On your own at altitude: lessons from Ebola evacuations

When an Ebola patient needs to cross borders, the flight is only one part of the challenge. The aircraft may be ready. The medical team may be trained. The isolation equipment may be in place. But permissions can take days, ground support may disappear, and a single change in a patient’s condition can alter the entire risk profile.

This year, our team transferred a small number of patients with suspected or confirmed Ebola virus disease (EVD). Guidance on fixed-wing transfer of high-consequence infectious diseases (HCIDs), particularly EVD, remains limited. Every mission exposed something we could improve.

These are some of the lessons we learned.

Make the decision together

An HCID mission is a team decision, not an instruction. We ask every crewmember whether they are willing to participate.

Once EVD is suspected, the full HCID protocol applies. An unconfirmed diagnosis does not justify a lower level of protection.

We refined our standard operating procedures (SOPs) with a global network of HCID experts who support decision-making on individual cases. For high-risk contacts and unconfirmed cases, our SOPs have no ‘orange’ category: a patient is either green, or red and inside the isolation chamber.

The reason is simple. If a patient considered low-to-moderate risk leaves the chamber and vomits in-flight, we cannot know immediately whether it is motion sickness or EVD. By then, the cabin and healthcare workers could already be contaminated.

Train for the moment you hope never comes

HCID missions can come at very short notice. Training therefore cannot start when the phone rings.

We simulate regularly. Once a mission is confirmed, we run full drills, first with the medical team and then with the pilots. We repeat them until everyone is confident.

Once a mission is confirmed, we run full drills, first with the medical team and then with the pilots

Pilots are an essential part of the medical operation. They need to understand the medical processes well enough to oversee what is happening in the cabin, from donning and doffing PPE to loading the stretcher.

Across these missions, we trained more than 15 healthcare staff and eight pilots.

Every mission operates with at least four trained healthcare crew and two pilots. Confidence comes from repetition.

Do the medicine before takeoff

One of our clearest lessons came from simulation.

Intervening through the isolation chamber in-flight is possible in the aircraft we use, but it significantly increases risk. Our approach is therefore to optimise the patient fully before departure and maintain a no-touch environment until landing unless there is an absolute emergency.

Our patients were stable and fully alert.

That mattered. We could explain what was happening, reassure them and prepare them for the journey.

A patient who requires active treatment in-flight presents a very different challenge.

We are therefore expanding our capability with an EpiShuttle, a single-patient isolation system designed to provide safer access to the patient during flight while simplifying decontamination.

More cleaning does not always mean more safety

Hindsight is useful.

After our first mission, we realised that we had probably been overzealous with in-flight cleaning, decontaminating areas that should have remained classified as green, or clean, zones.

It sounds counterintuitive, but excessive intervention can create its own risks.

It causes delay. And delay matters when a patient is inside a hot isolation chamber and the crew are working in full PPE.

We now apply risk levels so that decontamination during the mission is proportionate to the actual risk.

The deep clean comes afterwards: on the ramp, again at base and finally through an external contractor the following day.

The hardest part may happen on the ground

One mission took three days from first notification to handover.

The active flight phase lasted only six hours.

The remaining time was spent clarifying the patient’s condition, agreeing the transfer plan and securing permissions. Four governments had to agree the parameters of a single transfer.

The people supporting the mission do not stop being part of a team when the aircraft lands

The most difficult decision fell to the country hosting the handover.

Ebola carries significant stigma. Political and public pressures can make accepting a patient extremely difficult, even when the medical need is clear.

Integrated government, regional or global guidance for HCID medevacs could support earlier preparedness, clarify responsibilities and help streamline transfers.

When nobody is coming to help, plan accordingly

On that three-day mission, our aircraft was denied all ground services after pickup.

That meant planning fuel for every sector, including the return to base.

When the handover overran, the crew kept the aircraft powered and cooled for the patient while closely monitoring fuel burn to ensure there was enough to get home.

No handlers approached the aircraft. Local health officials monitored every interaction.

Even simple logistics became critical. Our documentation is fully digital, but some handling agents still prefer cash, so payments need to be settled in advance.

Our operations centre tracked the aircraft throughout. We did not launch until the long-range aircraft was within five hours of the rendezvous.

Arriving with a patient and no-one to hand over to would have left us stranded. That is the reality of HCID aviation: when something goes wrong, there are very few easy alternatives.

An aircraft with a technical problem and an HCID patient cannot simply divert. Airports may refuse it, and transferring the patient elsewhere is not straightforward.

Backup is therefore not a luxury.

We keep a second aircraft and crew available to recover the mission. The addition of another aircraft to our fleet has allowed us to maintain that resilience without withdrawing cover from other patients.

The mission ends. The responsibility does not

Post-mission monitoring follows UKHSA and CDC guidance.

After our first mission, while our SOPs were still being finalised, the crew isolated for seven days as a precaution. Since then, low-risk crew have self-monitored for 21 days.

But the bigger challenge was not clinical. Some families were uncomfortable having crewmembers at home, even when they had been assessed as low risk, and asked that they isolate. We honoured those requests as a company.

We also brought in external EVD trainers for all staff, not just those involved in the missions. That education mattered.

It dispelled myths and meant colleagues did not avoid those who had flown.

This is an often-overlooked part of HCID preparedness. The people supporting the mission do not stop being part of a team when the aircraft lands.

What we need from our partners

My request to assistance companies and insurers is simple: give us time, and give us information.

As much notice as possible allows teams to prepare properly. Transparency about the patient’s condition and any changes is equally important.

Disease progression, particularly from dry to wet symptoms, the patient’s location and remoteness, transfer time and the type of handover can all change the risk assessment and the operational plan.

Referring and receiving teams should also work from the same risk definitions.

The safest missions are built on open dialogue between the assistance company, insurer, referring team, receiving team, medical crew, operator and authorities.

No one organisation can manage the risk alone.

No team should face it alone

I am grateful to the colleagues and global Ebola experts who gave their time, often day and night, to support these missions.

Better guidelines will help. Better equipment will help. More training will help.

But every HCID transfer will still require case-by-case judgement.

The lesson we keep coming back to is simple: prepare together, communicate openly and never underestimate what can happen once the aircraft leaves the ground.

No team should face these transfers alone – on the ground or in the air.