Long-haul critical care transport by commercial airline stretcher

One morning in January, Jet Companion received a call from China. A severely ill Canadian expat in his 30s had been in an intensive care unit (ICU) for over two months with a bilateral pneumonia and a near-fatal sepsis.

Admittedly, the worst of the crisis was over at this point: extracorporeal membrane oxygenation (ECMO), haemodialysis, and vasopressor support were no longer needed. But there was also a disappointing setback: the patient had failed two extubation attempts. Fearing long-term dependency on mechanical ventilation, the family now felt that they needed to make the move back to Canada as soon as possible.

With the long stay in ICU, every cent of the travel insurance emergency medical coverage had already been spent. There was no way that the family could afford to pay out-of-pocket for an air ambulance across the Pacific, so while friends and colleagues took care of crowdfunding, we started conversations with the doctors in China to better understand what this patient needed for a safe transfer on a commercial airline stretcher. Was it in the best interest to transport as soon as possible in the current state, or to wait for further improvement?

Intubated for the flight

The green light was given a few days later, for a commercial airline stretcher transport mission with a critical care team. The most recent chest X-rays, blood gas and bronchoscopy results, infection parameters, FiO2 requirements, and clinical observations, were all pointing towards a much improved and stable condition. Doctors believed that the infection had cleared, and the patient was now strong enough to tolerate a third, this time successful, extubation.

However, for patient safety reasons, the decision was made to keep the patient intubated, and on the ventilator for transport. Arguments brought up were the heavy body weight and composition of the patient, workspace management, the length of the itinerary, physiological stressors of flight and the limitations to safely intervene in case of a ‘can’t intubate/can’t ventilate’ scenario in the cabin of the airliner: a term used to describe a hypoxic emergency following a failed airway.

With a secured airway and mechanical ventilation being a condition for the transfer, we established the necessary crew configuration (physician, respiratory therapist and registered nurse with full critical care gear) and started looking for a suitable itinerary.

Crossing a bridge

We learned that the quickest way to set up a commercial airline stretcher mission was to have a Chinese ground ambulance crew transfer the patient from the discharging Chinese hospital to Hong Kong. But this was easier said than done: due to geopolitical factors, the Chinese ambulance was not allowed into Hong Kong, and a Hong Kong ambulance was not allowed into mainland China. Local procedures for cross-border patient transfers are very strict: the discharging hospital obtains pre-approval from local immigration authorities, and on the day of the transfer, the Chinese team could only cross the Hong Kong-Zhuhai-Macau bridge in a neutral bus and transfer care to a Hong Kong ambulance crew. The trip took 40 minutes.

Behind the scenes

Back in Canada, our team was working around the clock to find a suitable flight with stretcher capacity out of Hong Kong. The goals were to reduce the total transfer time as much as possible, land as close as possible to the final destination in Alberta, Canada, and drop off the patient safely, without exceeding the budgetary limits of the client.

Several direct flights to Vancouver were out of the question due to patient weight restrictions or other airline limitations. The best scenario was to request stretcher service on two connecting flights, with a stop in South Korea. The transit involved multiple additional bookings, local coordination and a pre-arranged short-stay admission at a local hospital emergency department, close to the airport.

Ultra-long-haul missions

Over the last five years Jet Companion’s team has gained ample experience with high-complexity ultra-long-haul (ULH) transfers between low-density areas worldwide. While airlines define ULH as any flight that lasts for longer than 16 hours, a commercial medical repatriation between two continents involves both ground and air segments and pockets of wait time in between. The cumulative transfer time from bed to bed can quickly add up to anywhere between 40 and 60 hours! One of the challenges that comes with these extra-long transfers is the need to carry sufficient battery power for different pieces of equipment, in our carry-on medical kits, not only during the transfer, but also on the repositioning flights.