International aeromedical evacuation

Aeromedical Transport for Critically Ill Patients

Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed.

SIMULATED AEROMEDICAL EVACUATION EXACERBATES ACUTE LUNG INJURY VIA HYPOXIA-INDUCIBLE FACTOR 1Α-MEDIATED BNIP3/NIX-DEPENDENT MITOPHAGY

ABSTRACT

Background: With the advancement of medicine and the development of technology, the limiting factors of aeromedical evacuation are gradually decreasing, and the scope of indications is expanding. However, the hypobaric and hypoxic environments experienced by critically ill patients in flight can cause lung injury, leading to inflammation and hypoxemia, which remains one of the few limiting factors for air medical evacuation. This study aimed to examine the mechanism of secondary lung injury in rat models of acute lung injury that simulate aeromedical evacuation. Methods: An acute lung injury model was induced in SD rats by the administration of lipopolysaccharide (LPS) followed by exposure to a simulated aeromedical evacuation environment (equivalent to 8,000 feet above sea level) or a normobaric normoxic environment for 4 h. The expression of hypoxia-inducible factor 1α (HIF-1α) was stabilized by pretreatment with dimethyloxalylglycine. The reactive oxygen species levels and the protein expression levels of HIF-1α, Bcl-2-interacting protein 3 (BNIP3), and NIX in lung tissue were measured. Results: Simulated aeromedical evacuation exacerbated pathological damage to lung tissue and increased the release of inflammatory cytokines in serum as well as the reactive oxygen species levels and the protein levels of HIF-1α, BNIP3, and NIX in lung tissue. Pretreatment with dimethyloxalylglycine resulted in increases in the protein expression of HIF-1α, BNIP3, and NIX. Conclusion: Simulated aeromedical evacuation leads to secondary lung injury through mitophagy.

Comparison of kinetic changes during helicopter medical evacuations: civilian versus military flights

BACKGROUND

Helicopter evacuation is crucial for providing medical care to casualties. Previous civilian studies have demonstrated that air transport can enhance survival rates compared with ground transport. However, there has been limited research on specific accelerations during helicopter flights, particularly in military flights. This study aims to analyse and compare the accelerations endured during civilian and military helicopter evacuations.

METHODS

Accelerations were recorded during evacuation flights from the site of injury to the first medical responders in civilian helicopter EC135 T1, and military Puma SA.330 and Caiman NH90 TTH helicopters. The research investigated global acceleration and compared acceleration distributions along the vertical, lateral and longitudinal axes. A specific comparative study of the take-off phases was also performed.

RESULTS

The analysis showed that vertical loads caused the most extreme accelerations for all types of helicopter but these extreme accelerations were rare and lasted for less than 1 s. Military flights show similar acceleration intensities to civilian flights, but accelerations are higher during short periods of the take-off phase.

CONCLUSIONS

The findings suggest that helicopter evacuations during military operations are as safe as civilian evacuations and highlight the importance of patient positioning in the aircraft. However, further research should investigate the haemodynamic response to accelerations experienced during actual evacuation flights.

Injuries and medical emergencies among international travellers

BACKGROUND

Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings.

METHODS

We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled).

RESULTS

All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur.

CONCLUSIONS

Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.

Evaluation of free-floating tracheal intubation in weightlessness via ice-pick position with a direct laryngoscopy and classic approach with indirect videolaryngoscopy

Long duration spaceflights to the Moon or Mars are at risk for emergency medical events. Managing a hypoxemic distress and performing an advanced airway procedure such as oro-tracheal intubation may be complicated under weightlessness due to ergonomic constraints. An emergency free-floating intubation would be dangerous because of high failure rates due to stabilization issues that prohibits its implementation in a space environment. Nevertheless, we hypothesized that two configurations could lead to a high first-pass success score for intubation performed by a free-floating operator. In a non-randomized, controlled, cross-over simulation study during a parabolic flight campaign, we evaluated and compared the intubation performance of free-floating trained operators, using either a conventional direct laryngoscope in an ice-pick position or an indirect laryngoscopy with a video-laryngoscope in a classic position at the head of a high-fidelity simulation manikin, in weightlessness and in normogravity. Neither of the two tested conditions reached the minimal terrestrial ILCOR recommendations (95% first-pass success) and therefore could not be recommended for general implementation under weightlessness conditions. Free-floating video laryngoscopy at the head of the manikin had a significant better success score than conventional direct laryngoscopy in an ice-pick position. Our results, combined with the preexisting literature, emphasis the difficulties of performing oro-tracheal intubation, even for experts using modern airway devices, under postural instability in weightlessness. ClinicalTrials registration number NCT05303948.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Traveler's knowledge, attitude, and practice about travel health insurance: A community-based questionnaire study

BACKGROUND

Travel, especially international travel, has become one of the most popular leisure activities in the world. The risk of accidents and travel-related illnesses, including infectious and non-communicable diseases, should not be neglected. To provide a more comprehensive pre-travel consultation to international travelers, this study aimed to investigate the knowledge, attitude, and practice of travelers about travel health insurance.

