Dr. Rose Recommends for Healthy & Safe Travel
Health Guide Chapter 18
Companies that provide emergency medical transport require prepayment or guarantee of payment
Travelers, especially those going to remote or medically underserved locations, should be covered by insurance that pays for emergency medical transport
Stretcher transport on a commercial airliner is much less expensive than a chartered air ambulance
Flight clearances into many countries may be difficult to obtain in short notice. The larger, more experienced air ambulance and assistance companies are generally better able to arrange flights to countries in Africa, the Middle East, and Asia.
What is Medical Evacuation?
Medical evacuation is required when a medical condition cannot be adequately treated in the current location. It involves moving a patient to another location with a higher standard of care. Medical evacuation may not involve moving the patient to their home country; it may be more appropriate to bring the patient to a location with quality medical care within the same region.
Medical evacuation can be as simple as a ground ambulance ride or as complicated as an air ambulance moving an unconscious patient from one country to another. Air ambulances are basically flying intensive care units with specially trained medical staff.
Arranging Medical Transport
Medical evacuations are complex to organize, especially if you are the patient! Even for family or friends, the logistics and cost can be daunting. If you are covered by a travel insurance policy, the insurance company will work with a medical assistance company to make all the arrangements (Chapter 17) and hopefully pay the costs through the insurance policy.
If you are uninsured, you can make the arrangements yourself or contact a medical assistance company directly and pay their fees. Either way, you will have to pay up front and hope your medical plan or HMO back home will reimburse you. Before you are reimbursed, your plan will want to see documentation verifying why the transport was medically necessary and also see copies of all invoices. They could very well delay or deny your claim. So, unless the situation is extremely urgent, try to contact your primary care provider or health plan from overseas to obtain authorization for the transport. This will help prevent problems later over reimbursement. If you are making the arrangements yourself, here is some information that will assist you.
Transport by Commercial Airliner This can range from transporting a wheelchair-bound traveler who only requires assistance with boarding, to transporting a bed-ridden patient. In cases where the patient must lie down, the airline curtains off a section of seats and installs a stretcher unit and oxygen (if needed). Seats are allotted for a medical attendant and sometimes a family member.
Stretcher transport is offered by some, but not all, airlines. The arrangements are more complex if the travel involves a change of aircraft or airline. Commercial airlines will not accept patients with unstable medical conditions. This is because if the patient's medical condition deteriorates in flight, the aircraft (and it's passengers and crew) may need to be diverted to the nearest location that can treat the patient. This is very expensive for the airline and inconvenient for the other passengers. Unstable patients can only be evacuated by air ambulance.
To arrange medical transportation by commercial aircraft, your first step is to call the airline/s and ask for their medical department, special services department, or “stretcher desk.” (If you are the patient, have a friend or relative make the arrangements.) Explain the problem and the airline will tell you if and how they can assist. The airline's medical director must authorize the transport, and a medical attendant, either a nurse or a doctor, must accompany the patient. Sometimes a family member can be the attendant when medical treatment or monitoring will not be needed en route.
Ground ambulance pick up must be arranged at either end and coordinated with departure and arrival. Often the stretcher will not fit down the jetway and through the aircraft door. In these cases, a lift truck (the same as is used to load food and supplies onto the plane) is used to lift the stretcher up to a larger rear aircraft door. All these arrangements must flow smoothly, and making these arrangements can be quite a feat, especially when you may be dealing with non-English-speaking people halfway around the world and many time zones away.
The cost of stretcher transport on a commercial airliner is usually nine to ten times the cost of a one-way economy seat (or four times the cost of a first-class seat). Oxygen, nurse or doctor's fees, and ground transport will be extra. Scheduling normally takes 48 to 72 hours, or more, and is dependent on seat availability as well as the airline's acceptance of the case.
Most U.S. airlines do not perform stretcher transportation. If you are arranging stretcher transport of a sick or injured relative back to the U.S., the patient will first arrive at a major U.S. international airport and then you will have to arrange further transport to their hometown—this can only be done by ground or air ambulance.
Some air ambulance and assistance companies can also make stretcher arrangements on a commercial airliner on your behalf. This can be very helpful, especially in complex cases where there is considerable leg work involved. They will provide medical attendants for the flight, obtain medical clearances and have their physician consultant speak with the doctors caring for the patient, arrange ground ambulance pick up, and arrange, as necessary, ongoing air ambulance transport in the United States after arrival from overseas. The fees charged will vary from company to company, so it's best to get several price quotations.
Transport by Air Ambulance If the medical condition requires immediate air ambulance evacuation, you must contact an air ambulance company that can provide a medically equipped and staffed aircraft—often a small jet or turboprop. Air ambulance companies vary in their capabilities, especially outside developed countries, and it may be difficult to determine if the company provides quality medical care and safe aviation. Also, air ambulances are expensive, usually three times the cost of a comparable stretcher-equipped commercial flight. You will be required to prepay the total cost of the flight—or arrange guarantee of payment if you have insurance coverage.
