Depending on a patient’s condition, complete medical repatriations can be performed via ground ambulances over short journeys when transportation by air isn’t practical, but to what extent are long-range ground repatriations possible, and are there circumstances in which they might even be preferable? The Covid-19 pandemic has necessitated an increase in long-range ground ambulance repatriations – air travel restrictions, visa requirements and inequitable vaccine distribution being just some of the reasons why. Although there can be certain limitations to this mode of patient transport, being able to perform long-range ground repatriations when aircraft are in limited supply has saved lives and potentially opened up new possibilities for long-range repatriations over land.
Investigating the increase
Belgium-based Ambuce Rescue Team told ITIJ that it has witnessed a significant increase in long-range ground repatriations and confirmed that the overriding reason for this is the pandemic. “We at Ambuce have seen a rise in long-range ambulance transfers of up to 50 per cent in the ‘high-season’, and a decrease in medical escorting missions by aeroplane. This can be attributed to the Covid-19 pandemic,” said a spokesperson.
Ambuce Rescue Team pointed out that holidaymakers have been staying closer to home due to restrictions and also due to the fear of being stranded away from home. The resultant uptick in European vacations among its clients has resulted in more repatriations by ground ambulance. “Vacationers choose a safe vacation spot over risk, and this safe spot is mostly within Europe, since travelling within the European area is mostly ‘easier’,” the Ambuce spokesperson told ITIJ. “Also, travellers need to be able to get back. For example, when you travel to Morocco in Covid-19 times, there is always a risk that you’ll get stuck there, and won’t be able to get back in time for work, school, or personal affairs. When you choose to travel closer to home and take, for example, the car or camper for a vacation, the possibilities to get back home are better when a certain country decides to go into lockdown. Since most people chose stay-at-home vacations, or destinations who are easier to reach, long-range ambulance transfers have increased.”
In many cases, long distance ground transportation is much less costly than air
ITIJ also spoke with ADAC Luftrettung’s Susanne Reuter, who agrees that travel within Europe rather than worldwide has been the trend seen during the pandemic and this has contributed to a rise in ground repatriations. “Travel behaviour has changed as a result of the pandemic: instead of travelling worldwide, many ADAC members or insured persons travel to other European countries or stay in Germany,” she stated. “Before the pandemic, we had just over 5,086 ambulances on the ground, in 2021 it was 2,975.” According to Reuter, repatriation via ground ambulance is sometimes preferable to air ambulance, both for patient and provider, for myriad reasons. “We carry out transports with ground ambulances up to a distance of approximately 900km, and in exceptional cases, also longer distances,” she told ITIJ. “Many patients prefer to be transported by ground ambulance, which can be completed on average two to three days after the doctor has determined that the patient is fit to be transported, provided there is a sufficient fleet of vehicles. Transporting the patient lying down in an aeroplane, on the other hand, is very time-consuming to organise and involves longer waiting times.”
Global Air Ambulance is another company that has observed growing numbers of ground ambulance repatriations; first due to the Covid-19 pandemic and subsequently due to inflation, and acknowledges that during the past several years, long-range ground repatriations have increased significantly. “We saw the rate of increase rise steadily since the start of Covid-19 and have since seen another bump in response to inflation, which has impacted industry pricing,” said Ben Carothers, Medical Flight Coordinator at Global Air Ambulance. “In many cases, long distance ground transportation is much less costly than air. Also, during the surge of Covid cases, ground transports sometimes allowed patients to be transported sooner due to lack of availability of air transport.”
Benefits and limitations of ground ambulance missions
There are a number of potential advantages to long-range repatriation by ground ambulance but, equally, limitations mean that this is not always possible. “Ground transports begin with a much lower base fee, but they typically have higher mileage fees,” Carothers expanded. “For shorter-range trips, and those patients requiring lower levels of medical care, ground transports offer considerable cost savings over air.” Carothers also told ITIJ that, in some circumstances, ground transport is the sole available option. “Some morbidly obese patients cannot fit into air ambulances and can only travel by ground no matter the distance,” he said.