METHODS

This was a cross-sectional study. Anonymous structured questionnaires were distributed to 1000 visitors to the Taiwan International Travel Fair in May 2019.

RESULTS

The top three important travel health insurances were accidental death and disablement insurance (92%), accidental medical reimbursement (90.4%), and 24-hour emergency assistance (89%). In addition to education level, travel-associated illness, and special activities during travel, a significant association was observed between the willingness to buy various travel health insurances and the willingness of pre-travel consultation.

CONCLUSIONS

Most travelers would buy travel health insurance; however, disproportional respondents understood the content of travel health insurance. Most travelers considered travel clinics to be the most reliable information source regarding travel health insurance. Therefore, travel medicine specialists are encouraged to offer more information about travel health insurance during pre-travel consultation.

Changes in vital signs, ventilation mode, and catecholamine use during intensive care aeromedical evacuation flights

Introduction

Especially after (natural) disasters, local health systems are also destroyed or their ability to work is massively restricted. The transport of injured patients is therefore often necessary for further care. Numerous nations keep fixed-wing aircraft with intensive-care capabilities available for secondary transport, but little data on the transport is available to date.

Methods

An analysis of all flights with the German Air Force's intensive care fixed-wing-aircraft carried out in the context of humanitarian aid missions since 2002 with a focus on intubated patients was done.

Results

A total of 38 patients were transported. Two patients had to be intubated on or during transport. There were significant changes in the necessary positive end-expiratory pressure (PEEP) and the fraction of inspired oxygen. Circulatory parameters did not change.

Discussion

Overall, there are no clinically relevant deteriorations due to secondary transport with corresponding air transfers. Due to the hypobaric hypoxic conditions on board of all aircrafts, intubation in clinically borderline patients should be performed electively on the ground before flight.

Aero-Medical Evacuation during SARS-CoV-2 Pandemic: Extraordinary Measure or Emerging Treatment Option?

Aero-medical evacuation has been considered as a feasible and safe treatment option during COVID pandemic, particularly when the needs of affected patients exceed what local clinics and hospitals are supposed to provide. In this article, we analyzed the clinical course of 17 patients medically evacuated to the "L. Spallanzani" Institute in Rome, Italy from foreign countries, mainly Africa and Eastern Europe, who had COVID-19 pneumonia with, or without, coinfections such as malaria, HIV, tuberculosis and microbiologically confirmed sepsis syndrome. The aero-medical evacuation of patients with infectious diseases has become one of the greatest medical achievements we have reached during this pandemic; in fact, only two patients with life threatening coinfections have died. Although logistically difficult and cost consuming, medical evacuation should be considered as a treatment option more than a single extraordinary measure, especially among complex cases that require specific technical and human resources.

Emergency air evacuation of patients with acute respiratory failure due to SARS-CoV-2 from Mayotte to Reunion Island

In February 2021, an explosion of cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia overwhelmed the only hospital in Mayotte. To report a case series of patients with acute respiratory failure (ARF) due to SARS-CoV-2 who were evacuated by air from Mayotte to Reunion Island.This retrospective observational study evaluated all consecutive patients with ARF due to SARS-CoV-2 who were evacuated by air from Mayotte Hospital to the intensive care unit (ICU) of Félix Guyon University Hospital in Reunion Island between February 2, and March 5, 2021.A total of 43 patients with SARS-CoV-2 pneumonia were evacuated by air, for a total flight time of 2 hours and a total travel time of 6 hours. Of these, 38 patients (88.4%) with a median age of 55 (46-65) years presented with ARF and were hospitalized in our ICU. Fifteen patients were screened for the SARS-CoV-2 501Y.V2 variant, all of whom tested positive. Thirteen patients (34.2%) developed an episode of severe hypoxemia during air transport, and the median paO2/FiO2 ratio was lower on ICU admission (140 [102-192] mmHg) than on departure (165 [150-200], P = .022). Factors associated with severe hypoxemia during air transport was lack of treatment with curare (P = .012) and lack of invasive mechanical ventilation (P = .003). Nine patients (23.7%) received veno-venous extracorporeal membrane oxygenation support in our ICU. Seven deaths (18.4%) occurred in hospital.Emergency air evacuation of patients with ARF due to SARS-CoV-2 was associated with severe hypoxemia but remained feasible. In cases of ARF due to SARS-CoV-2 requiring emergency air evacuation, sedated patients receiving invasive mechanical ventilation and curare should be prioritized over nonintubated patients. It is noteworthy that patients with SARS-CoV-2 pneumonia related to the 501Y.V2 variant were very severe despite their young age.

