T h e n e w e ng l a n d j o u r na l o f m e dic i n e Current Concepts
Peter G. Teichman, M.D., M.P.A., Yoel Donchin, M.D., and Raphael J. Kot, M.D.
From Victoria Healthcare International (P.G.T.) and Family Medical Practice Viet- Worldwide, when the needs of injured or ill patients exceed what local clinics and hospitals can provide, urgent evacuation by air to the nam (R.J.K.) — both in Ho Chi Minh City, Vietnam; and the Patient Safety Unit, Ha- nearest well-equipped medical facility becomes the key to preserving func- dassah Medical Organization, Jerusalem, tion and saving lives. The international aeromedical evacuation industry is expanding, Israel (Y.D.). Address reprint requests to in part because of two recent trends: increasing travel to regions where road trauma Dr. Teichman at Victoria Healthcare In-ternational, 79 Dien Bien Phu St., Da Kao and infectious diseases are endemic but dependable medical care is unavailable and Ward, District 1, Ho Chi Minh City, Viet- an increasing number of travelers who are predisposed to injury or illness by advanc- ing age or underlying medical conditions.1-7 Nearly all international travelers, even those who are elderly or who have chronic Copyright 2007 Massachusetts Medical Society. conditions, are able to complete their trips successfully.7,8 Fewer than 0.5% of travel- ers require medical evacuation.9 However, when 1 to 2 billion people travel by air every year, even a small percentage of severe medical incidents translates into thousands of annual international aeromedical evacuations.2 Indications
The health conditions that frequently require transport reflect the population risk fac-
tors of both the home countries of the travelers and of their destinations. For inter- national evacuation, the most common conditions include neurologic and orthope- dic sequelae of road trauma, acute coronary syndromes, infections unresponsive to available therapies, and complications of pregnancy10-15 (Table 1). A more detailed list of indications has been compiled by the National Association of EMS [Emergency Medical Services] Physicians.16 It was designed in response to controversy over the appropriate use of air medical transport in the United States, where scene-to-hospital evacuation is far more common than in developing nations.
Decision to Evacuate
International aeromedical evacuation begins when an attending physician who is fa-
miliar with the local medical system determines that a patient’s needs surpass avail- able resources.17,18 If the condition and the additional rigors of evacuation are surviv- able, prompt evacuation should then ensue. Cardiac, neurologic, orthopedic, surgically remediable, and obstetrical conditions are most likely to benefit from immediate evac- uation.10-14 Acute psychosis and tenuous conditions — such as florid pulmonary ede- ma, alcohol withdrawal, and uncontrolled seizure — benefit little from relocation and are especially difficult to manage inside an airplane.19 For these conditions, evacua- The evacuation of patients whose conditions are less severe is indicated when they require hospitalization in facilities in which adherence to universal precautions is not dependable (e.g., where sinks and gloves are unavailable), hygiene is a low priority, n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. or the absence of expertise or special equipment logistic expertise, and an existing network of re- (e.g., orthopedic hardware for larger patients) risks ceiving hospitals, such aircraft are the transfer creating unnecessary complications that can be method of choice when time is of the essence.
avoided by travel to a comprehensively staffed and Private air ambulance companies can complete stocked center. Because blood is not an export bedside-to-bedside retrievals of patients in any na- commodity in any country, the early transfer of a tion that will grant passage and in any location patient at risk of bleeding (e.g., from an ectopic that has a secure runway. The aircraft that such pregnancy) to a facility with a replete and reliable companies operate are usually positioned in devel- blood bank can avert a tragedy. This is a special oped nations so that they are unavailable for im- concern in sub-Saharan Africa, where the safety of mediate international transfers. Such services are blood supplies may be suspect, and in Southeast useful when patients need highly specialized treat- Asia, where Rh-phenotype blood is not always ments, like organ transplantation, that are limit- ed to a few global locations. Drawing on the re- Evacuation is also warranted when critical drugs sources of major medical centers, they can include are substandard, prone to being counterfeited, or staff from any medical specialty, though they most unavailable owing to supply disruptions, govern- often travel with flight-trained nurses and para- ment regulations, or practice standards. We have medics.
performed evacuations when intravenous acyclovir Most medically distressed travelers rely on con- was unavailable owing to regulatory restrictions tinental or global assistance companies to arrange and for pain relief after major abdominal surgery travel to the nearest medical center.20 Such com- when local standards preferred acetaminophen over panies employ medical directors who coordinate treatment and transport plans with the attending physician and those at receiving hospitals. Assis- Arranging the Evacuation
tance companies are most likely to engage com- After determining the need for transfer, attending mercial airlines in aeromedical evacuation.
