take anywhere between 12 to 24 hours before all the required permits have been granted. The cost involved to overfly a country varies from country to country, however, the costs are anywhere between US$50 to $400.” In some cases, a mission will launch before the permits are obtained, said Philipp Schneider, Key Account Manager at Germany’s Quick Air Jet Charter: “Sometimes, we are instructed by the client for medical reasons to start a mission even if we do not have all necessary permits in place. In these urgent medical cases, most of them concerning African countries, we inform the authorities of the affected countries that the urgent air ambulance mission has already started.” Schneider added that the company has always experienced a good level of co-operation from these particular authorities and gained the necessary permits, even if the request goes in at the last minute. He added: “For those cases, we definitely have a fall-back option in place, which means that we, worst case, have to pause the mission until a missing permit can be issued. This could lead to extra costs, for example, for an additional required landing. The client always has to be involved in [developing] Plan B, as they will be the responsible party concerning the costs and alternative outcome.”

very long flights can need additional crews to be prepositioned en route to ensure the flight crew remain within their flight and duty limits Visas for the crew are less of a hindrance, noted Salt, saying that due to the nature of the flight, generally, visas for flight and medical teams can be obtained upon arrival, with the exception of a handful of countries. Irena Dimitrijevic, Head of Sales and Business Development for Jet Executive, shed light on the question of where this might present a 8|

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problem: “One example is Russia or China, as these countries insist on a valid crew visa before arrival. If our operating crew on this mission doesn’t hold a permanent visa – this is the case especially for medical specialists who don’t work on a regular basis for us – they need to visit the embassy in Germany before the flight date to obtain the visa.”

Short vs long-haul

While some elements of planning are common to all flights, longer missions bring extra complexity, noted Salt of Capital Air Ambulance. For the UK-based provider, operating within the European Economic Area (EEA), North Africa and parts of the Middle East generally requires just the standard landing and handling arrangements, but going further afield requires greater planning and preparation before the aircraft can be dispatched. Dimitrijevic highlighted the difference in planning time for short and long-haul missions. For short-haul flights: “We can set up a flight within more or less one hour, and maybe another two hours until our crews reach the facilities at our home base airport, equip the aircraft, check-in and start towards the patient’s pick-up destination. Long-haul flights need at least 24-hours notice, often

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even longer depending on which geographical region we are [flying] to, due to all the overflight and landing permits we need to obtain in advance.” Another factor is that very long flights can need additional crews to be prepositioned en route to ensure the flight crew remain within their flight and duty limits, said Black of AMREF Flying Doctors. This prepositioning can be achieved by sending crew members out on scheduled passenger flights, explained Dimitrijevic.


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FEATURE

Flight schedules have to be adapted to the daily temperature forecast, avoiding fuel stops during a midday temperature peak

Security

A major consideration is the security and travel risks associated with countries where the crew may make a fuel stop or overnight stay, said Glenn Salt. Considerations need to be for the crew and also for the parked-up aircraft, he said. To find the necessary information, providers can take advantage of aviation travel security briefs offered by a number of companies, which provide country-specific medical and security data. Salt added: “If a patient is in a country deemed unsafe to visit where an overnight layover is required, a neighbouring country would be selected for the layover, where the risk factor is much lower. The aircraft could then fly over to the country in which the patient is located and, subject to the patient’s condition, a tarmac handover of the patient may be performed, whereby a suitably qualified team bring the patient to the air ambulance.” The political environment also needs to be taken into account, said Philipp Schneider, as this can affect airport availability: “The current situation between Pakistan and India affecting airway closures leads to an extended flight time on the way, for example, to Southeast Asia, directly affecting possible flight crew duty times, which have to be considered carefully. 10 |

Safety warnings issued by the European Aviation Safety Agency and the Federal Aviation Administration have to be taken in consideration on a daily basis.”

Factoring in the unexpected

And then you get to the issue of fuel, and here, the planning goes well beyond simply scheduling stopovers at set distances. “When we consider all of the many aspects good flight planning involves, perhaps the most important is the fuel planning,” said Philipp Schneider. “Temperatures, for example in India or Sudan, can easily be a limiting factor for the amount of fuel we are able to uplift. Flight schedules have to be adapted to the daily temperature forecast, avoiding fuel stops during a midday temperature peak.” Extra fuel is carried in case the weather is not as predicted, or in case of other emergencies, said Schneider: “There are many situations where a different airport other than the original is needed. Finding an alternative airport is an important factor that needs to be considered with good flight planning.” Emergencies on the ground are an uncommon, but potential, source of disruption, which can make an alternative landing destination a much-needed option. “In 2016,” continued Schneider, “two of our

ambulance aircraft were on their way to Brussels Airport when the terrorist attack lead to a total airport closure. In 2018, one of our aircraft was heading to Schipol Airport in Amsterdam when an electrical failure lead to a blackout of the whole airport, causing an airport closure. Such situations are rare, but they happen.” Doing your homework in advance helps to control fuel costs. Glenn Salt explained that existing relationships with fuel suppliers are a vital link in the chain: “An established credit account needs to be in place with several suppliers who offer fuel prices via portals. This gives you the ability to cross reference suppliers and select the most competitive price for your trip. A fuel release will be provided by your supplier to ensure fuel is supplied down route for the crew, avoiding any need to provide a credit card.” Returning to the theme of preparing your Plan B, Mike Black commented: “Unexpected events need to be addressed very quickly if the patient is onboard at the time. How the challenge is dealt with will depend on its nature and may even require another aircraft to be dispatched should the aircraft have a technical issue en route that affects its airworthiness and ability to continue the flight, although this is an extremely rare event.” More common challenges, said Black, include a delay in the patient’s discharge from hospital, or the planned ground time on a technical/refuelling stop being exceeded, both of which could require the flight planning to be revised and changes made to clearances, landing slots, and so on. He added: “Each flight is closely monitored by the company’s aviation operations department to make sure any adjustments to the flight plan are made quickly and where necessary, the relevant authorities communicated with, including the receiving hospital.”

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AIR AMBULANCE REVIEW

FEATURE

Operations teams also have to keep up to date with current flight restrictions

Dynamics

No two flights are identical, as either the mission profiles (details such as origin, destination and patient condition) differ, or external factors (such as political situations) change over time. As an example, Philipp Schneider highlighted how flying within Europe is increasingly challenging: “European airways are more crowded than they have ever been in the history of commercial flying, and so even as an active air ambulance aircraft, we are facing difficulties in finding practicable routings during peak times. Two years ago, we faced, for the first time in our company history as an air ambulance operator, problems with airport availability for our air ambulance aircraft.” He added that on occasion during the summer season, repatriation missions from Ibiza, Mallorca and Lisbon have had to be scheduled according to available airport slots, without any option of prioritisation due to patient needs. Operations teams also have to keep up to date with current flight restrictions, including NOTAMS (notices to airmen) issued by air authorities. Volker Lemke, Director of Sales and Marketing for Germany’s FAI Flight Ambulance, noted that since flight restrictions can occur relatively quickly, a detailed audit is essential. Mid-flight surprises can require operations staff to pull out all the stops to make the mission a success. Lauren Dulin, Chief Operations Officer at Air Ambulance Worldwide, recalled one such flight: “While working on a mission to Guyana, we were told that permissions would not be granted for the N-registered aircraft at the time of our estimated arrival. However, our team didn’t accept the initial deterrent and were able to reach the embassy, where the ambassador to the Republic of Suriname was the person whose influence helped bring our trip together.”

