Medical Directors' Forum

Medical Directors' Forum audience
ITIC Global 2019

The Medical Directors’ Forum at ITIC Global 2019 provided an opportunity for industry figures to openly discuss difficult decisions they have faced during medical repatriations. Dr Thomas Buschein led the discussion, which was co-hosted by Dr Cai Glushak and involved additional speakers who depicted challenging medical repatriation cases

Dr Thomas Buschein began the forum by referencing a case involving a 38-year-old Nigerian man suffering from a sore throat who was eventually diagnosed with inoperable oropharyngeal carcinoma. The patient was kept in a hospital in Sarjha, UAE, where he received aggressive chemotherapy, which did little to help him. He was hooked up to a monitor, with access to a ventilator throughout the night, and placed in an ICU. Thomas explained that, realistically, the patient did not have a favourable chance of survival, and with ever-increasing medical costs, the patient’s family decided to bring him home. However, the hospital that the family chose to repatriate the patient to was inadequate. Unfortunately, the Nigerian patient had only very basic insurance, which had already reached its coverage limit, and so – the new facility being the only one that the family could now afford post-air ambulance flight W– there was little other choice. Thomas said that, upon delivering the patient, the doctor at the new treating facility assured FAI Air Ambulance that they would find a solution for the patient. But as soon as FAI left, the treating facility disconnected the patient and he sadly died.

Dr Thomas Buschein
Dr Thomas Buschein

Dr Simon Forrington, Chief Medical Officer of Capital Air Ambulance, followed Thomas’ presentation, using an example of a challenging repatriation of a patient with traumatic brain injury from North Africa to the UK. The patient had fallen from a third-floor balcony, and was suffering from an extradural haematoma, which had to be drained surgically. However, the patient’s health continued to deteriorate, and after continued diagnoses, a CT scan revealed that they were suffering from ongoing bleeding from an unstable pelvic fracture, which had been missed on the original scan. 

The team then had to decide how to safely repatriate the patient, who desperately needed more blood products. However, the air ambulance transportation would have taken several hours back to the UK and, with no blood products available, the move would have proved extremely risky for the patient. The team decided that the best course of action was to move the patient to the nearest trauma centre in southern Spain. 
By maintaining constant communication with all parties (the Capital transfer team, the assistance provider and the patient’s family), the patient was safely moved, and ultimately was able to be transferred back to the UK as soon as it was safe to do so. Simon emphasised the importance of being flexible and adaptable, practising good communication and having strong working relationships between the air ambulance provider and assistance company.

Dr Simon Forrington
Dr Simon Forrington

An incident involving a 29-year-old-male with a five-day case of malaria being treated in Songo, South Africa, was put forward by Dr Charles Crawshaw of ACE Air & Ambulance. Trying to transport the patient proved to be particularly difficult due to the rural location, with factors such as a short 900-metre runway, no local immigration facilities (the air ambulance would have had to fly in via Tete to pick up the patient), delayed flight clearance and limited flight hours impeding ACE’s rescue capabilities. Eventually, ACE had to fly in two different transport vehicles to pick up the patient – the company’s King Air Ambulance, which would fly into Tete and await a road-to-wing patient transfer from a road ambulance, as the large air ambulance could not land on the 900-metre runway in Songo. The patient was eventually transported after nine days in the facility. 

After repatriation, the patient’s health improved, and he eventually fully recovered. Dr Crawshaw reiterated, that as an industry, improving flight clearance into less developed or military-governed countries is integral to improving patient access to care, particularly in time-critical cases, such as those involving malaria.

Dr Charles Crawshaw
Dr Charles Crawshaw

Dr Yann Rouaud, Group Medical Director of Airlec Ambulance, relayed an instance in which his team was involved in transporting a 75-year-old Jehovah’s Witness in a critical medical condition. The Airlec Ambulance was tasked with flying the patient with no blood onboard the aircraft, as per the patient’s religious beliefs. However, with acute gastric bleeding and at high risk of recurring acute gastric haemorrhage and cardiac arrest, the lack of blood proved to be tricky. Airlec organised a call with the client’s medical director in order to review the case; organised a comprehensive pre-flight briefing with the flying doctor and nurses to give an overview of possible limitations to medical care with regards to the patient’s religious beliefs; and also contacted the District Attorney to clarify the legal aspects of the repatriation pre-flight. Sadly, the patient suffered four cardiac arrests during the flight, the last of which proved to be fatal. Overall, Dr Rouaud hoped to offer up his experience so that the rest of the attendees could share in his learning. He highlighted that, although technology is an important factor, medical firms must respect patients’ decisions. 

Dr Yann Rouaud
Dr Yann Rouaud

In her example, Dr Ferial Ladak, Director of Global Medical Affairs at Global Excel, referenced the case of 63-year-old female who travelled to a developing country for an elective mini-gastric bypass. She explained that in her home country, the patient would have been denied the operation because she was a high-risk case. Once the treating facility had operated on her and decided that they could no longer care for her, they considered placing the patient in a public hospital, which was not covered by her travel insurance. Global Excel was eventually able to step in and transfer the patient to one of its large network of hospitals, and the woman’s insurance agreed to pay for some of the medical costs involved. The patient ended up staying in the hospital for 77 days before needing to be transferred home by air ambulance. Ferial referred to this instance as a case of ‘medical tourism gone wrong’ and discussed the importance of having full disclosure with patients, especially as the treating facility, having noted her high-risk status, should not have acted with profits in mind, rather than patient safety. Ferial concluded that it would be beneficial if the industry had an option that offered coverage for medical travellers. n

Dr Ferial Ladak
Dr Ferial Ladak