During the surge of Covid cases, ground transports sometimes allowed patients to be transported sooner due to lack of availability of air transport
Ultimately, underlined Carothers, the trade off between ground and air is time versus cost. “Air ambulance trips can sometimes respond the same day or the next day while gathering ground crews to do long-range trips can sometimes take 48 hours,” he stated. “For patients that have a high risk of medical instability, the speed of an air ambulance sometimes outweighs the additional cost. Also, because of the long time involved in some ground trips, ground ambulances are not able to accommodate some patients requiring large volumes of oxygen.”
Ambuce agreed that time can be a substantial limiting factor in long-range ground repatriations: “The limitations are usually driving time,” said the company’s spokesperson. “There is currently no Belgian law defining the driving times for medical personnel, but our company sets a priority on safety for our crew and patients, and limits the range driven per day. When there is a need for a longer transportation than our driving limit, we will need to stretch the case from two days to three or even four days.” The Ambuce team went on to describe two case studies: “One case we were able to perform over six days from Faro in Portugal to Belgium with a perfectly stable patient who was able to sleep in a hotel without medical supervision. In another case, we performed a repatriation from Malaga to Belgium (over 2,000km) with a patient who couldn’t stay overnight in a hotel. No hospital wants to keep a patient for just one night, and we couldn’t have only one team for this trip because of the long distance. We eventually changed crews in Bordeaux (halfway through the transfer), so the patient (intubated/ventilated) was transferred in one haul, but with two different crews who were flown up and flown down from Bordeaux.”
With patient wellbeing consistently at the heart of repatriations, patient feedback is important and not taken lightly. The spokesperson at Ambuce Rescue Team said that the company has taken great pains to maximise patient comfort: “We have equipped our international fleet to be the most comfortable fleet within our company, with air suspension, floating stretchers and custom mattresses. All of these efforts have meant that the overall feedback is positive.” The Ambuce spokesperson also pointed out that repatriation by ground ambulance can sometimes be smoother for the patient as they are performed in one long trip without multiple changes. “When a patient travels by aeroplane and needs an ambulance from the hospital to the airport, has to wait several hours at the airport, travel by aeroplane, and require an ambulance from the airport to their home/hospital in the destination country, there is usually a larger travel time, smaller luggage capacities and lots of transfers and changes involved,” they said. “A ground ambulance transfer takes away this stress, since the patient is picked up, can stay relaxed on the stretcher and will be dropped off at their destination by the same vehicle, same crew and same medical team.”
Carothers agrees that long-range ground repatriations can reduce stress, but emphasises that the right type of ground transport must be utilised to match the patient’s needs: “Clients are more familiar with what to expect from ground ambulance transports than they are with air ambulance, so we’re able to meet their expectations and provide comfortable transport given the circumstances,” he told ITIJ. “However, it is critical to match patient needs with the right type of ground transport. While all air ambulance transports are essentially critical care, ground transports have varying levels from stretcher van to basic, advanced and critical care life support. As ground transport is limited primarily by time and distance, this can make it difficult to transport the most critically ill patients.”
Clients are more familiar with what to expect from ground ambulance transports
The pandemic has necessitated a rise in the number of long-range ground repatriations being performed, due to aircraft limitations and changes in travel behaviour, which are factors that were further compounded by the impacts of inflation on industry pricing. In many ways, this has been beneficial due to the lower costs typically associated with long-range ground repatriations, as well as patient feedback which, in general, has been positive due to better familiarity with ground transport, and a smoother and less stressful process without potentially disruptive changes and consistent crew. The bottom line is that being able to perform long-range ground repatriations when aircraft haven’t been available has saved lives. Considerations when performing long-range ground repatriations include identifying the correct type of ground transport according to patient needs and maximisation of patient comfort by appropriately equipping ground ambulances. Further factors are that, typically, repatriation by ground ambulance is less complicated to organise and reduces waiting times, which could prove to be critical considerations. With patient wellbeing the most important consideration, whether long-range ground repatriation is possible or practical is evaluated on a case-by-case basis, but the ability to transport patients over long distances when aircraft are unavailable is crucial.