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Sometimes, however, a swift change of plan can be used to control costs, even when the mission can’t be completed as originally hoped. Dulin recounted one such time: “While en route from Denver [US] to Cancun [Mexico], we received devastating news that our patient in Cancun had passed prior to us getting there to pick them up. Through ATC and our Garmin communication, we were able to reach our crew, who were mid-flight repositioning to pick up this patient, allowing [them] to put down in Texas. By the quick response of our dispatch and their efficient communication with our crew, we were able to redirect the aircraft mid-flight and save the client additional costs.” Reflecting on the need to expect the unexpected, Irena Dimitrijevic put it this way: “Aviation is challenging, exciting, and external factors such as the weather are changing all the time, so our teams need to be professional and experienced to consider all these challenges – aviation can never be foreseen 100 per cent, we are creating individual services and no flight is like another.”

European airways are more crowded than they have ever been in the history of commercial flying


AIR AMBULANCE REVIEW

FEATURE

Bringing it all together

The true art of planning an efficient mission is to balance all of the factors at play to find the optimal outcome. Lauren Dulin commented: “On longer missions in which crew near duty day limits, our co-ordinators will assess the benefits of the required overnight, keeping the aircraft and crew out an additional day and accruing the cost of such, or [whether]

scheduling a fuel stop slightly outside of our line of flight to swap pilot crews would be more beneficial, both in cost to the client and to the company to have the aircraft return to base in a more timely manner.” As a specific example, Dulin said that for missions between Mexico to Canada, the company will look at the benefits of planning for a fuel stop in the US to avoid costly navigation fees, or incurring a slightly higher cost by choosing to overfly the US, offering the patient a direct flight. Summarising the flight planner’s art, Dulin said: “The team behind the scenes are always looking at the combination of superior clinical care, appropriate aircraft and routing, support to our clients both in service and financially, as well as keeping each mission successful and safe.” The end of planning is the handover to the crew so the flight can begin. Volker Lemke said: “As the final step prior to boarding the aircraft, the crew must be fully briefed on all aspects of the mission … including any restrictions, any refuelling issues, and any required procedures prior the start of the flight. The operations department is responsible for all the above issues. Operations

also creates a flight order of the route which has all the necessary details included. The pilot takes ownership of all the documents, which include fuel releases, flight orders, NOTAMs, hotel and transportation bookings, etc.” And with that, it’s time to board the aircraft, close the door and fasten seatbelts, en route to bring another patient home safely. n

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AIR AMBULANCE REVIEW

CASE STUDY

NEW ZEALAND PATIENT DROP-OFF

CHINA PATIENT PICK-UP

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MEDEVAC IMPEDED BY POTENTIAL CRIMINAL CHARGE MEDEVAC.FLIGHTS’ experience in handling complex cases, both medically and operationally, was highlighted by one of the company’s recent missions repatriating a patient from China to New Zealand, where poor patient care and a potential criminal charge resulted from an altercation between the patient and nursing staff The case

The patient was a 78-year-old male from New Zealand, who was travelling in China with a tour group. He became unwell with respiratory failure and was admitted to a local hospital. The patient was being treated for pneumonia, but while in hospital had a mechanical fall and as a result suffered a fractured neck of his femur. A decision was made by the orthopaedic surgeon not to perform surgery in China, with the preferred option being an air ambulance back to New Zealand prior to surgery. The patient had a history of ischaemic heart disease and coronary bypass surgery, cardiomyopathy (likely ischaemic), chronic kidney disease, permanent pacemaker and/or internal defibrillator and an abdominal aortic aneurysm (previously repaired). 14 |

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Hospital altercation

The team landed in China and made their way to the hotel with the medical equipment. Shortly after, a call came through on the operations assistance line stating that the patient’s condition had deteriorated and he had become violent and aggressive, possibly attacking one of the staff members. The operations team quickly contacted the medical team in China and they attended the hospital immediately to get firsthand information regarding the situation. They were met by some very distraught nurses, who immediately called the night doctor in to explain the situation. The flight nurse was shown a picture of a bleeding thumb and told that this was a ‘very bad man’, that he had caused this damage by biting a nurse and it might be an arterial bleed. This had occurred when the patient became distressed in bed and was not

The success of this mission was due to the incredible medical and retrieval experience of the doctor and nurse team


AIR AMBULANCE REVIEW

case study

The patient

taking the advice of the nurses. Due to the altercation, the patient had been sedated. The flight nurse told the hospital’s medical staff that the patient would be medevaced the following morning and that he would be returning to collect the patient then. The hospital’s doctor and nurse repeatedly said that the patient was a ‘very bad man’, and that the police had been called to start criminal proceedings. It appeared that there was a high chance the patient was going to be detained in China while the incident was investigated. This was all relayed by the operations team to the insurance company, who were also advised that they should send a representative from their China office, as this was a serious incident where the patient may be detained and criminal charges could be laid. Upon their return in the morning, the medical team found a cast of many, with doctors, nurses, executives and police in attendance, including the MEDEVAC.FLIGHTS’ doctor and nurse team, as well as their interpreter. The medical team was initially denied access to the patient, but were later granted access after extensive work by the operations team and a representative of the New Zealand Embassy.

Upon gaining access to the patient, they found him in a disheveled state in bed, still heavily sedated, with no monitoring or oxygen attached. This was concerning as the patient had presented with pneumonia and had continually been on 2L O2 via nasal prongs – giving him SATS in the low 90s. After finding the patient very hard to rouse, the medical team queried the hospital medical team as to what sedation he had been given. No definitive answer was given, however, as the doctors were preoccupied with the police situation outside the room. Placing a SATS probe on the finger of the patient gave a reading of 78 per cent on room air. The patient was cyanotic and hypoxic with no supplemental oxygen. He was lying in soiled and wet bed linen, and his pants and underwear were around his knees. Clinically, he was dehydrated. Further assessment of the patient found that he was not catheterised, had no cannula and had extreme dry mucous membranes, with thick yellow phlegm in his mouth. He was in acute urinary retention, and later drained >800mls of urine once a urinary catheter was inserted. The medical team immediately applied their own oxygen, catheterised and cannulated the gentleman and commenced IV fluid therapy. The patient’s aggression had clouded the management of this patient and so the basics of care had not been performed. MEDEVAC.FLIGHTS reported all findings to the Ambassador from the New Zealand Embassy and advised that given the situation, this patient could not continue to be cared, or not cared for in this case, in this facility. The same was communicated to the insurance company client and they were advised that if the patient was not allowed to depart China at this time, that an alternate hospital must be found, as the patient was being neglected by the current facility. Through extensive discussions with the insurer, the operations team and the medical team, it was determined the patient’s health and safety would be compromised if he remained in the hospital in China. Therefore, the patient was to be medevaced to New Zealand immediately without delay. The medical team were worried about the patient’s age and low Glasgow Coma Score (GCS) following a night of hypoxia, and were prepared for the likelihood that this patient may require intubation and ventilation for transfer home.

