ITIC Global: Medical Directors forum
Moderators Dr Bettina Vadera and Dr Alex Veldman, alongside panelists, discussed the aeromedical transport of patients with psychiatric problems
Yann Rouaud, Inter Mutuelles Assistance Groupe
When psychiatry meets diplomacy
Dr Rouaud began his presentation by outlining the details of his case study, namely a 58-year-old female diagnosed with acute depression and hypomania, but coupled with the complication of being an international diplomat and the immunity that accompanies that role.
Complications of this case exceeded just the patient’s diagnosis and included pressure from the Ministry of Foreign Affairs to protect the individual as well as the country’s reputation, avoiding any international incident. This required a ‘low profile’ repatriation, with the instructions described by Rouaud, ‘to bring her home, no matter what’.
This resulted in the patient needing pre-flight sedation. However, as a Diplomat, staff at the hospital were not allowed to treat them against their will. This complexity was further compounded by an air ambulance doctor also unable to administer sedation, due to not being licensed to practice in the country of transfer. Following three hours of negotiation, including help from the Ministry of Foreign Affairs, the patient was sedated by a local medical team, after authorisation.
Dr Rouaud confirmed that in this incident, ‘sharing of information with partners was vital’.
Dr Laurent Taymans and Clive Gillard, International SOS
Air Ambulance Case Review
This case involved a 29-year-old US national, who was located in remote Somalia. Following the call from his manager, he required repatriation home within 48 hours. The patient had a previous medical history of drug and alcohol abuse and had lost his father to suicide two weeks before the incident.
Dr Taymans confirmed that despite verbal and written consent to be moved to Nairobi and admitted to hospital, the patient then insisted he had been forced to leave and demanded return to the remote site in Somalia. Instead, following a diagnosis of depression, it was recommended he be repatriated to the US with a medical escort.
Despite the patient self-discharging, International SOS kept in constant contact with him, and facilitated his return to the US on a commercial flight as a result. However, on returning to the US, he then denied drug and alcohol abuse, claiming he was forced to give consent and had been kidnapped. Subsequently, no legal action was taken.
When asked if any evidence had been recorded to confirm the patient’s drug use, Taymans stated: “Our role is to undertake a safe movement – not to be detectives. Those measures should be taken by other parties.”
Dr Neslihan Erdal, Deputy Medical Director, Redstar Aviation
A psychiatric case – business as usual?
Psychiatric cases in air ambulance are low frequency, equalling less than one per cent per year, with the stigmatisation surrounding these cases still a factor in medevac situations.
This case saw a 40-year-old ex-military patient with suicidal and homicidal tendencies.
Highly sedated, but still considered a flight risk, he had shown no violent tendencies since admittance to the Intensive Care Unit (ICU), but wanted to ‘kill bad people’.
Despite having no direct communication with the patient, the mission was cleared and a decision to increase crew numbers for manpower, if needed, was made. A female nurse was included, providing a positive influence.
The aircraft interior was changed, so nothing could be utilised as a weapon and the patient was sedated, but not restrained, to avoid any agitation. Following an uneventful flight, he was delivered to ground crew in the same condition.
This case was a precedent for Redstar Aviation, with Erdal opening the conversation surrounding ‘no mutual accepted guidelines’ within the industry, and that there is an ‘ethical obligation to help them’, with an approach based on an ‘unbiased assessment of each psychiatric case’.
Cai Glushak – AXA
A behavioural challenge
This case study saw the repatriation of a 24-year-old female student, who following a public display and an attempt to slash wrists, was admitted to a private facility in St Petersburg. With a diagnosis of Borderline Personality Disorder, the issue presented was to move her out of Russia before she was subject to a move to a public facility and a judicial tribunal.
This prompted an evacuation to Helsinki via air ambulance, and readmission to a facility while pending commercial escorts to the US. However, the doctors wouldn’t certify the patient into escort custody, as despite posing a risk to herself, suicide is legal in Finland.
The patient is eventually moved to the US once readmission insurance has been funded by a student health programme, following the patient refusing to be sent home to her family.
Issues surrounding navigation of local psychiatric regulations and practices were prevalent with this case, further compounded by family and home complications.
Glushak concluded: “Kids are not usually screened before they go on these long (student) travels … we pick up the pieces and readmission to hospital in the US. Arranging a psychiatric admission in the first place is hard, but without insurance, it’s impossible.”
Dr Alex Veldman Medical Director UNICAIR GMBH
Navigating the fine line between kidnapping and informed consent
Veldman recapped that the four case studies were all examples of navigating this fine line, and despite attempts to gain legal clarity, it is a beast no-one wanted to ride.
The numbers relating to how many travellers experience a psychiatric problem sit at 11.3 per cent. Of that, those middle-aged between 41 and 70 represented the largest group.
The main concerns, urged Veldman, were not just around the safety of the patient, but also that of the crew. ‘Recognising risk’, particularly around non-consensual and involuntary transport, is paramount, and can lead to legal uncertainty for all parties.
One of the sore points is a lack of international legislation and/or guidance for non-voluntary/non-consensual cross border movements of patients, with Veldman keen to elicit advice and interaction from legal colleagues on this matter. Even under the assumption of consent to treatment, documentation of action is so important in these cases, eliminating the element of doubt.