ITIJ Assistance and Repatriation Review April 2019

April 2019 Issue

ASSISTANCE REPATRIATION

International Travel & Health Insurance Journal

R E V I E W

The right time to repatriate - P04

Remote island retrievals - P16

Putting ‘permanxiety’ on the

what happens when involved

patient evacuations from

Developing relevant corporate

How is this decision made and parties disagree?

The challenges of organising isolated regions

All things considered - P22

Gaining ground - P32

repatriation companies

the use of road ambulances

Working with specialist funeral

Navigating the options around

corporate travel agenda - P18 assistance provision + More Inside

Contents

ASSISTANCE & REPATRIATION REVIEW

CONTENTS

EDITORIAL COMMENT

The right time to repatriate - p.04 How is this decision made and what happens when involved parties disagree?

There’s no place like home - p.08 How the needs of a patient with mental health issues can shape a repatriation Great expectations - p.12 Understanding the processes and challenges inherent in the funeral repatriation industry

Life-saving firsts in Panama - p.26 ISOS on the first on-site implantation of a VAD

Remote island retrievals - p.16 The challenges of organising patient evacuations from isolated regions

China: The challenges of overcoming language and cultural barriers in medical assistance - p.28 Catering to the growth of the Chinese travel market

Putting ‘permanxiety’ on the corporate travel agenda - p.18 Developing relevant corporate assistance provision

Gaining ground - p.32 Navigating the options around the use of road ambulances

All things considered - p.22 Working with specialist funeral repatriation companies

Emergency Brexit - p.36 How Brexit might impact the funeral repatriation sector Cardiac arrest over the Egyptian desert - p.40 A challenging medevac from Yemen to Beirut Q&A with Carlos Hernandez, Operations Manager at Tangiers International - p.42

Editor-in-Chief: Ian Cameron Editor: Sarah Watson Copy Editors: Mandy Langfield, Stefan Mohamed, Lauren Haigh & Robyn Bainbridge Contributor: James Paul Wallis Designers: Robbie Gray, Tommy Baker, Will McClelland Advertising sales: James Miller, Kathryn Zerboni Contact: Editorial: +44 (0)117 922 6600 ext. 3

The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned is hereby excluded. The views expressed do not necessarily reflect

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I hope you enjoy this issue.

Sarah Watson Editor

those of the publisher.

Advertising: +44 (0)117 922 6600 ext. 1

Published on behalf of: Voyageur Publishing & Events Ltd,

Delays are one of the key friction points in the insurance industry, both in terms of interactions with insureds and those with industry partners. Nowhere is this felt more keenly than in cases involving the death of a loved one abroad, where feedback and information regarding the status of a case is anxiously awaited by all involved parties. At a time of highly charged emotions, delays around the repatriation of mortal remains only add to the consternation already felt by family and friends, which is why it’s important to understand the protocols and challenges faced by specialist funeral repatriation companies. Two of our features in this issue of the Assistance & Repatriation Review focus on the processes involved in international funeral repatriations and offer insights on how travel and medical assistance companies can better work with their international funeral director partners. Finding out how working together better can improve issues like delays can only be beneficial for all parties, not least the insured’s family.

Elsewhere, we take in in-depth look at the factors affecting choices to repatriate patients by road ambulance, we ask how decisions regarding the ‘right’ time to repatriate are made, and we talk to Carlos Hernandez of Tangiers International about his role, technology, and the global assistance landscape. We also have a collection of Industry Voice articles offering thought leadership on topics ranging from remote island evacuations to mental health, and from language barriers to Brexit.

without permission INTERNATIONAL TRAVEL & HEALTH INSURANCE JOURNAL ISSN 2055-1215

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ASSISTANCE & REPATRIATION REVIEW

Feature

THE RIGHT TIME TO REPATRIATE?

There are multiple choices to be made during the repatriation process, but the decision of when to repatriate a patient is the pivotal consideration. How is this decision made and what happens when involved parties disagree? Christian Northwood finds out

M

edical repatriations are rarely simple. The medical assessment involved is rigorous – not only does the patient have to pass several tests in order to be considered fit to fly, but the repatriation itself, whether on a commercial aircraft or air ambulance, requires specialist medical knowledge on behalf of the organising and accompanying teams.

Repatriations can also mean eye-watering costs for

those shouldering the bill, which in many cases is the insurer. James Page, Senior Vice-President and Chief Administration Officer at AIG, told ITIJ: “If you’re travelling from Miami to the Caribbean, you may only need US$25,000, because that’s probably what it will cost to get you home. If you’re going from Miami to Sydney, you may need an amount upwards of $125,000.”

And these are from locations that have good infrastructure. If a patient falls ill in a remote

location, with a complicated condition, those costs can spiral. The patient’s medical condition and the cost associated with the various options regarding their treatment and repatriation are main considerations in repatriation cases, but other factors can muddy the waters and decisions over the right time to repatriate are not always easy to make.

Working together As you might expect in an often-sensitive situation, with various parties involved who all have a responsibility toward the patient, the stakes are high, and disagreements can occur.

However, with the clock ticking, all sides need to be able to identify where potential disagreements might be and know how to mitigate or deal with them as swiftly as possible.

AP Companies’ Business Development Manager Natalya Butakova puts the disagreements that are had during the process into two categories, ‘objective’ and ‘subjective’. She explained that objective disagreements occur when: the level of treatment in the home country is lower than in the country of temporary stay; when treating doctors don’t know much about medical transportation guidelines and when and how the patient can be transported; when medical facilities don’t want to release the patient due to financial reasons; when the insurance limit is not sufficient to cover both medical expenses and repatriation costs, but the condition of the patient requires immediate repatriation; and when an air ambulance provider doesn’t accept the patient on board.

“ With the clock ticking,

all sides need to be able to identify where potential disagreements may be and know how to mitigate them as swiftly as possible ” 4 |

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ASSISTANCE & REPATRIATION REVIEW

Subjective disagreements can include instances when the patient does not agree with the medical decisions being made. The desire of patients or their families for a swift decision puts pressure on all other parties involved. Like many areas of the insurance sector, Page believes that patient education needs to be worked on to help improve the repatriation experience, and he advises travellers when buying or even not buying that ‘your limits are important’. “The further away from home you’re going,” he said, “the higher level of evacuation coverage you should have.”

Travellers also need to be more up to speed with what their travel and healthcare policies cover, another issue that improved education may be able to mitigate. Page emphasises: “Like anything else, customers need to read the exclusions in their policy, make sure they understand the conditions and how they apply, and if they have any questions, contact their travel insurer prior to purchase.”

Despite this, Page states that the most common disagreement that an insurer has to deal with is payment, and he agrees with Butakova that patients’ desires can often be a cause of stress for those wanting to treat them in the most efficient way: “When you’re at

home and you have a medical situation and you go see a doctor, you might wish to also get a second opinion so that you can gather more information to make a better decision about your care. But for some reason, when people are travelling, they don’t want to hear other options. They don’t want to hear that there are other choices to be made. They often think there’s a single answer: they want what they want, which is usually to go home. But it’s not always that simple.”

However, there does seem to be a reasonably simple method to negate many of these issues.

“ The desire of patients

It’s good to talk

or their families for a swift decision puts pressure on all other parties involved ”

“ Insureds can often want to stay put in a facility because it provides the best healthcare, but that may not be medically necessary or cost effective ”

It seems almost too obvious, but for every party spoken to for this feature, good communication is one of the key ways to mitigate disagreements and facilitate efficient decision-making with the best outcomes for all. “Communication

between the hospital and assistance company is key to the success of the repatriation,” said Eve Jokel, International Director at Luz Saude, the holding company of Hospital da Luz, a network of private hospitals and clinics in Portugal. “The first priority is the clinical situation and decision to repatriate. Secondly, the assistance company must know in advance what conditions are required for the patient to experience a secure discharge and journey to his or her destination.

Agreement should be reached between the clinical teams, in consideration of the wishes and consent of the patient and family.”

Nicole Bootsma, Medical Director at Eurocross Assistance in the Netherlands, also believes that being open and taking the time to explain decisions can avoid parties butting heads over issues: “Repatriation requires very specific knowledge, which the treating doctors do not always have; they may feel like they are being controlled. That is why it is important to have a good dialogue.”

“ Good communication is one of the key ways to mitigate disagreements and facilitate efficient decision-making ” Doctors in hospitals may not have the intimate knowledge of the International Air Transport Association (IATA) fit-to-fly guidelines that are so important in medical repatriations, asserted Bootsma – so fully explaining why decisions need to be made, plus listening to the ground medical staff, helps both medical teams to push in the same direction. On the flip side, ‘good knowledge of the financial details is crucial, like the costs of the hospital abroad, costs of the transport, and so forth’, when it comes to >>

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ASSISTANCE & REPATRIATION REVIEW understanding the motivations of an insurer.

Page points to a different factor that he believes is key to a successful medical repatriation: providing the insured with options. “If any of the three parties are not completely aligned on the path forward,” he explained, “the solution is found by providing options or choices.” Insureds may want to stay put in a facility because it provides the best healthcare, but that may not be medically necessary or cost effective for the insurer. On the other hand, a patient may want to be repatriated home immediately, but the care they’re receiving is more than adequate. “In such a case,” said Page, “the treating physicians should give them options and we, as an insurance or assistance company, should give them options. While none of the options presented may include what they consider their optimal choice, they at least have an opportunity to select the next best thing.”

Bootsma added that keeping the patient in the

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“ Patients need to be

given the impression that ‘they are being managed under a coordinated effort’ ”

loop also makes the decision-making process smoother: “It is very important to manage the expectations of the patient and the patient’s family about the repatriation process by informing them, listening to their wishes and discussing the different steps.”

At the same time, Jokel explained that patients need to be given the impression that ‘they are being managed under a co-ordinated effort’ and should be shielded away from any of the disagreements the other parties may be having.

“The client should never be placed in a position where they need to tell the hospital what the plans are for collection or inform the assistance company about what information the hospital will deliver and when,” she said, explaining that she has seen a position develop several times where the client is in the middle of the co-ordination ‘as a result of assistance companies’ struggle to co-ordinate with hospitals, either due to language issues, experience with repatriation, inadequate response time or resistance, from the inpatient service or treating physician’.

This situation creates a great deal more pressure and stress for the patient and their family, creating a negative experience that can ultimately affect the entire repatriation process.

Time is of the essence So, keeping all these factors in mind, when is the best time to repatriate? It likely won’t surprise regular readers of ITIJ that the answer is, basically: it’s complicated. As Butakova puts bluntly, ‘there is no unique answer to this question’.

Instead, every case is evaluated on its own factors, and although experience and knowledge help to make decisions, each case is a unique balancing act.

As well as constant discussions and evaluations from attending medical staff, insurers, air ambulance staff and assistance companies, Butakova also points out that there is a further legal angle to take into account. “There are certain rules, especially for air travel, 6 |

established by the responsible authorities,” she said. “The most important reference in this field is the Medical Manual issued by IATA. There are also a certain number of local documents – Air travel and transportation of patients, written by the Danish Aeronautical Medical Association, for example. These documents describe situations and give recommendations regarding timing and air transportation options.”