physicians may refer patients to an international The benefits of the use of commercial aircraft evacuation company that maintains a medical clin- include substantially lower costs, long flying rang- ic in the same nation or region as the patient, no- es that decrease overall transfer time by eliminat- tify a private international air ambulance service ing refueling stops, and fewer takeoffs and land- in the patient’s home country, or contact an assis- ings that avoid the acceleration and deceleration tance company. The first two services favor the use forces that could worsen conditions such as spinal of purpose-modified air ambulances. Regional cord injuries. Outside the United States, most air- evacuation companies own or lease aircraft that lines will transfer patients unless such a service is can be dispatched within hours. With trained staff, likely to cause a flight diversion or pose a risk to Table 1. Medical Conditions That May Require Aeromedical Evacuation.*
Acute neurologic, vascular, surgical, or cardiac emergencies requiring time-sensitive intervention Critical conditions in patients with compromised hemodynamic or respiratory function Critical conditions in obstetric patients whose time of transfer must be minimized to prevent complications in the Critical conditions in neonatal or pediatric patients with compromised hemodynamic or respiratory function, metabolic acidosis more than 2 hours after delivery, sepsis, or meningitis Electrolyte disturbances and toxic exposures requiring immediate lifesaving intervention Conditions requiring treatment in a hyperbaric-oxygen unit Burns requiring treatment in a burn-treatment center Any trauma that is potentially threatening to life or limb, including penetrating eye injuries * Adapted from the Air Medical Physician Handbook.15 n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. T h e n e w e ng l a n d j o u r na l o f m e dic i n e other passengers or to the aircraft itself. On the to nations where transfers terminate. We uniform- basis of travel-insurance claims, it appears that the ly include physicians in international evacuation majority of international aeromedical evacuations because of the severity of injury or illness in pa- are accomplished with commercial aircraft. Expe- tients we transport and the likelihood of encoun- riences with the commercial-aircraft transport of tering additional medical risks and complications patients who are undergoing mechanical ventila- when retrieving a patient. Physicians are also tion while awaiting lung transplantation or who uniquely effective in ad hoc negotiations with re- have fulminant hepatitis requiring liver transplan- ceiving physicians and civil authorities and in im- tation have demonstrated the safety and technical provising solutions to bureaucratic logjams.27 Airlines place stretcher-bound patients in the Equipment
rear of the aircraft to facilitate loading and to Evacuation equipment, medications, and power minimize interference with the aircrew and other supplies are geared to the specific needs of each passengers. Stretchers are allocated six seats that transport. Planning must ensure the availability are folded forward, a privacy curtain is drawn of adequate oxygen and power. The consumption around the patient, and the medical evacuation of both will dramatically increase if the condition team is assigned seats across the aisle from the of a patient who is being mechanically ventilat- patient. For long-haul flights with severely ill pa- ed worsens. Unplanned weather and mechanical tients, a relief evacuation team may also be aboard. delays further deplete supplies. Backup oxygen Some airlines permit access to aircraft electrical tanks, electrical converters, and spare batteries can systems, whereas others specifically prohibit the avoid disastrous supply disruptions22,28 (Table 2). use of such systems for medical equipment.24 Air- crews typically allow temporary modifications to overhead bins for hanging intravenous bags and The keys to successful aeromedical evacuation are American-based commercial airlines have cur- planning for and responding to any deterioration tailed services for acutely ill passengers, and some in the condition that mandated urgent transport contracts of carriage specifically refuse to trans- and to conditions induced by the aerospace envi- port patients who are in stretchers or who can- ronment. Contraindications to aeromedical evac- not sit upright in a seat or follow safety instruc- uation have to be assessed relative to the risks of tions.24-26 This reluctance to transfer patients has forgoing advanced treatment, but the impulse to shunted much aeromedical traffic destined for the “scoop and run” must be balanced against an United States (and nearly all domestic evacuations) evacuation’s inherent hazards (Table 3).29-32 The to private air ambulances and has reduced trans- two major stresses that altitude exposure impos- es on human beings are hypoxia and gas expan- Patients are still evacuated to the nearest avail- sion in body cavities.28 Physiological responses to able facility that will meet their needs. An injured either of these factors can be immediate and life- U.S. national in Central America could be trans- threatening.33 ported directly to the United States, whereas in central China, a patient would be evacuated to a Hypoxia
medical center in Asia and, after treatment and Hypoxia results when the amount and rate of oxy- recuperation, returned to the United States. The gen diffusion across membrane surfaces decrease last step, called aeromedical repatriation, is now with ascent.28,34 Cabin pressures in modern pas- more likely to involve an air ambulance.
