Correspondence
International Aeromedical Evacuation
N Engl J Med 2007; 356:1685-1687April 19, 2007
- Article
To the Editor:
In their review of international aeromedical evacuation, Teichman and colleagues (Jan. 18 issue)1 mention that infectious diseases are contraindications to aeromedical evacuation. In fact, because of the strict criteria on suitability for air transport of patients who have infectious diseases, even those with severe acute respiratory syndrome (SARS), the benefits of air transport clearly exceed the risk. During the SARS outbreak in Asia, patients with suspected SARS were safely transported by air with the use of an airtight portable isolation unit.2 Negative-pressure portable isolation units are equipped with air-purifying respirators. The construction is light and durable and has working ports through which the medical crew can monitor patients and perform procedures. So far, four patients with active pulmonary tuberculosis have also been safely transported in such novel isolation units, with an average flight time of 8 hours. The medical crews reported no problems during or after transport3 (and unpublished data). Meticulous preparation for air transport and post-transport monitoring are mandatory for transporting patients with communicable diseases who require respiratory isolation.
3 ReferencesShin-Han Tsai, M.D., Ph.D.
Wan Fang Hospital, Taipei 116, TaiwanWan-Lin Chen, M.D.
International SOS, Taipei 104, TaiwanWen-Ta Chiu, M.D., Ph.D.
Taipei Medical University, Taipei 110, Taiwan
wtchiu@tmu.edu. tw 1
Teichman PG ,Donchin Y ,Kot RJ . International aeromedical evacuation. N Engl J Med 2007;356:262-270
Full Text | Web of Science | Medline2
Tsai SH ,Tsang CM ,Wu HR , et al. Transporting patient with suspected SARS. Emerg Infect Dis 2004;10:1325-1326
Web of Science | Medline3
Tsai SH ,Kraus JF ,Wu HR , et al. The effectiveness of video-telemedicine for screening of patients requesting emerging air medical transport. J Trauma 2007;62:504-511
CrossRef | Web of Science | Medline
To the Editor:
Teichman et al. do not discuss the significant financial gains that air-ambulance companies and local “expat clinics” serving them derive from evacuations. Such gains may lead to evacuations even when satisfactory local care is available. We have seen air evacuations of patients with uncomplicated dengue fever, with discharge of the patients the next day. A tourist who was evacuated by air ambulance to Bangkok because of “exfoliative dermatitis” was found instead to have a drug-related maculopapular rash. Evacuation companies and their “expat clinics” tend to downgrade local health care capabilities instead of seeking out capable local doctors with language and communication skills and developing cooperative care. This increases costs and hinders improvements of local facilities. Moreover, eagerness to evacuate can result in delay of urgent care.1
1 ReferencesHenry Wilde, M.D.
King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand1
Wilde H ,Roselieb M ,Hanvesakul R ,Phaosavasdi S ,Pruksapong C . Expatriate clinics and medical evacuation companies are a growth industry worldwide. J Travel Med 2003;10:315-317
CrossRef | Web of Science | Medline
To the Editor:
Teichman and colleagues present a comprehensive guide to evacuation for medical emergencies in travelers. I recently volunteered at an AIDS clinic in East Africa and was asked to help evaluate and care for a Canadian missionary in whom an unstable cardiac arrhythmia had developed. Even though we were in a city with a regional referral hospital, the intensive care unit had few intravenous medications and no defibrillator. We decided to have the patient flown by air ambulance to Nairobi. Fortunately, he had purchased evacuation insurance and remained in stable condition during the 18 hours it took to get approval from the insurance company's medical director and then to wait for daylight so that the plane could land.
The situation led to discussions among the expatriate doctors and researchers and the native medical officers and students about the blatant difference between the standard of care expected by travelers and that received by the natives dying (without even intravenous fluids or antibiotics) in the medical wards just next door. What about the ethics of international evacuation?
Katherine Brown, M.D.