Bootsma also finds that technical hurdles can often change when and how a repatriation takes place, and these have to be taken into consideration – along with most patients’ desire to be home as soon as possible. “Except for the medical condition of the patient, when and how a repatriation will take place can depend on the possibilities of commercial flights (for example, stretcher possibilities), medical clearance of the airline and the policy condition of the insurance company (for example, whether an air ambulance is covered),” Bootsma explained.

There is also the issue of working out where the patient is going to end up, and making sure that there is a hospital bed available for them when they arrive – often a challenge if the decision to repatriate has had to be made swiftly.

Page argues that medical repatriation should happen ‘when the patient is able to travel in the least obtrusive way’. For AIG, he told ITIJ, the ideal optimum time is when a patient is able to travel on their own in a safe way. However, patients are always put first, and if this is simply not possible – whether due to the patient’s condition or the lack of amenities at the attending hospital – AIG moves to acquire a medical escort. “We weigh what is best for the patient first,” he said.

“After that, cost might become a factor, if there are multiple options that are all equal from the patient-safety standpoint.”

With no medical repatriation being the same, no

“ Technical hurdles

can often change when and how a repatriation takes place, and these have to be taken into consideration ” matter how much preparation is feasible, there are always going to be curveballs, but that should not stop companies from striving to prepare as much as they can. As Bootsma asserts: “There is always a space for improvement, and the only way to improve is to take lessons and experience from each and every case, and understand what the best plan of action is and why.” ■

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Industry Voice

THERE’S NO PLACE LIKE HOME Dr Adrian Hyzler, Chief Medical Officer of Healix

International, explores how the needs of a patient suffering from mental health issues can change the shape of a repatriation

T

he protocols for medical repatriations when holidaymakers and business people working abroad have been involved in an accident or suffered a physical illness are well established. What is more challenging is assessing the suitability for repatriation of an individual suffering from mental health issues – and the actions that need to be put in place to ensure the repatriation goes as smoothly as possible. It is important to appreciate that mental health conditions require quite a different approach for repatriation.

Psychological implications of physical injuries First and foremost, it’s essential for an insurer to understand whether a psychological condition is a consequence of physical injuries or a primary

8 |

condition that is entirely unrelated to an individual’s physical condition.

Data from Healix International shows that between five and 10 per cent of physical injury cases result in some form of psychological complications, and those complications must be taken into account when organising a repatriation for a physical injury.

When a patient is suffering from hypoxia (low oxygen concentration) or from septicaemia (widespread generalised infection), they will often become agitated or confused, and this may lead to a state of delirium. It is also important to always consider the potential psychological sideeffects of drugs.

The added stress of being in a foreign country, perhaps with little understanding of the local

language and without friends and family, can further the risk of psychological side-effects from physical injuries. While mental health issues resulting from a physical injury are, more often than not, fairly short-lived, usually resolving as the patient’s physical condition improves, they still need to be factored into the repatriation process.

For individuals who are experiencing mental health issues that are unconnected to their physical condition, clearly the insurer will have insight from those treating the patient. But again, it’s important to recognise and plan for the unsettling impact of unfamiliar surroundings, foreign languages and a lack of family or friends for support, which could exacerbate the patient’s condition. Repatriating mental health patients who have previously been admitted to a mental health facility abroad while receiving their initial treatment will have been used to a fairly predictable routine, in a controlled and safe ward environment.

Taking them out of that environment could immediately change their condition. >>

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CM

“ A chief role of medical

escorts must be to manage the care of the patient, taking into account their mental wellbeing ”

MY

CY

CMY

K

60 YEARS

OF AIR AMBULANCE & MEDICAL ASSISTANCE LONDON

STOCKHOLM

DUBAI

ROME

CHINA BEIJING TOKYO

DAKAR CONAKRY

DOUALA MADAGASCAR

CAPE TOWN

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FROM AFRICA TO THE REST OF THE WORLD 24 Hour Emergency Control Centre Tel: +254 20 6992000 / +254 20 6992299 Mob: +254 (0) 733 639 088 / 722 314 239 Fax: +254 20 344170 Email: emergency@flydoc.org www.flydoc.org

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Industry Voice

Understanding and recognising the symptoms is, therefore, crucial to help insurers manage the best outcome for their policyholder. It will help determine the type of repatriation necessary – from simply an escort on a standard flight to the arrangement of a medical air ambulance. It will also help determine the level of escort needed.

Avoiding the hurly burly One of the first things to consider when planning a repatriation for a patient experiencing psychological symptoms is the airport environment. For even the calmest and most confident traveller, the hurly-burly of the departures process can, figuratively and physiologically, raise the blood pressure.

Thousands of fellow travellers elbowing themselves through check-in, security and onto the plane can severely exacerbate the situation for someone already experiencing mental health issues.

It is vital, therefore, that the patient is provided with as calm an environment as possible during the repatriation, and this is where medical escorts are crucial. A chief role of medical escorts must be to manage the care of the patient, taking into account their mental wellbeing. Utilising airport lounges, avoiding large queues and using priority boarding can all help to reduce the likelihood of external factors causing additional stress. Such arrangements should therefore be factored into the repatriation arrangements.

“ It’s essential

for an insurer to understand whether a psychological condition is a consequence of physical injuries or a primary condition that is entirely unrelated to an individual’s physical condition ”

A protective buffer Medical escorts also provide a calm and capable presence on the plane itself. Patients experiencing psychological issues need to be protected from any potentially difficult interactions with air crew or fellow passengers.

Medical escorts can act as a protective buffer, problem solving and taking responsibility away 10 |

from what is often an anxiety-inducing and exhausting experience for those with mental health problems.

The time of day or night of the repatriation is another factor that can significantly impact on someone already experiencing psychological issues. In normal circumstances, night time is often associated with an increase in disorientation and confusion for those facing mental health issues. Unfortunately, the same feelings can occur when the lights go out during long-haul flights.

Someone who has, during the daytime, been stable and shown little signs of stress can become disturbed, or even refuse their medication, simply because they are disorientated. It therefore makes sense, when there is the potential for a patient with mental health issues to become agitated and even aggressive, to use two escorts when repatriating on long-haul flights – usually a doctor and a nurse.

Another good reason for two escorts is the time a repatriation takes, from door to door. With some lasting 30 hours or more, it is important that at least one of the escorts is fully awake at all times; it is also important that each escort gets a chance to rest so that they are alert and able to look after the patient when it is their shift.

In the unlikely event that the patient becomes acutely disturbed during the flight, having two healthcare professionals on hand helps to defuse the situation as quickly as possible.

The need to create a calm and unpressured environment also justifies upgrading patients

with mental health issues to business class for the repatriation. And it is important to consider the benefits, and possible drawbacks, of having the patient’s relative sitting alongside the patient and medical team. In a situation where the patient has been observed during their hospital stay getting agitated when the relative is not around, there is certainly a strong argument to have them nearby. However, it should always be noted that the relative may actually be one of the exacerbating factors and a ‘break’ from them during the flight could actually have a positive effect!

Repatriation of patients with psychological symptoms is certainly challenging and requires close teamwork and co-operation among all involved, from the treating medical team to the transfer team, the airline crew and the medical escorts. Nevertheless, with careful planning and an in-depth consideration of the patient’s condition and needs, such repatriations can be highly rewarding. ■ Dr Adrian Hyzler is Chief Medical Officer of Healix International. He qualified as a doctor in 1990 from Sheffield University Medical School and pursued a career in emergency medicine, which led to an interest in travel medicine. Dr Hyzler joined Healix International in May 2001 as a flight doctor. He moved on to become a medical co-ordinating officer, then Senior Medical Officer, and is now Chief Medical Officer, with an additional responsibility as Director of Medical Communications.

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GREAT EXPECTATIONS Understanding the processes, challenges and protocols inherent in the funeral repatriation industry is key for those who partner with such companies in the global travel and medical assistance arena. Fiona Greenwood shares her unique personal insights into this industry

S

ince the 1970s, emergency assistance and repatriation has kept pace with travel trends and the increasing demands of passengers moving around the world. Our company chairman Tony Rowland recalls introducing repatriation services from European resorts almost 50 years ago, with conversations about cover and exclusions during the early days of package holidays and travel insurance.

Then and now, exclusions and financial limits apply, but expectations around cost, service and timeframe have never been greater, both across the industry and among the travelling public.

A unique story News travels fast, especially bad news. Bereaved families sometimes react emotionally and automatically by setting a date for the funeral, expecting the briefest interlude between the death in one country and the funeral in another.

12 |

Expectations are usually built on their experience of a bereavement and funeral at home, which unfortunately does not prepare them for a process which merges regulations across two countries thousands of miles apart.

It’s a fact, funerals and repatriations need documents. Documents issued by one authority have to be adapted to meet the needs of another. Local authorities around the world record the death, permit a burial, cremation or transfer of a deceased to another country.

While some countries are introducing computergenerated forms, paper-free repatriation seems unlikely. When we travel as passengers, we need identification, and the papers that bring the deceased home work on a similar basis, dovetailing civil records from one country with home government formalities.

The documents that accompany the coffin or urn tell the unique story of the deceased to

officials at the point of departure and destination. Translations, legalisations, permits, and consular registration are essential and swell the bundle for some countries, whereas others only expect minimal paperwork. Different governments take different approaches. Some need to know the cause of death, others can accept that it is still under investigation at the time of repatriation; some issue permits free of charge while others charge a fee. Attention to detail is important. Certificates issued with errors take time to correct and cause delays. Families are already distressed and documents that are incorrect are a secondary blow, potentially delaying the funeral and possibly estate matters too.

“ It’s important to listen

carefully and share information that could affect funeral decisions ” While mistakes can be corrected, living with a different identity can compromise the chance of a funeral at home as we learnt recently, when a gentleman died using a false identity in London, with no records in his true identity to support his repatriation home.

Some faiths expect the funeral within days. Some designate cremation, others burial. Some families have no faith but will have funeral preferences and also expect their loved one home promptly.

We cannot change local jurisdiction or process,

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“ Assistance teams know if there are limitations and families can make an informed choice from the available options ” and naturally we sympathise when families feel thwarted by local regulations. It’s important to listen carefully and share information that could affect funeral decisions; for example, if embalming is unavoidable or cremation is not an option in that country. Cumulative experience among our network of trusted partners helps to set realistic expectations, so assistance teams know if there are limitations and families can make an informed choice from the available options.

Chain reaction Tragedies abroad can attract huge media interest, potentially adding further distress to emotionally charged situations. Recent reports in the British press include the crash into the English Channel of a light aircraft that was carrying a footballer to his new club; the fatal

ASSISTANCE & REPATRIATION REVIEW

consequences of a nut allergy in a holiday resort; and an inquest into the deaths of three young friends who died on holiday in Vietnam.