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AIR AMBULANCE REVIEW

CASE STUDY

The involvement of the member of the Embassy was invaluable; without her it would have been extremely difficult to secure the release of the patient

Evacuation underway

The medical team and the New Zealand Ambassador were able to liaise with the Chinese police and Government to secure the release of the patient, allowing him to be medevaced. The involvement of the member of the Embassy was invaluable; without her it would have been extremely difficult to secure the release of the patient and transport him back to New Zealand. The medical team packaged the patient and placed him on their stretcher, at the protest of the local nursing staff. They were still adamant that this man had done wrong by them and should receive police punishment. The New Zealand Embassy managed to smooth over the situation and enabled passage to the waiting ambulance. The medical team proceeded with lights and sirens to the waiting Learjet 60 aircraft. The patient’s GCS started to improve, and he became more aware and lucid. He was able to communicate in simple sentences. The team cleared customs and loaded the patient onto the jet. Due to the lengthy delay at the hospital, the flight schedule had to be pushed back and the cut-off time for departure that would allow the team to make it all the way back to New Zealand on the single jet had passed. This situation had been communicated previously to the insurer and MEDEVAC.FLIGHTS had devised a solution to be able to transport the 16 |

Post-mission analysis

patient home – a second jet, a Falcon 50, was to meet the first aircraft for a wing-to-wing handover of the patient in Australia. This meant that the patient did not have to stay another night in China and did not need to be admitted into a hospital in Australia. After the drama in China, it was an uneventful flight. The patient’s behaviour was not an issue, he was never aggressive or abusive, but rather pleasant and compliant. He had minimal to no pain and tolerated the transfer very well. He even asked whether he could buy some gin at duty free when the jet arrived in New Zealand!

It was surprising that only simple interventions were needed to improve the patient’s condition. The flight medical team surmised that the patient could have been hypoxically delirious, which may have led to his fall in hospital. He then remained hypoxic and confused and was not catheterised, so was potentially trying to get out of bed. This led to an argument with the nursing staff, which was compounded by a language barrier and the patient’s frustration, resulting in a nurse’s thumb being bitten. The success of this mission was due to the incredible medical and retrieval experience of the doctor and nurse team, as well as the operations team’s preemptive planning and strong communication between the numerous relevant parties. n AUTHOR BIO William Cassidy (BSc, BCom, MFin) is Managing Director of MEDEVAC. FLIGHTS, which is the first air-ambulance Accredited Service Provider for International Assistance Group on the East Coast of Australia, and has recently obtained ISO 9001:2015 Quality Management Systems Accreditation. community.


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FEATURE

MIND YOUR HEAD CH

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Dr Thomas Buchsein of FAI Flight Ambulance (FAI) in Germany spoke to ITIJ about the challenges of transporting patients after a decompressive craniectomy

Bone flap storage Depending on the individual situation, it is often decided to keep the resected bone flap for later replantation. For this purpose, it is usually preserved deep-frozen in a ‘bone bank’ (several studies document various methods of bone cryopreservation and storage practices in neurosurgical centres throughout the world, with temperatures between -35°C to -84°C in liquid nitrogen cooling systems, and cryoprotectant solutions vary likewise). An alternative solution is to sew the flap into the subcutaneous tissue of the abdominal wall, where its viability is maintained by the body. Advantages of storing the flap in the abdominal wall include sterility, continued nourishment and simple transport inside the patient’s body. A disadvantage is the not-so-rare phenomenon whereby weeks – or sometimes months – later, neurosurgeons, when intending to retrieve the bone flap from the abdomen to close the skull, find it in a partially-resorbed state.

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midline-shift to the right and compression of the left lateral ventricle. An immediate burr hole O TH evacuation of the haematoma was performed. DR Two days later, the patient developed a significant re-bleed with increasing mass effect in the left cerebral hemisphere, and so a craniotomy was performed to evacuate the blood once again. Intraoperatively, the cerebral tissue appeared to be under considerable pressure and began to prolapse into the craniotomy opening. At this point, the decision was taken to proceed with a more extensive opening of the cranial bone by performing a decompressive craniectomy. The operation went well, and the resected bone flap Decompressive (slightly larger than the craniectomy average size of a palm) was deep-frozen and A neurosurgical procedure in which a part stored in the hospital’s of the skull is removed to allow the brain to bone bank. AS

On a sunny day in late spring 2018, a small group of Scandinavian holidaymakers were on a mountain bike tour in Monte Conero, Provincia Ancona, Italy. On a scenic coastal road, one of their party – a lady in her late forties – lost control of her bike on the sloping road when the front wheel skidded sideways on a patch of gravel. She hit the ground hard, headfirst, and her loose-fitting helmet was knocked off her head. She lost consciousness instantly. When rescue services arrived at the scene – a rather remote site – 35 minutes later, the medics found her unresponsive with one fixed and dilated pupil. They established IV access, intubated her, and rushed her to the Trauma Center of Ospedali Riuniti di Ancona. Urgent radiological imaging identified a large left frontoparietal subdural haemorrhage with

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expand, thus relieving intracranial pressure. The technique is used in patients with traumatic brain injury or severe stroke, where the elevated pressure within the cranial vault can no longer be managed with conservative means (such as osmotherapy with Mannitol IV or elevation of the upper body by approximately 40° etc.) and cerebral perfusion becomes difficult to maintain.

Using liquid nitrogen as storage.

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An intracerebral pressure probe showed satisfactory results that were close to the norm. The further clinical course was characterised by a slow but steady neurological recovery, and three weeks later, while still intubated and ventilated, the patient displayed increased alertness, seemed to recognise familiar voices, reacted when spoken to and, after a few more days, began to respond to and follow simple commands. However, a significant residual motor weakness of the patient’s right side was observed. The process of weaning the patient off mechanical ventilation was progressing satisfactorily and a nosocomial airway infection seemed to be responding well to antibiotics.

The mountain bikers were riding through Mount Conero Natural Reserve Regional Park, located along the Adriatic coastline of Italy, when the accident happened.

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AIR AMBULANCE REVIEW The assistance company’s perspective

FEATURE (c) FAI - The patient wearing a protective helmet.

Communication is key

At this point, it became increasingly clear that the treatment focus would soon shift to intensive neurological rehabilitation; a lengthy process that would be best carried out near the patient’s home, close to her family and friends. It was also unlikely that the patient would be fit to fly on a commercial scheduled flight any time soon, so the assistance company contacted FAI requesting a quote for an air ambulance repatriation to Sweden.

The air ambulance provider’s perspective

With 17 such flights in 2018, and similar numbers in previous years, FAI is experienced in repatriating post-craniectomy patients. And we have seen it all: ward nurses running after us, unexpectedly handing over a Styrofoam box with dry ice fog pouring out, and proudly announcing: “Our doc says you need this, it’s the patient’s brain – oops, sorry, the skull! Oh no, not the whole thing, only parts of it!” We’ve had clients failing to inform us at all that such a procedure had been done, as well as desperate pleas from family members urging us not to leave any part of the patient behind.

