"Floating base" concept in commercial medical escort - the new digital nomads?

What is a floating base?

Air medical transport, whether as an air ambulance flight or a commercial medical escort, is usually structured as a triangular route: Origin base - patient pickup location - patient destination - origin base. Flights to and from the patient's location are often considered "empty legs" as the medical team is simply transported to the scene without actually being working. Floating base is a concept that attempts to avoid the number of empty legs and aims to use every leg flown for a patient transfer. While this concept is being implemented by some air ambulance companies, we did not find a report of this type of operation in the commercial medical escort service. Therefore, we conducted a trial as a "proof of concept" that we are pleased to report.

In preparation for the floating base, we had to consider what kind of medical escort and what kind of medical equipment to have ready, since we did not have a planned mission at the beginning of the study. In order to be prepared for all possible medical situations, we decided to send a critical care physician with a complete advanced life support emergency kit and a portable oxygen concentrator to Miami, Florida, where he would prepare for any upcoming missions.

Floating base in practice

After two days on standby, AMTRAS received its first mission confirmation to transport a patient from Jamaica to Cleveland, Ohio. From Miami, it was only a 1 hour and 20 minute flight to the patient's destination, so the pre-flight assessment could be completed in less than 24 hours after confirmation. The flight was scheduled for the following day and proceeded without incident. However, on the flight to Jamaica, the airline forced the medical escort to check in his personal carry-on bag, as they considered the medical bag to be the maximum they would allow on board that flight. As fate would have it, however, the checked bag was not carried on the escort's flight, and he arrived with all the medical equipment but no personal items or clothing. After some correspondence with the airline, they were able to locate the carry-on bag while still in Miami, so it was carried on the next available flight and delivered to the medical escort's hotel late that same day. Since the bag was equipped with an Apple airtag, we were able to track our bag and check on its progress.

On the day of the aeromedical transfer from Montego Bay to Cleveland via Dallas, AMTRAS' next mission was confirmed. A patient with a heart condition needed a physician and oxygen for his transfer from Puerto Vallarta, Mexico to Canada. Because our escort was immediately available after the handover in Cleveland, we were able to send him down to Mexico the next day with only five hours of rest in Cleveland because flight connections did not allow for anything else. Again, the pre-flight assessment could be made in less than 24 hours, and the transfer could be scheduled without delay.

Upon entering Mexico, all bags had to be x-rayed by customs and the medical bag was pulled out for further examination. Mexican customs only allows the importation of items for personal use and commercial goods with a value of less than $500 USD. So, they required payment of import tax for the portable oxygen concentrator, which has a much higher value, even though this item was needed for a medical repatriation and was scheduled to leave the country the next day. Fortunately, AMTRAS had all the necessary customs documents, called the A.T.A. carnet (or "goods passport"), which allows duty-free transit of commercial goods. However, the processing of this carnet takes a lot of time, which reduced the resting time of the medical escort in Mexico.

?The next day we picked up our patient, his wife and their cat and drove to the airport. Again, all customs forms had to be filled out and it took quite a while before we could board the flight to Montreal. Medically, this flight was also uneventful, and the family was glad that we had arranged a seat in the cabin for the cat as well, so that it could travel together with its "human can openers". Departing in sunshine and 30 degrees Celsius, we landed in the middle of winter with 2 meters of snow and -5 degrees in cold Montreal, Canada.

In the meantime, we have received confirmation of another mission that had already been postponed for several days due to the patient's condition. Now she has been deemed fit to fly and we could send our escort from Montreal directly to Jacksonville, Florida, to check her condition at the hospital.

?The woman had suffered a fractured femur after a fall and had undergone surgery a few days ago. Now she was confined to a wheelchair, unable to walk and unsure of what would happen. During the pre-flight visit, we took quite a while to explain the whole process of the aeromedical transfer to her and her family, which was very reassuring for her. We made sure she was taken to the seat on the plane in a wheelchair, so she didn't have to take a step at all.

Since she was traveling with her husband, they had four large suitcases and two carry-on bags, and the family had also ordered a walker and wheelchair for her to take with her to London, UK. Given the amount of luggage, we encouraged the family to reconsider buying the wheelchair in the US and to help transport the luggage to the airport so we could get all the suitcases to London. They happily agreed and waived the order for the wheelchair. A lot of attention was needed during the transfer as the poor lady could not move without the help of two people. However, we managed to provide frequent restroom visits, which took quite a while after the hospital refused to place a urinary catheter because there was no medical indication. We agree to some extent on this point, but an air medical transport is a different environment and the medical indication may change depending on the new situation. Frequent bathroom visits on an airplane with an immobile patient present another fall risk that could be avoided by temporary placement of a urinary catheter, keeping in mind the risk of urinary tract infections.

?

After an uneventful flight from Jacksonville to Charlotte, we were almost denied boarding for the flight from Charlotte to London. The gate agent noticed that the immobile patient in the wheelchair was wearing only non-slip socks and asked that she put on shoes. Since the lady had bilateral edema, no shoes would fit her in the hospital, so we decided to continue with these socks. While we understand that wearing shoes on an airplane is beneficial in a sudden evacuation and when walking over debris, the situation is different for a patient who cannot walk at all. It is unclear to us whether there is a federal law forcing passengers to wear shoes in order to board, or whether it is a safety recommendation.

After landing in London, the patient was escorted to the receiving hospital and handed over to the appropriate emergency department staff, allowing the escorting physician to complete his ten-day service and board the flight home.

Conclusions

We found that the concept of a floating base is feasible in commercial medical escort.

The 10-day test phase gave us a lot of insights and a good experience for future operations of a floating base. To summarize our experience:

?

Advantages:

• Extremely fast response times. The medical escort can be dispatched immediately after confirmation of a mission
• Cost reduction. Any "empty leg" to the home base can be avoided
• Efficient use of staff. The medical escort can be employed for several days in a row

?

Things that need to be considered:

• Only the medical equipment that has been packed is available. If special equipment (e.g., defibrillator, vacuum mattress, etc.) is needed, it is not readily available
• ?High consumption of medical supplies. Typically, we have low usage of supplies, and the most commonly used items are blood glucose strips, pain medication, and oxygen cannulae. If a patient needs more in a medical emergency, there may not be enough medical supplies for subsequent missions.
• Keep in mind the entry requirements of various countries and make sure the medical escort has all necessary and valid visas.
• Have the proper customs documents and forms ready for your medical equipment.
• A delay in one mission may result in a delay in the following mission

Geographical limitation:

Theoretically, this concept could be applied anywhere in the world. However, it will work best in areas where patients are spread across a continent, such as the US or Canada. In contrast, in Europe, with many countries in less space and therefore many different insurance companies, it is more difficult to coordinate consecutive patient transfers, and air routes are more complex and less efficient.

We are very much looking forward to further optimizing our operations and implementing new processes whenever it makes sense, and trust that our customers will appreciate these advantages.

Dr. Stephan Klose