Case Study: How to get an off-loaded cruise passenger with a fear of flying home? Repatriation under sedation

When a patient needed to be repatriated to the US from Australia, but was too afraid to fly, repatriation under sedation was the only option. LIFESUPPORT Air Medical Services share an interesting case.

In December 2019, Charles and Nancy set off from New York on their six-month, round-the-world cruise. The not-so-distant memory of 9/11 had a profound impact on Charles, exacerbating his anxiety and worsening his fear of flying. The cruise was the chance for Charles and Nancy to explore the world without ever having to set foot on a plane.

Blissfully enjoying their world cruise, news of the rapidly spreading global pandemic was trickling onboard as the ship approached the coast of Australia. The next morning, Charles and Nancy awoke to an announcement from the Ships Captain that their vessel was steaming for the nearest port in Perth, where all passengers would disembark from their now cancelled cruise.

Covid was ripping across the world, and countries were recalling their citizens home. Cruise lines were offloading passengers by the tens of thousands as global aviation was beginning its paralyzing halt, while simultaneously rushing to get everyone home, except for Charles, now stranded in his hotel room – gripped and paralysed by his intense fear of flying.

Fear of flying prevents repatriation

Knowing that there was no other option to get himself and his wife Nancy home, Charles worked hard to build up the courage that it would take to board his Qantas Airlines Flight, connecting onward from Sydney and home via Los Angeles to New York. Having nervously seated himself, Charles could not overcome or break through his extreme anxiety – bolting for the nearest exit just as the doors were about to close.

Charles and Nancy settled into their accommodations in Perth while reaching out to their travel assistance company for help. LIFESUPPORT Air Medical Services was contacted by their assistance company, and they dispatched one of their critical care registered nurses from Fort Lauderdale, Florida to help Charles and Nancy home. Sedation on a commercial flight is a matter of striking a fine balance – the patient must be made comfortable enough that he can complete the journey, while not posing a risk to himself or others, but not to the point that he becomes unable to follow commands and thus becomes a different type of risk.

Patient breakdown prevents boarding flight

LIFESUPPORT’s Florida-based Flight Nurse Penni arrived in Perth with a detailed mission plan, sedatives and a clear understanding of what needed to be done. The next day, Penni departed with Charles and Nancy for the airport. Arriving at the Qatar Airways check-in counter, Charles had been given enough pre-flight sedation to feel comfortable, but was still able to participate in the check-in process.

Unfortunately, as the boarding passes were handed over by the gate agents, Charles had a breakdown and security was summoned by airport staff. Returning to their respective hotels, it was very clear that Charles would not be travelling. By this time, Western Australia and the city of Perth was going into full lockdown. The window for Charles to depart on a commercial flight was rapidly closing, and options were narrowing.

It was clear to the medical and logistics team at LIFESUPPORT that drastic and immediate action needed to happen – and quickly.

Air ambulance transfer under sedation was the only option

The challenge at hand was to ensure that Charles was transported as rapidly, and as quickly, as possible while under enough anaesthesia that at no point would he pose a risk to himself, others, or the aircraft. Charles had two choices – consent to anaesthesia and deep sedation, or become a resident of Australia until cruise ships sailed again in an uncertain future. Charles quickly accepted the option to return home and was connected online with Dr Marek Rozwadowski, LIFESUPPORT’s Chief Medical Officer, himself an anaesthesiologist licensed to practice not only in Canada, but also in Australia.

Using video conferencing technology, LIFESUPPORT conducted its first virtual pre-flight assessment with an overseas patient. Dr Rozwadowski interviewed Charles in his hotel room in Perth, ensuring that the proposed plan was safe and that the patient was fully consenting to all risks associated with deep sedation and anaesthesia in flight. Once the video conference was completed and all parties in agreement, LIFESUPPORT’s team went to work on the detailed arrangements necessary to enter Australia during lockdown – including border force, immigration and local police permissions, all of which were quickly obtained.

The right aircraft, and team, for the job

The beginning of May had arrived, along with the height of the global pandemic, locked down borders and with severe restrictions making travel almost impossible. LIFESUPPORT’s medical team wanted to ensure that the patient was transported as quickly as possible, so as to minimise the amount of time that he was under sedation. Moreover, with countries in lockdown and landing rights and permits strictly constrained, an aircraft that could overfly most countries was required.

LIFESUPPORT’s team found the right solution – a Gulfstream V. LIFESUPPORT’s most experienced team, consisting of Dr Rozwadowski, Marcie Harrison, CC-RN, LIFESUPPORT’s Chief Flight Nurse, and Francine Jones, CC-RN, Clinical Nurse Educator, set out for Australia. With them they carried 250 pounds of critical care transport equipment, portable oxygen concentrators, suction devices (all back ups in triplicate), as well as an extensive pharmacy supply.