Large left-sided frontal parietal subdural haematoma with associated midline shift. Wikipedia image.

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Replantation

A craniectomy defect is typically reclosed between six and 20 weeks after removal. Frequently, the patient’s own cryopreserved or abdominal wallstored bone flap will be replanted, but also, quite often neurosurgeons choose artificial materials to replace the bone flap. Typically, this either uses the natural bone fragment as a mould for an artificial cover plate, or else computer-aided design (CAD) is utilised for skull reconstruction with titanium implants. For legal reasons, very few neurosurgeons accept bone flaps for replantation that have not been stored according to their own protocols and supervision in their own hospital – even less so with an air ambulance flight in between!

Decompressive craniectomy flights are one of the medical situations where the success or failure of the whole process depends on the quality of communication between the client (the assistance company) and the provider (the air ambulance operator). FAI has distributed an information leaflet to all our clients that outlines some key information to be mindful of: • The logistics and effort involved in taking liquid nitrogen containers onboard the aircraft in line with Dangerous Goods Regulations is out of balance with the ultimate benefit to the patient. While it can be achieved, it is not desirable. • We strongly encourage direct communication between all neurosurgeons at the sending and receiving facilities in order to clarify the conditions in which replantation of the bone flap should be considered and, indeed, whether this procedure is necessary. • We do offer to take the bone flap on board, though not deep-frozen for a possible replantation; it must be sufficiently cooled (at a maximum temperature of 4°C) so

This coronal view (frontal view) of a brain CT scan shows bilateral chronic subdural haematoma (blood clot), larger on the patient´s left hemisphere (same side as the vertical ruler). It is usually caused by minor head trauma.


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that it can serve as a mould for an artificial replacement of the bone defect. • We encourage the facility to provide a customised ‘helmet’ for the patient to protect them from any outside impact. Following a caniectomy, large parts of the brain are only covered by soft tissue, and are thus exposed to external impacts. To prevent further injury, patients need a specialised helmet that has been individually adapted to provide maximum protection while ensuring no pressure is applied to the head itself.

The bottom line

The three most important considerations when planning and executing air ambulance transport missions for these patients are: • Communication: Directly between the neurosurgeon of the sending and the receiving facility, as explained above. • Equipment: The provision of a customised ‘helmet’ for the patient to protect them from any outside impact. • Planning: Missions must be planned well in advance to allow for the appropriate amount of time required to achieve the above two objectives – patients are usually in relatively stable condition and so there is no room for poor planning and rushed timing. n

Literature X. Huang, L. Wen, ‘Technical Considerations in Decompressive Craniectomy in the Treatment of Traumatic Brain Injury’, International Journal of Medical Sciences, 2010; 7(6):385-390 © Ivyspring International Publisher.

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D. J. Cooper, et al., ‘Decompressive Craniectomy in Diffuse Traumatic Brain Injury’, The New England Journal of Medicine. Band 364, Nr 16, April 2011, S. 1493–1502, ISSN 1533-4406. doi:10.1056/ NEJMoa1102077. PMID 21434843.

AUTHOR BIO Dr Thomas Buchsein graduated from Munich Technical University Medical School in 1982, and obtained specialist qualifications in Internal Medicine, Intensive Care, Emergency Medicine and Aviation Medicine. 1994 brought first commitments with assistance medicine and the administrative aspects of patient transport when he worked for SFA, later GESA and AXA-Assistance Germany, as a consultant physician. Since being appointed as Medical Director of FAI in 2005, he has continued working (part-time) as a senior ITU-doctor in Munich-Harlaching Hospital and as HEMS physician with the Christoph 1 program.

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FEATURE

THE PRICE IS RIGHT – OR IS IT? Air ambulance operators around the world are under pressure from health insurance and assistance companies to keep prices down, while at the same time, many are dealing with increasing hull insurance premiums. Robin Gauldie spoke to operators about the challenge of finding the right policy at the right price

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he operating costs of medical evacuation and repatriation continue to increase – aircraft, equipment, staff, fuel, and flight permits all add up – and not all of these costs can be passed on to end users. Premiums for hull ‘all risks’ cover account for a relatively small segment of an air ambulance company’s costs, but with air ambulance average flight hour prices in Europe falling by between five and 12 per cent in recent years (www.itij.com/feature/costrepatriation-all-things-considered), margins are being squeezed.

A wide scope of operations

Underwriting insurance policies for the variety of air ambulance operations that exist around the world has its challenges – but appetite for insuring this risk appears adequate to provide a

Some air ambulance operators say premiums are now on the increase

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Appetite for insuring this risk appears adequate to provide a competitive market competitive market, and air ambulance operators have few complaints. Insurance is a relatively small element of an air ambulance operator’s fixed costs, compared with other factors such as maintenance, payroll, fuel, and investment in new aircraft and sophisticated on-board medical equipment. Many of these items are beyond any air ambulance operator’s control. The price of fuel, for example, can fluctuate wildly and there’s nothing anyone in the air ambulance sector can do about it. The price of insurance, however, is related to factors that are at least partly controllable by the aviation industry as a whole, and even by the individual operator. It’s not rocket science: fewer claims means lower premiums. However, after several years in which aviation premiums overall experienced a downward

trend in recent years, in line with a continuing decline in incidents leading to claims, some air ambulance operators say premiums are now on the increase. According to one industry insider, there is little difference in insurance premiums for medical flights and mainstream commercial operations. For both sectors, key factors are aircraft age, flying hours, countries and regions covered and the operator’s historic safety record. Less tangible factors include the insurer’s level of trust of the air ambulance operator – and, of course, that operator’s skills in negotiating a deal. “In general premiums are going up, without any difference between an air ambulance and an executive aircraft,” asserted Volker Lemke, Director of the Sales and Marketing at FAI Group. “The cost of medical configuration is only a fragment of the cost of the airframe,” he points out, and the cost of fitting out a high-spec executive jet is likely to easily exceed the cost of equipping a medical aircraft. FAI, with a large fleet of medical and nonmedical aircraft, is in a strong negotiating position with insurance companies, Lemke says. “We are getting a fair deal owing to the large fleet to be covered, including some very expensive jets that are many times more expensive than our air ambulance aircraft,” he says. “The mix makes it perfect for us. That said, we are still facing the problem that rising overall costs, including insurance, can’t be passed on to our clients without there being a risk of a negative impact on our business.” “We have insured many air ambulance operators over the years and built up a good understanding of their work,” said


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Tom Chamberlain, Underwriting Manager, Aerospace and General Aviation, London, at global insurance company Allianz. “The profile of a particular operator will of course differ dramatically based on its location and scope of operation. Air ambulance pilots and crew will face different challenges if they are, for example, operating at high altitude at low temperatures, compared, say, with inner city. Within Europe, air ambulance operations tend to be very well run, with experienced pilots suited to the type of work they are doing,” Chamberlain says. “Overall, we don’t see complexity increasing and we can cover all types of operations, including into high-risk areas.” For fixed-wing medevac aircraft, finding an

Flights into higher/ high-risk areas must be declared to insurers before the flight affordable deal may be easier than it is for HEMS rotorcraft. In US, the world’s biggest market for fixed-wing air ambulance services, such operations only account for around 33 per cent of the market, compared with 66 per cent handled by helicopters. From an underwriter’s point of view, the fixedwing air ambulance business is less challenging than the HEMS sector, because there are significantly fewer accidents worldwide. Premiums for HEMS rotorcraft may be up to four-times more costly than for a fixed-wing air ambulance insured for the same value. That said, both fixed-wing and HEMS operators are under pressure from their travel and health insurer clients to provide higher levels of coverage for aircraft liability and for medical malpractice, as reported previously in ITIJ (www.itij.com/feature/cost-repatriation-all-thingsconsidered).