Aeromedical Transport of Critically Ill Patients: A Literature Review

The aeromedical transport of critically ill patients has become an integral part of practicing medicine on a global scale. The development of reliable portable medical equipment allows physicians, emergency medical technicians, and nurses to transport wounded and diseased patients under constant critical care attention. Air transportation involves utilizing a fixed-wing (airplane) or rotor-wing (helicopter) aircraft to accomplish different types of transports ranging from scene responses to international transfers. The proper preparation and management of patients undergoing aeromedical transport require a basic understanding of the physiological changes and unique challenges encountered within the aircraft environment at 8,000 ft above sea level. The purpose of this paper is to review the literature and provide guidelines for approaching the aeromedical transportation of critically ill patients.

Flying After Concussion and Symptom Recovery in College Athletes and Military Cadets

IMPORTANCE

Concussions are a common occurrence in young athletes. Hypobaric hypoxemia, such as that experienced during airplane travel, can potentially cause alterations to cerebral blood flow and increased neuroinflammatory response. It remains unknown whether flying early after a concussion may influence the clinical course of injury.

OBJECTIVE

To determine whether there is an association between concussion recovery and airplane travel in collegiate athletes and military cadets.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted by the National Collegiate Athletic Association and US Department of Defense Concussion Assessment, Research, and Education Consortium from August 3, 2014, to September 13, 2018. Participant groups were categorized by those who flew within 72 hours of injury and those who did not fly. All participants included in the final analyses had complete data of interest and only 1 injury during the study. Data analysis was performed from September 2018 to March 2020.

MAIN OUTCOMES AND MEASURES

Recovery outcome measures were defined as time (in days) from injury to return to activity, school, and baseline symptoms. Symptom and headache severity scores were derived from the Sports Concussion Assessment Tool-Third Edition. Scores for both groups were taken at baseline and a median of 2 days after injury.

RESULTS

A total of 92 participants who flew (mean [SD] age, 19.1 [1.2] years; 55 male [59.8%]) and 1383 participants who did not fly (mean [SD] age, 18.9 [1.3] years; 809 male [58.5%]) were included in the analysis of symptom recovery outcomes (analysis 1). Similarly, 100 participants who flew (mean [SD] age, 19.2 [1.2] years; 63 male [63.0%]) and 1577 participants who did not fly (mean [SD] age, 18.9 [1.3] years; 916 male [58.1%]) were included in the analysis of symptom severity outcomes (analysis 2). No significant group differences were found regarding recovery outcome measures. Likewise, there were no group differences in symptom (estimated mean difference, 0.029; 95% CI, -0.083 to 0.144; P = .67) or headache (estimated mean difference, -0.007; 95% CI, -0.094 to 0.081; P = .91) severity scores.

CONCLUSIONS AND RELEVANCE

Airplane travel early after concussion was not associated with recovery or severity of concussion symptoms. These findings may help guide future recommendations on flight travel after concussion in athletes.

Évacuation sanitaire massive de patients COVID sur vecteur aérien civil

Dans le contexte de pandémie COVID, les capacités d’hospitalisations de patients infectés à la Réunion restent limitées et imposent une réflexion sur les alternatives envisageables. Les évacuations sanitaires (EVASAN) de masse sur des vols commerciaux long-courriers pourraient être une solution intéressante. Ce type d’opération est toutefois complexe à mettre en œuvre. Une réflexion a été menée autour d’une organisation dans les avions de la compagnie Air Austral (Boeing 737, 777 et 787) permettant d’assurer les soins et les déplacements dans l’appareil en définissants des zones de basse densité virale et haute densité virale. Un modèle de prise en charge des patients a été élaboré avec une planification des moyens humains et matériels nécessaires au transfert de plusieurs patients COVID « valides » et en civière. Ce dispositif a ensuite été déployé au cours d’une EVASAN de quatre patients depuis Mayotte vers la Réunion. Les évacuations sanitaires aériennes de masse de patients infectés par le Coronavirus apparaissent comme une solution à l’engorgement des services d’hospitalisation conventionnelle et de réanimation pour les territoires ultramarins. L’expérimentation réalisée sur un vol Mayotte-Réunion s’est avérée encourageante.

Effects of Early Altitude Exposure on the Open Abdomen After Laparotomy in Trauma

INTRODUCTION

While damage control surgery and resuscitation techniques have revolutionized the care of injured service members who sustain severe traumatic hemorrhage, the physiologic and inflammatory consequences of hemostatic resuscitation and staged abdominal surgery in the face of early aeromedical evacuation (AE) have not been investigated. We hypothesized that post-injury AE with an open abdomen would have significant physiologic and inflammatory consequences compared to AE with a closed abdomen.

