Guide to Medical Evacuations

Points to remember

Medical escort staff are specialists

Care of the patient in the air and on the ground while travelling is far harder than care of the same patient in a hospital, clinic, or home. The following are some of the complications faced by medevac crews:

• The operating platform is noisy, unstable, and cramped
• Privacy is non-existent
• The environment is often dirty, hot, and without basic utilities such as power and water, let alone a flat area to carry out sterile procedures
• Trained personnel are often lacking and the untrained are often panicking
• Basic medical techniques such as blood tests, X-rays and ultrasound are quite impossible
• In the case of air and sea transportation, the environment may induce physiological changes in even healthy people that are magnified by the physical changes caused by disease
• The patient needs to be escorted by at least one staff member that can speak his native language.

Therefore, we cannot and do not pick our medical escorts from just anywhere. Being a friend of the family, even if medically qualified, is not a valid reason to escort a patient.

Medical escort staff have to be called in at short notice

Doctors are needed who are experienced in preparing and executing medical evacuations. A medical escort should not be a doctor or nurse only used to working in hospitals who is unaware of the logistical and medical difficulties associated with transporting sick patients.

Trained professionals are in short supply and cannot be waiting on call for when a medical evacuation is required. The only way this is feasible is when a large urban hospital in a highly-developed country, supported by taxpayers and/or private donations, is prepared to release its medical staff on a rostered basis for such work. Even then, these medical flights are almost universally limited to under 30-40 minutes from home base. (The Flying Doctor service in Australia is actually no exception; while medical teams cover a very wide area, they are solely employed in this service and funding is provided by both private and public sources). There is consequently a short and unavoidable delay, as medical staff cannot simply abandon their patients and their work.

The medical equipment needed is far from ordinary

Medical equipment specialized for use in the medical evacuation environments is also needed. All equipment must be light, compact, robust, and battery-operated, all specifications which mean that double or triple the cost of traditional hospital-based equipment.

When two or more patients (or indeed two or more medevacs) need to be supplied at the same time, such equipment must be expensively duplicated, and then more sets bought and kept ready as backups. In a tropical environment, breakdowns are more common and equipment has to be sent overseas for servicing, increasing downtime. And then before each evacuation all medical equipment needs to be checked, as you can’t send out for spares while en route.

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

In our area of operations, there are no public-owned air ambulances available as governments and health authorities do not consider these a funding priority. The cost of us providing such an aircraft on permanent standby in Singapore is huge, covering not only the fixed costs associated with hangerage, crewing, maintenance and apron fees but also the lost opportunity cost when aircraft on standby are then unavailable for other operations.

Should companies wish to reduce the delay in launching a medevac to an absolute minimum, the answer is to put an aircraft with flight and medical crew on permanent standby and absorb the cost. Otherwise, if not done by our Singapore-based air ambulance, the evacution will be carried out in another aircraft chartered for the mission. This necessitates a reliance on the outside air operator’s crew availability and speed of response; and also builds in additional and unavoidable delays while medical equipment is transported and stowed safely on board.

Proper installation of equipment and consumables is paramount. When the aircraft hits a patch of turbulence, encounters tropical squalls or even icing conditions (entirely possible even on the equator when the outside air temperature is below four degrees Celsius), you definitely don’t want to share an aircraft cabin with loose steel oxygen cylinders or a wayward electrocardiograph.

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

A smaller aircraft is cheaper, and will burn less fuel, but fly more slowly and need to refuel more often. The majority of all fuel burnt is consumed getting up to an efficient flying altitude where the air is thinner and friction reduced. A smaller aircraft will need to climb more often and cannot reach as high a cruising altitude, and as such may actually be more expensive over a longer flight.

A jet will travel faster than a turboprop aircraft, but will require greater runway length for take-off and landing as well as a higher-quality runway surface. An unpressurized aircraft makes loading easier and allows for larger emergency exit doors. However, such an aircraft is noisier, slower, and a poor choice medically for illnesses or injuries where the effects of altitude can be dangerous or lethal.

More expensive aircraft also carry weather radar and can avoid much bad weather; this is essential as none of the commercially-available business jets that are the backbone of civil aviation fleets can match the maximum altitude attainable by the big Boeings and Airbuses, and military aircraft that allow larger airlines to provide a more comfortable ride.

Aircraft and helicopters cannot go where they should not go

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

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

Sadly, I have personally witnessed people trying to do one or more of the above…

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

The most important law is that of gravity. Time spent checking the aircraft pre-departure is not time wasted, as if the engines stop gravity cannot be reasoned with. Additional unnecessary passengers and luggage (as opposed to medical equipment) increase fuel burn and flying time. Civil laws are equally important.

A medevac is NOT a mercy dash and authorities do NOT condone associated illegalities. The fact that an aircraft is on a medical evacuation flight does not allow the patient, pilot and crew to ignore the laws of the country. There is NO regulation or agreement that allows visa- and passport-free entry into a country simply because there is a patient on board that aircraft. There IS a regulation that allows a pilot to declare a medical emergency and land in a country for which the plane and crew did not previously file a flight plan or carry visas – but ONLY if this emergency occurs and is declared in-flight.

If before take-off the patient or passengers do not have valid passports and exit/entry permits, at the very least there will be delays. In some cases, the medevac may be cancelled by the authorities and/or the aircraft and crew impounded. For this reason, passports should be scrupulously checked and we request copies or originals of passports be available as early as possible in an evacuation. Furthermore, observation of customs regulations often requires that all medical equipment leaving and entering a country be declared to the appropriate authorities.

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

Our medical teams always aim to arrive at the aircraft before the aircraft is ready; but for the logical and cogent reasons outlined above we do not “hurry up” professional air crew doing their job, both before and during flight. Flight times vary widely for any number of reasons, such as:

• Head winds
• Tail winds
• The need to go around weather
• The need to avoid restricted air space, especially for military reasons
• The need to refuel
• ATC (Air Traffic Control) restrictions on sharing airspace with large military/civilian aircraft to lessen mid-air collision risk and avoid wake turbulence (which behind a 747 can trail for 4 miles!)

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

Time spent after arrival with the patient, even if it delays expected take-off time, is never wasted. These medical crew may need to:

• check the patient’s medical history, as well as perform examinations and clinical courses required for medical procedures
• set up monitoring equipment
• load the patient safely
• report back to us with update in case the destination and mode of delivery from the airport to the receiving hospital need to be changed

International law requires every aircraft to fly with a passenger list. If we do not have passenger details before initial dispatch of the aircraft, this requirement adds delay at the retrieval site.

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

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

OK, so what does this all mean?

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

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

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

The ultimate safety blanket

If you want the option of an instant medical evacuation response, we can have an aircraft, pilot and medical crew on 24-hour standby on your site. Be prepared for a bill commensurate with the availability and expertise provided at a moment’s notice.

If you have any further questions about your medical care in Indonesia, see the Ask the Experts.

We trust this information will assist you in making correct choices regarding your health and welfare. However, it is not intended to be a substitute for personalized advice from your medical adviser.

Our appreciation to International SOS, an AEA Company who has contributed this article to help prepare expatries for medical evacuations from Indonesia.