Non-standard risk

Underwriting cover for air ambulance operators carrying out missions in high-risk conflict zones is more complex and, as a result, more costly to insure. In addition to standard hull and all-risks insurance, such operations also require ‘war and political risks’ cover that protects against physical damage or loss of the aircraft from ‘war or associated perils’, which are typically excluded from a standard hull allrisks policy. However, air ambulance operators seem resigned to paying higher prices for such cover and agree that – although insurers are arguably in a seller’s market – such policies are not exorbitantly priced. Dr Bettina Vadera, Chief Executive and Medical Director of Nairobi-based AMREF Flying Doctors, commented that such policies come with added hoops through which providers must jump to ensure compliance and coverage: “Flights into higher/high-risk areas must be declared to insurers before the flight, so it is a requirement, not a trend. Performing a flight without prior notification could jeopardise or invalidate any claim, both on the aircraft as well as the crew and passengers. In that case, the

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Some air ambulance operators say premiums are now on the increase

operator and its officers would likely be sued by the affected parties.” And not all flights are going to be considered insurable by the underwriters. “Insurers will refuse to quote where they believe the risk is unacceptably high and exclude the region or airport from the insurance policy coverage,” said Dr Vadera. “The additional premium charged will depend on the risk and the insurer’s appetite for that risk, and could include increased deductible amounts on the aircraft insurance in the case of a claim and/or reduced passenger liability amounts.” “High-risk areas are always reactive to current conditions,” agrees Utku Tekçeer of Redstar Aviation. Based in Istanbul, Redstar operates a fleet of four Bombardier LearJet 45 aircraft on missions that include high-risk regions such as Iraq, Libya and Afghanistan. “In the nature of air ambulance operations, we do fly to wartorn areas and the most distinct difference is liability including war risk for passenger, cargo and aircraft. Premiums may rise depending on the situations of the countries involved – for example, right now premiums for Libya are increasing due to rising tension there. Tekçeer seems resigned to paying substantially more for insurance cover when operating in high-risk zones. Insurers with an appetite for insuring such higher risks inevitably charge more, he concedes. “Mostly leading insurers offers this type of cover due the quantity of costs. It is definitely not fairly priced, especially in war-torn areas, but insurance companies are taking risks, so it is understandable.” Operators 26 |

cannot simply absorb all these additional insurance costs, he adds, and a proportion is passed on to the client. “We do our best not to reflect this in our own prices to our customers, but we have limits to how much we can compensate.” Dr Vadera concurred. “Insurers price their premiums based on the risk involved and their required financial returns, so what may seem fair to the insurer may not look the same to the insured,” she says. “Premiums are also affected by the quantum of aviation claims in general in a particular year or period. Operators price the normal/annual insurance premiums into their aircraft operating costs and hence the rate

per mile charged to the customer. Additional premiums charged are passed onto the customer on whose behalf the flight is done.” Seeking the cheapest possible deal may not be the smartest choice for operators, Dr Vadera noted. “Aviation insurance is a specialist area that is adequately served at the moment. It is important to find insurers that are reputable and not necessarily the cheapest to ensure any genuine claims are paid out fully and quickly.,” she added. The high cost of insuring operations into high-risk zones may be discouraging some air ambulance companies from such operations, said FAI’s Volker Lemke: “Quite a few operators are tending to cease operations into high-risk areas as the safety and security situation is getting more and more unpredictable and the effort required to mitigate the risk is getting bigger and bigger.” This is in part due, he added, to ‘a decreased capital capacity in the market, where only a few insurers are able to cover the aviation risks’.

Supply and demand

For now, however, while demand for fixed-wing air ambulance operations continues to rise, there appears to be enough appetite for risk from underwriters to allow air ambulance operators to shop around for the right deal, although the high-risk end of the market remains challenging – and expensive. n


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IT’S GOOD TO TALK

Post-transport debriefs form an important part of an air ambulance company’s efforts to continually learn and improve the service they are offering, according to the experts who spoke to James Paul Wallis

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ir ambulance transport missions require team members from both the aviation and medical professions to all work in concert to make them successful. While they may well be communicating throughout the flight, a debriefing meeting held at the conclusion of the mission offers an opportunity to discuss what went well and opportunities to improve. A debrief can therefore be considered a useful tool in the pursuit of quality. David Quayle, Clinical Services Manager at Air 28 |

Alliance Medflight, suggested that debriefing is a developing trend within healthcare in general, whereas debriefs have long been used in aviation, thanks in part to the military origins of powered flight. The military background can be seen in dictionary definitions of debrief, including Merriam Webster’s, which alludes to pilots sharing information with intelligence information officers. However, in modern medical aviation, the term is used more broadly to refer to post-flight discussions.


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Continual improvement

Overall, the purpose of any debrief is continual improvement, said Paul Tiba, Managing Director of French provider Airlec Air Espace. The first aspect of this is the practical benefits, as outlined by Denise Waye, President of AirCARE1, who said that debriefs have helped the US-based provider to ‘improve processes as well as led to increased safety and efficiency of operations’. David Quayle echoed this sentiment: “The postmission debrief is usually about reflecting on what elements went well or badly so that lessons may be learned and systems (plus individual practice) improved.” Beyond the technical benefits, there are human factors at play too. Waye commented: “Properly done, mission debriefs are a fantastic tool in increasing employee morale by stating what was done well, while providing constructive feedback for improvement.” Talking over a flight is even more valuable when it’s been a difficult mission. Quayle of Air Alliance Medflight highlighted the need for staff to decompress following traumatic events, adding: “The Royal College of Nursing

(UK) states that debriefs should be available to all nurses, while the Scottish Patient Safety Programme includes the concept of the safety huddle involving all members of the multidisciplinary team.”

