The patient – a 71-year-old male suffering from an intracerebral haemorrhage secondary to ruptured aneurysm – presented to a local hospital in Malaysia in May 2020 with sudden onset severe headache and vomiting. His blood pressure was markedly elevated upon admission, and his condition deteriorated quickly. He was soon in a coma and required endotracheal intubation and ventilator support in the intensive care unit. A CT brain scan and CT Angiogram confirmed right intracerebral haemorrhage and subarachnoid haemorrhage due to a ruptured aneurysm. Definitive treatment of aneurysm clipping and EVD were performed soon after diagnosis, and the operation was smooth and uneventful.
The patient subsequently spent a further one and a half months in the Malaysian hospital for neuro rehabilitation. The Glasgow Coma Scale of the patient improved gradually back to E4VTM4 and remained static. He developed extremities rigidity and remained bedbound. In early July 2020, a follow up CT brain scan post-EVD removal showed hydrocephalus, and a VP shunt was performed. Recovery of the patient was complicated by ventilatorassociated pneumonia, requiring broad spectrum anti-microbial therapy. The patient was tracheostomised and eventually weaned off ventilator support before transport.
Preparation for the repatriation of this patient had to take place amid the third wave of Covid-19 surge in Hong Kong, during tight quarantine requirements for all inbound travellers. In Hong Kong, the maximum number of newly diagnosed Covid-19 daily cases in the third wave were capped at 149. Multiple strategies were adopted by the government to combat Covid, and the relatively low number of new Covid cases was attributed to the awareness of the general population, especially taking into account the experiences learned from the SARS virus endemic in 2003.
All travellers were required to present a valid negative result from a PCR test that had been taken within two days before their arrival date at Hong Kong. There was also a mandatory 14-day home quarantine period for all inbound travellers following a negative PCR test in the arrival hall of the airport. Since there was a mini-outbreak of Covid-19 in Hong Kong during that period, the risk of infection was understood and discussed with family members. With all this in mind, they consented to proceed with the repatriation.
Our patient required direct hospital admission on arrival at Hong Kong, where he was unable to go through the normal procedure of mandatory quarantine. We went through the process of liaising with relevant government departments, airport security, the patient’s family, the Malaysian hospital for clinical information, and different hospitals in Hong Kong for hospital bed and admission policies. Repatriation by air ambulance was deemed appropriate due to complicated routing by commercial flight from Kota Kinabalu to Hong Kong with a tracheostomised patient with potential use of ventilator. Eventually, the patient arrived at Hong Kong by a Learjet 60 air ambulance following a three-hour non-stop direct flight under medical escort in mid-July 2020. He proceeded directly to hospital after simplified quarantine procedures, which took place with prior official approval.
Our medical escort team maintained full PPE throughout the escort mission. The road ambulance and equipment we used had to go through a process of disinfection afterwards. From preparation of repatriation to arrival of destination, this bed-to-bed international repatriation mission took our team 10 days to execute.
Compliance and patient safety key priorities
This case demonstrates that compliance with strict quarantine requirements can be managed in accordance with guidelines, without compromising patient safety. A thorough assessment of risks versus benefits of international repatriation should be undertaken in order to ensure international repatriation missions are undertaken in a safely and timely manner during this pandemic.