Does media coverage help or hinder? If finance is a problem, crowdfunding might help, so publicity could be a friend rather than a foe.

But heart-breaking press releases are often followed by a plea for privacy, which means the press is looking elsewhere for news about flights and funerals. We need to be on our guard.

Now the combination of GDPR and agreed communication protocols set by individual assistance companies reassures everyone that information will not be shared without express consent, even with other family members.

Emotional reactions to tragic news vary from numb to angry and tearful and pass through all points in between. When strong emotions are directed at us, we know they are not personal, but demonstrate the impact of a life-changing situation that feels beyond someone’s control.

When families make a funeral repatriation claim, we believe that starting arrangements straight away works best. If families know that progress is being made while medical history is explored, it allays anxiety, and promotes confidence between

family, assistance provider, underwriter and funeral repatriation provider. It can minimise storage costs, and complaints about delay or deterioration while a medical history review is underway.

We can’t change what has happened, but when we can avoid waiting, families are always grateful.

We talk about families but what is the >>

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“ Tragedy strikes

unexpectedly, on ships, on planes, on holidays, on business trips, and communication around what happens next is key. ” definition of a family in the 21st Century?

More importantly, who is entitled to give funeral instructions? Any disagreements must be resolved. For example, the parents of common law partners might step aside and allow the surviving partner to make funeral decisions.

Equally, the parents could decide to assert their rights and give their own instructions if they are still legally next of kin. Separation can complicate matters too. Relationships are sensitive. Longlost siblings or family members estranged from each other for many years may still feel obliged to step up and take care of arrangements, while others dismiss the idea emphatically. The fact that someone is listed as next of kin on a passport does not necessarily mean they will accept any financial responsibility for funeral arrangements.

Fortunately, rules around deaths, funerals and repatriation are more predictable. In England and Wales, for example, deaths from natural causes are normally registered within five days, but the coroner always investigates sudden deaths to establish who died, where, how and why, arranging a postmortem to find the medical cause, and an investigation or inquest if necessary.

Identification is critical. Visual identification is not always reliable, so DNA or dental records may be necessary. If tissue or organ samples are taken, next of kin are notified. This notification is a legal requirement in England and Wales, 14 |

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but not automatic in other countries, causing great distress if the information is unexpectedly received months later.

If someone is charged by law enforcement in connection with a death, the defence team can request its own postmortem.

If there is a criminal prosecution, the inquest is suspended. If not, evidence is heard at the coroner’s inquest, and the conclusion is recorded on the final death certificate. The coroner provides an interim death certificate and permission for burial cremation or repatriation as soon as practically possible, but the whole process can take months, and in high-profile mass casualty events even longer.

“ GDPR and agreed communication protocols set by individual assistance companies reassures everyone that information will not be shared without express consent ” Managing expectations While local rules set the terms for any investigation, nationality, faith and destination determine what happens next. For example, in London for a funeral in Paris, detailed paperwork is processed by the French consulate and the coffin is sealed before starting the journey home.

It remains closed in France, so it must be suitable for transportation and also the funeral. As France is geographically close, relatives might come to London to see their loved one for the last time before the coffin is sealed.

By comparison, if the funeral was to be on the other side of the world in New Zealand, there is no need to visit the NZ High Commission

in London for documents or to seal the coffin, which can be opened for viewing at home. So, although this is the longest journey, it is the simplest in terms of administration, but more expensive due to the cost of the flight. From other countries to these same destinations, there may be additional layers of administration, depending on conventions that apply around documents in the country of origin.

Viewing is always an emotional topic.

Expectations must be managed to ensure that families and consignees understand any concerns.

Storage, postmortem, cause of death, infection, objections to embalming all contribute to condition, which needs careful explanation. Even when flights are confirmed and the deceased is at the airport, delays or strikes or security alerts can conspire to undo all our good work. We all need a little help to look our best at the end of a long journey home, and it’s vital that condition is checked before families and friends pay their respects.

Thousands of families have been bereaved away from home, but no two funeral repatriation arrangements are the same. Tragedy strikes unexpectedly, on ships, on planes, on holidays, on business trips, and communication around what happens next is key. Global funeral assistance combines 360-degree knowledge with experience and empathy, cultural awareness, logistics and people skills. Once families are home, we step away as they move on to the next stage, the funeral arrangements. We don’t expect families to remember exactly what we did, or what we said, but they will always remember how we made them feel when they encountered such a difficult time in their lives. ■ Fiona Greenwood is Operations Director at Rowland Brothers International in the UK, bringing more than 25 years’ emergency assistance experience to funeral repatriation. Fiona directs a multilingual team, working alongside assistance companies worldwide, merging global emergency response with the expertise of an award-winning repatriation provider.

For more on the working relationship between specialist funeral repatriation companies and the wider travel and medical assistance industry, see our feature ‘All things considered’ on p.22.

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Industry Voice

REMOTE ISLAND RETRIEVALS

Aircraft type, fuel reserves and weather conditions are just some of the key challenges when organising patient evacuations from

remote islands. Alastair Lithgow, Fixed Wing Co-ordinator for ER24 shares his fascinating experience and insights

S

aint Helena, along with islands such as Tristan da Cunha and Ascension Island, is considered one of the most remote islands in the world. It is a volcanic island in the South Atlantic Ocean, 1,950 kilometres west of the mouth of the Cunene River between Namibia and Angola in southwestern Africa. Medevac missions to Saint Helena require careful planning and assessment of multiple factors, including weather and winds, prior to departure.

The most useless runway in the world Saint Helena’s runway was completed in 2015, with the airport opening in May 2016. It has since been the subject of intense scrutiny.

A problem of severe wind shear was detected only after the £285m-airport was completed – the airport can, at times, especially during winter, experience crosswinds of over 150 kilometres per hour. The first commercial operator who was approved to begin operations to the island pulled

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out and soon thereafter the airport was labelled

by British media as having the ‘most useless runway in the world’.

There is now, however, a commercial airline flying to Saint Helena twice a week, but there have been several occasions when it had to be cancelled or delayed due to adverse weather conditions. Thus, favourable weather plays a major role in air access to the island.

It was against this background that ER24 Global Assist and their aircraft operators Guardian Air launched its first medevac to Saint Helena in 2016. Ultimately, the mission resulted in the safe transfer of a newborn baby boy with respiratory complications to Mediclinic Panorama in Cape Town, South Africa for further medical care.

To get to Saint Helena, the flight team has a technical stop in Walvis Bay on the Namibian coast. This stop serves more than one purpose:

it is firstly a fuel stop, but also the final checkpoint to determine if the flight is a ‘go’ or ‘no go’ to Saint Helena airport.

It is the last point at which we can check weather conditions at Saint Helena’s much talked-about and vilified airport.

Winter in Saint Helena, although mild, results in extreme wind conditions especially around the airport. The planning process of any mission we fly to Saint Helena and Ascension Islands is in-depth and complex. It relies heavily on weather data compiled by British Weather Services based in Saint Helena.

Unfortunately, not every mission to Saint Helena has gone smoothly. A patient who sustained an intracranial bleed required urgent evacuation, but multiple attempts to land on the island were unsuccessful due to adverse weather conditions. On this particular mission, despite careful planning and weather checks, our crews were unable to land on several attempts over two days. After an unsuccessful attempt to land on the first day, we repositioned to Walvis Bay and attempted to land at Saint Helena the following day. This was again ultimately unsuccessful, and it was only a week later that the weather conditions improved, permitting us to land on the island. The patient was successfully transferred to South Africa.

“ At night, alternate

airports are few and far between ”

Industry Voice Technical considerations Aircraft selection is equally important in such missions, as there are factors such as ETOPS compliance and island holding time to be considered. ETOPS – Extended Twin Operations – measures the performance of the aircraft when operating far from airfields with little or no alternatives, with fuel reserves considerations also needing to be made. In order for a medevac provider to be approved for offering its services on the island, an exhaustive technical and legal review of the provider’s aircraft’s abilities has to be undertaken.

ER24 Global Assist was the third aircraft to land on the island, and one of only two operators in Africa that can legally complete medevac flights to Saint Helena and Ascension Islands.

Medevac operations in Africa can be complex at times: missing NOTAMS (Notice to Airmen), faulty airport equipment, unusual operating hours, difficult-to-obtain clearances, war zones and presidential movements can all complicate operations in the continent at any given time of the day or night. Some of the most complex missions we operate in amidst

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all of these include the African islands, such as Saint Helena and Mauritius.

Operations to Saint Helena or any of the African Islands requires careful planning.

Many of the islands do not have airports that are open 24 hours a day. This complicates

“ The airport can, at

times, especially during winter, experience crosswinds of over 150 kilometres per hour ” planning to destinations such as Mauritius, particularly at night. Mauritius is located almost 2,600km east of Maputo in the Indian Ocean. This also means transit there is often made difficult by tropical cyclones and storms in the Mozambique Channel, particularly during the summer months.

At night, alternate airports are few and far between. This, again, requires a close look at ETOPS considerations, remote area requirements and aircraft selection to ensure sufficient island holding time or the ability to

reach very distant alternate airports. If diverted from Mauritius, the closest island airport is on Reunion, which is most often subject to very similar weather as Mauritius. This risk underscores the potential pitfalls crews are faced with when carrying out the planning for these missions, particularly while trying to launch a medevac mission within a time limit or late at night.

We certainly have experienced these pitfalls and more, but thanks to our experienced crew and operators, we always find solutions to ensure our missions are completed successfully.

Alastair Lithgow has over 25 years’ experience in emergency medical services. Prior to working at ER24, he began in state as a firefighter and ambulance attendant. His background as a paramedic in ICU nursing and as a flight paramedic, as well as in critical care paramedic training and aviation, including accompanying disaster relief teams to Japan and Philippines, has given him a broad base from which to approach many cases.

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Industry Voice

PUTTING ‘PERMANXIETY’ ON THE CORPORATE TRAVEL AGENDA

Chris Knight, Head of Corporate Services for CEGA, opines on a new mental health phenomenon, and the impact that it could have on corporate assistance provision 18 |

I

f global travel intelligence platform Skift is right, ‘permanxiety’ could soon be the world’s new shared social experience; perhaps even the word on every corporate travel manager’s lips.

Skift first came up with the term to describe the high levels of worry felt by today’s travellers, about everything from Trumpism to technology, terrorism to racial tension, culture wars to climate change. After all, 2018 alone saw a number of anxiety-inducing events, with two different tsunamis hitting Central Sulawesi and the coastline around the Sunda Strait, Indonesia, causing multiple casualties and widespread damage; Hurricane Michael wreaking havoc in North and South Carolina, becoming the worst US storm in 50 years; devastating wildfires striking California; a UN report warning that we may have as little as 12 years to combat climate change, or pass the point of no return; and visitors to the Christmas market in Strasbourg falling victim to a random act of terrorism. It’s not surprising that people spend a lot of time feeling worried.

But how, if at all, should it be shaping corporate assistance needs?