senger aircraft are maintained at a level equivalent to that of 5000 to 8000 ft above sea level.1,35 At Staffing
this level, passengers without serious medical There are no federal or international standards re- problems typically have an oxygen saturation of garding the qualifications of the flight team. Pri- 94 to 95%, but in patients with poor perfusion mary care physicians from Western nations com- levels, oxygen saturation can drop into the pre- monly perform international transfers because they carious range of the hemoglobin oxygen-satura- are most represented in international health clinics tion curve.28,36-38 and because they hold passports that allow access Hypoxia can be preempted with supplemental n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. Table 2. Sample List of Equipment for Aeromedical Evacuation.
Infusion device (not dependent on gravity) Blood-pressure monitors, including electronic monitor Power inverter for use of aircraft power source Nutrition and hydration supplies for patient and crew Medication kit with drugs for resuscitation, anxiety, Suction device with catheters and drainage-collection units Continuous positive airway pressure systems oxygen, ventilation, preflight blood transfusion Gas Expansion
in patients with anemia, and low-altitude flight Gas expansion accounts for the majority of contra- paths.39 Patients with severe pulmonary disease indications to aeromedical travel. A change from have been safely flown for long distances at alti- sea level to 8000 ft of altitude will expand the tudes at which commercial aircraft are typically volume of trapped gas by approximately 35%.34 In flown.22,40 However, altitude-related concerns are vulnerable patients, this can provoke a tension most imposing close to the time of injury or ill- pneumothorax, dehiscence of surgical wounds, ness. Therefore, many pulmonary conditions, in- intracranial hemorrhage, and irreversible ocular cluding severe asthma exacerbations or flares in damage. Whereas hypoxia can be detected with chronic obstructive pulmonary disease, should be pulse oximetry and mitigated with supplemental treated in local hospitals, with evacuation deferred oxygen, the consequences of gas expansion are until the patient’s condition has stabilized.41 difficult to recognize and reverse aboard aircraft. Unlike pulmonary conditions, cardiac ischemia Recent surgery and head and chest trauma impose suggestive of impending infarct warrants rapid the greatest risks.42 On the ground, air retention reversal at a specialized facility. Supplemental oxy- may be overlooked when hemorrhage control or gen with continuous monitoring of response is wound management absorbs clinical attention. critical to avoid altitude-induced hypoxia and fur- Preflight checklists that prompt chest radiogra- ther ischemia. Despite the high morbidity and phy and cranial examinations in all trauma pa- mortality inherent in acute coronary syndromes, tients may help prevent in-flight decompensation even patients with substantial acute coronary ob- (Table 4).43-45 struction usually tolerate aeromedical evacuation Altitude exposure intensifies diving-related de- compression sickness and arterial gas embolism.46 n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. T h e n e w e ng l a n d j o u r na l o f m e dic i n e and certain infectious diseases mandate govern- Table 3. Contraindications to Aeromedical Evacuation.