A debrief can therefore be considered a useful tool in the pursuit of quality

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Group approach

Providers differ as to whether the whole crew debriefs as one, or whether there are separate channels for medical crew and pilots. At AirCARE1, debriefs involve all staff involved in the flight process, including medical crew, pilots, operations centre staff and also management, said Denise Waye. Meanwhile, the communications centre performs a separate written debrief that reviews any logistical issues that may have occurred. These reports are reviewed and analysed by management and the outcomes are discussed with the communications centre

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during regularly scheduled meetings, she said. Similarly, in Colombia, SARPA also brings together medical and flight crew, said Karen Arbelaez, General Manager, with the aim being to facilitate team integration, cohesion and co-operation of both medical and flight crew. Ultimately, this promotes efficient, safe, high-quality missions, said Arbelaez. Quayle explained that at Air Alliance, however, post-mission debriefings are usually in the form of a written report for the clinical services manager and medical team and are solely related to clinical and logistical issues. The pilots report back via other systems, he said. At SARPA, debriefs are led by the flight crew captain and the medical crew chief and follow a standard pattern. The flight crew captain discusses how the mission followed or deviated from initial plans, Arbelaez elaborated: “[We can identify] if there were any difficulties or unforeseen situations presented. If there are, then we can determine what actions are to be improved for the next mission.” Similarly, the

Providers differ as to whether the whole crew debriefs as one, or whether there are separate channels for medical crew and pilots medical chief addresses any unforeseen aspects to the medical treatment and how they were handled. Arbelaez continued: “[We] will also make an improvement plan to discuss with the health services directors [so that the event] won’t present itself again.”

Constant progress

The debrief is a great way to elicit feedback and provides a forum to discuss and identify any issues, said Denise Waye. For issues that arise, staff submit a process improvement / hazard identification (PIHF) form. The form identifies the hazard or process that needs to be improved, and the crewmember can also suggest a solution.


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AIR AMBULANCE REVIEW Waye explained: “The PIHF is then submitted for review where a committee, including management, can analyse and make suggestions that can include new policies, procedures or training. Filling out and submitting a PIHF empowers a crewmember to be part of improving a process.” At Air Alliance Medflight, issues raised from debriefs are revisited in later meetings. Quayle explained: “Further exploration and discussion of events takes place at monthly clinical governance meetings in which senior managers and clinical managers (medical and nursing) review our systems and learn from any issues raised.” More systemic issues are fed into the company via its online safety management system, he added. Germany’s DRF Luftrettung also uses a reporting system for logistical issues, said Stefanie Kapp: “[For issues] regarding landing fees, costs and quality of handling agents and hotels, as well as [other] special aspects, we created a report sheet, which is filled out by the flight crew and is handed over to operation centre personnel when returning to home base. This data will be entered in our Alert Center Management System (ACMS) database and will be used as a reference for upcoming missions.” At DRF Luftrettung, the debrief is affected

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by location and time of day. Kapp explained: “In general, the guideline for the briefing as well as for the debriefing is our mission report. This report is customised to our needs by our in-house IT department via our ACMS.” However, there are two typical debrief formats. At home base, debriefing normally starts around 30 minutes after landing: “Members of the debriefing are the medical crew, flight crew and one person from the operation centre on duty

and who was responsible for the performed flight. Typical aspects are: time schedule, used airports, permissions, refuelling processes, co-ordination of patient transport and/or pick-up of medical crew, and quality of provided medical information in relation to patient’s actual condition.” Away from home base, the debrief is held in the hotel with flight and medical crew. Kapp continued: “If there are relevant points to

One challenge is for the provider to foster an environment where problems can be openly discussed in order to harness the learning opportunities


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AIR AMBULANCE REVIEW be transferred to the operation centre, it will be either recorded on the written report, or immediately given via phone.” However, if it’s late in the evening, said Kapp, the debriefing can be delayed until breakfast the following day. The question of who is involved in a debrief may be affected by what needs to be discussed. Tiba told ITIJ that where something has gone awry during a mission, the debrief should cover both logistical and medical aspects: “We would aim to find the root cause and establish a barrier / plan of actions so that it does not happen again.”

Fair treatment

One challenge is for the provider to foster an environment in which problems can be openly discussed in order to harness learning opportunities. AirCARE1 utilises a debriefing structure that focuses on improving processes. A good debriefing structure is one where everyone feels valued and that their opinion will be heard, said Waye. “This includes using positive feedback in front of everyone and negative feedback on a one-on-one basis.” The ‘Just Culture’ concept plays an important

FEATURE

role here. David Quayle commented: “For a true reflection of events to be discussed openly and with candour, it is vital that the organisation has ‘Just Culture’ at its heart. Fear of punishment for speaking out or revealing errors, even where they were created through systems of work, inhibits staff from speaking frankly about events.”

Always learning

The practice of routine debriefing is not universal. For example, Airlec Air Espace of France only conducts a post-flight debrief after a complex mission, at the request of crew members who want to communicate something; for new pilots, for example, or if something went wrong, explained Paul Tiba. Having said that, whether a post-flight debrief is held or not, the provider’s medical director reviews every case. Tiba also

Fear of punishment for speaking out or revealing errors, even where they were created through systems of work, inhibits staff from speaking frankly about events

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highlighted the role of the pre-flight briefing, which the provider does hold for every flight: “Much more important than mission debrief is our mandatory mission briefing … with the whole crew (pilots and medical crew). It is important that all the crew has the same level of information before all missions.” And while the three main accrediting bodies, CAMTS, NAAMTA and EURAMI, all call for debriefings in their standards, only CAMTS says a debrief should follow every mission: “A post-transport debrief is conducted after each transport that includes the communications specialist when communications issues are involved.” Both NAAMTA and EURAMI allow providers to use their discretion with regards to the regularity of such meetings, with NAAMTA simply stating that an organisation should have


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‘a policy’ for post-flight briefings, and EURAMI saying that ‘proper and adequate debriefing of flight medical teams’ should be provided. Waye said that mission debriefs are an important component of the organisation’s operations. She is clear in her belief that post-flight briefings can help a provider to continually improve the quality of its services. She stated: “Our company is successful due to the fact we have learned from the mistakes we have made.”

Debrief and improve

Whether they are done as a mandatory part of the post-flight routine or on an as-needed basis, the benefits of detailed debriefing meetings seem clear. For the operations and flight crews, they can ensure seamless and cohesive departures, many of which are time critical in the air ambulance sector. For the medical crew who have dealt with a particularly complex patient, the opportunity to consider what equipment was lacking – or taken needlessly, for that matter – or where a patient’s care could be improved for the next flight, offers a chance for improvement that can only benefit clients going forward. n

ACCREDITED PROVIDER ACCREDITED PROVIDER

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CASE STUDY

MANILA, PHILIPPINES PATIENT DROP-OFF

CORON ISLAND, PHILIPPINES PATIENT PICK-UP

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OVERCOMING LOGISTICAL CHALLENGES

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CareJet is a medical assistance and air ambulance provider in the Philippines, managing cases for over 65 travel insurance and medical assistance companies worldwide. Conjuring up an image of an island paradise, many travellers will visualise an imposing, rugged, mountainous skyline, protecting the wild natural beauty of jungle-clad rocks, cascading down to golden sandy beaches, caressed by stunningly clear blue water. Sounds idyllic doesn’t it? For those of you that have visited the Philippines and, in particular the unspoilt beauty that is Coron Island, Palawan, you may feel that you’ve already found that paradise. Coron is growing in popularity with travellers seeking a stunning holiday escape mixed with a little bit of adventure – it is one of the most-visited destinations for wreck diving in the world and the sunken Japanese shipwrecks of World War II off Coron Island are listed in Forbes Traveller Magazine’s top10 best scuba diving sites. If one of the pleasures of paradise is that you get away from the hustle and bustle of cities, traffic and pollution, then one of the few downsides is that should a significant medical emergency occur, you can find yourself isolated and requiring specialist support to transfer you to a suitable hospital for treatment.

