ITIC APAC 2025 | Medical Directors’ Forum

The ITIJ team have been reporting live from ITIC APAC in Hong Kong this week (June 2025), sharing the discussions that took place at the conference. Read all reports

Stephanie Curtis, Corporate Manager and Senior Flight Paramedic, Retrieval Medics International

Curtis concentrated her presentation on a commercial mission that involved the repatriation of a cognitively impaired 79-year-old male with delirium, which came on with visual hallucinations post a long-haul flight to Cork, Ireland.

On the first leg of the mission from Cork to London there were no concerns, but on the second leg from London to Singapore the patient developed acute behavioural disturbance, disinhibition, persecutory delusions, and loss of insight. He was also increasingly combative and verbally aggressive, trying to open the plane door, and was unresponsive to reassurance or structured redirection. He was given medication but had continued auditory and visual hallucinations.

The crew decided to make a medical diversion to Istanbul in Turkey, and had assistance from an emergency toxicologist, registered nurse (RN), and a surgeon on the flight. No new or reversible cause of delirium was identified, but a probable relapse of delirium superimposed on underlying cognitive impairment, and exacerbated by sleep deprivation, time zone disruption, and sensory overstimulation. The patient stayed in Turkey for seven days.

An air ambulance was then activated to take the patient to Brisbane. There were aspiration risks for the patient, and risks to the clinical team too. 

But the patient made it home and experienced prolonged confusion for 48 hours. After a three-month follow-up he was formally diagnosed with mild dementia. There had been no recurrent episodes of delirium, and his driving licence was suspended temporarily during recovery.

Curtis said there are learnings to be had about commercial repatriations, and behavioural dysregulation occurring mid-flight, plus learnings for air ambulance crew.

She said this case reinforced the necessity of:

• Comprehensive pre-mission assessment
• Structured clinical planning with escalation pathways
• Informed consent and transparent communication with all stakeholders
• Systems-level adaptation and learning after each complex mission.

There was a lot of discussion from the audience about this case. They agreed that more research and scoring of the patient should have been done in the pre-flight stage. The hospital in Ireland would only give a vague idea of his mental health, so it was difficult to know how he had been behaving.

Shogo Ito, Lead Communicator, MS&AD Grand Assistance

Ito concentrated his presentation on assistance challenges in Japan. He said visitor arrivals  increased to 35 million in 2024, 80% of whom were from Asia.

He then spoke about a case study that involved a middle-aged woman from Europe who had a trimalleolar fracture of the right foot. Three medical centres were involved and the total length of the hospital stay was one month. Her accident happened late at night, and she was taken by ambulance to the ER. It was not suitable for the surgery she needed, so she was then sent to a university hospital. The waiting list was too long there, so she was taken to a specialist hospital. She had rehab for a month.

Ito went on to talk about the acceptance of foreign patients in Japanese hospitals, and said only half of the medical facilities there have seen foreign patients – 45.7% accept foreign patients, and 54.3% do not.

He spoke about the challenges they face in Japan and said the main three are: difficulties of guarantee of payment (GOP); obtaining medical documents; and language and cultural differences.

He said that understanding of GOP is not widespread in Japan, and solutions to this would be explaining the benefits and risks, and building trust. He went on to say that obtaining medical documents is slow, and that there is a lack of necessary information. He said purpose clarification and custom medical report formats would help.  

Ito said that language and cultural differences solutions could involve translation tools and using local assistance companies. 

Lenny L Zhang, Deputy Director, China International Air Rescue Center

Zhang began by talking about air rescue capabilities. He said his company’s new call centre integrates artificial intelligence (AI) algorithms and large data analytics for digital rescue operations. It combines optimal flight routes, aircraft status, and analyses patient data. It supports multi-terminal collaborative decision-making to enhance response speed and precision.

Zhang spoke about a case study where a 43-year-old patient was repatriated from Bolivia to Beijing. The patient was a smoker of over 20 years, was a type 2 diabetic and had high blood pressure.

In March he had developed coughing and dyspnea without obvious precipitating factors. The local hospital diagnosed him with a respiratory tract infection. Antimicrobial treatment was initiated, but his condition progressively worsened, with symptoms of dyspnea on exertion, bilateral lower extremity oedema, and an inability to lie flat. He was then admitted to Clinica de las Americas in Bolivia, where he was diagnosed with acute left heart failure (NYHA Class III), dilated cardiomyopathy (DCM) and coronary artery disease, as well as type 2 diabetes mellitus.

He received treatment with aspirin enteric-coated tablets, enoxaparin for anticoagulation, dapagliflozin and insulin for glycaemic control, atorvastatin calcium for lipid-lowering, candesartan for blood pressure management, and furosemide and spironolactone for diuresis. Then his family requested for him to be transferred to Beijing for further treatment.  

Two teams were needed to look after the patient on the flight.

The audience spoke about the Gulfstream 550 and said how great it is for long distances where fewer tech stops are needed (in this case, two). But the price was US$280,000 compared with $180,000 for the Learjet 60, which would have needed seven tech stops. Most people said the Challenger 604 would have been ideal – three tech stops and a cost of $160,000. Zhang said yes, it’s expensive, but they have used it a lot and it is proving popular.