Critical repatriations on commercial flights

Commercial plane on tarmac
Fixed-wing transport decisions

The decision of whether to fly a critically ill patient on a commercial flight or via an air ambulance is one of the most important decisions in fixed-wing transports. Femke van Iperen explores the issue

For those companies that book transports for patients and insureds, namely medical escort companies and assistance providers, there are some obvious benefits to transferring a critical patient on a commercial flight. Dr Thomas Buchsein, medical director at German air ambulance company FAI, explained that cost and time are key influences: “For the payer, it has always been an attractive option and, depending on the routing and other factors, it would provide not only the option of a direct flight, at long distances without fuel stops, but also substantial financial savings. These two motivations remain high.”

Tara Rose, president and medical manager of US-based Sky Nurses, a commercial medical escort company, recalled a recent repatriation mission from Johannesburg, South Africa to Los Angeles, US with a patient who had suffered a severe stroke, which could have cost anything up to $185,000 (based on the highest quote from an air ambulance provider), compared with $35,000 for a commercial transfer.

Since the rise in the number of airlines able to accommodate full intensive-care facilities and the development of portable oxygen concentrators (POC), Adam Booth of Mayday Assistance, UK, has witnessed a wider choice of flight options becoming available for critical-care patient flight transfers, and for him too there are obvious benefits to a commercial airline transfer. Patients may, for instance, be more comfortable in a business or first-class seat than on a stretcher in a smaller aircraft, and family members are able to travel with the patient, which is not always an option on air ambulance aircraft.

patients may … be more comfortable in a business or first-class seat than on a stretcher in a smaller aircraft

During the 2015 ITIC Global event in Athens, Graham Williamson, CEO of Canada’s LIFESUPPORT Patient Transport, listed similar benefits such as ‘more comfortable seating, hot meals, and fewer technical stops’. In addition, he said, medical staff, who can often reach the patient faster by use of scheduled flights, have the advantage of not needing to organise permits to fly to their destination.

For some patients, there is even the state-of-the-art option of an isolated patient transport compartment (PTC), described by the ABC of Transfer and Retrieval Medicine as a ‘specially-installed unit with comprehensive intensive-care capabilities and a wide range of medical supplies, and with configurations with access to power outlets and high amounts of oxygen’. However, Lufthansa is the only commercial airline that offers such a patient compartment and, generally speaking, before the decision is made to opt for either a commercial or an air ambulance flight.

A diversity of privacy, logistical, medical and financial matters also need to be weighed against each other. This is something Booth refered to as a ‘multifactor decision primarily led by the medical condition of the patient and their stability, suitability and practicality of safe transportation on a commercial aircraft’. He explained: “Although considerations such as ‘whether the patient can sit up for take-off and landing’ are a non-negotiable airline requirement, once we are airborne we can use multiple seats to make the patient comfortable.”

Commercial flight critical care transport

Logistically challenging

One of the overall factors is that a clinical-care commercial transfer will be logistically challenging. For example, Dr Gert Muurling, owner, CEO and medical director of German air ambulance and medical escort provider GlobalMED, said that, to begin with, there are ethical considerations that involve both other airline passengers and patients. “No other passengers should be disturbed by the sound or sight of a patient or their necessary treatment during a flight,” he argued, explaining the working conditions on commercial flights are rarely optimal, and that they cannot be achieved ‘with a stretcher under the overhead bins, or a first-class seat for a ventilated patient’. 

no other passengers should be disturbed by the sound or sight of a patient or their necessary treatment during a flight

For Muurling, whose company also provides health authorities in Germany with accredited training for air medical personnel, suitable conditions for a critical patient transfer would include a ‘disinfectible’ (i.e. no carpets) or closed compartment; a well-regulated electricity supply; appropriate working lighting; a minimum of 8,000 litres of oxygen; lift trucks for loading and unloading; and compartment high-efficiency particulate air (HEPA) filters – ‘many critical care patients carry multi-resistant germs and they are not screened for them’. But apart from Lufthansa, he does not know of an airline that offers any of these conditions. 

