The World Health organisation has recently declared that the Covid-19 outbreak is now a pandemic, and it’s impossible to ignore the rising numbers of those diagnosed with carrying the virus, and the steadily growing number of patients who are fatally affected. The silent nature of the infection in the pre-symptomatic yet highly contagious phase has created an enormous challenge for us all and, inevitably, there are particular concerns with regards to the transport of the victims of infection who are unaware that they are carrying (and, indeed, spreading) the virus. Serious dilemmas lay ahead and neither air ambulance services nor commercial aircraft medical escorts are exempt from facing these challenges. Being unprepared is not an option and thoughtful detailed planning is key. For some, the problem with planning is finding the place to start. This article makes no attempt to be a comprehensive tome but the musings that follow may help focus on key areas of concern. The content is mostly directed towards air ambulance operations since airline medical escorts will be constrained by individual airline availability, internal regulations and international restrictions and limitations.

Perhaps the easiest decision for air ambulance organisations is the one with the greatest possible contention. At some stage the decision must be made – should our service transport a patient who is symptomatic and has tested positive for Covid-19? Indeed, why would anybody want to move a highly contagious patient? Each service must be able to justify why they would want to risk the health and lives of others to transport a symptomatic patient infected by a potentially lethal pathogen, and then prove that the service has the highly skilled personnel and the appropriate equipment to be considered competent and safe for such high risk work.

Indications for transfer are therefore not quite so clear-cut as for non-infected patients.  Potential indications include:

• A patient transfer to a more appropriate facility where expertise and a higher echelon of medical care can be provided. Consider ‘if/when a bed is available’ and ‘if/when the higher level of care is appropriate’ (i.e. when the patient has a reasonable chance of survival).
• Repatriation for end-of life care (When there is nothing that can be done to save the patient).
• Diplomatic or other non-medical pressures to repatriate or transport (e.g. governmental decision to repatriate their citizens, inadequate facilities overseas, lack of high dependency or isolation beds in local hospitals, etc).

Even if an indication is justified, clearly everything depends on the capabilities of your service, but a decision tree might help with justifying the choices made. This starts with five key questions that should flag up important issues:

1. Does the service offer critical care capability in flight?

• Experienced and current intensive care flight physician and flight nurse(s).
• Equipment to manage planned or unexpected sedation, intubation, ventilation and cardiovascular support.
• Procedures and equipment to manage problem airways and peri-arrest scenarios.
• Comprehensive intensive care patient monitoring, including ‘bedside laboratory’ capability.

1. Is the aircraft suitable for specialist transport of highly contagious patients?

• Is the cabin big enough to allow easy loading of a patient isolator and is there room for the medical team to work safely around the isolator?
• Can the isolator be securely fitted to the aircraft (is an STC necessary)?
• Is there a flight deck door to isolate the aircrew from the patient compartment?
• Does the cabin conditioning system work efficiently, and does it include HEPA filtration of recycled air?
• How is the integrity of the isolator ‘skin’ maintained during loading and unloading?
• Will the centre of gravity of the aircraft be dangerously affected by the position or weight of the equipment, consumables and team required to conduct the mission?
• Will the power requirement of the medical equipment be within the limits of the aircraft’s power invertor? If not, have battery replacement calculations been made?
• Is the light inside the cabin adequate for good visualisation of the patient inside the isolator?
• Does the service have bariatric capability for patients over the specified weight limit for the ‘routine’ equipment?

1. Does the service offer patient isolation capability and management of highly contagious patients?

• Specific training in the transport of highly contagious patients for the flight medical crew, including use of full PPE (personal protective equipment), safe lifting, loading and securing patients with or without a patient isolator.  Frequent and fastidious practical training is essential prior to a mission.
• Specific training for the air ambulance aircrew or cabin crew/ loadmasters of non-air ambulance aircraft, as well as for anyone who will also work in the patient compartment on the aircraft during or after the transport.
• An air-portable patient isolator with secure airlocks, HEPA filters and protected access to the patient.
• A flawless policy and practical experience of decontamination, fumigation and deep cleaning after the flight.

1. Does the service understand the importance of comprehensive communication?

• Established contacts with public health expertise, port health authorities and infectious disease centres.
• Understanding of International Health Regulations and the need for notifications and regulations of the destinations countries/airports with regards to border procedures and notifiable diseases.
• Knowledge is key. Ensure full and up to date medical reports, discuss with referring and receiving medical teams and appropriate infectious diseases teams.
• Impeccable attention to detail and fastidious planning of each stage of the transport is essential and must be communicated effectively to all parties concerned with the transfer. Briefings should include all conceivable ‘what if’ scenarios.
• Awareness of ‘go’ and ‘no-go’ tech stops. For instance, if a flight has a planned fuel stop in Italy, will the aircraft then be allowed to land at its final destination. This is an issue even for positioning flights when there is no patient on board.

