General considerations

In this chapter we will pay special attention to the air transportation of patients suffering acute disorders and their follow-ups. Air transportation of disabled and chronically ill patients will be dealt with in Chapter 5.

The majority of patients receive primary treatment or full treatment from a local physician or at a local hospital.

Non-urgent repatriation from a foreign hospital to a home hospital is therefore the most common form of transportation.

Repatriation at short notice is often necessary if one chooses to transport the patient home for primary treatment.

Urgent repatriation is only necessary in few cases. For the most part, this will involve the evacuation of sick patients from places without the correct facilities for treatment or with very poor facilities. In these cases an air ambulance is often used.

The moving of patients abroad for primary treatment may have to be undertaken when the sick patient is at a remote location without facilities. In these cases one often makes use of the services of local air ambulance companies who, with the help of the relevant physician and escort nurse, are able to evacuate the patient to the closest location with reasonable treatment facilities.

Assistance organisations

In some cases the patient and the treating physician will make the transport arrangements themselves.

However, most patient transportation is arranged and carried out by assistance organisations, which have the necessary experience and contact network, as well as the requisite medical personnel able to evaluate transportation needs and escort the patient. Besides the detailed planning of the transportation itself, the staff must also ensure that the patient has a passport and that any required visa extensions have been obtained, etc.

This means that the work in the assistance organisation is a close teamwork between a lot of different professions.

Scrupulous planning of the transportation is a prerequisite for successful execution.

The medical evaluation of the patient

The function of the consulting physician

In cases where the patient’s condition is of a serious nature, a medical evaluation of the patient is necessary before taking a decision as to how and when transportation will take place.

This evaluation will normally be made by an experienced physician attached to the assistance organisation – the consulting physician – and who, besides having aeromedical experience, also speaks the relevant language.

The gathering of information

It is the consulting physician’s task to obtain, via telephone, internet, fax, etc., the broadest possible insight into the patient’s condition, and thus to reach a decision as to when and how the patient will be transported.

If the patient has not been admitted to hospital, normally only one physician will have been attending him, thus facilitating the task of information gathering.

If the patient has been admitted to a large hospital of reasonably high standard, it is, as a rule, easy to obtain relevant and correct information from the physicians giving treatment. Should the patient be in a small hospital with scant facilities for examining patients or perhaps with poorly trained physicians, it may be difficult to gather the requisite information.

 

It can often be difficult to contact a physician who is sufficiently familiar with the patient’s condition. In such cases the consulting physician may also use information supplied by other employees of the hospital, by the patient him- or herself, by the tourist guide, or perhaps by a close relative in order to form a better idea of the patient’s condition.

It is a good idea to ask the patient whether he feels capable of going through the planned transport. This can sometimes lead to the discovery of disabilities or injuries that should be considered in the total assessment.

If the patient has been admitted to hospital in a more exotic location, the language barrier may be a problem. In such cases the consulting physician may often obtain help from a local assistance organisation that employs physicians with sufficient knowledge of the local language.

If the consulting physician does not feel it is possible to obtain adequate information or he is not sure of the accuracy of the information he has obtained, it may be necessary to send out an experienced escort physician to make an on-the-spot evaluation of the patient’s condition and pass on the required information to the consulting physician.

Evaluation

When the consulting physician has formed an adequate picture of the patient’s condition, he will present – usually with the agreement of the treating physician – a transport description to the assistance organisation’s employees. This contains a complete description of the transportation from the patient’s place of sojourn to the home hospital/delivery point.

Escorted transportation has to be specified by the consulting physician so that, within reasonable limits, those complications which the patient may be in danger of developing during transportation can be sufficiently treated. The specifications that the consulting physician has to further consider include the choice of transport, disposition of patient, escort(s), equipment, etc.

The assistance organisation will use the transport description to plan all phases of the journey in cooperation with the airlines, etc.

In this book “commercial airline” is used for “scheduled airline” as well as “charter airline”.

 

The transportation description

The transport description can be divided into the following points:

• Time of transport

• Principal means of transport

• Disposition of patient

• Type of escort

• Transport to and from aeroplane

• Transport and sojourn inside the airport

• Pick up and delivery points

• Equipment

Time of transport

The earliest and, where applicable, the latest time when transport is to be undertaken.

Principal means of transport

The principal means of transport will be by commercial airline. Only in a few cases will ambulance flight be the chosen means of transport. Overland transport by ambulance can be used only when short distances are to be covered. The choice of means is usually based on a combination of financial considerations and feasibility. The patient’s health and recovery come before anything else; however, if these are not affected by choosing a cheaper yet reasonable means of transportation, these should be chosen.