Industry Voice

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“ Business travel spend is set

to reach an unprecedented $1.7 trillion by 2022 ” Creating a climate of worry Corporate travel assignments are expected to rise over the next decade – and significantly.

According to the Global Business Travel Association (GBTA), business travel spend is set to reach an unprecedented $1.7 trillion by 2022.

At the same time, business travel is expected to be increasingly synonymous with emerging destinations. The GBTA predicts that India and Indonesia will be the fastest growing markets in the sector over the next five years, with India likely to reach the global top-five by 2022. And a recent report by Travelport and the World Travel and Tourism Council shows business travel spend rising in emerging markets, not least in countries like Azerbaijan, Qatar and Mozambique.

Meanwhile, terrorist attacks in Europe, natural disasters in the US and political changes globally are shifting our perceptions of traditionally safe destinations. All of which means evolving travel worries too.

It’s no surprise, then, that the Association of Corporate Travel Executives reports that a third of travel managers are seeing a rise in enquiries about business traveller safety. Or that, according to the GBTA, over 50 per cent of corporate

travellers now think any destination could be high-risk; almost the same amount is worried about terrorist attacks abroad; and over 20 per cent see North American and Western European countries as only ‘somewhat safe’.

Ten worries in the life of a globally mobile employee: • •

•

•

• • • • •

Is there a risk of infectious diseases or unsafe drinking water?

What if local healthcare isn’t up to scratch and it’s hard to get essential medication for my family?

How likely are natural disasters like earthquakes, hurricanes or floods and will I get any warning?

How will I know how to react to a terrorist attack, and what if my employer can’t find me in its aftermath?

Will getting to hospital be difficult?

What about handling muggings and racially motivated attacks?

How can I avoid cultural no-nos?

My accommodation may get broken into and roads may not be safe.

Credit card or mobile phone cloning and insecure Wi-Fi may put me at risk.

•

I’m not sure if my employer will make me feel prepared.

Great expectations Recent GBTA surveys show that 73 per cent of business travellers expect their company to contact them proactively within two hours of an emergency abroad. They also reveal that almost half (44 per cent) of travellers expect their employers to use tools like GPS to locate them in an emergency.

Meanwhile, we are now seeing business travellers expecting the same seamless access to healthcare and security services the world over, whether they are in a developed country or not. It follows that clients in the corporate travel sector have an increasing hunger for assistance tools that enable them not just to react rapidly to emergencies, but also to support travelling employees before, during and after assignments abroad – and to reduce worries in the process.

The role of assistance partners Reducing a travelling employee’s permanxiety means anticipating and mitigating the risks of every stage of a trip overseas – and that includes the journey. Preparation is crucial, not least via pre-travel medical and security risk assessments, employee training for all eventualities, and education about everything from preventing mosquito bites and road accidents to avoiding cultural gaffes.

Equally essential is constant awareness of real-time health and security risks once an employee is abroad – for example, the likelihood of disease, impending bad weather, >>

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ASSISTANCE & REPATRIATION REVIEW

Industry Voice

or political unrest. And this must come handin-hand with expert medical and security advice and responses.

But delivering these risk mitigation measures is as important as planning them – and that’s where technology plays a vital part.

“ Surveys show that

73 per cent of business travellers expect their company to contact them proactively within two hours of an emergency abroad ” Essential tools According to GSMA Intelligence, there are now more mobile devices in the world than people, and these devices are multiplying a lot faster than we are. But they are also playing an important part in preparing, informing and protecting employees working abroad. All of which translates to reduced worries.

A mobile app can offer access to everything from pre-travel training to real-time medical and security intelligence and alerts. With locationbased monitoring, check-in and tracking tools, it can give employers a birds’ eye view of their global staff and assets in the context of real-time

threats on the ground abroad – so they can find, warn and assist staff quickly, if emergency strikes.

Importantly, an app can also offer employees speedy access to integrated medical and security assistance and remote advice, tailored to specific destinations and needs.

And it’s not just anxious employees who benefit: hand-held risk management tools can reduce the frequency and severity of emergencies overseas too, cutting costs for employers as a result. In this context, it’s clear that traditional global assistance just doesn’t cut it, and the onus is on assistance partners to act proactively – both to protect customers and to reduce anxiety the world over.

“ ‘permanxiety’ describes

the high levels of worry felt by today’s travellers ” What if … ... a travelling employee is worried about a medical problem in a remote and hostile area abroad? The right advice is not available locally and a good hospital could be dangerous to reach, but they need to see a doctor and any delay could turn a routine condition into an emergency. The clock is ticking.

If this individual’s employer can access preplanned and integrated medical and security assistance, real-time travel risks can be assessed quickly. A secure ambulance could soon be taking the employee to a good hospital elsewhere, accompanied by an armed escort.

And he or she would be in the safe hands of a skilled medic.

And if this seamless medical and security support wasn’t available? The employee’s worries could have been well-founded … ■ Chris Knight is head of corporate services, CEGA Group, a Charles Taylor company. In his senior positions in the British Army and security services industry, Chris underwent numerous tactical deployments to Iraq and Afghanistan and specialised in operational planning and intelligence analysis. He also managed medical, security and natural disaster evacuations from complex and challenging environments. Today, in his role at CEGA, Chris focuses on risk management and assistance for corporate travellers in the context of combined medical and security provision.

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IT HAPPENED. Let’s make things better.

Your Medical Assistance partner in the Alpine Region. competent. dedicated. resourceful. helpful.

Emergency Service | + 43 512 / 224 22-100 | taa@taa.at | www.taa.at IAG Core Partner

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Feature

ALL THINGS CONSIDERED Repatriating the remains of travellers and

expatriates who have died abroad calls for close communication between funeral

repatriation specialists and travel and

medical assistance companies. Robin Gauldie looks at how they can best work together

E

ach funeral repatriation case presents different challenges, but effective and timely communication is what makes a traumatic time for loved ones that tiny bit more bearable and makes the organisational process that much smoother. With a number of entities involved in organising and paying for matters related to the repatriation of an insured’s mortal remains when such a death occurs abroad, adequate communication between funeral repatriation specialist, assistance company or underwriter and the family of the deceased is essential to the process, says Fiona Greenwood, Operations Director at Rowland Brothers International, a UK-based international repatriation specialist.

“Everything we do is designed to mesh with emergency assistance protocols and wrap around the family’s needs,” she told ITIJ. “Communication is the essential component.”

In a nutshell, says Deborah Andres of Flying Home, a Singapore-based funeral repatriation specialist, the repatriation company takes over co-ordination from the moment they are awarded the case, including payment to in-country partners and all documentation.

“Assistance companies remain the ‘middle man’ between the families and the insurers, as well as the repatriation company,” she explained.

“However, if the family is present then the repatriation company also communicates processes and progress to the family.” In any case, communication must be ‘clear and without false promises’, she says.

With so many parties with a vested interest in

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making sure funeral cases run smoothly, it’s no wonder that communication plays such a pivotal role. However, specialist funeral repatriation companies and more general travel and medical assistance providers are not the only elements in the repatriation equation. Consular representatives, local authorities, local hospitals and funeral homes are also involved. “Strong relationships are important with everyone professionally involved in the repatriation chain, and a positive relationship with diplomats is no exception,” said Greenwood. “Even if they do not need to issue papers, families appreciate their reassurance. Our outreach and investment in diplomatic relationships in London is designed to help working relationships around the world.”

Liaison with all relevant officials, then, is critical.

“A core set of documents accompanies the deceased out of one jurisdiction into another, but some arrangements are more complicated than others, for example with consular death registration, consular permits, or sealing the coffin,” explained Greenwood. “Attention to detail, the ability to see the bigger picture and an experienced multilingual team can make all the difference.”

Communication between teams, patience and a clear understanding of everyone’s scope is what everything boils down to, says Andres. And good relationships, often built up over time.

“Everything is easier when the local embassy knows you,” added Alberto Simone Pozzoli, CEO of Servizi Funebri Pozzoli Srl in Italy.

“They can guarantee for you, they can make everything easier and faster.”

Going through the process Understanding the processes and considerations that need to be carried out and taken into account by all parties involved in the repatriation of mortal remains (RMR) can help each of those parties to understand how it complements the others.

If an insured dies while on vacation, holiday companies and travel insurers will likely be involved at some point in the process, and for expatriates and other longer-term residents who pass away overseas, different situations may require alternative solutions. “Long-term residents abroad often have a pre-need funeral plan to cover their funeral costs in resort or for repatriation in their home country,” explained Greenwood. “If employees of NGOs or large multinationals are affected, we can be appointed directly by them or by an assistance company working with them, and communication is often intense between all parties.”

With any such RMR case, though, there are specific factors that must be considered. “First and foremost, you’re transporting a deceased person’s remains, so legal requirements come into play and there are key actions that must be handled by a licensed funeral services provider,” said Justin Tysdal, CEO and Co-Founder of

Feature Seven Corners, a US-based travel insurance and specialist benefit management company. “When we get a call that an insured has passed, we first determine the location of the body. Typically, it is in a hospital, and most hospitals already have an established relationship with a funeral services provider.” If a body is at a house or other such location, Tysdal’s company asks the family if they have a preferred funeral service provider. “If not, we do our own research to locate one. Often, the family doesn’t know, because the deceased has passed while travelling.”

“ Attention to detail,

the ability to see the bigger picture and an experienced multilingual team can make all the difference ” In the case of accidental death, the coroner at the location where the person has died would normally retrieve the body from the scene except where ‘heroic measures’ required transportation to a hospital. “The funeral services provider initiates transportation of the body to the funeral

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home, which relies on [us] to relay the family’s wishes to them,” said Tysdal. “Our global assist co-ordinator reviews the benefits with the family in detail and explains what is covered.”

A key question for the family, Tysdal says, is whether they want burial or cremation: “For a burial, the funeral services provider prepares the body appropriately and transports it from the funeral home to the airport and plane. They have special credentials that allow them to do this. Another funeral services provider receives the body at the destination and delivers it to the receiving funeral home. Once the funeral home in the home country receives the body at the airport, we are no longer responsible.” For cremation, Seven Corners pays for the container the body is on before the oven, as well as a container to transport the ashes. “Most family members opt for the basic container covered by the insurance plan,” said Tysdal. “It’s discreet, so they can carry it on their lap or place it in their luggage.”

Religious and cultural preferences must also be taken into consideration at this point – both those of the family and of the locations in which the insured has passed away and to which they are being repatriated. “For example, in many countries, such as Greece and many Arab

“ Strong relationships are

important with everyone professionally involved in the repatriation chain ”

countries, cremation is not allowed,” explained Pozzoli. “In others, it is not possible – Malta, for example, doesn’t have a crematorium yet.

In these cases, we can satisfy the wishes of the family by cremating the body in a nearby country; for example, in Bulgaria for Greece or in Italy for Malta. Otherwise, we have to push the family for cremation in the homeland.”

