INTERNATIONAL MEDICAL REPATRIATION AT THE HEIGHT OF THE COVID-19 PANDEMIC
(Toronto, July 2020 – by Frank Condron)
The Covid-19 pandemic has impacted daily life for everyone all over the world. At the very least, the crisis has meant staying home, finding new ways to work and getting use to social distancing. For those working in international medical repatriation, however, simply staying at home was never an option. And while moving sick and injured patients around the world has always posed a unique set of challenges, the fallout from the pandemic has added layers of complexity to this already complex task.
During the last week of March, Tyrol Air Ambulance, an Austrian air ambulance provider based in Innsbruck, invited Fox Flight Air Ambulance, a similar provider based in Toronto, Canada, to collaborate on a wing-to-wing patient transfer from Cuba to Austria. The request itself was not unusual; both Tyrol and Fox Flight are well established in the industry and the two companies have collaborated on numerous wing-to-wing missions in the past. But with the global pandemic reaching its peak at the time, this mission posed a number of extraordinary logistical challenges.
Under normal circumstances this mission would be straightforward from a logistics perspective. The Fox Flight air ambulance team would first fly down from Toronto to pick up the patient from the sending hospital in Matanzas, Cuba. Fox Flight would then head for a rendezvous with Tyrol in Keflavik, Iceland, making technical refueling stops in Toronto and Goose Bay, Labrador, along the way. In Iceland the patient would be transferred to the care of the medical team from Tyrol for the final leg of the journey back to Austria.
Because the distances travelled for international medical repatriations are usually quite long, the logistics of these missions are greatly influenced by two factors: the range of the aircraft involved (generally a maximum of about four to five hours between refueling stops) and the confines of the mandated flight crew duty day, which vary from region to region. According to Transport Canada regulations, the duty day for Canadian pilots cannot exceed 14 hours, including prep time, flying time and technical stops. The duty period must be followed by a minimum of eight hours rest, and the rest period can be extended based on the number of time zones crossed during the mission.
Before an air ambulance team is dispatched, the mission must be planned to ensure that no single flight crew exceeds their daily maximum duty time. To achieve this, flight dispatchers have to account for factors like distance, weather conditions, the number of technical stops required and potential delays. These include things like a change in the patient’s condition, mechanical problems or ground services issues. Unexpected delays at any point in the mission can alter the flight plan completely.
Air ambulance dispatchers have to be flexible to allow for these time constraints. For example, it is sometimes necessary for the air ambulance crew to fly to the mission departure destination a day early to allow ample duty time for the repatriation flight the next day. Sometimes, on especially long flights, a second flight crew has to be pre-positioned along the route to take over for the first crew in order to complete the mission within the duty limitations. Also, not all airports are open 24 hours a day; depending on where the patient is located, it may only be possible to land during limited operating hours. This can determine when the crew can depart on the mission and whether or not they will have to stay overnight at either the departure destination or the final destination.
This Cuba-to-Austria repatriation mission in late March covered some 6,200 nautical miles (NM) and involved making multiple stops in four different countries. The mission would be challenging under normal circumstances, but at the height of the pandemic circumstances were anything but normal. Countries were in lockdown, most international flights were cancelled and quarantine requirements were in place for international travellers. This placed new and evolving restrictions on where and when planes could land and whether or not the crew could stay overnight. Completing the mission required detailed planning, precise timing, creativity and more than a little luck.
From a medical perspective, the mission was fairly routine. While on vacation in Cuba, the patient, a 57-year-old Austrian man, had been hospitalized suffering from shortness of breath, fever, cough and general discomfort. He was diagnosed with bacterial bronchopneumonia and treated with antibiotics and inhalation therapy. After several days in hospital, the patient’s condition began to improve, but his problems were far from over.
Once his illness was under control, the patient had to think about how to get home. Commercial flights into Cuba were severely restricted due to the pandemic, meaning air ambulance repatriation was the safest option given his condition. Also, the patient’s initial symptoms–shortness of breath, fever, cough—were identical to symptoms of Covid-19. He would have to be cleared for the virus before he could be moved safely or even allowed back into his home country. Due to the crisis all air ambulance missions were subject to strict review and approval by regional authorities. Detailed information was required relating to the patient’s medical and travel history, and a persistent cough or a temperature above 37.3C was enough for any jurisdiction to deny entry.
