Insider report: Medical assistance when there is no ‘normal’

However, on a clinical level, offering the best solutions to serve our clients has meant adapting and updating on a nearly daily basis as the epidemic spreads, healthcare resources become strained and borders close.

The first client need we identified, as we had learned after braving a number of infection-related threats in recent years (i.e. Ebola, Zika, H1N1), was to communicate early and transparently. In 2013, we identified the early warning signs of trouble long before global authorities acknowledged that Ebola posed a global threat. Because we saw countries effectively resisting evacuations of ill non-Ebola patients from West Africa early in the outbreak, we notified clients about avoiding non-essential travel to these areas two months before the WHO went public with this warning. Similarly, early in Covid-19, while doing our best to maintain a sense of calm, we started sending regular communications alerting clients to the risk of travel to affected countries to avoid becoming barricaded abroad with or without needing urgent medical care. Global authorities are arguably, but understandably, cautious about calling out threats of pandemic because of the consequent political and economic consequences of such actions. Our clientele have invariably come to appreciate the honest warnings we have provided to enable them to better prepare in an atmosphere where responsible stakeholders seek valid information about threats and predictions. 

On a clinical level, offering the best solutions to serve our clients has meant adapting and updating on a nearly daily basis as the epidemic spreads, healthcare resources become strained and borders close

Next, the global situation morphed into taking difficult decisions and unusual actions to meet new client demands and adapt to changing travel restrictions. It goes without saying that we have done our best to find flights for our clients who needed to come home after airlines cancelled their trips and for expats who had no reservations. The call for help has come from well individuals as well as those with chronic medical conditions that put them at risk for complications.

But the limits on standard options for referral and repatriation have confronted us with choices we have never had to make. They have forced us to create revised protocols, become especially agile with novel solutions and make risk/benefit decisions that we normally would not entertain. To head off this challenge, we cohorted patient travel situations that are affected by Covid into four categories:

• Worried well: potentially exposed or well Covid positive patients.
• Patients needing standard medical repatriation.
• Patients needing evacuation to a higher level of care, but with no Covid risk.
• Sick patients with Covid.

We have established a preferred approach to all of these situations but have to remain flexible in applying any solutions as conditions change rapidly. Some of the options that have to be considered in the best interest of the patient or as a result of limited options are:

• Staying in place for observation if not seriously ill until clear and able to travel without healthcare restriction
• Arranging teleconsultation instead of an in-person visit
• Telephone triage to avoid non-essential care instead of incurring the risk of exposure in a healthcare facility or ER
• Staying in place where care is adequate to recover from an injury or illness rather than early repatriation requiring a medical escort
• Using air ambulances for transport of non-critical patients who are considered potentially infected or who cannot fly home because commercial flights are unavailable. Pooling patients for access to limit special transports and make this more affordable.

The challenges we face to find solutions for our clients is fraught with uncomfortable ethical considerations. The questions that these pose include:

• Do we advise patients to seek medical care from healthcare centres that may expose them to coronavirus?
• Do we ask patients to return home for ongoing medical care when they are in a safe location, but the epidemic is raging in their home country?
• Do we insist expatriate workers return home, abandoning their local workforce and missions at the risk of being marooned if they run into medical difficulty?
• Do we offer an air ambulance when normally a simple commercial flight would suffice, especially when we had urged customers to return home when they had the chance?

There are few easy answers to these questions, but I find that conferring with my medical colleagues in my own organisation as well as the wider assistance community helps us all feel more comfortable with our decisions. I firmly believe that notwithstanding the non-clinical pressures facing our organisation, we are best advised to take the medical need of our customer/patient as our top priority, even as we respect the principles of crisis management: use precious resources to do the most good for the most people. 

The challenges we face to find solutions for our clients is fraught with uncomfortable ethical considerations

In the meantime, I find it energising to look for solutions to problems I had never encountered and take pride in some of the amazing missions we have successfully undertaken in the face of these challenges. Thanks to our internal expertise and the support of superb aeromedical and travel partners, we have arranged the secure and compliant transport of Covid patients to adequate places of care, helped travellers find the last flights home and arranged medical evacuations across tightly shut borders using diplomatic and governmental dispensation and well-positioned providers.

We expect these challenges and dilemmas to continue as the crisis evolves but that is when our profession shows its value as we wait for Normal to come back!