MATERIALS AND METHODS

Evaluation of resuscitation and staged abdominal closure was performed using a murine model of hemorrhagic shock with laparotomy. Mice underwent controlled hemorrhage to a systolic blood pressure of 25 mmHg and received either no resuscitation, blood product resuscitation, or Hextend resuscitation to a systolic blood pressure of either 50 mmHg (partial resuscitation) or 80 mmHg (complete resuscitation). Laparotomies were either closed prior to AE (closed abdomens) or left open during AE (open abdomens) and subsequently closed. AE was simulated with a 1-hour exposure to a hypobaric hypoxic environment at 8,000 feet altitude. Mice were euthanized at 0, 4, or 24 hours following AE. Serum was collected and analyzed for physiologic variables and inflammatory cytokine levels. Samples of lung and small intestine were collected for tissue cytokine and myeloperoxidase analysis as indicators of intestinal inflammation. Survival curves were also performed.

RESULTS

Unresuscitated mice sustained an 85% mortality rate from hemorrhage and laparotomy, limiting the assessment of the effect of simulated AE in these subgroups. Overall survival was similar among all resuscitated groups regardless of the presence of hypobaric hypoxia, type of resuscitation, or abdominal closure status. Simulated AE had no observed effects on acid/base imbalance or the inflammatory response as compared to ground level controls. All mice experienced both metabolic acidosis and an acute inflammatory response after hemorrhage and injury, represented by an initial increase in serum interleukin (IL)-6 levels. Furthermore, mice with open abdomens had an elevated inflammatory response with increased levels of serum IL-10, serum tumor necrosis factor alpha, intestinal IL-6, intestinal IL-10, and pulmonary myeloperoxidase.

CONCLUSION

These results demonstrate the complex interaction of AE and temporary or definitive abdominal closure after post-injury laparotomy. Contrary to our hypothesis, we found that AE in those animals with open abdomens is relatively safe with no difference in mortality compared to those with closed abdomens. However, given the physiologic and inflammatory changes observed in animals with open abdomens, further evaluation is necessary prior to definitive recommendations regarding the safety or downstream effects of exposure to AE prior to definitive abdominal closure.

Aeromedical Transport in Children: A Descriptive Analysis of 96 Cases

OBJECTIVE

Pediatric aeromedical transport (AT) is highly challenging. We aim to describe a series of 96 cases of children requiring medical transport in terms of the indication, modalities, and related adverse events.

METHODS

In this single-center retrospective study, we included air-transported patients less than 18 years old.

RESULTS

During the study period, 96 patients, with median age of 120 months (range, 0-204), were air transported. The reason for AT was repatriation to the home country from another hospital in 65 (67.7%), whereas for 31 (32.3%) patients, it was for transport from a hospital to another for a special procedure. The main diagnosis was trauma surgery (n = 38; 39.5%). Fifteen (15.6%) patients were mechanically ventilated. No patient sustained serious adverse events during the flight. Patients were transported by an air ambulance or by a scheduled aircraft in 55.2% and 44.8%, respectively. The median flight distance was 822 km (range, 277-9878), and most of the ATs were intra-European (n = 41; 42.7%).

CONCLUSION

This study describes an international experience in providing AT services for pediatric clinical cases. Among pediatric patients, the younger ones constitute a specific population, and most of them require mechanical ventilation. Therefore, the transport of these patients seems to be more appropriate in a dedicated air ambulance.

Safety and Flight Considerations for Mechanical Circulatory Support Devices During Air Medical Transport and Evacuation: A Systematic Narrative Review of the Literature

OBJECTIVE

The air medical transportation industry has seen a steady rise in the use of mechanical circulatory support devices (eg, intra-aortic balloon pumps, ventricular assist devices, and extracorporeal membrane oxygenation) during transport missions, either for definitive management or repatriation. As these complex devices become more common, the industry will have to adapt to support their use in their clientele. The goal of this narrative review was to assess our current experiences regarding mechanical circulatory support devices in air medical transportation and to identify important factors to ensure successful transport.

METHODS

We conducted a systematic search on MEDLINE and Embase using the following search terms: aeromedical transportation, air transportation, intra-aortic balloon pump, ventricular assist device, and extracorporeal membrane oxygenation. Results were cross-referenced to identify articles addressing both air medical transport and mechanical circulatory support devices.

RESULTS

After a systematic review of the available literature, 49 articles addressing mechanical support devices transported by rotary wing and fixed wing aircraft were reviewed. In summary, our review encompassed 811 total aerial transports (152 by balloon pumps, 12 by ventricular assist devices, and 647 by extracorporeal membrane oxygenation). We found air medical transportation with these devices carried out in the public, private, or military sectors, to be safe, with low rates of serious adverse events. Dedicated training sessions focused on device troubleshooting and problem-solving during transport, optimal medical crew composition, predeparture logistical preparations, and on-demand specialist consultation can improve mission success.

CONCLUSION

We report that air medical transportation of patients supported by mechanical circulatory support devices is safe. Complications can be mitigated by training and addressed either during the predeparture or in-transportation phase.