What’s more, long-range airliners often operate at night time, which ‘puts the medical team in the window of circadian low, the time of the day where all human beings are least effective and the patient at a higher risk compared to a daylight flight’, according to Muurling. Since few airlines offer the required patient destination, some insurance companies ‘send patients by road ambulance for parts of the route, on long and unsafe distances’ in order to save money. 

Preparation time

Another key factor that would influence the choice for an air ambulance versus a commercial airline would be the longer time it tends to take to plan an airline repatriation. Determining whether the patient is suitable for this type of transfer in the first place adds preparation time, as Williamson explained in his presentation in Athens, where he also told the audience that oxygen power supplies may need to be organised separately. To avoid potential complications between different airline medical departments, further time may need to be spent to book multiple flights with one airline, and it should be checked whether battery operated oxygen supplies are permitted.

For Rose, a plan of care with the treating physicians is vital, and the medical escort(s) should be sent to the patient location with all necessary medications and equipment. Spending time on telephone triage and thorough pre-flight assessment, she argued, can help prevent an aborted mission: “As a medical escort we are the ‘lone ranger’; we must act quickly and utilise critical thinking skills.”

Commercial flight critical care transport

Less control

Compared to a private air ambulance transfer, which is not dependent on airline schedules, flying with a commercial airline could also mean there is less control over the repatriation process. 

Ultimately, it is the carrier who has the final say on whether, how and when the patient will be transferred, and after the treating physician has filled in the airline’s medical information form, the airline company may give instructions on anything from whether the patient should be accompanied by a nurse or doctor to the size of the medical escort team.

Using a recent example of a patient with a pelvic fracture needing to be transferred through AXA Assistance with a German carrier, Buchsein said the assistance company was informed to use a doctor instead of the proposed nurse escort. “Basically, the airline anticipated a level of pain the nurse may not have been able to deal with effectively,” he said, illustrating how airlines have the power to affect the decision-making process when it comes to passenger medical clearance.

According to Buchsein, most airlines find the loading and unloading of the patient ‘too much of a lengthy procedure’, and it will ultimately be their decision on how and when the patient will be transferred. He also pointed out that costly delays may ensue if, for example, the ground ambulance didn’t arrive on time.

Changes ahead?

So, will there be any changes in the future when it comes to transferring critically ill patients on commercial flights? Experts such as Rose have recently witnessed an increase in such transfers. “Replacing air ambulance [flights] with commercial airline transport has saved millions of dollars for insurance companies,” she said, adding that this has also triggered a significant upsurge in airline profits, since the majority of critical care patients fly in business or first class. In addition, Rose anticipates more stretcher availability on some of the larger airlines, and that in future access to these will be as simple as ‘purchasing an economy or business class seat’.

ultimately, it is the carrier who has the final say on whether, how and when the patient will be transferred

Buchsein expects little to change: “The procedure and the reserves the air carrier has in terms of accepting a patient as a passenger, and the approach of payers, to my knowledge have not substantially changed at least for the last three decades. Airlines will remain restrictive in the case of critically ill patients as long as there is no physical division between [other] airline travellers and the patient.”

For many specialists, there are still lessons to be learned by all parties involved. Muurling, for example, would value a closer relationship between the insurance and assistance companies and air medical companies to help ‘provide safer, more cost effective, and more pleasant patient transfers’, and in order to create a ‘nice, suitable and well-equipped solution’ airlines would do well to ‘seek contact with both’.

Meanwhile, for companies such as Mayday Assistance, it has been the improved relationship with certain airlines that has ensured several ‘problem-free’ commercial repatriations for assistance companies. “Who knows what might come in the future, especially with advances in technology?” said Booth. “There may well be the option to manage more of a range of patients on a commercial aircraft. But what I do know is we will always require reliable air ambulance companies for patients who are too unwell to travel commercially, and cost saving will not compromise safe repatriation, ever.” △

This article first appeared in the ITIJ Assistance & Repatriations Review 2016.