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Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References

Background. The decision whether to immediately evacuate an international traveler who has become ill is a challenge for physicians of aeromedical evacuation companies. The aim of this study is to characterize international aeromedical evacuations in order to identify predictive factors that indicate urgent evacuation.

Methods. The records from all consecutive aeromedical evacuations and overseas repatriations carried out by Mondial Assistance France between August 2006 and July 2007 were reviewed for this study. Patients were allocated to one of two groups: those requiring immediate aeromedical evacuation by air-ambulance and those whose condition allowed subsequent, nonurgent repatriation. Data were compared between the two groups.

Results. Overseas repatriations numbering 402 were executed: 35 immediate aeromedical evacuations with air-ambulance and 367 nonurgent repatriations. Age ≤15 years [odds ratio (OR), 7.0; 95% CI, 1.6–30.6], whether there was a high standard structure in the country (OR, 0.28; 95% CI, 0.09–0.85), and location in sub-Saharan Africa (OR, 12.6; 95% CI, 2.3–71.4) were independent factors indicating the need for immediate aeromedical evacuation.

Conclusions. Patient age, availability of local resources, and locations are the criteria associated with the need for immediate aeromedical evacuation. Creation of a specific standardized scoring system based on these criteria could be of great value to help physicians of aeromedical evacuation companies in initial management of cases.

The number of international travelers, particularly the middle-aged and elderly, is increasing1,2 and therefore so is the number of the ill and injured in non-native countries. Several organizations offer medical assistance to travelers who become ill and require medical care. These organizations provide aeromedical evacuations and repatriations, depending on the patient's conditions. When the needs of these patients exceed the capabilities of local facilities, urgent medical evacuation by air is required.3 Aeromedical evacuations are expensive, have complicated logistics, and may cause emotional distress to both the patient and the family. The decision whether to evacuate urgently or not is therefore a challenge faced by physicians in coordination centers of medical evacuation companies. Decision tools designed to help physicians in this delicate process would be very valuable. An objective scoring system that could be used to determine which patients are eligible for costly resources could be very valuable. The aim of this study is to characterize international aeromedical evacuations in order to identify predictive factors that indicate the need for urgent evacuation.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References

This descriptive, retrospective study was carried out in Mondial Assistance France, which provides worldwide medical assistance and aeromedical evacuations. The company has a coordination center in Paris with a number of physicians, mostly emergency physicians or intensivists working part-time for the company and the rest of the time at the hospital. There are also medical teams for evacuations: These are emergency physicians, nurses, and nurse anesthetists. The company has a worldwide network of correspondents who provide medical reports and arrange local transfers at the request of the coordination center. All people who are insured by Mondial Assistance may contact the coordination center if they need emergency medical aid. Subscribers make a direct subscription, or are covered through their comprehensive or auto insurance, ticketing or travel package, or are insured by their company as business travelers. As a result, Mondial Assistance’ insured population is very large. All evacuation expenses are borne by the company.

Requests for aeromedical evacuation are received at the coordination center by dispatchers who immediately inform the physicians on duty. The dispatcher documents the identity of the patient, his/her age, and location, and a brief description of the reason for the request. In most cases, the Mondial Assistance physician on duty tries to directly contact the physician in charge of the patient so as to obtain detailed and accurate information. If this contact cannot be established, the intervention of a medical correspondent in the country is required. The correspondent sends a written medical report.

The records from all consecutive aeromedical evacuations and overseas repatriations executed by Mondial Assistance France between August 2006 and July 2007 were reviewed for this study by a single investigator, who is a physician of the coordination center. There were no exclusion criteria. The following information was collected: age of the patient; level of sanitary conditions in the place in which the injured/ill traveler was located, according to World Health Organization standards4 (Figure 1); whether there is a high standard structure (as defined below) in the country (Figure 2); whether the patient was in a French speaking area; whether direct medical contact could be established with the attending physician, the patient's primary diagnosis, whether urgent treatment was required, whether the patient required initial transfer to another local hospital with better medical facilities, and the available modalities of repatriation (according to the coordination center physician's decision). A high standard structure in the country was defined as a level 4 hospital in the Marco Polo program for evaluation of medical facilities worldwide. The rate from 1 to 5 depends on facilities after evaluation by a medical director of one business unit of the group, who is in charge of a part of the world. A visit is scheduled every year and evaluation is made using a standardized form. A level 4 or 5 hospital must have an Intensive Care Unit, advanced imaging (tomodensitometry and/or MRI), an operating theater, and a good global hygiene. The Marco Polo evaluation program was developed by Mondial Assistance Group in 2002 and is updated every year. Evaluations of 1143 hospitals in 423 cities and 120 countries are available.