Casualty Air Evacuation: Sine quo non of combat casualty

Management of combat casualties has always been a challenging task. Armed Forces world over have developed effective casualty air evacuation mechanisms. The history of casualty evacuation dates back to 1870s. The first evacuation of casualty by air was during the First World War. The paper highlights the background and evolution of air evacuation in the world and discusses the Indian Scenario of casualty air evacuation. The casualty evacuation capabilities of the aircrafts in the Indian Air Force (IAF) are highlighted. To ensure prompt casualty evacuation, the Armed Forces have a chain of casualty air evacuation, thus ensuring that the injured reach the health care center in the least possible time. An indigenously developed patient transfer unit (PTU) comprising of a trauma care recovery trolley with a complement of a portable ventilator, multipara monitor, infusion pumps and oxygen system is also discussed. In addition, the paper discusses the aeromedical considerations while evacuating casualties by air and contraindications for air evacuation. The advancements in the field of medical technology and medical care has ensured safe air evacuation of casualties and has reduced the morbidity and mortality of casualties, thus boosting the morale of the troops.

Air Medical-Evacuated Battle Injuries: French Army 2001 to 2014 in Afghanistan

OBJECTIVE

The purpose of strategic air medical evacuation (STRAT AE) is to enable the continuity of care and repatriation of wounded soldiers. Between 2001 and 2014, STRAT AEs have been implemented many times over the course of the military engagement in Afghanistan. The purpose of this work was to study the nature of the pathologies and the medicalization of patients most seriously wounded during the PAMIR Operation (Afghanistan).

METHODS

This was an epidemiological study conducted retrospectively from January 1, 2001, to December 31, 2014, of the STRAT AEs with the air medical team from the Afghan operating room to France. Data were collected from air evacuation medical records.

RESULTS

Between 2001 and 2014, 109 patients underwent STRAT AEs for a traumatic pathology originating from a battle injury. According to the categorization of Standardization Agreement 3204, 57% of the wounded were priority 1, whereas 43% were priority 2 and 80% showed high dependency (level 1 or 2). Seventy-two percent of evacuations were individual, and 28% were performed in groups. The air medical team was enhanced by a critical care anesthesiologist in 85% of the cases. No deaths occurred in-flight.

CONCLUSION

The French experience in Afghanistan was marked by performing mostly individual STRAT AEs among wounded warriors requiring extensive medicalization.

Guidelines for the prevention of travel-associated illness in older adults

International travel to the developing world is becoming more common in elderly patients (defined here as individuals greater than 65 years old). When providing pre-travel counseling, providers must appreciate the changing physiology, comorbidities, immunity and pharmacokinetics associated with the aging process to prepare elderly patients for the stressors of international travel. These guidelines present an evidence-based approach to pre-travel counseling, immunization, and pharmacology concerns unique to elderly patients seeking care in a travel clinic setting.

Epidemiology of 62 patients admitted to the intensive care unit after returning from Madagascar

BACKGROUND

To our knowledge, there is no data on the epidemiology of patients hospitalized in intensive care unit (ICU) after a stay in Madagascar or other low-income countries. It is possible that such data may improve transfer delays and care quality for these patients.

METHODS

In a retrospective study, we reviewed the charts of all patients admitted to ICU of the Reunion Island Felix Guyon University Hospital from January 2011 through July 2013. We identified all patients who had stayed in Madagascar during the 6 months prior to ICU admission.

RESULTS

Of 1842 ICU patients, 62 (3.4%) had stayed in Madagascar during the 6 months prior to ICU admission. Patients were 76% male and the median age was 60.5 (48.25-64.75) years; patients were more frequently residents of Madagascar than travellers (56.5%). In most cases, patients were not hospitalized or given antibiotics in Madagascar. The most frequent causes of hospitalization were infections including malaria (21%) and lower respiratory infection (11%). Carriage and infection with multidrug resistant (MDR) bacteria on ICU admission were frequent (37% and 9.7%, respectively). The mortality rate in ICU was 21%, and severity acute physiological Score II was 53.5 (37-68).

CONCLUSIONS

Patients admitted to ICU after a stay to Madagascar are mainly elderly patients with chronic illnesses, and often foreign residents. The admission causes are specific of the country like malaria, or specific to the population concerned such as cardiovascular accidents that could be prevented.

Assessing the risk of work-related international travel

OBJECTIVE

To identify factors affecting the likelihood of requiring medical services during international business trips.

METHODS

Data from more than 800,000 international trips and medical assistance cases provided to 48 multinational corporations in 2009. Travel destination countries were grouped into four a priori risk-related categories.

RESULTS

Travel to "low" medical risk countries in aggregate accounted for more hospitalizations and medical evacuations than travel to "high" medical risk countries. Nevertheless, the risk per trip was much higher for travel to higher medical risk countries.

CONCLUSIONS

Corporations with employees on international travel should allocate sufficient resources to manage and ideally prevent medical issues during business travel. Travel medicine must focus on more than infectious diseases, and programs are necessary for both high- and low-risk regions. Improved understanding of travel-related needs determines resource allocation and risk mitigation efforts.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the ‘European Network for HIDs’ conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.

