There is a lot more to repatriation than your average air ambulance flight – often, the route or patient has complicated needs that can’t be met with a simple, direct flight. International repatriations can involve commercial aircraft, road ambulances and even ships; cross-border repatriations can take place via train; and air ambulance repatriations can involve wing-to-wing transports.
Each of these modes of repatriation pose their own challenges for assistance providers and the various operators involved. Italian medical escort company DTMedicalService24 has been dealing with medical transport by ground and air ambulance and medical accompaniments on scheduled flights and ships for years. But Covid-19 has changed how they operate in ways they could have never predicted. Davide Toso, Business Development Manager at the company, recalled: “Never have we felt a crisis on this type of work as [we have] in 2020. Covid has drastically stopped us. But we can say, perhaps, that we were the only ones to carry out international repatriations in the lockdown by ambulances and medical flights of Covid patients with biocontainment capsules from Albany to Italy, from Kazakhstan to Italy, from Norway to Italy, from Spain To Italy, and from Italy to France. “In this period, what was normal for us, from the arrival of the request to the departure of the vehicle, was that everything was complicated. It takes several hours – if not days – to obtain transit permits at customs, to see if the person needs a Covid-negative buffer, in short, a lot of bureaucracy to carry out medical transport to help the neediest. Everything can be overcome, but we hope to return to normal soon.” The availability of Covid test kits, as well as the validity of these for the receiving destination, is a key factor that has to be carefully planned for, not to mention the variable response times for receiving test results, which determined how soon a mission could be affected.
Different Covid-19 protocols across borders (and at border control) also have to be ascertained and updated as per various stages of the intensity of the disease, and greatly affected whether a mission could be conducted timeously, or at all.
Additional Covid safety measures make repatriation more complicated
James Halsted, Managing Director at ACE Air & Ambulance in Zimbabwe, explained: “We have set up and continue to monitor and update our own database of regional ports, roads and airstrips, detailing current conditions and risks. This is updated and informed by our own pilots and local contacts set up for this purpose. In this way, we avoid planning mistakes by avoiding unsuitable routings and understand the local conditions before allocating vehicles to a mission. With regards to Covid-19, the measures discussed above also ensure that additional safety equipment and protocols are in place to ensure safe and effective missions, as well as staff education and communications to ensure staff are comfortable and confident to perform their duties.” Halsted added: “Once again, local knowledge and direct relationships and experience with these ports and their specific requirements and procedures is essential to ensuring cross-border missions run smoothly. “Obviously, the necessitation for putting Covid protocols in place has extended the duration of medical mission planning significantly, especially the requirement for patients procuring negative Covid-19 test results for repatriation in most cases.”
LOCAL KNOWLEDGE AND DIRECT RELATIONSHIPS AND EXPERIENCE WITH THESE PORTS AND THEIR SPECIFIC REQUIREMENTS AND PROCEDURES IS ESSENTIAL TO
ENSURING CROSS-BORDER MISSIONS RUN SMOOTHLY
In Halsted’s example, road borders in the region were generally closed during Covid-19, whilst airport immigration was mostly open. Halsted recounts that the status of whether patients were permitted to be transported cross-border and the differing conditions for acceptance meant that the team was continually reassessing the viability of each and every mission on a day-to-day or even hourly basis. For non-returning residents, documentation had to be processed through the relevant embassies, which added to the complexity and duration of mission approvals. “This obviously was hugely disruptive from a logistical and efficiency point of view,” Halsted said. “In addition, our own staff were experiencing fear of infection themselves, as well as the uncertainty of their job continuity and the state of the economy, and we had to continually keep communication open about Covid-19 infection control protocols and our status as a company with them to ensure they were comfortable to continue working.”