By far the majority of patients can handle a journey by commercial flight.

Listed below are the most important considerations to be taken when choosing the principal means of transportation:

Scheduled airline:

– The extensive network.

– The ability to arrange transport rapidly.

Charter airline:

– Often allows the patient to be repatriated without change of aircraft.

– Is often the cheapest alternative.

Air ambulance:

There are two different reasons for using an air ambulance:

Medical causes: Cases where an air ambulance is chosen for medical reasons.

Logistic causes: Cases where an air ambulance is chosen for non-medical reasons. 

(Look at Chapter 4, Transport by Air Ambulance).

PTC – Patient Transport Compartment (equivalent to air ambulance):

This is a fully equipped 6m² transport cabin with the same intensive care equipment as an air ambulance. The PTC is only offered by a single airline company (Lufthansa) on their long distance flight leaving from and going to Frankfurt.

The advantages are: fewer stopovers, more room, and a price that is approximately half of the cost of an air ambulance travelling the same distance. That being said, it can only be used on few services. Furthermore, one should take into consideration that an air ambulance will usually be needed from Frankfurt to the final destination – and maybe even to get to the airport of departure.

Disposition of the patient

Seated

Chosen only in those cases where the patient is able to sit up during the whole journey.

Seated with two seats

Patients who, for example, are not able to bend their knee because of a long leg cast must have two seats reserved for them. The second seat will generally be the one in front of the patient; the backrest is folded forward so the patient may rest his or her leg on it. These patients are usually considered as disabled and are hence seated in specific seats for disabled passengers. Often, it is more comfortable to sit in two or three seats side-by-side, placing the immobilised leg on the seat/seats beside you.  In such cases it is very important to note which leg is injured, making it possible to reserve seats in the left side of the plane if the right leg is affected or in the right side if the left leg is affected.  Three seats side-by-side are only possible in some planes. To be able to use side-by-side seats the patient has to be able to sit upright with his feet placed downward and forward during take-off and landing. This limits the possibilities of using side-by-side seats.

Seated at take-off and landing, partly recumbent/fully recumbent on long distance flights

For weakened patients capable of sitting upright during take-off, landing, and air turbulence who are going on long intercontinental flights, business class or 1st class may be preferred to a sleeper. On all long distance flights, the passengers in business class or 1st class are seated in seats that can be laid down partially (flatbeds) or totally (full-flat). Basically, all seats in 1st class can be laid down totally (full-flat).

It is important to check with each specific airline company which seats can be offered based on the knowledge of the patient’s condition.

As patients should not be an inconvenience to their fellow passengers, these classes can only be used by patients not needing any actual treatment or care during the flight.  They have to appear normal in regards to mental health, odour, and clothes.

Recumbent

In the transportation of recumbent patients by commercial flight, the stretcher is normally placed at the back of the aircraft, fixed on 3x2 or 3x3 seats, or resting upon its own stand. The stretcher is provided with a curtain and made up with a mattress, sheet(s), and blanket/quilt, together with a pillow. The patient will usually be strapped to the stretcher by a system of safety belts, including shoulder straps. More and more airlines now transport the patient with the head facing the direction of flight.

Airlines generally require that a nurse or physician escort the patient.

If a child is to be transported on a stretcher, the escort must bring a special system of safety belts made for children.

Lying across three seats side-by-side is not accepted.

Type of escort

Most patients can travel unescorted and will normally require no or only a few additional arrangements, such as a wheelchair at the airport. Thus, this requires that the patient be able to take care of him- or herself during the flight and not need any help from the cabin crew.

The following people may be used as escorts: close relatives, other non-medical escort, nurse, physician, or any combination of these.

The consulting physician will specify the nurse’s or the physician’s specialisation if the patient’s condition should require the presence of such.

Close relative

A close relative can often be used in the case of minor illness, where the patient is otherwise healthy. They can, however, never be used as the only escort for a stretcher transport.

Non-medical escort

A non-medical escort other than a close relative is generally not to be recommended as the sole escort. They may only be used as travel guides for a healthy person who, for example, because of language difficulties, is not able to make his own way through the airport.

Nurse

A nurse may only be used for a patient in a fully stable condition (both physically and mentally), where treatment and medication, in  cases where it is necessary, can be arranged in advance in agreement with the consulting physician. Thus, a nurse may not be sent out in those cases where there is a reasonable expectation that a medical evaluation will have to be made during the transport.