Limitations of stroke volume estimation by non-invasive blood pressure monitoring in hypergravity

Background

Altitude and gravity changes during aeromedical evacuations induce exacerbated cardiovascular responses in unstable patients. Non-invasive cardiac output monitoring is difficult to perform in this environment with limited access to the patient. We evaluated the feasibility and accuracy of stroke volume estimation by finger photoplethysmography (SVp) in hypergravity.

Methods

Finger arterial blood pressure (ABP) waveforms were recorded continuously in ten healthy subjects before, during and after exposure to +Gz accelerations in a human centrifuge. The protocol consisted of a 2-min and 8-min exposure up to +4 Gz. SVp was computed from ABP using Liljestrand, systolic area, and Windkessel algorithms, and compared with reference values measured by echocardiography (SVe) before and after the centrifuge runs.

Results

The ABP signal could be used in 83.3% of cases. After calibration with echocardiography, SVp changes did not differ from SVe and values were linearly correlated (p<0.001). The three algorithms gave comparable SVp. Reproducibility between SVp and SVe was the best with the systolic area algorithm (limits of agreement −20.5 and +38.3 ml).

Conclusions

Non-invasive ABP photoplethysmographic monitoring is an interesting technique to estimate relative stroke volume changes in moderate and sustained hypergravity. This method may aid physicians for aeronautic patient monitoring.

Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided.

CONCLUSIONS

Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation to provide a safe continuum of critical care during a disaster.

Stratification of patients in long-distance, international, fixed-wing aircraft

INTRODUCTION

A growing number of individuals with significant medical histories travel for business and holidays. Precise anticipation and stratification of transport-relevant illness severity in the planning stage of an air medical evacuation is crucial for mission success and patient safety.

METHODS

We developed a staging system (ie, Stratification of Air Medical Transport by Expression of Symptoms in Patients [STEP]) and applied it to 356 patients transported by a fixed wing aircraft between January 2010 and June 2011. Patients were stratified before transport, and the transport team performed independent staging of each patient during the actual transport. Data on transport modes, transport time, age, sex, diagnosis, the need for mechanical ventilation, and transport-related complications were collected. Data were analyzed for significant differences in STEP categories between operations staging and staging by the flight crew and for the correlation between operations STEP staging and actual transport acuity.

RESULTS

Complete datasets were available in 353 of 356 patients. Differences between staging by operations and flight crew were documented in 31 cases (P = .809); in 18 of them, the flight crew considered the patient to be more severely affected than previously estimated. Decisions for specific transport mode and configuration were found to be adequate in all but 3 cases (99.15%).

CONCLUSION

STEP is a useful tool to assess patient's illness/injury severity in the planning stage of a long distance, international, air ambulance transport and assists in choosing the appropriate mode and configuration of transport.

Country factors associated with the risk of hospitalization and aeromedical evacuation among expatriate workers

OBJECTIVE

To assess country factors associated with the risk of requiring aeromedical evacuation and hospitalization among expatriate workers and their dependents.

METHODS

The 2009-2010 data including 5725 aeromedical evacuations and 17,828 hospitalizations, and 2009 data of hospitalizations and aeromedical evacuations among 94,651 at-risk expatriates, were analyzed to assess 2 country risk rating tools. Each tool utilized four risk categories and reflected level of development and medical capabilities.

RESULTS

Country risk category was strongly associated with risk of evacuation and/or hospitalization for each risk rating tool (eg, 46-fold increase from lowest to highest country risk category).

CONCLUSION

Country risk tools strongly associate hospitalization and aeromedical evacuation with country risk category, and thus can be important indicators of relative medical risk. Employers may use these results to implement targeted prevention programs to support expatriate workers and their families.

[The elderly travellers]

We attend a considerable increase in the number of old travellers, because of facilitation of transport, and increase of the life expectation without incapacity. This way, practicians will be more and more confronted with old travellers avid councils before their departure. In spite of the risk of intercurrent pathologies, data shows that the age in itself is not a contra-indication of travel: the stage of life considered as a limit becomes a period privileged to discover the world. On a theoretical plan, the ageing characterized by a reduction of the functional reserve of organ, represents more a fragility than a contra-indication. On the other hand, comorbidities and their accumulation make elderly more vulnerable to medical complications potentially serious and in conditions of stress than can gather a travel. We could propose to the vulnerable old patient avid to leave, in coordination with the geriatrician and the travel doctor, a personalized prevention in the form of a consultation "old traveller" where we would adopt a geriatric approach to review the compatibility between the health and the type of travel, in particular at elderly with polypathologies and many treatments.