David Powell Community Health Center, Austin, TX 78751
katherine.brown@ci. austin. tx. us Author/Editor Response
We agree with Tsai et al. that as advanced equipment becomes available and reliable treatment protocols are developed, fewer medical conditions will be contraindicated aboard aircraft. However, portable isolation units used during domestic transfers may not effectively accommodate patients undergoing international aeromedical evacuations lasting longer than 2 to 4 hours.1 Nor are these units likely to assuage concern about transporting patients who are harboring infectious diseases that have pandemic potential. Highly infectious diseases merit consideration that extends beyond individual patient or provider preferences and capabilities. During the 2003 SARS outbreak and aircraft-borne transoceanic spread, international aeromedical evacuations were sharply curtailed, governments prohibited entry to infected travelers, and hospitals refused admission of suspect patients.2 Similar “social distancing measures” that are likely to ground aircraft have been incorporated into global containment operations, should epidemiologic signals indicate an approaching pandemic.3
Wilde's assertion that financial gains were not discussed neglects our statements that “Financial considerations alter the transfer process when economic incentives become entangled with patient advocacy,” and that “an evacuation represents a substantial financial gain to the company that completes the transfer.” Nevertheless, we share his concern regarding the intrusion of economic triage into clinical decision making and recognize that no medical specialty or setting is immune to its distorting effects. For those who make decisions about international transfer, we hope our review offers rational guidance.
We are not aware of support for the concept that “expat clinics” downgrade local health care capabilities or hinder opportunities for improving local facilities. International health clinics are inclusive enterprises that care for a wide variety of patients (“local” patients account for more than 70% of the patient base at one author's health center). International doctors who live in developing nations can provide high-quality care to all patients, train their colleagues in effective practices, and encourage their colleagues to remain in their home countries, rather than entice them to migrate to wealthier nations. Hence, international physicians are part of the solution to reducing global health disparities.
Brown is troubled by differences in the medical care received by wealthy travelers and that received by impoverished native citizens. Using the benefits of personal contingency planning for an injured or ill person presents less of an ethical dilemma than nationalized responses to incidents of mass disaster where “en masse scoop and run” of foreign nationals occurs against a backdrop of “sheltering in place” of local residents who are often more seriously injured.4,5 A noble strain of ignoring the boundaries of politics, race, and economics in order to provide care runs through the history of medicine. Embracing it could be the first step to erasing the blatant differences that Brown decries.
5 ReferencesPeter G. Teichman, M.D., M.P.A.
Victoria Healthcare International, Ho Chi Minh City, Vietnam
keqfap@yahoo.co. nz Yoel Donchin, M.D.
Hadassah Medical Organization, 91120 Jerusalem, IsraelRaphael J. Kot, M.D.
Family Medical Practice Vietnam, Ho Chi Minh City, Vietnam1
Tsai SH ,Tsang CM ,Wu HR , et al. Transporting patient with suspected SARS. Emerg Infect Dis 2004;10:1325-1326
Web of Science | Medline2
Emerging infectious diseases: Asian SARS outbreak challenged international and national responses. Report to the Chairman, Subcommittee on Asia and the Pacific, Committee on International Relations, House of Representatives. Washington, DC: General Accounting Office, April 2004. (Accessed March 29, 2007, at http://www.gao.gov/new.items/d04564.pdf.)
3
WHO pandemic influenza draft protocol for rapid response and containment. Geneva: World Health Organization, May 30, 2006. (Accessed March 29, 2007, at http://www.who.int/csr/disease/avian_influenza/guidelines/protocolfinal30_05_06a.pdf.)
4
Pajarinen J ,Leppaniemi A ,Castren M , et al. The evacuation of Finnish citizens from south-east Asia tourist resorts after the tsunami disaster. Int J Disaster Med 2004;2:82-88
CrossRef5
Tran MD ,Garner AA ,Morrison I ,Sharley PH ,Griggs WM ,Xavier C . The Bali bombing: civilian aeromedical evacuation. Med J Aust 2003;179:353-356
Web of Science | Medline
