CASE 49
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Incident
A 67-year-old male developed chest pain while on holiday in Bali. He was diagnosed with an anterior myocardial infarction and thrombolysed at the local hospital. He is now 6 days post-infarction and has been discharged that day from hospital. He is an Australian citizen who now needs repatriation. You have been asked to be a medical escort for the patient, who is currently in a local hotel.
Medications:
• Aspirin.
• Clopidogrel.
• β-blocker.
• Angiotensin-converting enzyme inhibitor.
Shortly after arrival, you locate the patient who is ambulant and looks very well.
Clinical information:
• P 52.
• BP 110/60 mmHg.
• SaO2 95% on air.
Relevant information
▪ Aircraft: Commercial jet airliner (as on the previous page). Return flight (5 hours duration) is booked for the next day
▪ Resources: Travelling as a solo physician, no other team members. Extensive portable medical kit including drugs, monitor and defibrillator
▪ Retrieving to: Patient’s home address in Australia
Questions
49.1 Is the patient safe to fly commercially? Give a balanced argument.
49.2 Describe, in detail, your plan for the journey home from start to finish.
49.3 After boarding, a member of the cabin crew tells you the supplementary oxygen cylinder has been ‘delayed’ and asks if you are happy to travel without it. Are you?
Discussion
49.1 Most medical repatriations are done through insurance companies and most of the paperwork and initial telephone assessment will have been done by experienced company staff (usually nurses with physician input). The role of the doctor ‘on scene’ is to assess the patient clinically and ensure the information given to the insurance company is accurate. For this reason, the doctor is often flown out the day before the scheduled return. It is unusual to find that the patient is clinically worse than expected.
There is clinical risk involved in the transfer of such patients and, for this reason, a physician escort has been arranged. Options are limited (see box below) and a careful risk-benefit analysis is required. A dedicated air ambulance may be the lowest risk for transfer but resource allocation and cost make this a poor choice under these circumstances.
Patient travels alone commercially.
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