Multidrug-resistant bacteria among patients treated in foreign hospitals: management considerations during medical repatriation

BACKGROUND

The repatriation of patients from foreign hospitals can foster the emergence and spread of multidrug-resistant bacteria (MRB). We aimed to evaluate the incidence of MRB in patients treated in foreign hospitals and repatriated by international inter-hospital air transport in order to better manage these patients and adjust our procedures.

METHODS

The records from all consecutive aeromedical evacuations and overseas repatriations carried out by Mondial Assistance France between December 2010 and November 2011 were reviewed for this study. Only inter-hospital transfers with inpatient destination of an acute care unit were considered. Patients were allocated to one of two groups: those identified as MRB carriers at their arrival in France and those who were not identified as such (either negative for MRB or not tested). Data were compared between the two groups.

RESULTS

Analysis was performed on 223 patients: 16 patients (7%) were identified as MRB carriers. Compared with confirmed non-MRB patients, MRB carriers came more frequently from a high-risk unit (88% vs 59%, p = 0.05) and had a longer foreign hospital stay [13 (3-20) vs 8 (6-14) d, p = 0.01].

CONCLUSIONS

The occurrence of MRB among patients repatriated from foreign hospitals is noted in a significant minority of such individuals transferred back to their home country. The typical MRB patient was admitted to a high-risk unit in a foreign hospital prior to repatriation with longer foreign hospital admissions. The prospective identification of these patients prior to transport is difficult. While these factors are associated with MRB presence, their absence does not rule out highly resistant bacterial colonization. A systematic review of this important medical issue is warranted with the development of guidelines.

Air medical repatriation: compassionate and palliative care consideration during transport

As the world's population ages, the number of elderly and very elderly international travelers continues to increases. Many of these travelers are afflicted with multiple, often severe, medical conditions; in fact, a significant portion of these elderly travelers are considered end stage with respect to their disease state. While traveling, they are exposed to travel hazards and deterioration of their already compromised health. Once acute illness or injury occurs, medically appropriate, compassionate repatriation of these elderly patients is associated with a range of complex challenges. In this series, we present 4 cases that demonstrate these challenges.

Large-Scale Airmedical Transport from a Peripheral Hospital to Level-1 Trauma Centers after Remote Mass-Casualty Incidents in Israel

Introduction:

Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs.

Problem:

The available data on airmedical transport from remote MCIs are limited. The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs.

Methods:

The study was retrospective and reviewed descriptive records of airmedical transports.

Results:

The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch. The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome.

Conclusions:

The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

Country-to-country transfer of patients and the risk of multi-resistant bacterial infection

Management of patients with a history of healthcare contact in multiple countries is now a reality for many clinicians. Leisure tourism, the burgeoning industry of medical tourism, military conflict, natural disasters, and changing patterns of human migration may all contribute to this emerging epidemiological trend. Such individuals may be both vectors and victims of healthcare-associated infection with multiresistant bacteria. Current literature describes intercountry transfer of multiresistant Acinetobacter spp and Klebsiella pneumoniae (including Klebsiella pneumoniae carbapenemase- and New Delhi metallo-β-lactamase-producing strains), methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and hypervirulent Clostridium difficile. Introduction of such organisms to new locations has led to their dissemination within hospitals. Healthcare institutions should have sound infection prevention strategies to mitigate the risk of dissemination of multiresistant organisms from patients who have been admitted to hospitals in other countries. Clinicians may also need to individualize empiric prescribing patterns to reflect the risk of multiresistant organisms in these patients.

Evaluation of a specific score for air medical evacuation triage

Age, local resources, and locations have been identified as independent factors indicating the need for immediate air medical evacuation. This preliminary case-control study aimed to evaluate the relevance of a score from 0 to 6 based on these criteria and to identify thresholds. The 3-step scale we obtained may help in prioritizing repatriation requests.

International travel and the elite athlete

International travel is a frequent occurrence in the life of the elite athlete; such travel can pose challenges to the sport medicine practitioner. Travel is also the reality of many recreational level or sub-elite athletes as opportunities for international competition and training proliferate. An appreciation of the range of responsibilities associated with the preparation for and the strategies to facilitate such travel is essential for any physician charged with the care of athletes and teams. An appreciation of (1) the medical and public health challenges associated with competition in a particular setting; (2) the requirements for vaccination and immunization; (3) the strategies for the management of jet lag and climatic or environmental extremes; (4) the range of supplies and equipment necessary for travel to certain locales; (5) the need to ensure the availability of ample familiar and nutritious foods; (6) the potential need for specialty care in strange settings; (7) the management of common travel-associated illness; and (8) the challenges associated with the evacuation of an injured athlete are fundamental to the successful management of international travel involving athletes and teams. The adoption of a methodical approach to pre-trip planning can ensure an enhanced travel experience, illness-free training and competition, and facilitate optimal performance.

Traumatic brain injury and aeromedical evacuation: when is the brain fit to fly?