Physician

A physician is employed as an escort in those cases where the patient’s condition renders necessary ongoing evaluation throughout the journey. The physician is responsible for bringing the medication needed en route, and for ensuring that during transportation any equipment he may have brought is fully functional.

Physician and nurse

The combination of physician and nurse is often necessary for seriously ill patients who require constant supervision or treatment. Patients who may need intubation must always be escorted by both an anaesthetist and an anaesthetic/intensive care nurse.

Such transports are almost always undertaken by an air ambulance.

In transports requiring that the patient be under constant supervision (including patients with mental disorders) and where the total time used for transportation is more than 6-8 hours, the patient should be accompanied by two escorts. For most airlines this is a demand.

Provisions relating to escorts

Vaccines

We recommend that escorts who travel on a regular basis be at all times protected by the relevant vaccinations and, as a minimum requirement, be up to date with vaccinations against hepatitis A and B, diphtheria-tetanus, and yellow fever, as this is required for entry into some countries.

Vaccination is important, partly as a protection for the escort and partly to ensure that he or she is able to travel at short notice.

 

Resting time

In those cases where transportation is not of an urgent nature – which is most often the case – the escort shall have a reasonable period of rest before the repatriation of the patient.  Resting time exists to ensure that the escort is sufficiently rested so as to be able to properly and professionally carry out the tasks arising from the transportation.

A lot of time is often spent on transport going to and from the airport, on attending to the patient in the hospital, speaking to physicians, making sure that everything is ready for the transport, etc. It is important that the assistance organisation take all these things into consideration when planning the trip so it does not affect the escort’s resting time.

Transport to and from aircraft

Taxi and car with a stretcher

Taxis go only to and from the airport gate and never to the aircraft itself.  In some locations one needs to order a stretcher-car. This can be regarded as a taxi with a stretcher. It does not have any ambulance equipment and only holds one chauffeur. It can therefore only be used for patients whose only problem is not being able to sit in an upright position.

Ambulance

To be requisitioned if the patient needs transport in a recumbent position all the way to the aircraft door and normally means that the patient can be carried on board to the stretcher or seat in the aircraft.

Helicopter

In certain cases helicopter transportation to and from the principal means of transportation can be an advantage if the roads are bad and the airport is distant. Certain hospitals have helicopter-landing pads.

Transport and sojourn inside the airport

Wheelchairs

Requisitioned if the patient cannot walk through the airport or if the patient is weak and finds it difficult to manage the long distances at airports. Airline or airport personnel will look after the wheelchair patient all the way from the check-in desk to the aircraft. This can benefit elderly passengers who may have difficulties in finding their way through a large airport.

When reserving a “wheelchair at an airport”, one should specify as follows:

• WCHR = The patient can board from the gate by him- or herself.

• WCHS = Patient is to be carried on board but can make his or her way to seat.

• WCHC = Patient is to be carried to seat.

Ambulance

If a stretcher patient must change aircraft, an ambulance should normally be requisitioned at the airport for this purpose. If the waiting time is short, the patient will normally remain in the ambulance, but, during a long stopover, the patient will be driven to a medical service centre or sick room at the airport.

Medical service centre

Most large airports have a medical service centre staffed by medical or paramedical personnel. Patients in transit may generally rest in a hospital bed in such centres.

Sick room

Smaller airports often have unstaffed sick rooms where the escort may take the patient.

Rest room

In most large airports there are a certain number of rest rooms primarily set aside for elderly patients who may use the facilities to lie down during a long stopover. Less seriously ill patients, who are travelling without an escort or perhaps with a close relative, can also benefit from the use of these rest rooms.

Pick-up and delivery points

In the transport specifications, the patient’s pick-up point (hospital, hotel, holiday home) and delivery point (hospital, home) should be carefully recorded.

In the case of escorted transportation, it should be noted whether the escort shall be present during the whole transportation, or just during the flight stage. Recumbent patients do not always require an escort between airport and hospital, as the ambulance personnel will suffice for this.

However, there are many advantages to be had if the escort is in attendance during the whole journey:

- The escort can ensure that the patient’s condition is as described and also that he is in a fit state     to be able to travel   as planned.

- The escort can ensure that all relevant documentation, medical files, X-rays, etc., accompany         the patient.

- The escort can ensure continuity of treatment.

