Case study: Trans-continental repatriation challenges

Case study map
Austria to Japan

Daniel Draxl of Tyrol Air Ambulance (TAA) details a medically and organisationally demanding case involving a Japanese patient with Guillain Barré syndrome, who needed to be brought home to Japan from Austria

Background
When we were first contacted by an interpreter working on behalf of the Japanese Embassy requesting an air ambulance, it seemed like a normal request, but it soon became apparent during the conversation that this was a special case involving a very sick Japanese patient. The wife of the male patient had enlisted the help of the Embassy as she and her husband, who had both been on holiday in Austria, only spoke Japanese.  

We learned that the male patient was in his forties and had been admitted to hospital in Vienna the day before he was scheduled to fly home due to an ascending paralysis. The interpreter requested an air ambulance quote for a repatriation from Vienna to Osaka and asked our doctors to contact the treating doctors for a medical assessment so the flight could be confirmed.

The medical assessment showed that the patient had been in hospital for eight days and had been diagnosed with Guillain Barré syndrome. His medical history revealed hypertension and polyneuropathy. Multiple attempts to wean the patient from an intubation tube had failed because the patient could not understand that the doctors were asking him to breathe and cough in order to aid the removal of the tube. Therefore, the patient could not speak and communicate with his wife.

In the meantime, the interpreter got back to us and confirmed they’d like to go ahead and arrange the flight. It had also been established that this repatriation was not covered by travel insurance as the couple had cancelled their cover because they said they had never needed it before! 

Once the go-ahead for the mission was confirmed, the operations team began organising and planning the flight.

Preparing to fly
As the flight needed to stop in Russia en route to Japan for refueling, a flight and medical crew with valid Russian visas was required for this mission. It’s not always easy to assemble a medical crew with the relevant visas for such a mission, as they all work on a freelance basis; however, it worked out and a medical crew was established. 

Then, in the course of further medical clarification, it became apparent that the patient had a multi-resistant germ in the tracheal secretion. This posed an organisational challenge, as bio-disinfection following the flight was now necessary upon arrival in Osaka, since the aircraft was scheduled to pick up another patient on its way back to Europe.

We contacted the handling agent in Osaka regarding this requirement and were immediately told that this would not be possible and that we would not be allowed to bring the required bio-disinfection materials into Japan onboard the aircraft (as they were classified as dangerous goods). The disinfection spray would also not be available on site. It took hours of countless difficult telephone calls and emails to find a solution, due to communication problems. Eventually, a medical provider at the destination was able to procure an appropriate solution after the necessary composition and mode of action (disinfection by room fogging) were explained and understood.

Medically, there were further challenges as, during the medical clarification, it turned out that the patient needed a fivefold combination of analgosedation to be able to be moved for just a short time. This was a challenge considering the long flight time, as the number of perfusors in the aircraft is limited to three; so, the medical team had to decide on the three most important ones and administer the rest manually by injection or as an infusion by means of a pressure bag.

In the meantime, the patient was declared fit-to-fly by the TAA medical assessment doctor, who was in direct telephone contact with the treating doctor.

Repatriation day
The crew arrived in Vienna the day before the flight, and the medical team visited the patient at the hospital and informed the patient’s wife about the flight details and in-flight medication plans via the interpreter. She then took a scheduled flight home, as was her desire. 

On the morning of the flight, at 5 a.m., the medical crew arrived at the hospital to pick up the patient while the flight crew prepared the plane for take-off. On arrival at the hospital, it was discovered that the patient’s passport was not included in the handover papers, as the wife had taken it with her! The flight nurse immediately informed the TAA Operations Control Center and the flight crew was informed there would be a delay due to the missing passport.

The interpreter and the Japanese Embassy were contacted and informed about the situation and all necessary airports and handling agents along the route were contacted to determine whether the patient could be accepted with just a copy of their passport. Russia granted entry and onward travel, as did Mongolia – the two fuel stops. However, for entry into Japan, the authorities insisted that the spouse must wait at the airport, when she arrived, with the patient’s passport to ensure proper entry.

Eventually, after these issues were resolved, both the medical crew waiting with the patient at the hospital and the flight crew could be given the further go ahead. Flight schedules were updated, crew rest periods were recalculated, handling agents were informed, and the journey could begin.

Flight and patient drop-off
The transport from hospital to the airport in Vienna went smoothly, although the flight itself was challenging as the patient was very tall and heavy and had to be regularly repositioned in the plane in cramped conditions. He also needed high doses of medication, so the right choice of medication had to be carefully considered in view of the long flight, as well as how much medication we could carry and the possible side effects of those medicines.

There were no abnormal events during the flight and, by changing the analgosedation, the patient could be kept stable throughout. The patient’s physical position was supported by special gel padding, which is standard on TAA aircraft.

In the early morning, the ambulance flight landed in Osaka. The entry formalities went smoothly, thanks to the wife waiting with the patient’s passport. A ‘rescue car’ carried out the ground transport to the hospital. Due to the special situation with the multi-resistant germ and the fact that communication with the paramedics was more or less reduced to hand signs, the medical crew decided to take as much equipment as possible from the plane with them in case it was needed during the ground transport. 

Despite these precautions, the ground transport went well. During the handover in the hospital, discussions arose regarding the morphine administered to the patient. The attending physician explained that the use of opioids in Japan is associated with a ‘bad spirit’ and was unhappy that they had been administered.
However, in the end, everyone was happy, including the patient’s parents, who had been waiting hopefully for their son.