A test of resolve

Dr Gert Muurling of GlobalMED tells us of a repatriation that took place over three continents – from India to Canada – with several logistical hurdles to overcome
The patient
GlobalMED received a request to perform the bed-to-bed air ambulance transfer of a young male patient from Ludhiana, India to Brampton, Toronto, Canada. The patient had a fulminant SDH and ICB after a cerebral aneurysm had ruptured. He underwent surgery to reduce the pressure on his brain and was ventilated for several weeks. After receiving a tracheotomy, he was weaned off the ventilator. Nevertheless, he still was in a fragile condition, occasionally needing the help of a ventilator.
Getting to the patient
One of the biggest challenges in this case was the remote location of the patient. Although the hospital had a good reputation, and was a medical college, the nearest airport at which our Learjet could land was nearly 160 km away in Amritsar. This meant a three-hour drive from the airport, and the statistics regarding fatal road accidents in this region of Punjab are shocking. 
Flying to such a location, you normally do not want your crew to be separated. In this case, however, we had to change the initial planned crew, as the first physician we scheduled for the trip refused to travel there once they knew about the long and dangerous road transfer involved. We also had to ensure that the hotels in which the crewmembers were booked to stay offered the best available hygiene standards, as they needed to stay healthy in order to pick up the patient.
We knew that the crew would arrive at around 20:00 hrs local time in Amritsar, and we agreed with the insurance company that our medical crew would not drive to Ludhiana in darkness so as to not increase the risk of an accident occurring during this leg of the transfer. It was decided that it would be best if the whole crew were to stay in Amritsar for one night, and on the second day, a previously organised well-insured ground transport company would take the medical crew, with all their necessary equipment, to Ludhiana.
So far, so complicated. But the adventure really began at Amritsar airport, where the immigration process was a lot more convoluted than expected. The process of getting a visa-on-arrival took nearly three hours, as the officer was repeatedly not able to write the four names of the crew correctly, despite having all their passports in front of him! The handling agent then asked the crew to send them details of the ground ambulance and its driver, his driver’s license, and a declaration from the hospital stating that changing ambulances at the airport could have a negative effect on the patient’s condition. All this was apparently necessary to guarantee tarmac access for the ground ambulance when it returned with the patient. We contacted the treating physician by mobile phone and asked them to prepare such a document.
As their second day in India dawned, the medical crew was driven to Ludhiana. The trip itself was uneventful, thankfully, although the traffic situation and behaviour of other drivers were very ‘surprising’, according to our crew! Upon arrival at Dayanand Medical College and Hospital, the team was able to examine the patient, whose condition was as it had been described in the latest medical report, so there were no medical surprises to cope with. 
Overcoming setbacks
The medical report was prepared, and it seemed as if almost everything was going to be ready for a fluid handover of the patient the next morning. However, it then transpired that the document needed to secure tarmac access at Amritsar airport had not been prepared, and it took another four hours in the hospital before the essential paperwork was handed to our medical crew. It was early evening by the time they returned to their hotel in Ludhiana. 
Back at base, meanwhile, we had received details of the ground ambulance, including some pictures, which showed no medical equipment inside. The standards of ambulances, it’s fair to say, are still quite different from those we benefit from in the West. All the essential items were thus quickly mailed to the handling agent in Amritsar. We tried to organise the ground ambulance ourselves, but there were delays in answering our request, and the ‘English’ we had to deal with on the phone was extremely difficult to understand. We finally handed this job over to a professional ground ambulance organising company.
Early in the morning on the crew’s third day in India, the patient and medical crew were driven to Amritsar airport, where all went smoothly. About four hours after the handover from the hospital in Ludhiana, the Learjet took off on time from Amritsar at 12:30 hrs local time.

The journey home

The complete flight from Amritsar to Toronto would take about 22 hours, and this very long transfer time needed a special pre-flight briefing that included doing physiotherapy with the patient, rolling him to one and the other side when he was sleeping, not sedating him for long periods, and not feeding him via the naso-gastric tube.
Flying via Zahedan in Iran and Trabzon in Turkey, the flight eventually reached Cologne (our base), where an extensive handover was done to our second medical crew at 18:30 hrs local time. Together with three fresh pilots, the flight continued via Keflavik and Goose Bay to Toronto, where they landed at around 01:00 hrs local time, and were met by a ground ambulance.
Forty-five minutes later, the patient was handed over to the treating team in Brampton. For the patient, the transfer had lasted for 26 hours from bed to bed. Thanks to our memory-foam antecubital mattress, combined with frequent movement of the patient, there was no worsening of the patient’s pulmonary condition, and no red skin that could indicate a developing decubital ulcer. 
Our aircraft base in Cologne is more or less exactly halfway between Amritsar and Toronto, meaning both crews had around the same flying time, and were able to stay below our postulated maximum of 16 hours’ duty time (including ground transfer). The medical crews who performed this long and complicated mission consisted of two consultants (ICU and emergency medicine) and two ICU nurses (one of them being head nurse at an ICU specifically for patients who are difficult to wean off a ventilator).
For three days, we stayed in very close contact with the insurance company, informing them at every step about the patient’s situation. In total, after 13,000 km and five fuel stops, we were delayed by less than 30 minutes.