BACKGROUND

To review the inflammatory sequelae of traumatic brain injury (TBI) and altitude exposure and discuss the potential impact of aeromedical evacuation (AE) on this process.

METHODS

Literature review and expert opinion regarding the inflammatory effects of TBI and AE.

RESULTS

Traumatic brain injury has been called the signature injury of the current military conflict. As a result of the increasing incidence of blast injury, TBI is responsible for significant mortality and enduring morbidity in injured soldiers. Common secondary insults resulting from post-traumatic cerebral inflammation are recognized to adversely impact outcome. AE utilizing Critical Care Air Transport Teams has become a standard of care practice following battlefield injury, to quickly and safely transport critically injured soldiers to more sophisticated echelons of care. Exposure to the hypobaric conditions of the AE process may impose an additional physiologic risk on the TBI patient as well as a "second hit" inflammatory stimulus.

CONCLUSIONS

We review the known inflammatory effects of TBI and altitude exposure and propose that optimizing the post-traumatic inflammatory profile may assist in determining an ideal time to fly for head-injured soldiers.

[Emerging multidrug-resistant microorganisms among travelers returning to France and persons repatriated from foreign hospitals]

The spread of multidrug-resistant bacteria has become a major problem in France in recent years, owing to increasing antibiotic exposure, growing international exchanges, repatriation of hospitalized French patients, and treatment of French and foreign travelers in French hospitals. This article examines how different pathogens may become endemic in France.

Decision criteria of immediate aeromedical evacuation

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 < or =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.

Predominance of neurologic diseases in international aeromedical transportation

BACKGROUND

International travel industry in Taiwan is expanding. The number of people traveling abroad was approximately 480,000 people in 1980; 2,940,000 in 1990; 7,320,000 in 2000, and in 2007, it has reached 8,960,000, which was more than one third of total population. Air medical transportation will be necessary when local medical facilities do not approximate the international standards. No previous study on epidemiology in Taiwan on patients received international medical repatriation. This is the first report to discuss the epidemiology of Taiwan's international aeromedical transportation and its focus on neurologic diseases.

METHOD

Retrospective analysis of all international aeromedical transports on Taiwanese patients from October 2005 to September 2007 was performed. All materials were collected from the databank of International SOS, Taipei. The data were analyzed with Microsoft Excel and SPSS v. 11.0 software (SPSS, Chicago, Ill).

RESULTS

A total of 416 patients were transported. Excluding expatriates transported outbound and 2-stage inbound transports, the Taiwanese patient number with international aeromedical transport was 379; 51 by air ambulance and 328 commercially. There were 271 male (72%) and 108 female patients (18%). Of the 379 patients, 178 (47%) were neurologic diseases. Two hundred ninety-five (78%) patients were transported from China. Patient transports peaked in autumn by 105 (28%). Of all 33 ventilated patients, 12 (36%) were neurologic diseases. In-flight complications occurred in 10% of neurologic and 2% of nonneurologic cases. No in-flight mortality occurred in both groups.

CONCLUSION

Neurologic diseases comprise most of the Taiwanese patients that requires medical transportation. With relatively suboptimal medical standard and high medical expenses in China, patients with neurologic conditions need timely and safe aeromedical transport than those with other diseases. Transport of patients with neurologic diseases, either by air ambulance or commercial flights, can only be safely performed by well-trained medical escorts and comprehensive logistic arrangements.

Treatment of war wounds: a historical review

The treatment of war wounds is an ancient art, constantly refined to reflect improvements in weapons technology, transportation, antiseptic practices, and surgical techniques. Throughout most of the history of warfare, more soldiers died from disease than combat wounds, and misconceptions regarding the best timing and mode of treatment for injuries often resulted in more harm than good. Since the 19th century, mortality from war wounds steadily decreased as surgeons on all sides of conflicts developed systems for rapidly moving the wounded from the battlefield to frontline hospitals where surgical care is delivered. We review the most important trends in US and Western military trauma management over two centuries, including the shift from primary to delayed closure in wound management, refinement of amputation techniques, advances in evacuation philosophy and technology, the development of antiseptic practices, and the use of antibiotics. We also discuss how the lessons of history are reflected in contemporary US practices in Iraq and Afghanistan.

Medical issues associated with commercial flights

Almost 2 billion people travel aboard commercial airlines every year. Health-care providers and travellers need to be aware of the potential health risks associated with air travel. Environmental and physiological changes that occur during routine commercial flights lead to mild hypoxia and gas expansion, which can exacerbate chronic medical conditions or incite acute in-flight medical events. The association between venous thromboembolism and long-haul flights, cosmic-radiation exposure, jet lag, and cabin-air quality are growing health-care issues associated with air travel. In-flight medical events are increasingly frequent because a growing number of individuals with pre-existing medical conditions travel by air. Resources including basic and advanced medical kits, automated external defibrillators, and telemedical ground support are available onboard to assist flight crew and volunteering physicians in the management of in-flight medical emergencies.