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CareJet describes a medical evacuation from Coron Island, Palawan, to Manila An

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When trouble strikes in paradise Our CareJet team was contacted on 26 March 2019 and advised of the need for a medical evacuation for a client from a hotel in the relatively remote location of Coron Island, Palawan. We were quickly able to perform a verbal medical consultation with our Medical Director to determine the nature of the emergency so that we could obtain the necessary approvals and documentation to ensure that the patient was fit to fly. Following a fall, the patient had sustained a number of injuries, the most serious of which had been diagnosed as a fracture to the Medial Tibial Plateau. With a clear understanding of the patient’s condition, we were able to select and prepare the appropriate medical team and brief them with a carefully crafted evacuation plan on the complexities of the patient evacuation, in particular the logistical challenges of the location and terrain on Coron Island. On 28 March, our King Air 350 aircraft landed with the medical evacuation team at Busuanga

Airport. We were met by our long-time ground ambulance partner on location in readiness for the drive to the patient’s hotel. Having completed numerous medical evacuations from the area in the past, team knew already how challenging the evacuation was going to be.

Getting there

The outbound journey was a 55 km drive, which on a developed expressway in a metropolitan area would usually take around 45 minutes. The drive on Coron Island, however, was through a network of partly surfaced, provincial roads – zig zagging, extremely challenging terrain which meant it took more than two hours for the team to reach the destination. It’s at times like this that local knowledge is key to meeting expectations of insurers and their clients – a company unfamiliar with the route to the hospital may have given an unrealistic arrival time for the medical team, meaning disappointment and frustration for the customer. The walkway from the parking area to the hotel itself added an additional challenge – it was a long, winding, uneven path consisting of a stone base that had been molded into steps – this was the only route that was available to transfer the patient from the hotel to the ground ambulance.


AIR AMBULANCE REVIEW

case study

Flight inbound

From hotel to airport

Having reached the patient, our medical team removed the temporary elastic banding and dressing to further evaluate the injury. There was significant swelling and redness on the left knee, and the leg was supported with a long leg posterior mould. Even after administering oral pain medication, the patient was still in significant discomfort. In order to avoid any further damage to the fractured area while being transported along the rugged terrain, the medical evacuation team decided to immobilise the patient’s left leg further. Moving the patient would be more complicated as a result, but their comfort and welfare, and minimising further damage to the injury, were paramount.

Roller bandaging was re-applied and the patient was transferred onto a Vacuum Mattress (VacMatt), and with the support of the hotel’s emergency support team, we were able to carry the patient several hundred metres back along the stone pathway to the ambulance. Our medical team, with a clear understanding of how uneven and challenging the ride back to the airport would be in the ambulance, implemented the appropriate pain management protocol with continuous monitoring of the patient, and having intravenous pain medication (PRN) suitable for the patient’s weight ready, should it be required. In this instance, we were pleased that the additional protection around the injury and the expert driving skills of our partners meant that escalated pain management was unnecessary. Transportation of the patient from the ambulance onto the aircraft brought another logistical challenge. The VacMatt was doing an excellent supporting job, so with one member of the team assisting from inside the aircraft, four other team members carried the patient on the VacMatt and carefully manoeuvered them through the narrow aircraft passenger door.

CareJet air ambulances are fitted out with critical care equipment and our team was able to make the patient comfortable for the flight back to Manila. Our ground ambulance partner in Manila was there to meet us and we completed the journey with the patient to a partner hospital, Makati Medical Center, a Joint Commission International-accredited tertiary hospital with stringent safety standards and excellent patient care. The patient was very relieved to be settled at the hospital after the lengthy journey and grateful to the CareJet Team for the professional way in which the evacuation had been managed. All that was needed now was a period of recovery and the journey to repatriate them to their home country.

Meeting client needs

As travellers seek out new adventures in more remote parts of the world, it’s clear that emergency medical evacuation support is becoming increasingly important. Having multilingal case specialists working around the clock to assist travellers with doctors’ appointments, guarantees of payment, inpatient hospitalisations, outpatient consultations and medical evacuations both in remote locations like this one but also in large cities, are key to ensuring a prompt service is offered to international insurance company partners. n Anthony Decoste is President and CEO of CareJet, a leading air ambulance and medical assistance provider in the Philippines. He founded CareJet to make quality healthcare accessible to travellers all throughout the archipelago. A long time resident of the Philippines, Anthony holds a Doctor of Business Administration degree and serves on the boards of several non-profit organizations that aim to make healthcare accessible and affordable to the community.

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“GJC’s experienced flight crew members have performed 1000’s of patient transports. Their vast experience with different types of patient conditions gives them the expertise required to react to unexpected medical emergencies that can occur while 40,000 feet in the air.” 38 |


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Speed is of the essence in many critical cases, and as such GJC’s ability to move patients within as little as 24 to 48 hours is so important and unique. This swift turnaround gives customers the ability to ensure patients are moved to a higher level of care facility and also can be taken to their home country for care and to be with family. Additionally, GJC has the ability to transport a family member with the patient at no additional cost. This is very important often to the stability of the patient and ensures that they feel safe throughout their flight. Patients and family members traveling with GJC know that they are in truly safe hands. The firm’s flight coordinators are experts in what is required to move patients from one country to another. GJC’s experienced flight crew members have performed 1000’s of patient transports. Their vast experience with different types of patient conditions gives them the expertise required to react to unexpected medical emergencies that can occur

while 40,000 feet in the air. Their vast knowledge on how to use applications to translate any language allows them to communicate around the world. This is critical to working with personnel from airports, hospitals, ambulance services as well as patients and family members, and ensures that every flight goes completely according to plan and that everyone involved feels comfortable and supported when they fly with GJC. Additionally, with so many regulations and rules, it is important to know the routing, permits and contracts to be able to navigate the world as safely and efficiently as possible, and as such GJC leverages its team’s expertise to ensure a safe flight every time. All of these services are provided at accessible rates, enabling the firm to welcome a wide variety of patients and their families on board. Due to the high volume of transports GJC undertakes, the firm is able to offer customers optimum pricing by connecting

multiple transports together. Often the company can give one-way pricing from locations as a savings of thousands of dollars to insurance companies and private families. Alongside its high number of transports, the firm also benefits from its central location. Being based in Florida, GJC is centrally located between Asia, Europe, Canada and South America. This allows the firm the ability to move patients cost effectively from the United States to and from these locations. The team are also able to move patients from non-US locations such as South America to Europe. For those patients that are traveling from further afield, GJC’s collaborative approach ensures that they receive the standard of service and support they need. The company has partnered with other trusted Air Ambulance companies from locations such as China, India, Europe and South America to perform wing-to-wing transfers when time is of the essence or

the patients’ condition is better treated by local experts. Recently, GJC had its 5th Learjet put into service, and with worldwide capabilities the vehicle will allow the company to expand its operations even further in the future. The aircraft has been fully equipped with the latest avionics and advanced medical equipment to transport patients with special needs for long distances. As such, it will be able to help the firm to offer even more transports to patients around the world over the years to come. Ultimately, GJC is driven to provide the highest possible standard of care and service to patients, their families and insurance companies, and this will remain the firm’s core focus as it looks to a bright and opportunity filled future. With demand for private air ambulances increasing the firm has many chances to grow and adapt to its customers’ everevolving requirements.

