First published in ITIJ 103, August 2009
Today, medical escorts have better resources than ever before, but they still take on a notable responsibility when accompanying a patient in-flight. Andrew Lee gives his personal perspective on the role of medical escorts, especially those working on commercial airlines
I like to think that the job of medical escort is for the brave, but I also feel that those who make these trips must be little crazy to undertake this lonely and often scary task. Make no mistake; transferring patients on a commercial flight is a difficult and pressurised job. Anybody who knows me may remember my own dalliances with escorting patients some years ago. Being left standing on the tarmac, bag in hand as the patient, receiving medical crew and ambulance disappeared into the distance leaving me to find my own way to a not so good ‘hotel’ that was really more of a place for the homeless, was a less than exciting experience, and one I thankfully did not repeat too many times. Times change, however, and with it a change for the better in medical escort services.
We should have nothing but admiration for professional medical escorts (PMEs). Be they doctor, nurse or paramedic; all do a fantastic job. Travelling alone with a sick person at some 38,000 feet is a daunting experience. There is nobody down the hall to ask or call should the situation deteriorate, so you are it – the decision-maker. Not only are you responsible for the patient’s welfare, but also for any relative travelling (who often sees you as the font of all knowledge), as well as other passengers who like to ‘rubber neck’, staring children, plus cabin crew to deal with should things get a little turbulent – in more ways than one. All in all, an escort’s lot is a very busy and demanding one: diplomat, confidante, tour guide and medic all rolled into one.
"an escort’s lot is a very busy and demanding one: diplomat, confidante, tour guide and medic all rolled into one"
Many escorts work on a freelance basis, still continuing their clinical work and thus keeping their skills current. Others are employed by assistance companies directly or by third party providers, such as air ambulance operators, air ambulance brokers and, in some cases, companies that should not be offering these services at all. More on that later.
A fair deal
As most people in the industry know, procuring a commercial stretcher is difficult and can be virtually impossible in some areas of the world. In a recent survey carried out by Air Ambulance Connection, out of 15 commercial airlines contacted, only three actually still accepted stretcher cases. These were all international carriers. No airline in the United States would allow for a stretchered patient. This makes medical escorts all the more necessary, both on air ambulance flights and also on commercial airlines for seated patients.
Nevertheless, the role of medical escort is not, as some people think, jetting round the world on a sightseeing trip. There are a number of elements that need to gel to make each trip a success. Medical kit, for instance, is fairly substantial for an individual to carry, and even getting it to the departing airport can be difficult – sometimes taking as long as the flight itself. Meeting all required scheduled times is also an escort’s responsibility. Ground ambulance transfers can be difficult, especially in areas of the world where there are no properly organised services, and dealing with the treating medical team overseas has its own problems too. Aside from language barriers, the treating team may not have been as informative about the patient’s condition as they could have been, meaning the patient’s condition may be a little more serious than previously thought. Most escorts in these circumstances will make their own assessment and decide if moving the patient is the right option. Usually this is the case as, if the hospital has not reported the patient’s condition correctly, would you really want the individual left there, unless moving them was considered life threatening?
When I was in assistance work, I had a great team of escorts available to me who were called for trips on a rotational basis. There were those in the system, however, who believed, through their seniority, that they should be given certain jobs at certain times of the year – such as New York in November or December. In general, ‘cherry picking’ jobs was not the case and all performed to an extremely high standard. There were some whose expenses were questionable: one nurse, no longer working in the industry, was quite open about the type of movies she watched. She considered that, if the TV was poor in a foreign country, this type of entertainment was universal. Fair point. Another doctor expected a wine allowance with his evening meal – he only lasted the one job. All in all, though, they are a great bunch of dedicated and capable people, who do not receive the level of recognition they deserve. Then, there are the others.
Like in other areas of the industry, such as air and ground ambulance, medical escort provision is also open to abuse by those who seek to deceive. Some companies claim to provide ‘qualified’ staff but the problem is, are they qualified to do the job? Some companies use ex-ambulance men (not even paramedics) or retired nurses who want to earn some extra cash, but have been out of a clinical environment for many years. Junior doctors are also used regularly, but could be placed in situations beyond their capabilities, creating higher risks for a patient’s safety.
