Handle with care
On 5 March 2013, in conjunction with Air Medical Italy, Flight Ambulance International (FAI) flew a patient with Multiple Chemosensitivity Syndrome (MCS) from Naples, Italy, to Dallas in the US. This special mission involved planning on an unprecedented scale, and vital co-operation between all involved parties.
On 5 March 2013, in conjunction with Air Medical Italy, Flight Ambulance International (FAI) flew a patient with Multiple Chemosensitivity Syndrome (MCS) from Naples, Italy, to Dallas in the US. This special mission involved planning on an unprecedented scale, and vital co-operation between all involved parties.
Understanding MCS
Undertaking the transport of a patient suffering from MSC is not a decision that is taken lightly. The planning and preparation needed for both the aircraft and crew is unlike that for any other kind of repatriation, and success is not easy to guarantee. MSC is a chronic medical condition characterised by symptoms that the affected person attributes to low-level chemical exposure. The triggers are often unrecognisable to other people, with commonly accused substances including smoke, pesticides, synthetic fabrics, scented products, plastics, paint fumes and petroleum products. Symptoms are often vague and can include nausea, fatigue, dizziness and headaches, although other symptoms commonly include inflammation of the skin, joints, airways and gastrointestinal tract.
There are no recognisable pathophysiological roots to the illness, and it fits neither the established principles of toxicology with its reproducible cause and effect patterns, nor is it an allergy in the classical meaning. Thus, common sense seems to tell us that this illness must be psychological – or at least a strong psychological overlay to some sort of environmental hypersensitivity. Even though,
to date, scientific studies have not identified pathogenic mechanisms for the condition or any objective diagnostic criteria, it is an undeniable fact that affected people suffer considerably – some are severely distressed and functionally disabled as a result of their illness, and in some cases are confined to living in full isolation in ‘cleanrooms’ lined with ceramic tiles and fitted with special air filter systems.
Prior planning
The transport of a patient with MCS, needless to say, requires a great deal of planning. Special considerations surround every aspect of the transfer – from communicating with the patient to moving them from their home to the aircraft, and from preparing the aircraft to planning for the logistics of refuelling when the patient must not get even the faintest hint of the fumes!
To start, probably the most important issue for the air ambulance company is having a complete understanding of the psycho-social implications of the pathology and their consequent effects on the patient. For this reason, before starting a technical-logistical transport schedule, it’s absolutely necessary to follow some basic steps:
Obtain an exact knowledge of the disease and of any current pharmacological therapies used by the patient through an in-depth study of their medical records;
Make direct contact with the doctor who usually takes care of the patient;
Get in touch with the patient’s family, first by telephoning them and then meeting them personally, to consider the family’s involvement with the patient and its potential support or hindrance in the matter of the patient’s air transfer;
Telephone the patient and perform an initial evaluation of their psychological ‘structure’. It was at this stage in this particular mission that it was established that the patient could be flown to the US for treatment. It was clear to Air Medical Italy that nothing would be finalised until the patient was actually onboard the aircraft, but after a detailed conversation with the patient, the company was confident that the chances of a successful mission were good.
Go to the patient’s home and talk with the patient. Representatives of Air Medical Italy went to the patient’s home to speak with her where she was most comfortable. The staff had to follow a self-preparation regime that was suggested by the patient’s parents. At this point, it’s important to explain in detail to the patient the special measures that will be taken by the air ambulance companies involved to assure the patient of a tolerable transfer. The doctor in charge of the transport should be able to understand the developmental degree of the patient’s MCS, the level of psycho-somatic involvement and its link with the objective and verifiable clinical responses;
Allow the family members to personally inspect the aircraft and see the special equipment onboard.
Without taking these steps, or by performing them superficially, the risk is that all the following efforts to arrange the air medical transfer would be fruitless. Every effort needs to be made to ensure that when the patient sees the aircraft they do not reject it as unsuitable. If this happened, not only would it mean a substantial loss of money for the client, but it may also negatively impact the recovery expectations of the patient.
Every effort needs to be made to ensure that when the patient sees the aircraft they do not reject it as unsuitable
In the case detailed here, all of the logistics – from communicating with the patient’s parents to setting up the necessary ground transportation – was carried out by Air Medical Italy. The company also provided the medical crew for the flight and took full financial responsibility for the setting up of the aircraft and the mission itself. Air Medical worked with FAI, as a long-range jet was needed for the transatlantic mission, which FAI provided in the form of its owned and operated Challenger CL 604. The aircraft was flown by FAI pilots, and the company also supplied operational and medical support ahead of the flight, headed by senior flight nurse Markus Schlatte.
The flight
It took the best part of a day for the medical team to modify the aircraft interior to meet the patient’s needs. The modification had to take place whilst ensuring the aircraft maintained its uncompromising compliance with all the relevant aviation safety regulations.
All removable parts of the aircraft were taken out, including but not limited to: seat cushions, textile covers, blankets, carpets, towels and soap dispensers in the lavatory. Special attention also had to be paid to eliminate all potential sources of ‘chemical smells’, and all drawers and storage compartments were thoroughly searched. All remaining non-removable surfaces were treated with a special odourless, biological, patient-approved cleaning substance.
The aircraft floor, including the lavatory, all the seats, and the stretcher itself were then lined with aluminium foil and special MCS patient-acceptable odourless plastic material. Last but not least, a Plexiglas box was built around the stretcher and fitted with its own ventilation system to create a positive air pressure/airflow from inside the compartment to the cabin. Three days before the mission, the crew was briefed to abstain from using any scented personal hygiene products, a ban was put on dry-cleaning uniforms, and shoe polish was not allowed to be used.
Eventually, with all preparations completed, the patient’s parents checked over the aircraft. They gave their approval and the patient was brought from their house, where she lives in a secluded cleanroom, to the airport. The patient was transferred to the airport by her parents, with their car appropriately prepared for her needs. Air Medical Italy liaised with the airport operations staff to inform them about the critical condition of the patient that was being transported.
The patient wore a 3M protective facemask at all times, but when she was at the airport she noticed a laundry detergent smell coming from one of the flight doctors. This nearly halted the entire mission, but disaster was averted when the doctor changed his T-shirt. The patient was then happy to continue.
Another hurdle that had to be overcome was the fact that the patient wanted the aircraft doors to be closed during refuelling. According to aircraft regulations, refuelling has to be carried out with the aircraft doors open, but this caused the patient to become concerned about potential fumes from the aviation fuel. This problem was overcome by the patient agreeing to have the doors open, as long as she was able to stay in her Plexiglas ‘bubble’ with her facemask on.
The flight took place without further incident and the patient was delivered to the ground grew in Dallas, which had been specially prepared following instructions given by Air Medical.