mental approval before border crossings are per- Absolute contraindications
mitted.49 Under an executive order, the Division Unsafe flying conditions, as determined by pilot of Global Migration and Quarantine of the Cen- ters for Disease Control and Prevention is autho- rized to quarantine passengers who are suspect- Acute infection or contamination in communicable phase of illness ed of having any one of nine infectious diseases Combative or uncontrollable status of the patient (i.e., a risk to aircraft The World Health Organization provides fur- Relative contraindications
ther information on the transportation of poten- tially infectious materials and methods of alert- Pneumothorax, unless reduced by chest tube with Heimlich valve in place ing public health officials in suspected cases of highly contagious infectious diseases.51 For poten- tially lethal communicable diseases for which no effective treatment is known, an aircraft transit Bowel obstruction from any source (commonly postoperative) isolator can be used to evacuate a patient to a maximum biologic containment facility. The Aero- medical Isolation Team of the U.S. Army Medical Research Institute of Infectious Diseases deploys teams that use the world’s only aeromedical maxi- Laparotomy or thoracotomy within previous 7 days mum biologic containment suites.52 Requests for such services are routed through local and state health departments (see the Supplementary Ap- pendix, which is available with the full text of this Hemorrhagic cerebrovascular accident within previous 7 days Severe uncorrected anemia (hemoglobin <7.0 g/ml) Preparation of Patients
Acute blood loss with hematocrit below 30% In locations where the stabilization of the patient’s condition is not an option and the physical safety of staff is an added concern, the preflight focus Congestive heart failure with acute pulmonary edema is on securing the patient’s airway, stopping hem- orrhage, and reducing open fractures. All other Acute phase of chronic obstructive pulmonary disease evacuations should be approached deliberately. Though patients or their families may press for im- mediate departures, intercontinental flights do not hold the promise of a quick handoff to definitive care. The space-conserving design of airframes thwarts the provision of care equivalent to that in an intensive care unit, so all lifesaving interven- tions and monitoring procedures (intubation, Ideal care entails low-altitude evacuation to the wound decontamination, and placement of intra- nearest recompression chamber.47 Unfortunately, venous lines and Foley catheters) that are likely for security reasons, some nations prohibit civil- to be needed during the evacuation should be per- ian flights from cruising below 15,000 feet. Flying formed before flight, preferably in the departure a transportable recompression chamber to the pa- hospital.53 tient may be an alternative to delayed treatment.48 Meticulous “packaging” of patients before flight — including ensuring and securing a patent air- Infectious Diseases
way; preventing lines and cords from snagging on Though travel is often undertaken as an antidote transport structures; securing equipment to walls, to personal isolation, it is also a notorious vector seats, or stretchers; and spinal immobilization in of contagion. Nations are understandably loath to neck trauma cases — will decrease the risk of in- grant entry to travelers with contagious infections, juries associated with handling and turbulence. n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. Tarmac and aircraft noise smother auditory cues, so capnographs or other devices for the detection Table 4. Sample Preflight Checklist.
of carbon dioxide are invaluable for confirming Confirm there are no contraindications to evacuation proper placement of endotracheal tubes in case of displacement during loading or in-flight jostling.54 Perform chest radiography to rule out pneumothorax Addressing the comfort of patients and alleviating anxiety are important components of care. Pa- Perform radiography or computed tomography of facial or skull trauma tients who start their journeys in tropical climates Obtain informed consent from the patient or a representative need to be protected from relative temperature Check that all pertinent medical equipment is present and functioning changes within aircraft and when deplaning. Hav- Calculate electrical power and oxygen requirements, including reserves ing a family member accompany the patient on the flight improves communication and coop- Aboard commercial flights, overcoming the intricacies of loading nonambulatory patients is Deflate air-filled balloons (i.e., Foley catheter) or fill with noncompressible time-consuming. Aisles are too narrow for stan- dard wheeled stretchers, so patients must be car- Collect passports and visas for the patient, escort, and evacuation team ried on scoop stretchers or moved on an impro- Orient the patient (or escort) to emergency egress procedures vised device. On crowded flights, maintaining the Reserve ground ambulance for departure and destination airports privacy of patients is difficult, and the obvious Ensure that lift crews are available at both airports presence of a working physician aboard a trans- oceanic flight often elicits requests for care from Ensure that a hospital bed and physician are available at the receiving Evacuation physicians will find their skills Pack all medical records, radiographs, and care documents pushed to include care that would have been pro- Review altitude restrictions (if any) with flight crew vided by nursing and ancillary staff in their home Discuss contingency plans, including diversion options, with flight crew institutions. Immobilized patients require nearly constant attention with positioning, food and drink, toileting, and remoisturizing lips and eyes physicians accede to pressure for the early evacu- to counter the discomforts of the ultra-low humid- ation of unprepared patients.