1. Are the employees of the service willing to undertake these missions?

• Have detailed and bespoke risk assessments been undertaken prior to each mission?
• Are pilots, engineers, aircraft handlers, equipment and aircraft cleaners as well as the flight physicians and nurses fully informed about the risks and do they freely give their consent to take part in the transport?
• Has evidence been provided that due consideration has been taken in regards to medical team flight duty limitations and the effects of working in full PPE over long periods in the constraints of the aircraft cabin? If so, have mitigations for fatigue, exhaustion, and hyperthermia been factored in to the mission planning?
• Are they all properly trained, practiced and equipped to fulfil their roles under the constraints imposed by the appropriate and necessary infection control procedures?
• Do they have adequate personal health cover insurance? Does the service provide all-risks cover?
• Who has the information on the medical histories of the personnel involved? Are they being screened to exclude those who are at higher risk of serious complications if they become infected?
• Have the personnel concerned discussed the issue with their family and loved ones?
• Has the possibility of arranging tarmac transfers at both airports of origin and destination been considered, so that exposure of the medical team to extra risk be avoided?
• Is there any useful prophylactic treatment or has vaccination been developed yet?

If the answer to any single one of these issues causes doubt or concern, then the decision is simple – the mission cannot be safely undertaken. This is, in fact the simplest scenario. The more difficult decisions come from what at first appear to be much more benign scenarios - asymptomatic patients or those with only minor and vague symptoms and who have not been tested for Covid-19. The difficulties don’t end there. Does your service have a policy for the management of all patients being transported from a Covid-19 hotspot (currently China, South Korea, Iran, Italy and Spain, at the time of writing). Likewise, would it be ethical to transport any patient to such a hotspot?

As if that doesn’t give us enough to think about, how can we be sure that any of our patients, being transported for any reason at all, is not already infected with Covid-19, even though they may not have respiratory symptoms. For instance, the elderly lady with a fractured hip may pick up the virus during her short hospital stay overseas, or perhaps it was the cause of her fall in the first place. If this has not been taken into consideration, she would be the ideal vehicle for the carriage of Covid-19 (as well as all the multi-drug resistant bacteria that are always a concern). It’s not just the elderly and those with chronic health issues that are at high risk, it is any patient who has a compromised immune system or any reduced ability to shake off pathogenic invasion. This is particularly true of intensive care patients. Don’t forget to check on the health of the travelling companion(s) too!

Some experts have determined that possibly as little as only 10% of Covid-19 infected patients have been diagnosed (and that is, of course, only in the countries that have introduced mass testing of ‘likely’ virus carriers).  When our eyes are opened to these issues, we are compelled to consider how we manage all patient transfers during the pandemic.

The suggested decision tree in Figure 1 (Ref: CCAT Aeromedical Training, 2020) is a simple algorithm to help with transport choices, but the key part is the actual detail of the best and most appropriate measures to be taken for each of the four main categories of patients. It is relatively easy to plan appropriately for known Covid-19 patients who have symptoms, and Covid-19 positive patients without symptoms are also a ‘known’ entity. It is the rest of the patient transport population that cause concern, so the following suggested guidelines make perfect sense, even if some may feel that the response is overly complicated. In a pandemic in which death is a real risk, then being risk averse is by far better than being laissez-faire.

Suggested minimum procedure for all patient transfers during the pandemic.

• Flight medical team to wear ‘routine’ PPE (gloves, apron, N95 mask[1] and face shield or goggles) when assessing the patient pre-flight.
• Initially, measure the patient’s temperature whilst taking recent medical history and chronic health/other risk factors history. Ask specifically for respiratory tract and flu-like symptoms.
• Examine the chest. Check for dehydration and measure BP and oxygen saturation (stating FiO2).
• Look at the oropharynx.
• Review chest Xrays if available.
• Review recent blood results (especially for markers of infection/inflammation).
• Complete the remaining usual pre-flight assessment indicated for each individual patient.
• Review recent observations/MEWS/NEWS (etc) chart.
• Test for Covid-19 if available and time allows.
• Flight medical team to wear routine PPE for entire flight if the patient has no significant findings or history of Covid-19 infection.
• If the patient raises a high index of suspicion, he/she should be treated as a highly contagious patient.
• All patients to have routine clinical observations recorded once onboard the aircraft and at least hourly thereafter.
• Any deterioration or new illness occurring enroute should be documented and treated symptomatically. If indicated, ask the patient to wear an N95 mask.

Additional minimum procedures for asymptomatic patient transfers from hot zones

• Patient (and traveling companion) should wear an N95 mask throughout flight.
• Aircrew should also wear an N95 mask and the flight deck door should remain closed except for emergencies. Hence, intercom communication with the flight deck is essential.
• Extra vigilance is needed for management of biological fluids and waste.

Finally, much more advice and expert opinion can be found online and through official postings from august bodies and legal entities. The author therefore invites comments and other useful information from the readership. This global problem not only deserves, but requires, international co-operation and sharing.  Furthermore, it remains essential in these days when news and guidance can change daily, that the latest intelligence and advice is checked at the start of every day and before every patient transport flight. Frequent updates should cover such issues as:

• WHO statistics of international spread.
• WHO and local advice on management of the pandemic and of individual patients.
• Changes to IHRs.
• Declaration of new ‘hotspots’.
• Travel restrictions imposed by governments, airlines and other provider agencies.
• Progress in the development of vaccination and other therapeutic agents.

Beyond these words of advice, fly safe, fly within your capabilities and don’t take unnecessary risks.

[1]   Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings    https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse…

 NIOSH, March 2020