In mid-March, however, Greece passed a decree that could see the first crematorium built in the country, despite opposition from the Orthodox church – a move that will help ease the burden on over-crowded cemeteries. Greece’s prime minister is behind the reforms, as are a number of key city mayors, including Athens’ mayor, Giorgos Kaminis, the city in which the crematorium will likely be constructed. Thessaloniki’s mayor has also openly supported the building of a crematorium, following his personal experience of having to transport his late wife’s body >>

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ASSISTANCE & REPATRIATION REVIEW across the border to Bulgaria for cremation.

Furthermore, assistance providers and specialist funeral repatriation providers have to accommodate uncommon requests as best they can.

Tysdal recounts a case in which a father asked that his daughter not be embalmed before transportation; he wanted all preparations done in the US due to religious reasons. “Making accommodations like this depends on the country where the body is located and the receiving country,” he explained. “For this case, the US embassy stepped in to make this happen for the family.”

Indeed, one of the most fundamental issues when handling RMR cases is managing the families’ expectations, agrees Andres. “So, when talking to the insurance company or family, an assistance company can confidently say that the repatriation may take up to three weeks.”

Once the assistance company has awarded the repatriation company the case, the repatriation company will take over co-ordination and keep all parties informed of the progress step by step, she explained. “However, having said that, next of kin are usually anxious and demand answers and feel the need to call and check in with the assistance companies. The assistance company should remain calm and confident that the repatriation company is going through the due processes as quickly as it can.”

Delay issues Despite all parties’ best efforts, delays can be unavoidable, however. The location where the death occurred, the destination that the

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Feature

remains will be returned to, the nationality of the deceased if different to the destination, and their religion, says Andres, are all factors that can greatly affect the time taken for a repatriation. All the while, the assistance company is often under pressure to answer questions from relatives and get answers from the repatriation company. “However, on the funeral side, there are many variables to consider,” she told ITIJ. “At times, the replies may seem too slow for the assistance company.”

Determining cause of death can be another complicating factor, with suicide and drug involvement commonly excluding funeral repatriation cover, notes Tysdal. “If a situation arises where the cause of death is questionable, we have to wait for completion of activities, which could include autopsy, investigation, or other requirements,” he said.

“For questionable situations, our claims team reviews appropriate documentation before approving benefit payments. Obtaining a death certificate from the funeral services provider is part of the claims process. It is helpful in determining the cause of death but can take time. We have had cases where we had to wait a month for a death certificate.”

Documentation to accompany the deceased must include a death certificate and obtaining a final or interim death certificate can be time consuming, agrees Greenwood. “Local procedures vary, especially in terms of who can register the death. Our local funeral partner keeps in touch and ensures that arrangements start as soon as the deceased can be released.”

In terms of varying local procedures, depending on the location where the death occurred, there may not be a consulate or embassy nearby, so documentation needs to be couriered to the nearest embassy, explains Andres. “Embassy hours vary depending on the country they represent, so it may take two or three days for them to process the documents then courier them back to the funeral home, after which the documents need to go to the ministry of foreign affairs to get their approval.”

In some countries, cultural variations around working norms can cause delays too. “For example, if a death occurs in Spain on a Friday, where – unlike us in Singapore – not all companies work 24/7 and government agencies are closed over the weekend, documentation will be delayed, even though the funeral repatriation company has no issue with doing its part,” said Andres. Once the documentation is received, it may need to be translated, which may take another two to three days; and only when all documents have been approved and translated can flight arrangements be made. Some commercial carriers will only take a casket if their flight is not full, she adds.

Other documents accompanying the deceased must also include a freedom from infection certificate, and epidemic outbreaks can present further obstacles to the repatriation process.

During the 2013-16 Ebola outbreak, coffin repatriation out of affected countries was prohibited and only cremated remains could be

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“ Timely payment to the funeral repatriation company is always appreciated ”

repatriated abroad, Greenwood notes.

Finding a common language in which to communicate can also be an issue, even in the developed world, says Pozzoli: “It often happens that the staff of local funeral homes may be really professional, but they don’t speak English or any other well-known language. It can happen not only in remote areas, but in developed countries like Germany, Russia or Italy. We have multilingual staff, but problems can come when local funeral homes must deal with the family of the deceased on the spot.”

Unexpected costs While the cost of repatriation includes normal transportation of the deceased from place of death to funeral home and then to the airport, as well as embalming, dressing, basic casket,

packing, documentation and administration fees, extra costs may include shipping of personal effects, a local autopsy and additional storage fees if required, religious rites, passenger tickets, additional legalised copies of death certificate, translations, upgrading the casket model, and, if the deceased has dual nationality, additional documentation or payments may be required.

Such additional requests are subject to approval by the assistance and/or insurance company, says Andres.

Unforeseen additional processes and costs can be a headache for funeral repatriation companies, she notes: “If a death occurs in a remote area, the timeframe for the repatriation will be greater, as will the charges involved, as usually one needs to engage a private mode of transportation from that area to the nearest major city. If death occurs in a

Muslim or Jewish state, the deceased may need to be transported to another city for embalming for repatriation on a commercial carrier. If cremation is requested, we may need to transport to the closest city that allows cremation.”

These additional transportations incur extra costs, which usually require authorisation from the assistance or insurance company. “The funeral repatriation company is constantly making payments on behalf of the assistance company or family,” explained Andres. “In return, timely payment to the funeral repatriation company is always appreciated. Sometimes, in the past, we have had to wait almost six months to a year for repayment.”

Setting financial expectations is as important for the assistance company as it is for the family, especially if cover is limited or could be declined, says Greenwood: “Some details are known when we are instructed; others only become apparent when we start work. For example, the precise location of the deceased, cause of death, details of personal effects, storage charges, and larger-thanaverage deceased requiring a larger-than-average coffin. All these can affect cost, but regular communication ensures smooth repatriation.”

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ASSISTANCE & REPATRIATION REVIEW

Case Study

MIAMI, FLORIDA PATIENT DROP-OFF PANAMA CITY, PANAMA PATIENT PICK-UP

ey rn jou t n e Pati

LIFE-SAVING FIRSTS IN PANAMA Robert L. Quigley MD, D.Phil. at International SOS tells how the first on-site implantation of a

ventricular assist device by an international team facilitated a repatriation from Panama to the US Background To date, experiencing an acute coronary event in an emerging market environment can be a death sentence, particularly if the event is complicated by cardiogenic shock. Many remote hospitals do not have adequate resources to support such a compromised patient. Ideally, International SOS Assistance (Intl SOS) would manage an acute coronary syndrome locally by one of its credentialed local providers (identified in its Global Assistance Network, GAN, database), but in some circumstances, where the medical care needs to be upgraded, the patient will require movement – as was indicated in this case. Extrapolating from the domestic hub-andspoke model presently utilised between academic tertiary care facilities and community hospitals, we outline in this report the creation of such an ad hoc arrangement between Panama (spoke) and South Florida (hub).

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Conventional treatment options for refractory cardiogenic shock focus primarily on medical management, with more severe cases requiring implantation of a ventricular assist device (VAD). A VAD is an invasive mechanical circulatory device used to support a failing heart.

Due to resource allocation, and/or economic constraints, these specialised interventions have traditionally been offered exclusively at tertiary care facilities, limiting the scope of care that can be delivered at remote or community hospitals where patients invariably present. Most of the VADs available today remain somewhat bulky with complex intra/extracorporeal components. The HeartMate II, although tested and approved for air transport and 60-percent smaller than currently approved LVADs (which support the left side of the heart), still requires a thoracotomy for implantation. On the other hand, the Impella 2.5 LVAD, known

to significantly reduce morbidity and mortality, is a viable option for remote centres with limited cardiac resources, as it is implanted percutaneously (via needle-puncture of the skin).

We transported a team of cardiovascular experts from Florida to Panama, in tandem air ambulances (to limit mandatory crew rest time), to implant an LVAD in a patient in cardiogenic shock refractory to mechanical/pharmacologic support. The low-profile Impella 2.5, inserted percutaneously by the American team, stabilised the American patient, enabling his air ambulance transport back to South Florida.

This case is notable because it demonstrates the successful organisational framework of an ad-hoc hub-and-spoke, the first use of the Impella for the purposes of international air transport, and the first implantation of the device by an American cardiovascular team in a facility outside of the US. Here, we outline the challenges and logistics involved in the planning, resuscitation, and air ambulance repatriation of the patient.

Case report The patient was a 42-year-old American citizen on assignment in Panama. Following his routine daily workout on the treadmill, he presented to an ER in Panama with severe retrosternal angina and diaphoresis. Following the ACC

Case Study

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“ Less invasive LVADs are

valuable to the spoke-andhub model for delivery of specialised cardiac care, where necessary, even in the international arena ” STEMI protocol, he was rushed urgently to the cardiac catheterisation suite where angiography revealed a 100-per-cent proximal left anterior descending artery occlusion and otherwise normal coronaries. He underwent balloon angioplasty and deployment of a stent. Within minutes of reperfusion, his vital signs began to deteriorate.

Despite the use of inotropic agents (norepinephrine) and anti-arrhythmics (amiodarone), and an intra-aortic balloon pump (IABP) in place, the patient continued to experience signs/symptoms of cardiogenic shock. The patient subsequently developed severe respiratory distress requiring intubation and mechanical ventilation. Echo-cardiography

revealed an ejection fraction of approximately 20 per cent with global left ventricular dysfunction.

Within two hours of his admission to the Panamanian hospital, Intl SOS was contacted, by a third party, to facilitate repatriation to the US to a tertiary heart centre to further upgrade his care. Due to his critical status and requirement for maximal support (pharmacologic/mechanical), it was evident after discussion with the treating medical officer that he was not fit to fly.

Unfortunately for the patient, local resources had been exhausted and he was not likely to survive as he was developing multi-system organ failure. His only chance of survival was access to an LVAD. LVADs were not available on site.

Leveraging our relationship with an established cardiac transplant centre in South Florida, we mobilised a team of cardiovascular specialists (interventional cardiologist, perfusionist, nurse, and respiratory therapist) within two hours of the first call in an air ambulance. Similarly, with the hospital in Panama – since they were also a credentialed provider in our GAN database and familiar with Intl. SOS policies and procedures – we were able to secure temporary operating privileges for the American team. Due to the fact that time was of the essence and we could not wait for the standard crew rest period (FAA guideline) on arrival, we deployed a second air ambulance to land in Panama just as the LVAD was implanted.

Co-ordination of ground ambulances on both sides of the journey was part of our existing protocol. The IABP was removed and the battery powered LVAD supported the patient’s haemodynamics to include partial weaning of the norepinephrine drip. The return air ambulance mission was uneventful from a haemodynamic standpoint. The patient was kept sedated and paralysed for the repatriation.

Conclusion The patient arrived in the Coronary Care Unit in South Florida where he remained for several weeks. Although he subsequently experienced some moderate renal failure, he was ultimately weaned from the norepinephrine, started on dolbutamine, and had the LVAD removed within the first week.

