International Patient Transports

Recent flight By Dr. Chali Mulenga to Surabaya, Indonesia.
“The kindness of the locals was a true highlight.
I am already keeping in touch with some of the people I met.
Such wonderful people.”

Author: Amy Ho, MD
University of Chicago
Originally Published: Modern Resident April/May 2016

International transports and repatriation is a part of flight medicine and emergency medicine that the University of Chicago Emergency Medicine residency has taken special focus on. Its residents have dedicated time for these experiences, working as flight doctors for international repatriation of patients who fall ill and require stabilization in a foreign country but then desire to seek the remainder of their care in their home country. Here we interview the Chief Residents of the program responsible for running these opportunities, Drs. Chali Mulenga (CM) and Kelvin Adjei-Twum (KA), on their insight into these programs.

What are some of the international medical organizations you work with?
KA: One of the organizations we work with is Fox Flight, based in Toronto, Canada. It is an air ambulance company focused on critically ill international patient transfers. Teams include ACLS trained physicians (such as ourselves), nurses, respiratory therapists (RT) and paramedics. Critically ill patients are transferred on Learjets that are configured into mini-ICUs. More stable patients have medical escorts through commercial flights. These escorts carry with them medications and equipment to assist with active patient needs and management.

Who are the patients and how are they funded?
KA: There are an array of patients who use these organizations for their repatriation. Most are people who have travelled from their native country due to business or other employment opportunities, and have fallen to illness. Some patients are simply away for vacation or personal reasons. Our patients also include students who are studying abroad. Services are usually covered via medical travel insurance fees that patients have opted to pay into.

How do they find doctors and staff?
KA: A medical doctor contracted by the company reviews each case and deems whether the patient will require a non-medical escort, nurse escort, physician escort or some combination. Nurses and RTs are hired and work for each company on a call basis. Physicians, such as ourselves, are reached out to when a patient is medically cleared for flight. If the physician is available, travel arrangements and information on the patient are made available as soon as possible. Typical repatriation flights take approximately three to four days.

How do you see these experiences lend hand to the education of residents or attendings?
CM: As emergency physicians, we seldom get the chance to really sit down and connect with patients and their families given time constraints. Patient transports have afforded me the opportunity to spend several hours with patients and their loved ones. I have come to learn how far the little things we do for otherwise stable patients can go in earning their respect, trust and admiration, and frankly I have been incorporating that more and more in the ED.

KA: As emergency physicians, we will be faced with an array of patient disease presentations and backgrounds. Being a part of an international team gives you some insight into how other countries approach different disease processes. You also continue to learn about emergency medicine from a non-traditional care setting. This requires using some out of the box techniques with limited resources. All in all, this enables us to be better prepared to handle stressful situations in an environment we may not be use to.

Any interesting or memorable transport stories?
KA: We just recently had a really interesting case where one of our residents, Dr. Eric Toone, MD MBA, was the flight physician for a repatriation for a patient from Japan back to the states. This patient had severe necrotizing fasciitis requiring amputation of an upper extremity, including clavicle and scapula. Not only was the patient critically ill, requiring a flight nurse and Dr. Toone as the physician escort, but their trip included stopping for fuel at a WWII army base in Kamchatka, Russia!

We also get an opportunity to learn about different cultures and spend time with groups of people we may never meet for a span of three days. I had the opportunity to transport a patient back to his native Lima, Peru. He had been teaching Japanese in Peru for over five years. I had a great time listening to different experiences he had in Peru, prior to his unfortunate NSTEMI requiring multiple stent placements.

CM: I recently helped with the repatriation of an elderly male who had recently had a spontaneous subarachnoid hemorrhage needing surgical evacuation. We flew from Uruguay to Paris and then to Tokyo. We were together for over 24 hours. His wife and a translator accompanied us. He probably went to the bathroom every two hours and I ensured I helped every time. I administered subQ meds, offered to get him food and water and conversed with him and the wife wherever and whenever I could. When all was said and done, I was exhausted, but almost brought to tears by how much the little I had done meant to the wife and the patient. They had the kindest things to say about me and were simply overwhelmed with gratitude. Since then, I've made more of a conscious effort to graciously help with the little things in the ED, even with our very stable patients and their loved ones. I'll help move a patient, find a chair for a loved one, help the nurses put in difficult IVs more readily, grab a boxed lunch, etc. Never would I have imagined gaining so much perspective from caring for a stable patient all the while getting to see Montevideo and Tokyo and flying business class. It really is a beneficial part of our training.

Pros and Cons of having these opportunities as part of residency?
KA:

Pros:
You get to travel the world! We've had residents go to Japan, Spain, Scotland, China, Trinidad & Tobago, Canada, London, France and many more places.
Build great relationships with patients and their families.
Opportunity to take care of people (isn't that what EM is about!) in a non-traditional role.

Cons:
Your everyday shift doesn't feel quite the same after a transport.
If you have a fear of flying, this won't be an experience you may be looking forward to!