Following a negative Covid test and a rigorous infectious disease screening process, the patient was ultimately deemed “fit to fly” by the air ambulance providers and the relevant authorities in the countries involved. Once all the necessary approvals were in place, Fox Flight and Tyrol could begin planning the logistics of the mission. Based on their various commitments, the two companies determined that the repatriation would have to take place between Monday, March 23 and Tuesday, March 24.
The initial leg of the mission, from Toronto to Cuba, is a distance of about 1250 nautical miles (NM), which takes approximately three hours and 22 minutes to fly. After collecting the patient, the Fox Flight crew would have to cover the return leg to Toronto followed by a leg to Goose Bay (954 NM; about 2 hours) and the final leg to Keflavik (1316 NM; about three hours). All told, the Fox Flight portion of the mission (not counting return to base) covered 4,770 NM and approximately 12 hours of flying time.
The sheer distance involved created the first logistics problem. With time added to prep the plane prior to departure, plus time on the ground to collect the patient and for two technical stops, even assuming no other delays, the Fox Flight crew could not possibly complete their portion of the mission in a single duty day. Normally this problem could be eliminated by sending the crew down to Cuba a day early to rest overnight, giving the pilots ample duty time the next day to complete the three legs to Iceland. But that was not an option during the last week of March. Due to the pandemic, Cuba was no longer allowing foreign flight crews to stay in hotels on the island overnight.
Since pre-positioning was not possible, the initial Fox Flight crew would have to fly to Cuba, collect the patient and leave the same day. Because the initial crew would clearly not have enough duty time left to carry on to Iceland, a second flight crew would have to take over back in Toronto.
Likewise, it would be common practice for Tyrol to pre-position its crew in Iceland a day prior to the planned patient exchange. By late March, however, Keflavik International had been listed by the European Union Aviation Safety Association (EASA) as an airport located in an area with “high risk of transmission of the Covid-19 infection.” If the Tyrol crew spent their rest period in Iceland, they would be subject to a two-week quarantine upon their return to Austria, so pre-positioning was impossible. The Tyrol crew could only fly to Keflavik, stay with their plane at the airport, collect the patient and leave immediately for home.
The initial portion of the mission was further complicated by new airport restrictions in Cuba. Normally the airport in Varadero, a busy tourist destination, accepts commercial flights at all hours of the day and night. But again, due to the pandemic, incoming flights had been restricted to cargo, military and air ambulance, and airport hours had been reduced to daytime only. All foreign flights were expected to arrive no later than 3:00 p.m. and depart before 6:00 p.m. These restrictions placed a limit on how late the Fox Flight crew could leave Toronto for Cuba on March 23. The departure time from Cuba, in turn, determined when the Fox Flight team could expect to arrive in Keflavik for the patient exchange with Tyrol on March 24.
The flight from Innsbruck to Keflavik is about 1,496 NM and can be covered in roughly four hours, but Tyrol’s estimated departure time was dictated by both airport operating restrictions and prior duty time limitations. Leaving Austria as early as possible, Tyrol could not commit to making the patient exchange any earlier than 10:00 a.m. Keflavik time (GMT) on March 24. That would leave a limited window of about two hours on the ground in Iceland to make the patient transfer in order to allow the Tyrol crew to get back to Austria well within their EASA-mandated duty day.
Given Tyrol’s time constraints, the Fox Flight crew would have to time their departure from Toronto to arrive in Iceland after the Tyrol crew but within the two-hour time window. It was important for Fox Flight to arrive later so the patient could be transferred immediately to the Tyrol air ambulance and continue on to the receiving hospital as quickly as possible. Any delays on the front end of the mission could place the Tyrol aircrew in a difficult position, so the timing of the patient exchange was crucial.
The “high-risk” Covid designation for Iceland created problems for the Canadian crew as well. Normally, following the patient transfer, the Fox Flight crew could rest overnight in Keflavik before either flying home or continuing on to the UK or continental Europe to pick up a patient requiring transport back to North America. But new Canadian government restrictions dictated that anyone returning to Canada from Europe would be subject to a two-week quarantine. In order to avoid “officially” entering Europe, the Fox Flight crew was only allowed to remain on the tarmac in Keflavik, transfer the patient and refuel before departing for home.