He was extubated and finally discharged from the hospital after 30 days.

Although this case was carried out in 2014, no further cases of this type have since arisen for Intl SOS, most likely due to the fact that mechanical assist devices are becoming more ubiquitous as bridges to cardiac transplantation, which is now more commonly performed at regional centres of medical excellence. By providing an economical and technically straight forward alternative to multiple organ system failure and death, however, this case demonstrates that less invasive LVADs are valuable to the spoke-and-hub model for delivery of specialised cardiac care, where necessary, even in the international arena. ■ Robert L. Quigley, MD, D.Phil Professor of Surgery is Regional Medical Director and Senior Vice-President of Medical Assistance, Americas Region for International SOS Assistance.

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ASSISTANCE & REPATRIATION REVIEW

Industry Voice

CHINA: THE CHALLENGES OF OVERCOMING LANGUAGE AND CULTURAL BARRIERS IN MEDICAL ASSISTANCE The remarkable progression of the Asian market has seen

Chinese tourists and businesses becoming ever-more active across the globe. With the resultant growth in the need for local

assistance services, Executive Officer of Emergency Assistance

the first that comes to mind is medical translation, where sensitivities can be triggered if the bridge between languages is not forged correctly. There are two main points to consider in this regard – the use of translators and the issue of trust:

�

Translators

�

A question of trust

Japan (EAJ) Takaaki Chiyo looks at the challenges of language

barriers in his line of work and explains how these obstacles can be overcome

O

ver eight million Chinese people travelled to Japan in 2018, which is an increase of over one million from the previous year, and for this year’s Lunar Chinese New Year period alone, about seven million Chinese citizens are estimated to have travelled somewhere abroad. Japanese businesses have been trying their best to prepare for this significant market: for instance, one of the most recognised ski resorts in Northern Japan has started providing ski lessons with Chinese-speaking instructors in an attempt to match the recent Chinese market shift from consuming tangible products to seeking cultural experiences.¹

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Japan, despite being a neighbouring country of China, is certainly no exception to those countries being overwhelmed by the impact of language barriers and cultural differences when meeting and dealing with Chinese clients and travellers. That other parts of the world struggle even more comes as no surprise, and the fact that assistance companies in these countries are in need of strategic approaches to handling cases involving Chinese patients – or dealing with Chinese hospitals treating foreign patients – is clear.

Medical translation When considering the areas of medical assistance most affected by the language barrier,

Failure to dispatch translators with the appropriate language skills can lead to a badly communicated diagnosis, whereby information is not relayed accurately, causing unnecessary upset for patients and their families. For example, there was a case in Japan some years ago in which a Nepalese boy was diagnosed with a brain tumour and had only three months to live. The translator did not understand the word for ‘life expectancy’ in Japanese and gave the parents a contradicting diagnosis: that the boy would be fine. The article noted that it was immediately apparent that there was miscommunication, as the parents continued to smile after being told the diagnosis. The hospital hired another translator and after an eight-hour word-forword translation of the medical diagnosis, the parents were told the true outcome and were able to properly comprehend the situation. The risks of miscommunication in medical translation can also lead to numerous other issues, from medical mistreatment to an inability to collect payment for outstanding bills.

Our Chinese-Japanese translator in Shanghai (who is from Japan) revealed some of his experiences of medical translation in China – describing difficulties in communicating specifically with Chinese patients. First, he said, before the medical translation even starts, one must gain a patient’s trust, as, generally speaking, it can be hard for some Chinese people to trust someone they have only

Industry Voice just met. The translator’s experience of China is that people tend to trust their acquaintances more than others and, surprisingly, information from the internet is regarded as more trustworthy than that received from an unknown person – doctor or not. However, when these patients are influenced by word of mouth and the internet, it can lead to misinformed expectations of the medical service, which later results in complaints; although this is applicable to any nationality.

This trust issue lies not only with the patients but also with the medical providers. In some difficult cases, our translator has had experience of some medical providers in China who assumed that medical translators would not be able

“ Growth in the

privatisation of hospitals has been escalated by a fast-growing wealthy population ”

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to fully understand the medical terms and, as a result, the informed consent process ended up being insufficient and, yet again, resulted in problems for the patients. The key, then, is to ensure effective communication.

Communicating effectively Based on our experience, the following strategic approaches should be implemented to ensure the best possible avenue of communication in assistance cases: • Always provide an opportunity to communicate with the patient and the medical provider at the earliest possible opportunity in order to manage all parties’ expectations. More specifically, ask the patient or doctor to kindly speak more slowly, if necessary, to let the translator catch up in order to provide a highquality translation.

• Utilise supplemental written information with both patients and medical providers.

This will avoid misunderstandings and confirm whether there is any content that has been missed out.

“ Information from the

internet is regarded as more trustworthy than that received from an unknown person – doctor or not ”

Infrastructure When looking at the impact of different expectations among different cultures, a key consideration for the assistance industry is medical infrastructure. When it comes to China, there are three things to consider in this regard: medical service and hospitality, fees for the medical service and cleanliness.

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Medical provider classification As many are aware, there is a classification system for medical providers and facilities in China – for the medical facilities, this is a combination of the three-tier system and the subsidiary three grades, which results in a total of nine levels; and for the providers, there are three grades of title after the associate. These classifications apply >>

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Our customer base includes insurance agencies, assistance services, government agencies and funeral directors.

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Languages spoken include English, Spanish, French, Dutch and Arabic.

Besides repatriations, we organise local burial and incineration as well as international transportation of the ashes. Our is a one-stop service – from obtaining the required documentation and permits, flights reservation and translation of documents to religious rituals and collecting and shipping personal effects.

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SFS_ITIJ214.indd 1

17/10/2018 11:53

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within the building to help the patient with anything they need, including taking care of the registration documents and caring for their personal needs. Since private hospitals cannot always secure the most experienced doctors as public hospitals are able to, some doctors from public hospitals with higherranking titles occasionally work at private hospitals too.

Having said this, the characteristics described above can apply to both private and public facilities depending on the area the facility is in and its specific circumstances – so it is actually quite difficult to generalise.

to both public and private hospitals, so the factors we are discussing below should be seen as supplemental information for the classification of each provider and facility.

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Fees Growth in the privatisation of hospitals has been escalated by a fast-growing wealthy population. Like in many other countries, the largest difference between public and private medical providers is the fee structure – in China, private hospitals charge a much higher fee, which can be up to 10 times more than that of public fees. The difference in the fee structure is mostly reflected in the level of hospitality service provided and not so much in the medical service. While public hospitals mostly provide a wide variety of medical services, which are considered of a much higher level than those available in the private sector, private hospitals mostly specialise in a specific medical area and distinguish themselves by providing luxurious hotellike suite rooms for the patient and their family to stay in. Also, they often come with escorts located in multiple locations

Industry Voice

�

Cleanliness Cleanliness in medical facilities is a fundamental requirement and is one of the determining factors when it comes to choosing a medical provider in any culture.

Private hospitals in China are mostly spotless, while in public hospitals you might occasionally witness a stained floor or walls with some cracks in the exterior of an old building – although nothing too critical. A Japanese dentist who has worked in China

References 1 – Nikkei. (3rd February 2019) 春節商戦「コト消費」に工夫. Online at: http://eaj-garoon. emergency-assistance.co.jp/cgi-bin/cbgrn/grn.cgi/message/view?cid=22219&rid=833448&mid=239 253&follow_id=698#follow (Accessed on 25th February 2019) 2 - Yamaoka, J (17th January 2019) 余命3カ月」を友人が誤訳…日本医療の外国人患者対応に 壁.AERA.dot. Online at: https://dot.asahi.com/aera/2019011600021.html?page=1 (Accessed on 25th February 2019)

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for a while told us that the regulation for sanitation is very strict in China. Their acute awareness of sanitation and care can be seen in the tools they use – such as dental drills that are almost always disposable.

Conclusion As the global economy and political situation changes rapidly, the importance of having local guidance to help navigate processes in a foreign country cannot be over-estimated. We, as a medical assistance company, can only arrange for medical services according to the patient’s needs, but it is important to be aware of the different options and what each one involves.

At EAJ, we have created a variety of checklists for assessing medical providers in different structures and according to their areas of medical provision. These allow us to maintain our own standards by using quality medical facilities all around the world, despite their various differences. ■ Takaaki Chiyo, the executive officer of EAJ, has been involved in the industry since the establishment of the company, gaining in-depth knowledge and management strategies of the operation and the networks for inbound and outbound medical assistance. Having lived in the US, China, Singapore and Vietnam for over a decade, he also takes a role as a president of EAJ China to serve the dynamic market with rapid advancement of digitisation

ASSISTANCE & REPATRIATION REVIEW

Feature

GAINING GROUND

The repatriation of a patient is a complex process that involves decisions by many different parties in the assistance chain.

While we often talk about the air ambulance sector within ITIJ as part of this process, Mandy Langfield explores its groundbased counterpart, the road ambulance

N

ot all terrains and geographies lend themselves well to ground repatriation services, but others are remarkably well adapted. Where road networks are of a good quality, the ground ambulances that use them are basically rolling intensive care units, and the care provided by the medical personnel onboard is the same as you would expect in an air ambulance. Across the world, ground ambulances are commonly used to repatriate people or move patients between medical facilities, where this is a logistically feasible and cost-effective transport option.

ITIJ spoke to Jane Hegeler of Tangiers 32 |

International about how the company views ground ambulance transports differently in various parts of the world: “There are areas in the Middle East and Africa where flying restrictions, or no fly zones, may result in ground transfers.

When air travel is contraindicated by our medical team, but the patient needs to seek treatment at a higher level of care facility, we would opt to use ground transportation.

Every case is different, and decisions are made depending on individual circumstances and the origin and final destination. For example, there are some cases in remote areas that do not have a nearby operating air field, where we are left with

no choice but to move patients by ground to a destination where they can continue by air.”

The decision on whether or not to use a ground ambulance, she said, are both medical and logistical – primarily, it is the medical condition and security aspects of the case that are considered first, and then logistics are worked out on that basis.

For US-based Gateway EMS, the last few years have seen an increase in the number of insurance and assistance companies seeking its services. Oliver Muller, CEO, said: “We have seen a consistent growth for over seven years now in volume.

“ The ground ambulances that use road networks are basically rolling intensive care units ” While we would like to think that a big part of this is due to our excellent customer service, we are also realistic and aware that the economy has been going up sharply in the last [few] years, leading to more business and leisure travellers.

In turn, there is a higher percentage of possible travellers falling ill or injuring themselves.” The current economic climate means he is cautious about the future, though: “At the same time, we are watching the economy closely as there is prediction for a

Feature slowdown in 2019 which will likely lead to fewer travellers and we need to prepare for this as well.” In certain seasons, there is a spike in the number of insured clients being moved by road ambulance, according to experts who contributed to this article. Muller explained that seasonal holidays have a significant impact on patient volume, and on the type of injuries for which these patients need care: “Whether it is the snowbirds going to Florida, the Caribbean or other islands, or skiers from all over the world going to the Rockies or Canada, the type of illnesses or injuries we see is very cyclical.”