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Figure 1. Countries with Western sanitary standards are colored in black on this world map.

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Figure 2. Countries in which there is a high standard structure according to the Marco Polo program for evaluation of medical facilities worldwide, are colored in black.

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Patients were allocated to one of two groups: those requiring immediate aeromedical evacuation by air-ambulance and those whose condition allowed subsequent, nonurgent repatriation. Data were expressed as mean ± SD and percentage of patients and compared between the two groups. Statistical analysis was performed by ANOVA for quantitative data and a chi-square test for qualitative data. Multivariate analysis was also done. A p value less than 0.05 was considered the threshold for significance. We used statistical package Stat-View 5^® (Abacus Concept, Berkeley, CA, USA).

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References

During the study period, 402 overseas repatriations were executed: 35 immediate aeromedical evacuations by air-ambulance and 367 nonurgent repatriations. The most common conditions necessitating transport were trauma (40%), cardiac diseases (17%), neurological disorders (14%), and respiratory diseases (8%). The primary diagnoses in the two groups were not significantly different. Other results are shown in Table 1. Two hundred and two patients (50%) required urgent therapeutic measures, mostly a surgical intervention (27%). A transfer to another hospital was initiated by the physician on duty in the coordination center for 92 patients (23%). All immediate evacuations were performed aboard air-ambulances providing advanced life support. A part of nonurgent repatriations was also done aboard air-ambulances providing advanced life support for 69 patients (19%) mostly for logistic reasons (no commercial flight available, complicated flight connections, regrouping, etc.). Commercial aircraft were used for the remaining patients. Oxygen was required by 117 (29%) patients during evacuation.

Table 1.  Characteristics of patients requiring aeromedical evacuations (August 2006–July 2007)
 Immediate aeromedical evacuation N = 35Nonurgent repatriation N = 367pTotal N = 402
  1. Data are expressed as N (%) unless otherwise indicated

Age (yrs)47 ± 457 ± 10.02 
Age ≤155 (14%)8 (2%)<0.00113
Location:    
North Africa13 (37%)85 (23%) 98
Sub-Saharan Africa15 (43%)34 (9%) 49
Asia2 (6%)41 (11%)<0.000143
America2 (6%)25 (7%) 27
Europe3 (8%)182 (50%) 185
Western countries' standards2 (6%)143 (39%)<0.001145
There is a high standard structure in the country21 (60%)328 (89%)<0.0001349
Direct medical contact31 (89%)215 (59%)0.17246
French speaking area25 (71%)128 (35%)<0.0001153
Urgent treatment required34 (97%)123 (34%)<0.0001157

Multiple logistic regression showing the independent factors indicating the need for immediate aeromedical evacuation were aged ≤15 years [odds ratio (OR), 7.0; 95% CI, 1.6–30.6], whether there was a high standard structure in the country (OR, 0.28; 95% CI, 0.09–0.85), and location in sub-Saharan Africa (OR, 12.6; 95% CI, 2.3–71.4).

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References

The international aeromedical industry provides a medical response for injured or ill travelers, particularly when their needs exceed the capabilities of local clinics or hospitals, making overseas travel much less hazardous. Rapid response to medical and/or surgical emergencies is a key point that ensures health security of travelers. For medium-haul destinations (up to 4 h flight), aeromedical evacuations are most of the time provided by French teams from our staff. For onward destinations, flight durations made the direct return to home country irrelevant, and major medical assistance companies have built a worldwide network allowing the setup of evacuations in most places in the world. In those cases, the patient is transferred toward the nearest place where Western countries' customary facilities are available. Assistance companies periodically check the level of expertise, the reliability of medical equipment, and the responsiveness of these local partners.