Every assistance company has their own policy on medical escorts, but Craig Poliner, president of MedEscort International, points out that every patient should be treated as if they were a member of the escort’s family. Poliner identified capping spending as a regularly encountered problem, which sometimes makes it difficult to maintain or raise the level of comfort and care to the patient. There are instances when the level of service might be dictated more by the policy limits than the assistance company or the escort service. This will, at times, give the escort a professional dilemma – wanting the best for the patient but the limitation on spending making it difficult to provide that. This usually affects routes and class of travel and is more prevalent in the US than Europe. At the same time, it is important to be considerate of the other passengers on the flight. By and large, Poliner feels there has been an overall improvement in trying to do the best for the patient, which consequently has made the escort’s job easier.
Other pluses for escorts relate to equipment. In many cases, this has become smaller, lighter and easier to operate and transport. At the same time, assistance companies are much more aware of their due diligence requirements and are more considerate to the escort, with realistic schedules that do not push people to the limit. However, I would still expect there to be issues about pay – this is always an issue, regardless of the industry. In the current economic climate, everyone is trying to save money at every corner. This is also the case in the medical escort industry. Assistance companies will look for the cheapest seats, which often mean longer routes.
Escorts can be paid in several ways. Hourly, with a set minimum per trip or a 24-hour rate that then reduces. Of course, if they are on the staff of the assistance company, they will be advised what the rates will be. The need for the escort to be well versed in so many different arenas should be well compensated. Escorts are not just ‘hand-holders’, they must know different customs and airline etiquette, as well as what is medically necessary for the patient. Many times they are viewed as babysitters when, truly, they have a mammoth task when undertaking a new patient.
There are some good training courses available, such as Clinical Considerations in Aeromedical Transport in the UK. The course director is Dr Terry Martin, who has done a magnificent job, taking it from the early days of seeking recognition to becoming a globally recognised accreditation for participants. There are also other courses that can be found with some online research. As already mentioned, undertaking this work without some experience of what is involved is potentially very dangerous. These courses are designed for doctors, nurses and paramedics who act as aeromedical escorts. They are taught by aviation physiology and retrieval medicine experts, and deal with relevant issues of the special physical, physiological and psychological stresses that are important in the flight environment, the types of conditions that are susceptible to this form of transfer and how patients may be safely transported.
Commercial airlines are basically public transportation. They are not designed to be medical transports and therefore do not have true provisions for carrying patients. However, in the US, in the Americans with Disabilities Act, there are requirements for all industries to have accessibilities for those with disabilities, while the American Aviation Medical Assistance Act of 1998 increased the requirement for medical equipment carried aboard commercial airplanes, including mandatory defibrillators. Europe has a somewhat different outlook and certainly the UK is, to say the least, very choosey with what it will and will not take with regards to a seated patient.
"Like in other areas of the industry, such as air and ground ambulance, medical escort provision is also open to abuse by those who seek to deceive"
Commercial escort cases have a significant time requirement. This is needed to arrange items like oxygen, when available and needed, or, when applicable, a stretcher. Airlines can increase these timescales if they wish, making the availability difficult so that, although they don’t decline, they make choices limited. Domestically in the US, it is nearly impossible to arrange a stretcher on a commercial airline. International carriers that do carry stretchers are much more flexible and acquainted with handling medical cases. This familiarity leads to an ease in transferring patients. There is often a more knowledgeable staff and crew that are familiar with the equipment and cases. Unfortunately, there are far too few of these carriers.
Medical escorts are more common in Europe and the UK because of the greater amount of international travel undertaken. There is a marked increase in the amount of travel insurance purchased in this region and this leads to a greater knowledge and understanding of what avenues to pursue if sick or injured on holiday. Medical escorts can be a cost effective resource for transporting a patient when an air ambulance is unnecessary and, resultantly, there has been an attempt internationally to use medical escorts more frequently. This is difficult in the US because of airlines downsizing: they often use regional jets, which make accommodating medical passengers more difficult. And other difficulties arise at times, like embarking the patient and having to make numerous connections due to a shorter range on the originating flight.
Meanwhile, there have been mutterings around doing something about regulating the PME industry but, as with air and ground ambulance, this would be a very difficult task. Self regulation would be the only possible route and even then this is debatable. My suggestion would be a global register of PMEs accessible online that shows qualifications and indemnities for all registered members. This concept was discussed at a recent Air Ambulance Forum at the International Travel Insurance Conference, where an ISAMTP – International Society of Air Transport Medicine Professionals – was proposed. The Society has been slow getting off the ground, but it has international industry backing, and with sustained input and effort, it could be the start of a self-regulated industry.
So what is my opinion of the brave verses a fool? I think the role of medical escort is an incredible job performed by brave individuals who must be slightly foolish to want to undertake this often unrecognised and difficult task.