Christoph Ullrich, Senior Manager of International Network for ADAC Ambulance Service in Germany, pointed out that the sheer size of his company (20 million members and counting) means that there is a less noticeable shift in terms of assistance cases in different seasons, but that the locations to which the company is called certainly correspond to tourist activity. “Of course,” he explained, “Switzerland, Austria, the French Alps and northern Italy contribute the main volume in winter season, whereas in spring/summer southern France, Italy, Croatia, and so forth, are the main countries.”

Christian Nagiller of Austria-based MediCar confirmed that for his company, 90 per cent of all transports performed during the winter season are from ski resorts in France,

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“ If the patient is not

stable enough to survive a transport, then the mission is declined – this rare occurrence happens around three to five times a year ”

Switzerland, Austria and Italy, with the main injuries being fractures of the lower leg and ruptured ligaments. He added: “During the summer season (from June to the end of September), it changes completely; the pick-up places move to the south of Europe, especially Italy, Croatia, Spain, France and Austria, and the problems are more serious like stroke, heart attack and other internal problems.”

Those providing such services in Europe may not have the same logistical – or security – concerns as those in other areas. As Hegeler of Tangiers International told ITIJ, when it comes to using a ground ambulance in a highrisk area or war zone, risk mitigation measures have to be taken to ensure the safety of the crew and patient. She explained: “We always

try to use an experienced ambulance company in the area where the transport is taking place and use the support of our own network of field agents on the ground that can assist with additional logistics, as well as the services of armed escorts and security where necessary.”

Going the distance There are pockets of the world where ground ambulance services aren’t practical – for instance, in areas where the roads are in a particularly poor state of repair and a bumpy journey wouldn’t help a patient with severe injuries. The decision to repatriate a patient by road has to take into account the distance travelled as well as the local topography. Ullrich told ITIJ: “Usually, we travel a maximum distance of between 800 km and 1,000 km, always depending on the geography, infrastructure and the condition of the patient. For instance, covering 400 km in southeast Europe is definitely more challenging than travelling 700 km within central Europe.”

Muller said that although the company doesn’t keep data on the maximum distance it has ever transferred a patient, he said that long-distance transfers are undertaken ‘as long as it is safe for the patient from a medical perspective and safe for the ambulance crews from the perspective of duty times’. “Some of the transfers,” he said, “can be up to 10 or 12 hours, and have several crew members involved or overnights before getting to the patient.” There is no ‘typical’ condition of patients, with critical care transfers being common for patients suffering an injury after a car accident, or cardiac or even cerebral issues.

Nagiller has noticed that, over the past few years, he is being asked by clients to perform more and more long-distance transfers, as well as trips from islands such as Mallorca,

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ASSISTANCE & REPATRIATION REVIEW Ibiza and Elba. “In our opinion,” he told ITIJ, “it is better for the patients to bring them back home by ground ambulance with a doctor escort if the distance is not too big.”

The maximum distance he has transported a patient is around 3,000 km, which certainly underlines the fact that a flight is not always necessary across Europe.

While not all patients are fit to be transported by ground ambulance, according to Muller, almost every patient that can be flown by air ambulance can also be transported via road. When it comes to critically ill patients, according to Nagiller of Medi-Car, a high number of his patients are intubated and ventilated. “Usually,” he told ITIJ, “there are two different kinds of ICU transport – patients who had a car/bike accident, so most of them have a polytrauma; and patients who have internal problems.”

“ In the US, there has been a real increase in the number of patients being driven, rather than flown, home ” Declination Inevitably, it is impossible to transport all patients by ground ambulance transportation. Ullrich said that for ADAC, this occurs ‘only if the patient’s condition is not stable enough, or there is no proper insurance coverage and the patient, or their family, won’t cover the cost of the transport’.

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Feature

Mueller at Gateway EMS explained: “As the provider that organises the ambulances on behalf of the air ambulance or assistance companies, we ourselves do not decline.

We provide the medical information to our preferred and vetted ambulance providers who will then make an assessment if it is safe to transfer a patient via ground ambulance.

It is very rare for an ambulance company to decline a patient, especially if for example the air ambulance medical crew is going bedside.

When transfers are declined it may be due (but not limited) to factors such as distance.

For instance, maintaining a vented patient via ground should only be done for a certain period of time, or for psychiatric patients where the safety of the medical crew may be in question.”

Medi-Car’s leading doctor assesses every case the company is tasked with, and if the patient is not stable enough to survive a transport, then the mission is declined. Nagiller told ITIJ that although this isn’t a frequent occurrence, it happens around three to five times a year.

“ 90 per cent of all transports performed during the winter season are from ski resorts in France, Switzerland, Austria and Italy ” Sustained growth?

Most of the companies ITIJ spoke to for this feature reported a general increase in enquiries from insurance companies about ground ambulance transportation for their clients – some significant, others less so; it seems there is a geographical divide. In Europe, demand for such services has been strong for some time and remains consistent. In the US, there has been a real increase in the number of patients being driven, rather than flown, home. For Tangiers International, Hegeler reported that less than 15 per cent of repatriations are completed by ground ambulance, and this has been the same for some time, as the company has always worked in areas of conflict and transfer by air is a more typical option in such regions.

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Industry Voice

EMERGENCY BREXIT •

Sam Tester, Operations Manager at

Homeland International, ponders how Brexit could impact the funeral and repatriation sector

T

here is so much uncertainty regarding Brexit, and we must ensure that we are ready to face whatever outcome prevails. In the absence of an established consensus in the UK Parliament at the time of writing, we are under the assumption that on 22 May 2019, the UK will be withdrawing its membership from the European Union. It is impossible at this stage to predict the likely impact that this will have, as it will depend on the outcome of the UK Government’s response and approach going forward.

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Known knowns and known unknowns In the event of a no-deal Brexit, we believe that the UK funeral and repatriation sector could face certain challenges in the immediate period following the withdrawal, specifically in three areas, which may affect mortal remains repatriation (RMR) services to and from the UK. These are as follows: • We can feasibly expect to see an increase in the processing time between the date of death and the repatriation date. One reason for this is due to there likely being

•

increased pressure on healthcare providers as well as the authorities in the UK. The necessary paperwork may take longer to collate, and if coroners’ investigations are required, this will extend the time for repatriation further than usual.

Another problem may be a temporary rise in flight costs, as there is likely to be an increase in fuel charges and limited availability through organisations opting to send freight in bulk. This could delay timings for repatriations as flights may need to be booked at later dates. Queues and processing times at airports could also cause issues for repatriation timescales.

Thirdly, there is likely to be more complex repatriation paperwork/clearance processes. There may be a requirement for additional documentation to allow repatriation to and from different jurisdictions (potentially including EU member states). The destination country is likely to require further documentation too for its own import procedures. This could complicate repatriation cases temporarily, as people try to learn, adopt or implement any new procedures. >>

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info@commercialmedicalescorts.com +1(561)451-8063

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Industry Voice

“ Strengthening and retaining key

relationships with stakeholders in the EU is something that every organisation must start doing in order to be prepared ”

Ensuring continuity As an organisation, we have put in place contingency plans to ensure that we are able to mitigate the effects of an increased timeline and are working with our provider network to ensure their awareness of potential issues, as we’re sure all other similar companies are. We will, of course, continue to monitor developments carefully, as the situation continues to evolve.

Please note that this is applicable only in the case of repatriations to or from the UK. For the assistance sector as a whole, we would expect the biggest problems may be financial – especially for those with fluctuating currencies; as well as those relating to paperwork and legal complications. Organisations may opt to move holdings to countries within the EU; we have seen this already in the UK with firms moving to Ireland to operate, for example. On the other hand, if the business environment does not become too demanding in the UK, firms are likely to stay in London due to their locational advantages and close proximity to many underwriters.

“ To be responsive and adaptive to change is a fundamental part of delivering consistent high-quality services to customers ” Strengthening and retaining key relationships with stakeholders in the EU is something that every organisation must start doing in order to be prepared following March 2019.

The better a relationship is, the easier it is to overcome challenges together. With every good relationship comes great trust – if you can build trust with your stakeholders, you have 38 |

an opportunity to fix things quickly. There may be changes to your processes in the short term following Brexit, which may be difficult and could hinder your operational standards temporarily. If you have trusting stakeholders they will understand this is only a short-term issue. If you have no relationships or trust with these stakeholders, they may cut ties with you and your organisation. They may have less of an understanding of the issues you are facing and may not believe you will be able to adjust.

“ We can feasibly expect

to see an increase in the processing time between the date of death and the repatriation date ” Agility is key To be responsive and adaptive to change is a fundamental part of delivering consistent, high-quality services to customers. This goes without saying for every business regarding the way they should operate on a daily basis.

With Brexit and the businesses it may affect,

it is even more important to be responsive to change. Accepting the alterations and dealing with them is highly important if you want to be consistent in quality; if you fail to adapt to these changes quickly then it could be difficult to retain customers and to preserve your operational quality as an organisation. Much of the aftermath to date has been something of a guessing game, but as more information comes to light, it is crucial to act upon it.

A good place to start is by implementing contingency plans, which are an excellent way to prepare for adapting quickly.

Much of this focuses on UK business but, of course, in this international sector there are organisations within the EU that rely heavily on UK business. Our advice on this point from the experience of some of our own providers in the EU is to communicate now.

Start the conversation with UK stakeholders and work together on planning for business post-Brexit. It is likely that the changes will in some way affect the way you operate, so a solution will be needed when the time comes.

It is easy to think that Brexit will not affect your business model, but it can be damaging if you have no plans in place for all that could occur following Brexit. It is worth setting aside time to pre-plan for as many of the eventualities as you can – after all, calculating and managing risk is what many of you do every day! ■ Sam Tester is the Operations Manager for Homeland International, in the UK, a specialist provider of international repatriation services to funeral directors, private families and corporate clients.

The mission of AIMS is to become the premier provider of medical management and assistance within South Africa and neighboring countries We are committed to ensuring our clients that Humanity, Dignity and Respect is maintained at all times. AIMS provides an excellent needs-led service oering the most appropriate medical care and attention to the foreigner in crisis.

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ALLIANCE INTERNATIONAL MEDICAL SERVICES T: + 27 11 783 0135 | 24hr: + 27 83 228 7806 | F: + 27 11 783 2950 operations@aims.org.za | http://www.aims.org.za/ AIMS House | 3 West St | Bryanston | Sandton | Johannesburg | 2191 | South Africa

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Case Study

CAIRO AIRCRAFT CHANGE

BEIRUT PATIENT DROP-OFF

SANA’A

SANA’A

ASWAN TECHNICAL STOP

PATIENT PICK-UP

PATIENT PICK-UP

DJIBOUTI NIGHT STOP

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NAIROBI START POINT

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CARDIAC ARREST OVER THE EGYPTIAN DESERT Dr Joseph Lelo of AMREF Flying Doctors, a dedicated air ambulance company based in Nairobi, Kenya, describes the challenging medevac of a seriously ill man from Yemen to Beirut, fraught with logistical and clinical challenges

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ro poff

DJIBOUTI FUEL STOP

Background

The request

Yemen has been locked in a civil war since 2014 that has led to millions of people being displaced. The collapse of the country’s health system caused the world’s largest outbreak of cholera, killing thousands and further complicating the war and famine.