WE HAVE HAD INSTANCES WHERE
WE HAD TO NEGOTIATE BORDER
CONTROLS TO BE OPENED
SPECIFICALLY OUT OF HOURS FOR
Complicated medical conditions can pose a risk
Dr Daniel Boulanger, Chief Medical Officer at Europ Assistance in France, has planned several ‘unusual’ repatriations during his time with the global assistance provider, even before Covid-19. He tells ITIJ that patients with nondrained pneumothorax after a road accident are particularly complicated to transport. “For these patients, flying is a contraindication: air pressure means life danger, they have to stay at sea level. So, we repatriated the patient with a combination of transport modes: by boat, train and ground ambulance. “Recently, we transported two people severely injured in a car accident in Wallis-et-Futuna [French oversea territories in the Pacific Ocean]. They had to be transported to Nouméa Hospital. But there was no air ambulance available, and regular flights with a local company could not be adapted, so we got the support of local air military forces to transport them in a military plane we adapted.”
Boulanger also lists a few ‘tricks’ he has learned while planning complicated repatriations:
- Daily continuous remote monitoring of patients (for those who were localised in underequipped regions).
- Moving patients who really need to be moved because of their medical conditions from some underequipped countries.
- Transporting two infected patients from the same region on the same plane.
Road transport can pose problems in rural areas
ACE Air & Ambulance’s Halsted told ITIJ that road transport poses huge problems in remote areas of Southern Africa, where a short distance of road on a map can take much longer or be impossible to traverse due to the adverse conditions of the road itself.
Just because a road is marked on a map does not mean it is a formal road or even in existence at all. In fact, in all likelihood, it may not be in a suitable condition for ‘normal’ vehicles. The same can also be said for airstrips, says Halsted; however, aircraft safety protocols are often far more rigid, and an error in airstrip or flight planning can mean a mission is cancelled or impossible. Planning for the extraction of patients without knowing the local conditions of roads and airstrips can lead to major issues, especially if a patient is time or motion sensitive.
Furthermore, cross-border missions also require local knowledge of the ports and their specific requirements. Border officials, especially in remote African ports, often have differing standards to what may be posted on official websites or published documentation. Halsted added: “Most of our repatriation missions involve multiple modes of transport as international patients usually require transport out of Zimbabwe or our neighbouring countries to South Africa, where medical treatment facilities and international repatriation flight options are better.”
Non-medical vehicles might be needed for transports
Expanding upon the point, Halsted explains that most cases therefore involve one of their ground ambulances, or a non-medical vehicle, transferring a patient to the nearest suitable airstrip, whereafter the fixed-wing aircraft transfers the patient to the designated medical facility, often located in South Africa. In some cases, where the patient cannot be accessed suitably by ground ambulance or other ground transport, the company deploys its helicopter service to retrieve the patient to the nearest suitable medical facility or airstrip, where they can then be transferred by fixed wing to a suitable medical facility cross-border in South Africa. Halsted said: “We have had instances where we had to negotiate border controls to be opened specifically out of hours for emergency purposes, which cannot be done effectively without ensuring open and continual relationships are maintained with the necessary officials and regulatory bodies.” He particularly remembered one such case: “We had a case of a patient from a neighbouring country, Zambia, who was coming from their capital city Lusaka and we were requested to take over the transfer at the Zambia/Zimbabwe Chirundu border post and fly them on to Bulawayo, a city in Zimbabwe’s southern region. Our medical flight team was activated and arrived at the prescribed time at Chirundu. “However, the patient and handover medical team was nowhere in sight. There was significant time pressure because the airstrip at Chirundu is a dirt strip with no lighting and in a remote location with dangerous wildlife roaming free. The call would have to be abandoned at sundown, which was approaching in a short while. Eventually, the patient arrived, not in an ambulance but on a regular bus service (with no accompanying medics), which had been delayed. The patient was eventually loaded just in time for our team to take off before sunset, with much relief from our team!”
While using different types of transport can be complicated to plan for, especially during Covid, it is still necessary in cases where the patient’s health demands it, or when there are infrastructure problems that need to be overcome.