Because of their geographic proximity, it is best to use a U.S.-based air ambulance company for evacuations from Mexico, the Caribbean, Canada, and/or South America. U.S. companies can usually arrange transport from Europe or the Pacific Basin to the United States, but when dealing with medical evacuation from other parts of the world, it may be better to deal with European- or Asian-based companies. This is especially true when charter aircraft must be flown into Africa, Asia, the Middle East, the former Soviet Union, or Eastern Europe. American companies, unless they have overseas affiliates, are too remote to provide this service, and they may have difficulty obtaining the necessary flight clearances to enter countries in these regions.
An air ambulance is often required to provide urgent evacuation from a remote or medically under-served area to a more suitable, higher-level medical facility. For example, an injured patient might be flown from North Africa to Switzerland. After further treatment and stabilization, the patient might be returned home by stretcher-equipped commercial airliner for ongoing treatment or convalescence. This last leg of the trip is called repatriation.
Companies Providing Air Ambulance Services
If you look in the Yellow Pages of any metropolitan telephone book, you'll find listed numerous air ambulance companies. What you can't be sure of is their quality. The companies listed in this chapter are well established and have a record of quality care and reliability. Some of these companies are hospital-based and provide local helicopter “life flights,” as well as staffing fixed-wing aircraft with their medical teams for overseas evacuations.
A listing of air ambulance companies and assistance companies is also found on the State Department's website: Medical Information for Americans Traveling Abroad (http://travel.state.gov/travel/tips/health/health_1185.html)
U.S.- and Canada-Based Companies (Also serving the Caribbean/Mexico/Latin America)
1-800-463-3482 (North America)
Tel: 1-514-497-7000 (Worldwide)
800-468-5232 (U.S. and Canada) or
1-215-245-4707 (from overseas)
MEDEX ASSISTANCE CORP.
1-410-453-6330 (overseas collect)
Heathrow Air Ambulance Services
 208-897-6185 or 800-513-5192 (toll-free U.S. access)
Europe, Russia, the Middle East, and Africa, Repatriation to U.S.
Swiss Air Ambulance
Sabiha Gokcen International Airport
Turkey's primary air ambulance and rescue company
HMC MEDEVAC INTERNATIONAL
Herzliya Medical Center
 (9)-959-2444 or  9-959-2433
AMREF Flying Doctors Service
Evacuation services for East Africa and surrounding countries.
 (0)-20 315 454 or  (0) 20 605 093
Medical Air Rescue Service, Ltd.
Belgravia, Harare, and Zimbabwe
 (0) 11-403-7080
Extensive assistance network in sub-Saharan Africa. Mobile decompression chamber for diver emergencies.
Tel:  (11) 541 1300/1350
Fax:  11 541 1076
International SOS opened its office in South Africa in Johannesburg in 1993. The International SOS South Africa alarm center specializes in delivering medical assistance, evacuation and speciality services throughout South Africa and sub-Saharan Africa for insurance companies, corporations and individuals.
Johannesburg, South Africa
 (0) 11-315-3999
East West Rescue
New Delhi, India
India's largest assistance company. Service to India, Bangladesh,
Bhutan, Sri Lanka, Nepal, Maldives, and Pakistan.
Asia, Australia, Oceania
1-800-468-5232 (U.S. and Canada)
Evacuations from China, East Asia, SE Asia, Pacific Rim, Australia, and the western-most Pacific islands
Medical Transport of the Overseas Employee
If you are an overseas employee and are sick or injured, your company can help arrange medical transportation to a local hospital. If the local hospital is not adequate, you may need to be flown to another hospital, perhaps in the United States. The following checklist will help your company arrange this type of transportation. They can do the following:
Assess availability of local ground ambulance and rescue services
Establish ground ambulance access protocols. Determine if you will need a language interpreter in emergency situations. Suggestion: Contact the consular section of the U.S. Embassy, a United States consulate, or a corporate neighbor. Because they have already arranged emergency protocols for their own personnel, they can identify reliable English-speaking doctors and also relate their experience with local hospitals, pharmacies, and ambulance services.
Formulate medical evacuation protocols for emergencies that can't be handled locally, including planning for disasters as well as individual medical evacuation cases.
Check availability of stretcher transport on commercial airlines for nonemergency cases.
Establish access and credit arrangements with an international air ambulance company such as International SOS Assistance, Swiss Air Rescue, EuropAssistance, or one of the other companies listed in this chapter. Commercial airliners will not transport emergency cases.
Determine if exit visas or other formalities are required.
Provide on-site employees with 24-hour telephone or telex number(s) of an assistance company, and/or the home office, in case of a medical emergency.