Moderators

• Dr Bettina Vadera Chief Executive & Medical Director, AMREF
• Patrick Schomaker Director of Sales & Marketing, European Air Ambulance
• Eva Kluge Director of Sales & Business Development, Air Alliance Medflight GmbH
• David Ewing Executive Vice-President, Global Markets, Skyservice Air Ambulance
• Andrew Lee International Business Executive, ER24

“This year’s forum was very well attended, with extra seating needed due to the excellent response, and we still had people standing at the back of the room,” commented Forum moderator Andy Lee. “This was very encouraging, and the most satisfying fact was that the split was around 60/40 in terms of insurer and assistance provider attending.”

Discussion on the case studies opened the door to wider issues that exist between all parties and promoted more understanding of each other’s potential challenges. “The drive behind this session was to build a better and stronger relationship between the payers and suppliers, to create safer and risk-free patient transfers,” said Lee.

Presentation: Dr Matt Kalina, Group Medical Director, Europ Assistance

Dr Kalina reported on a particularly challenging case involving a medical evacuation from a cruise ship – the patient was removed from the cruise ship and left in a remote coastal town, where he was taken care of by Haiti Air Ambulance paramedics overnight in a hotel. A helicopter evacuation to Port au Prince took place the following morning, but there was no hospital with interventional cardiology capabilities available, so an evacuation to the US was required. The air ambulance provider that was supposed to take the job refused to do so, claiming that the patient was not stable enough; but in reality, asserted Dr Kalina, they were just worried about the liability issues inherent in transporting an unstable patient. The Europ Assistance medical director tried to speak to the air ambulance medical director, unsuccessfully, to discuss the case. After several hours’ delay, the air ambulance provider accepted the flight – but only after being provided with a discharge of responsibility.

Discussion

Concerns were raised by those in the audience about doctors on cruise ships not always being appropriately trained in the medicine they will be providing, nor in the equipment they are using. It was suggested that the assistance industry approach the American College of Emergency Physicians to discuss more appropriate qualifications for onboard doctors. When asked about the de-brief with the involved parties, Dr Kalina said that there had been excellent discussions with the air ambulance provider, but these were less productive with the cruise company, who – potentially for liability reasons – were reluctant to admit that the patient shouldn’t have been offloaded in the first place.

Melanie’s presentation centred on the case of an expatriate who was hospitalised in remote Mongolia. The local clinic diagnosed flu and insisted there was no need for an evacuation as the patient was being managed in the facility. By day five, however, the treating medical officer urgently requested an evacuation, as there was no improvement in the patient’s condition. The assistance company engaged an air ambulance provider to evacuate the patient to Beijing, but there was a two-day delay due to political red tape and clearance issues getting a helicopter into the country. The patient was then evacuated to South Korea instead. Points of discussion raised by Melanie included:

• When is it appropriate for an assistance team to override the treating doctors?
• How can an assistance company be more proactive in knowing what flight requirements and clearances are required?

Discussion

Audience members pointed out that the reasons why treating doctors hold on to patients vary – it can be ignorance of treating facilities elsewhere, or cultural pride, or even a considerable financial incentive to treat an insured patient. It can be difficult to intervene with treating doctors due to regulation, and cultural norms, according to one audience member. There are workarounds, though, such as talking to the patient and their relatives, which allows the assistance company to make a more informed decision about the patient’s condition.

Zack’s presentation focused on an evacuation from Baghdad to Dubai. The patient was in rapidly deteriorating acute respiratory distress with suspected pneumonia; he required ventilation, intubation and sedation prior to the flight, which were initially performed by the treating doctor, but the facility in which the patient was being treated was not experienced in such procedures. Obtaining a landing permit for Iraq can be problematic – after hours, or during holidays, it can be especially challenging, said Zack. Due to the patient’s diagnosis and deterioration, the decision was made to take off from Dubai without the Iraqi landing permit in place, despite the fact that the patient was not stable. Communication between the treating physician and flight doctor was maintained throughout the flight, which Zack pointed out was essential to keep the case moving forward, as the treating doctor was keen to keep the patient in situ.

Discussion

The issue of the assistance company having a lot of faith and trust in the air ambulance company to perform the mission, allowing them to take off without the landing permit, was brought up. There was constant communication between the assistance company and air ambulance company medical director to agree that this was the best course of action for the patient.

Yasir’s case involved a severe injury to an employee in Kandahar, Afghanistan. There was an air ambulance already flying from Columbo (Sri Lanka) to Helsinki with a patient, and it was agreed that a co-transport would take place, picking up the second patient up in Kandahar en route. However, the first patient was then found not to be suitable for co-transport. Evacuation of the second patient was becoming more urgent, but there was no provider ready to fly into Afghanistan to pick them up. Another provider was found eventually, and the patient was repatriated onboard a Challenger air ambulance.

Discussion

The major focus of the discussion following the presentation lay in the fact that the challenge for assistance companies is in finding air ambulance providers who can fly into warzones – such dangerous destinations are becoming more common, so the need for air ambulances to fly to them is greater. The issue of insurance was brought up, and Dr Bettina Vadera pointed out that providers may not be aware of the different types of war risk insurance that is available to them. The issue of co-transports was also raised – it is always a risk that one patient’s condition may adversely affect the other patient and the ability of the air ambulance company to perform both evacuations simultaneously.

This case centred on the evacuation of a patient with a history of breast cancer who was on holiday in the Caribbean. Her preliminary diagnosis was cardiac failure due to chemotherapy; the patient had already arranged to be transferred by air ambulance to Toronto, but mid-flight, she suffered a ventricular fibrillation. The plane diverted to the Bahamas, but the patient was declared dead at hospital there. The rest of the family, flying to Toronto via Chicago, were expecting to be updated on her condition on their layover in Chicago.

Discussion

The discussion centred on what would other assistance companies do – when would they tell the husband, who was travelling with two young children, that his wife had passed away? A vote was held, and the majority of the room would have waited until the family reached Toronto. Cai said that AXA decided to inform the family while they were in Chicago, as it was thought that if they waited, at some point the question would be asked of ‘when did this happen, and you had the opportunity to tell me earlier, why didn’t you’? It was a difficult decision, said Cai, but one that had to be taken.