Landing in Perth, the team visited Charles and Nancy in their hotel room, and prepared for the journey home to New York that would commence the next day. Written consent was obtained from Charles and the details of the medical procedure and anticipated risks were thoroughly explained.

On the mission day, local paramedics from Perth arrived with their ambulance stretcher at the hotel room. Taken aside by LIFESUPPORT’s air medical crew, the situation was carefully explained as to why they were in a hotel, collecting a conscious and otherwise healthy individual who would shortly be eased into a deep sleep. Before the paramedics arrived, it was agreed upon that Charles would be awake and alert, allowing him to explain to the paramedics that he was consenting to repatriation – removing any doubt or perception that a black-op mission may be occurring in Perth. Charles hopped into the ambulance stretcher, IV access was carefully obtained, after which Charles said: “See you all in New York!”

The Gulfstream V-SP (otherwise known as a G550) has a crew of two pilots, one flight attendant, and a spacious cabin capable of holding 19 passengers, with fold-out beds and couches. The G550 is equipped with forward and aft galleys, two lavatories, a private bedroom, and spacious living area. Built for long-range cruise, the aircraft has a range of 6,750 nautical miles, or 12,500 kilomentres – essentially able to remain aloft for 12 hours between technical stops.

Originally, the flight plan called for one stop en route via Honolulu, Hawaii. However, winds across the Pacific were unfavorable, and the mission was planned on a more northerly route via Seoul, where the flight crew changeover would occur. US customs clearance was obtained for Anchorage, Alaska, which reassured Charles that should anything go wrong, he would be safely home on US soil and could simply drive home in a rental car from Anchorage.

Having arrived at the FBO in Perth, Charles was carefully taken aboard via vacuum mattress lift with the assistance of the paramedics, the air medical crew and ground handlers. Charles was secured safely to
the spacious bed onboard, and the aircraft departed for its first stop in Seoul, then onward to Anchorage.
Touching down in Anchorage, Alaska, the aircraft was met by US Customs.

Fully briefed in advance of the aircraft’s arrival, nonetheless, US Customs and Border Protection Officers were intrigued by a Canadian medical onboard a US flagged aircraft with a sedated passenger from New York. The aircraft was quickly cleared, refueled and prepped for its final leg to New York.

As was the clinical goal throughout the mission, only a minimal amount of sedation was used to keep Charles safe and comfortable, yet unaware. While on the ground in Anchorage, LIFESUPPORT’s anaesthesiologist gently reversed the sedation – and Charles opened his eyes. “Good Morning Charles, you’re almost home – we are in Anchorage, Alaska.” Gaining his composure, Charles and sat up on the edge of the bed. “I’m OK?” he asked. Indeed – the mission was going exactly as planned. “What’s for breakfast?” asked Charles. Taking off from Anchorage, Charles was now fully awake, alert and recovered. Hot coffee was served and now seemingly cured of his fear of flying, Charles walked off the aircraft in New York, bypassing the waiting ambulance that was on scene as a precaution. Charles took a sedan home with Nancy, where LIFESUPPORT’s air medical crew settled him safely back into his own bed.

Covid changes mission profiles

Throughout the last year of the pandemic, LIFESUPPORT Air Medical Services, Inc. has kept itself busy with long-range missions. “We have conducted more ultra-long-range, long-haul air ambulance and security evacuation missions in the last 11 months than we have in 15 years,” said Graham Williamson, LIFESUPPORT’s CEO. “We have operated throughout the Middle East, including Iraq and Afghanistan, Africa, Europe, Asia and the Pacific.” Williamson notes that the availability of commercial flights, and more specifically the willingness or ability of airlines to offer stretchers on commercial flights, has led to the increase in LIFESUPPORT’s long-haul flying.

“Looking into the future, we predict that travel will obviously return, but the ability to evacuate and repatriate travellers quickly and safely with speed and range will be paramount.” Williamson predicts that smaller medevac planes that make more frequent stops will continue to become increasingly difficult to operate. “That is why, over the last 11 months, our team as been working hard to secure an ultra-long-range Challenger 604 aircraft that will be able to evacuate our customers quickly, with speed, range and efficiency,” he concluded.

LIFESUPPORT is looking forward to the launch of their Vancouver-based Challenger 604 medevac program in March of 2021 as a way of ensuring that the needs of their customers continue to be met during the pandemic, and beyond.