Strict conditions are necessary so that this system works. Skilled physicians and nurses must be available anytime. A medical assistance company such as Mondial Assistance France has a large evacuation equipment provision. Monitoring devices (ECG, blood pressure, pulse oximetry, capnography), defibrillators, pacing devices, ventilators, aeronautical oxygen systems, infusion devices, mattresses, medications including resuscitation drugs … must be available 24 hours a day. All equipment must be certified for aeronautical use, and a permanent logistics team ensures its preventive maintenance. Medical equipment has to be in sufficient quantities for an unpredictable number of requests and also for events involving numerous victims (bus accident, bombing, etc.). During these disaster-like interventions, medical teams are promptly sent out and deployed at the scene to provide care, stabilize patients, and bring them back to home country. Psychologists who had specific training on post-traumatic stress disorders also take part in these special events.

All the logistic aspects of aeromedical evacuation business are essential. Indeed, transportation of patients aboard aircraft imposes specific constraints. The two major stresses related to aeromedical evacuation are hypoxia and gas expansion in body cavities.3 Because aircraft cabin pressure is maintained at a level equivalent to 5000–8000 ft above sea level, relative hypoxia and approximately 35% expansion of trapped gas are observed.5 Other factors that should be taken into account when deciding whether or not to undertake an emergency aeromedical evacuation are the dramatic isolation aboard aircrafts, particularly during transcontinental flights, and the duration of the flight. These factors should weigh heavily in the risk/benefit balance.

If a patient can be treated and/or stabilized before evacuation, the risks of transport are lessened. Indeed, managing a severe condition in a well-equipped setting with high medical standards is often preferable to repatriating. Setting up an aeromedical evacuation has some unavoidable time intervals: team recruitment, checking aircraft availability, travel to the airport, travel time to the incident site, and the evacuation itself. When a patient requires immediate treatment, the quickest response is attained if the medical resources in the city or region where the injury or illness occurred are of the same standards as those in the home country. One of the roles of the physicians on duty in the coordination center is to call the patient or his/her relatives to explain why local management was chosen before transporting the patient back to the home country, even if the initial demand was for immediate evacuation.

The decision-making process surrounding emergency aeromedical transport is based not only on the patient's clinical condition but on many other factors as well. The challenge for decision makers is to gather the facts, which are partially subjective. The economic constraint of this cost-consuming activity cannot be avoided while ensuring the right medical response to the affected. A specific standardized scoring system could be a helpful tool. Our study showed that criteria associated with the need for immediate aeromedical evacuation can be summarized as age, local resources, and locations. The medical needs of our injured or ill clients can easily exceed local resources; this disparity is especially true for pediatric care. Few pediatric care facilities are available in developing countries,4 and those that have them tend to offer care that falls below Western standards. As already mentioned, the possibility of local transfer for better facilities is of great value when urgent management is required. The importance of the patient's location has been documented by others.3,6 Cases occurring in sub-Saharan Africa demand extreme caution. Sanitary conditions in that region are some of the poorest in the world. Traveling to this tropical area is associated with increased health risks including life-threatening diseases such as malaria.7 Some illness and injuries tend to worsen under the influence of a tropical climate.8 Travelers from Western countries are also exposed to a wide range of specific infectious diseases and other health hazards in sub-Saharan Africa, often contracted from the indigenous population.9 Physicians in medical assistance must have a good knowledge of medical facilities in numerous countries. A database like the Marco Polo evaluation program is of great value to physicians who need a quick and documented evaluation (regarding quality of care; availability of equipment, imaging studies, and laboratory tests; general hygiene) of the hospital to which the patient has been taken, and of hospitals in the area.

Conclusion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References

The decision-making process surrounding emergency aeromedical evacuations is based not only on the patient's clinical condition but on many other factors as well. The challenge for decision makers is to gather the facts, which are partially subjective. Age, local resources, and locations have been found to be independent factors of immediate evacuation. On the basis of these criteria, the creation of a specific standardized scoring system could be very helpful to this process.

Declaration of Interests

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References

The authors state they have no conflicts of interest to declare.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Declaration of Interests
  8. References