- The patient feels more secure with the escort present during the whole journey.

Equipment supplied by commercial airline

Basic equipment

Stretcher with mattress, sheet(s), blankets, pillow, and curtain.

The stretcher usually – but not always – comes supplied with a bedpan, urinal, or urine bottle. It is important to check that the airline in question supplies such articles; otherwise the escort shall bring this equipment him- or herself.

Equipment that must be ordered in advance

Electricity supply:

Most of the equipment that the escort needs to bring runs on batteries, though some equipment will require an external power source, usually 12V DC or 220V AC.

Many airlines are unable to supply electricity. If a power supply is required, one should, during the planning phase, ensure that the airline in question is able to supply power.

Moreover, it should be noted that all electrically-powered equipment must be approved beforehand by the airline. Most airlines have lists of approved equipment.

Oxygen supply:

Delivery methods:

Oxygen bottles with fixed output, usually to 2 or 4 liters / min.

Oxygen concentrator with flow meter, usually provides 0-4 liters / minute. Requires power.

"Oxygen-on-demand". It is a very oxygen-saving system in that it only releases oxygen when the patient inspires. This allows for a much smaller amount of oxygen (about ¼) compared to the systems that give continuous flow. The oxygen is delivered via a nasal catheter. The system arrangement results in, that it cannot be used for:

- patients who cannot breathe through the nose

- troubled or confused patients

- children under 7 years

Since most airlines now use "Oxygen-on-demand", it is important to ensure that the patient does not belong to one of the above patient groups when ordering oxygen.

“Oxygen-on-demand” may well be set to deliver continuous flow, but this means that at 2 liters / minute it can only last 5 hours and at 4 liters / minute only 2½ hours. However, the longest permitted flight time for this setting is only 4 and 1½ hours respectively.

People who need oxygen in flight and who are used to administering the oxygen delivered can travel unaccompanied. If not, they should be accompanied by a person who can, usually a nurse.

Ordering oxygen:

If the patient needs oxygen during transportation, it should be noted using MEDIF expressions such as litres oxygen/min. continuously or non-continuously.

• Litres oxygen/min. continuous flow:   

   The airline will then carry this quantity of oxygen along with a normal reserve of 50% in case           flying  time should be prolonged. If the patient also requires oxygen on the ground, the airline         needs to be informed.

• Litres oxygen/min. non-continuous flow:

   Airlines interpret this type of order in a wide variety of ways. On occasion, they will supply as         little as 20-30% of the continuous flow amount. We must, therefore, advise against ordering           “non-continuous flow oxygen”, as one does not know what will be supplied.

The amount of oxygen and the type of output (high pressure/low pressure) different airlines are able to supply vary greatly. Some airlines do not even supply oxygen. This may be a crucial factor in deciding whether a particular airline can be used at all for the transport.

Equipment supplied by the assistance organisation

Equipment that must be ordered in advance

The assistance organisation should be in possession of, or be able to procure at short notice, the equipment listed below. In this list we name single instruments or sets of instruments, relevant parts of which can be packed together in cases or boxes according to the necessities of the individual transportation.

•  Standard medical case   

    Contains sphygmomanometer, diver’s probes, catheterisation equipment, etc.

•  Infusion and injection equipment

    Drip preparation equipment, essential IV fluids in plastic bottles, together with a pressure bag        for  high-pressure IV infusion, box for the disposal of hypodermic needles, ampoules, etc.

•  Intubation and ventilation equipment

•  Humidifier

    Where possible a self-humidifier is to be preferred. Certain airlines can supply humidified oxygen.

•  Ventilator

    Commercial flights rarely accept a ventilated patient and therefore most of these transports are

    carried out by air ambulance.

•  Pulse oximeter

•  Suction apparatus

    Usually electrically powered with a large battery capacity if there is no outside power supply.

•  Pleura drain

    Including equipment for the installation of the drain, together with one-way valves.

•  ECG-monitor

•  DC-defibrillator

•  Nurse’s case

    Containing diver’s articles for the care of patient en route, wash cloths, diapers, etc.

•  Vacuum mattress

•  Traction-splint

    To maintain the extension of fractures in the lower extremities during transportation.

    Traction is applied between the ischial tuberosity and the foot. It should be dynamic, e.g. based      on air hydraulics.

•  Collar

•  Incubator

    Almost all transport needing an incubator takes place with an air ambulance. This theme will be 

    described in more detail in chapter 16.

Equipment in air ambulance

See chapter 4.

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