Flying into conflict areas is a challenge, organising an air ambulance mission from a conflict zone even more so – meticulous planning, adequate risk assessment with up-to-date situational reports and reliable communication is required.

In this particular case, issues to do with a lack of acceptance of the patient and his accompanying person affected the time to dispatch and brought about a change in final destination country.

In January, we received a priority request to urgently evacuate a male Yemeni in need of advanced tertiary care from Sana’a in Yemen to Cairo, Egypt. The initial medical report gave details of a patient with a chronic heart condition that had deteriorated, requiring advanced intensive care. Being a Yemeni national, the patient and the accompanying passenger required a pre-authorised visa in order to be allowed into Egypt.

AMREF’s medical and operations department immediately began mobilisation, with the medical team getting in touch with the treating physicians for medical updates, and the operations team planning the flight routing and applying for security clearance into the Saudi-controlled Yemeni airspace.

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Operational challenges Flight approvals into Yemen give you just a small timeframe (a number of hours) within which an aircraft operator must get in and out of the airspace. However, after 24 hours, the client reverted with the news that they could not get visas for the patient and his accompanying person to enter Egypt. This meant the original flight plan had to be cancelled while the team involved in caring for the patient sought another destination where the patient would be accepted. A few more hours elapsed before a hospital in Beirut was settled upon. Lebanese authorities agreed to take in the Yemeni patient and his accompanying relative. A new flight plan was filed; however, the initial airframe (a Cessna Citation Bravo jet) identified for the mission was already tasked for a different flight, leaving the option of a turboprop Beechcraft King Air 200.

Using this new aircraft meant that the crew would run out of their duty time, since the aircraft would launch from Nairobi. This meant that for the flight to be performed as quickly as possible, a partner based in Cairo would perform the last leg of the flight in a faster aircraft.

The plan After careful planning with the involvement of the client, treating doctor, receiving facility and our medical and flight crew, the operation plan was agreed upon. We would launch the air ambulance from Nairobi, pick the patient up in Yemen and transfer to a partner aircraft in Cairo for onward movement to Beirut.

Case Study Routing The flight routing from Sana’a to Cairo had to proceed in an indirect way due to restrictions on flights from Yemen flying through Saudi airspace.

This had the impact of increasing the flight duration and thereby the crew duty time for the mission. It was therefore necessary to have the patient and medical crew change in Cairo onto a faster jet to complete the patient transfer to Beirut.

“ Flying into conflict areas is a challenge, organising an air ambulance mission from a conflict zone even more so ” The flight The Beechcraft King Air aircraft, with two pilots and a medical crew consisting of an intensivist and flight nurse, departed Nairobi in the afternoon for Djibouti, where they arrived in the early evening for a night stop. The next day, after confirmation of a window to approach, land and take-off from Yemen, the flight departed for the one-and-a-halfhour sector to Sana’a. Ground time in Sana’a was restricted and the handover fortunately proceeded quickly; and the aircraft was refueled and ready for departure with the patient in less than one and a half hours.

The flight back to Djibouti was uneventful, refuelling was carried out, and the next leg – which would take four hours – to Aswan for a technical stop commenced smoothly. During this leg, the patient was closely monitored. Three hours into

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the flight, the patient developed acute ventricular fibrillation and became unresponsive, which necessitated CPR and defibrillation. Fortunately, as part of our protocol for patients with such a chronic heart condition, defibrillator pads had been placed on the patient at the start of the mission and guaranteed a quick response.

Epinephrine was also administered and after just one cycle of CPR, the heart’s rhythm converted to a fast sinus rhythm and the pulse became palpable.

The patient regained consciousness a few minutes later. The medical crew reviewed the possible causes of the cardiac arrest and consulted with the pilots on options for a diversion. As they were only one hour from their planned destination, it was decided to proceed and review the patient’s condition on arrival in Aswan.

On the stopover at Aswan, the patient was fully conscious and wanted to walk out of the plane but was obviously convinced by the medical team not to do so. Less than an hour was spent in Aswan and the flight took off and proceeded north for Cairo. Tests run on the patient included blood sugar checks and blood gas analysis – all were within normal range. The patient was placed on continuous 12-lead ECG monitoring, five-minute interval blood pressure recording and kept on oxygen via nasal prongs. The client (the patient’s employer) was appraised of the situation and advised of the decision to proceed onward to the planned destination. The patient, now conscious and orientated, and his accompanying relative, were also fully briefed and counselled by the medical team on what had happened and the possible causes and complications expected from his condition.

“ Three hours into the flight, the patient developed acute ventricular fibrillation and became unresponsive ” The control room in Nairobi contacted the receiving facility in Beirut and updated them on the clinical situation and estimated arrival time at the Beirut-Rafic Hariri International Airport.

In Cairo, the partner jet was waiting on the apron to take over the last one-hour leg of the flight to Beirut. With the aircraft parked side-by-side on the apron, the medical crew stretchered the patient off the Beechcraft King Air and onto the Citation Sovereign jet. With a new flight crew, but the same medical crew, the flight to Beirut proceeded without further complications.

The receiving team in Beirut was well prepared and waiting when the jet landed. The handover was smooth yet detailed, and the patient proceeded in a stable condition for intervention and care at a hospital in Beirut.

“ The patient and the accompanying passenger required a pre-authorised visa in order to be allowed into Egypt ” The AMREF Flying Doctors crew flew back to Cairo for a well-deserved rest. It arrived back in Nairobi a day later, happy to have delivered the patient safely to advanced care despite the challenges with the circuitous routing and the patient’s medical condition. This mission was particularly challenging as it involved pick-up in a conflict area with security restrictions and a wing-to-wing transfer with the first aircraft being a turboprop. With AMREF Flying Doctors now having acquired two of its own dedicated medevac jets (Citation Bravo and XLS), such flights can now be carried out with the same medical team and aircrew within a day.

Dr Joseph Lelo is the Chief Medical Officer at AMREF Flying Doctors, specialised in anaesthesiology and critical care, with an interest in retrieval and aviation medicine. As well as providing direct medical supervision to the team at AMREF Flying Doctors, Dr Lelo has also performed hundreds of primary and secondary retrieval medevac flights and international repatriations as the physician on board.

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Profile

ITIJ caught up with Carlos Hernandez, Operations Manager at Tangiers International, to talk about his role, digital claims, and a particularly challenging assistance case How did you first get started in the assistance industry, and how did your career progress to your current role?

It was purely by chance! I was given the opportunity to use my language skills when working for a health check screening company based in Wakefield, UK, in the early 2000s and that was my first contact with the travel insurance world. From there, I got a taste for helping people and my interest in assistance grew. Later that decade, I moved into repatriation and claims handling where I gained a deep understanding of complex medical evacuation protocols, providers, hospital liaison and expectation management and team management.

Finally, the chance arrived to make the leap to Operations Manager with Tangiers International early in 2017.

Can you talk us through a typical day in your role as Operations Manager?

This is a challenging role! Apart from checking that all systems are working and all members of the team are ready for work, there are other things such as: making sure that payments to providers are made in a timely manner; delegating tasks; contacting providers and updating existing contracts; checking that 42 |

all members of my team are up to date with training, protocols, and so forth; creating reports, organising and attending meetings, supervising cases and claims; contacting underwriters and brokers; checking, updating and creating new schemes; liaising and informing accounts when we need to invoice; guiding the Operations Team; reporting to the General Manager; solving problems; updating rosters ‌ and anything else that may come my way.

What, in your opinion, are the key elements of facilitating a smooth and co-operative relationship between an insurance company and an assistance company?

Clear and precise communication is vital – knowing who is doing what and how to contact the correct person if necessary. A good explanation of benefits and exclusions on the policies, avoiding ambiguity. And quick responses in case authorisation are needed for high-cost cases.

How has the global landscape for assistance changed over the past decade, in your view?

People are travelling to more challenging places, where there might be problems with

communication, political unrest or lack of services. Insurance companies have had to adapt to this changing world and have opted to offer assistance in other ways such as telephone apps for on-the-spot information about medical facilities in an area, information on safety or by having on-theground agents that can actually call or visit the insured directly and give local advice in the local language.

Has introducing your Tangiers Travel App made a noticeable difference to your relationship with your clients?

It has changed in the way that it is easy for them to submit claims without the need to use emails or even call us! They can attach all the necessary documents and get an instant reply with their reference number, and a member of the team can message them asking for further information or call them if required. They can also use the app to get a list of hospitals and medical facilities in the area where they are, should they need them. Obviously, we are always at the end of the phone 24/7 if our clients prefer to speak to one of our operators.

Can you give us an example of a recent case that proved particularly challenging?

Profile We had to transfer one of our clients from Afghanistan to India for an operation. There were issues with the Indian Embassy as it would not issue a visa to this particular person unless there was an invitation letter from the receiving hospital in India. To expedite things, we contacted the hospital directly and also our Tangiers International agents in India and Afghanistan. They sent the letter, but still the visa was declined as the claimant’s companion was not considered a close family member (they were a cousin). This was changed, so that the new companion was the patient’s father. Still, the visa was declined as the patient had less than six months on his passport! Eventually, all was fixed with the help of our field agents on the ground and the claimant made it to India. He was operated on and discharged. Pakistani air space was closed on the day he was scheduled to travel back to Afghanistan, plus the airline lost his booking.

Again, our agents had to intercede and accompanied the patient to the airport, where they managed to solve the problem with the

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ticket and helped the patient with wheelchair assistance, and so forth.

Finally, the claimant arrived back in Kabul, where one of our Tangiers International agents was waiting for him, although he decided to travel onwards with a family member who was also there.

Of course, all assistance cases are complex in their own way, but are there any hotspots around the world at the moment that pose a particular headache when providing assistance?

Yes, in particular war-torn countries, where it is difficult to have an agent and where the infrastructure has been decimated and where it is difficult to get permission to land in case of medevacs. Examples are Yemen, Libya and remote areas of South Sudan.

What are the most challenging aspects of your job?

Finding a solution for every problem or challenge while under pressure and in a timely manner.

What are your proudest achievements, both professionally and personally?

I was part of the team that designed and implemented a new system for repatriations. It was great to see other people being trained on something I created. As a person, my proudest achievement was helping a dear friend to come out of his depression following a serious health problem. He now lives a full and productive life.

If you could invite any three people – living or dead – to a dream dinner party, who would you choose and why?

My mother – she was the wisest and most caring person I know. My other half – just because I love him and he could just not be out. And my best friend – because she’s the best and keeps me in check!

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