ity of aircraft cabins. Airframe vibrations interfere with monitoring devices, and ambient noise de- Flight Safety
creases the usefulness of stethoscopes and frus- Statistics from the Flight Safety Foundation reveal trates communication between patients and team an average accident rate of fewer than two per year for international fixed-wing aeromedical flights Anticipating and attending to additional stress- during the past decade.61 U.S. studies of EMS air- ors on patients and evacuation teams can reduce plane accidents highlight the dangers of pilot dis- the tumult involved in an evacuation. Problems traction, nighttime operation, and adverse run- arise when physicians cannot adapt their usual way surfaces.62 Human errors are responsible for practices to a cramped, crowded, and noisy envi- three quarters of accidents.63 Behind the statis- ronment. Such problems are compounded by cir- tics lurks the “rescuer ethic” that drives risk tak- cadian asynchrony and the loss of situational ing and pressure on medical staff to forgo stan- awareness that results from the prolonged perfor- dard flight protocols to save time.63 The isolation mance of multiple duties that require sustained of flight operations from medical decisions may Major adverse events occur in about 12% of evacuations.58 Failed evacuations result from in- complete or rushed assessments of patients, in- transit immobilizations, and fatigue of physicians, Quality Measures
especially when those who have spent hours sta- International aeromedicine is not as developed or bilizing a patient embark on a prolonged trans- as studied as its domestic counterparts in devel- port.59,60 Evacuations are also imperiled when oped nations.64-69 Self-regulation, uneven training, n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. T h e n e w e ng l a n d j o u r na l o f m e dic i n e Medicaid) will not cover international aeromedi- Table 5. Nine Diseases for Which Patients May
Be Quarantined by Executive Order.*

cal evacuation or repatriation. During pretravel consultation, physicians can advise patients about Influenza viruses that cause pandemics or have pan- acquiring supplemental travel insurance for evac- uation, repatriation, or return to country of origin and about the exclusions and limitations of indi- Financial considerations alter the transfer pro- cess when economic incentives become entangled with patient advocacy. Physicians who are not in- volved in the direct care of patients often arbitrate transfer decisions without an appeals process. As- sistance companies sometimes contract with travel brokers who solicit bids for evacuations from com- peting international clinics or retrieval firms. An * Adapted from guidelines of the Division of Global Migra- evacuation represents a substantial financial gain tion of the Centers for Disease Control and Prevention.50 to the company that completes the transfer, where- as providing care in place avoids both transfer and limited feedback between distant facilities hin- costs and the expense of treatment at tertiary care der quality-improvement efforts. Provisions of the hospitals. Depending on the patient’s citizenship, Emergency Medical Treatment and Active Labor early transport from private pay hospitals to na- Act are not well known, and direct communica- tions with socialized health systems can neutral- tion between physicians is often insufficient and ize the transport-related costs of insurers. By be- ing aware of the varying influences, physicians can Logistic considerations amplify the complex- aim to maintain a high quality of care and avoid ity of international aeromedical evacuation. Such unnecessarily endangering their transport team.
considerations range from the obvious (the need to transfer records) to the mundane (how to pay airport departure taxes). Support personnel can smooth over logistic details and minimize dis- International aeromedical evacuation has success- tractions in care. Such personnel should main- fully delivered thousands of distressed travelers to tain connections with embassies and consulates, advanced medical care. The field will thrive until so that visas can be rapidly obtained, and with the global diffusion of modern equipment, effec- ground transport services, so that fast or slow tive treatment, and broadly trained personnel can police escorts from airports to hospitals can be begin to catch up with the development in multi- national industries and tourism. There are encour- aging signs that this progress is already occurring. Medical students enthusiastically pursue interna- No private company or commercial airline will per- tional health rotations, ministries of health in de- form an evacuation without securing a payment veloping nations and major American and Euro- commitment in the form of a guarantee of pay- pean universities are collaboratively building some ment from an insurance or medical assistance of the world’s most advanced hospitals in nations company or a preflight transfer of funds from the that once struggled to provide care, and interna- private account of a patient or a family member. tional medical clinics are succeeding in attracting All forms of aeromedical transportation are expen- travelers and native citizens alike. These welcome sive, but air ambulance service is especially so, with trends may help convert the ephemeral “air bridg- some transoceanic retrievals topping $100,000. es” of aeromedicine to effective permanent med- Patients and their families are sometimes unhap- ical care in all nations.
pily surprised to learn that many domestic medi- No potential conflict of interest relevant to this article was cal insurance policies (including Medicare and reported.
n engl j med 356;3 www.nejm.org january 18, 2007 Downloaded from www.nejm.org at HEBREW UNIVERSITY on March 8, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. References
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Selección de cuentos de ajedre Hac í a bastante tiempo, demasiado, que no pasaba por el parque Rivadavia. En una época, no hace mucho, se había convertido en una costumbre para mí recorrer los distintos puestos allí instalados en busca de libros de autoayuda y similares, los cuáles, por supuesto, conseguía a precios más que accesibles. Esta vez me interesaba uno de Bucay, por lo qu

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