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Web: Address: globaljetcare.com

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AIR AMBULANCE REVIEW

CASE STUDY

SPAIN PATIENT DROP-OFF

MOROCCO PATIENT PICK-UP

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A trauma case in Morocco demonstrates how working for an air ambulance company dealing with foreign repatriations requires the ability to navigate a wide range of unexpected circumstances on arrival to the patient. The medical information received prior to arrival can be incorrect, incomplete or, as in the case described below, the situation of the patient can deteriorate. Dr Kerry Hunter, Senior Flight Doctor of Capital Air Ambulance in the UK, reports

A

s our Learjet 45 touched down on a sunny and calm landing strip in Morocco, we transferred ourselves and our intensive care kit into an ambulance and drove to a small district general governmental hospital. The information that we had received described a young man who had fallen from a three-storey building four days earlier and sustained a large extradural bleed. This had been drained in theatre and the CT report at that time stated that there were no further spinal injuries and a fracture of the ischium. 40 |

Deteriorating conditions

Waiting outside the intensive care department we were met by some concerned family members and the grave face of the resident ICU doctor. Apparently run ragged as the sole doctor covering a busy 10-bed ICU department, he was trying his best to keep control of his patients and had clearly been up all night. He had minimal nursing support and resources were scarce. He informed us that the patient had deteriorated overnight. He had become septic, spiking temperatures of 38.5oC and a

lumbar puncture had returned positive for bacteria, indicating a meningitis – an infection inside the brain cavity as a result of either the previous brain surgery or frontal skull fractures allowing the entry of bacteria. He was already on appropriate broad spectrum antibiotics to cover the meningitis. His routine bloods from that morning had also returned and had showed a massive acute drop


AIR AMBULANCE REVIEW

case study

in his haemoglobin level from 12 to 6.1g/dL – he was bleeding from somewhere internally and he was critically unwell and unstable. Before doing anything else we arranged for an urgent blood transfusion. Blood in many countries globally is a scarce resource, but with the support of the hospital manager, authorisation was given to allow for blood to be retrieved from the blood bank. The only intravenous access in-situ was a very thin bore femoral line, which allowed for only the very slow administration of fluids, so we placed two wide bore peripheral cannulae to allow for the rapid transfusion of four units of blood and tranexamic acid. We also placed an arterial line for closer monitoring of his cardiovascular parameters and to take off blood samples. He very quickly pinked up following the transfusion and his cardiovascular parameters stabilised, albeit perhaps temporarily. His ventilation was also problematic – he had severe bilateral atelectasis – probably from a lack of repositioning and suctioning. Despite efforts to re-recruit he had poor lung function and was requiring 70 per cent oxygen. The next problem was to work out where the bleeding was coming from. To have dropped his haemoglobin level so acutely he must have lost

the hospital did not have the facility to run blood gases, so we used our bedside iStat machine to test his haemoglobin level

several litres of blood. There was no bleeding visible. The cranial cavity would not be able to conceal such a large quantity of blood. His respiration on the ventilator and oxygen requirements had not worsened and examination did not show any signs of a haemothorax. There were no signs of obvious lower limb injury which could be concealing blood loss, which left the abdominal and pelvic regions as the potential sources of bleeding. In order to differentiate between these sites, we organised an urgent CT scan. This presented many logistical hurdles which we had to overcome, as the hospital did not have any portable ventilators or oxygen cylinders, so we transferred the patient over onto our portable equipment. This also required a lot of coordination with the local staff in order to make this happen. The CT was not up to the level of a usual trauma scan, but we were able to ascertain that the bleeding was coming from the pelvis due to fractures of both the ischium and trochanter and that an unstable pelvic fracture had been missed on his initial assessment. A pelvic binder, which provides pressure to squeeze the pelvis inwards in order to prevent further blood loss, was not available, so prior to transfer to CT we folded a bed sheet and wrapped this around the hips, maintaining tension with an arterial clamp, an act which has much the same effect. We transferred him onto our vacuum mattress with the intention that this would also provide a degree of pressure on his

pelvis to prevent further blood loss. The hospital did not have the facility to run blood gases, so we used our bedside iStat machine to test his haemoglobin level, which had now increased to 9.9g/dL following transfusion. His sodium was increased at 159mmol/L, suggesting that he was still very dehydrated and that his true haemoglobin if he was normovolaemic would in fact be lower than this. At this point we had replaced the critical blood loss, ascertained the source of bleeding and hopefully temporarily controlled the bleeding. This was however, only a stop gap prior to definitive treatment, which would require an operation to fixate his pelvis and thus prevent further catastrophic blood loss.

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AIR AMBULANCE REVIEW

Careful co-ordination

A conference call was rapidly arranged between our team on the ground, our senior medical team back at base and senior medical representatives from the insurance company organising the repatriation. Amidst the din of the hectic ICU unit, we managed to relay the necessary information as to the current situation and a concerted decision was agreed upon. Much of medical repatriation is based upon the decision to transfer a patient to the most appropriate place of safety. It was clear that despite the best intentions of the team in Morocco, they did not have the ability in their resource-poor environment to provide the best level of care to the patient. There was a general surgeon on call, but he did not have the capabilities to perform complex pelvic surgery. They had limited blood products available in their blood bank if he were to continue bleeding. Despite his instability, it was not an option to leave him where he was. On the other hand, if we were to fly him in our air ambulance, we would also have no access to blood products during the transfer, which would take 42 |

CASE STUDY

several hours. The flight would also involve flying over multiple safe places of care – trauma referral centres which did have the ability to stabilise his pelvis and provide a high level of intensive care management. We decided, therefore, to fly to the closest hospital that could provide an optimal level of care. We received military permission to fly to Gibraltar and from there a Spanish ambulance met us on the tarmac and we made the short drive to a Spanish hospital, where around 10 experienced trauma team members were waiting gloved and gowned up with open arms ready to accept our patient. Within minutes they had whisked him off for a full body trauma

CT scan, from where he was directly admitted to ICU and that night was operated on to stabilise his pelvis as well as providing optimal neurological treatment for the meningitis. Two weeks later he was stable enough to allow for his safe transfer back to the UK.

Closest appropriate care

This case demonstrates the utmost importance within the field of aeromedicine to make appropriate decisions as to the safest place of care for patients, a decision which must take into account many variables and is relative to the current situation of the patient. As so often is the case, this decision comes down in a large part to the ability to communicate effectively within a supportive team environment. This makes the difference between a potentially stressful situation running out of control, to an immense amount of job satisfaction and allowing for a management plan which is the best available option for the patient. n Dr Kerry Hunter is a senior Flight Doctor with Capital Air Ambulance and has been working with us since September 2019 on a par t time basis. When she is not working for Capital, she works as a senior NHS Anaesthetist in Edinburgh.


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