Normally the goal of any mission is to minimize delays and get the patient to their final destination as quickly as possible. But the time restrictions in Cuba and Austria imposed limitations that actually required this mission to be delayed.
Since the Fox Flight crew could not postpone their departure from Cuba until late Sunday night, they could expect to land back in Toronto in the early evening to refuel and swap out the crew. However, if the new crew departed as quickly as possible, which would be standard procedure, they would arrive in Keflavik in the middle of the night local time. That would be much too early given Tyrol’s 10:00 a.m. target.
The only solution to this problem was to purposely delay the mission. To accomplish this, Fox Flight had to request special permission from Canada Customs for the patient to remain on the ground in Toronto for several hours before continuing on to Iceland. Permission was granted with the strict understanding that the foreign national could not leave Fox Flight’s restricted hangar area.
The Fox Flight air ambulance with two pilots and two medical personnel departed from Toronto’s Lester B. Pearson International Airport at 11:30 a.m. (EST) on March 23. It arrived at Juan Gualberto Gomez Airport in Varadero, Cuba at 2:45 p.m. (EST). In accordance with regulations, the crew stayed with the plane on the tarmac and waited for the patient to make the short journey from the hospital via ground ambulance.
In many cases, upon arrival at the departure destination, it is common for the medical repatriation crew to go to the hospital to confirm the patient’s condition at the bedside and accompany them to the airport. At that time, however, foreign medical personnel were not allowed to enter the hospital in Cuba or even leave the airport’s restricted area. Once the patient was on board, the plane departed immediately for Toronto at 4:45 p.m. (EST).
The Fox Flight jet arrived back in Toronto at 8:15 p.m. (EST) and taxied over to the company hangar, which is located within the airport’s fenced restricted area. The patient, who was awake and comfortable, was lifted out of the plane on a stretcher and transferred to the company’s ground ambulance where he would remain for the duration of the layover. The original aircrew logged off duty shortly after arriving back in Toronto and prepping the plane for the flight to Iceland. The original medical crew remained with the patient in the ambulance until a second medical crew relieved them.
Not long after landing in Toronto, Fox Flight received a visit from Canada Customs officers who confiscated the Austrian patient’s passport for safekeeping. Over the course of the four-hour layover, both Customs and Canadian Border Security Agency (CBSA) officers dropped by the hangar several more times to make sure the restrictions were being followed. In spite of the inconvenience, the patient understood why the delay was necessary given the pandemic restrictions and he remained in good spirits. The stopover did give the patient an opportunity to eat a hot meal in relative comfort, which would have been much more difficult on the plane.
The second Fox Flight aircrew arrived at the hangar at about 11:30 p.m. (EST) and final preparations were made for the journey to Iceland. The plane took off from Toronto just after 12:30 a.m. (EST) on Tuesday, March 23, bound for Goose Bay.
Through every step of the mission, dispatchers at Fox Flight and Tyrol remained in constant contact so they could update their respective crews on the status of the patient and the timing of the transfer. With the Fox Flight air ambulance about 40 minutes out of Goose Bay and on track to land in Keflavik just after 10:00 a.m. local time, the Tyrol air ambulance got clearance to take off for Iceland at about 8:00 a.m. Innsbruck time (CET). The Fox Flight jet landed for its technical stop in Goose Bay at 3:40 a.m. local time (ADT), on schedule and expected to arrive in Keflavik just after Tyrol.
Once on the ground in Goose Bay, the Fox Flight crew was met with another new pandemic-related restriction. Usually during refueling stops it is common for flight and medical crewmembers to exit the plane to stretch their legs, use the bathroom and maybe get a hot drink or snack if possible. But due to local concerns over virus spread from international travellers, crews transiting through the small Goose Bay airport were no longer allowed to exit their plane while refueling. Customs officials had even resorted to checking passports through the plane windows to reduce personal interaction with travellers. With the fuel topped up, the Fox Flight crew departed on their final leg to Keflavik at 4:00 a.m. local time.
Flying in clear weather all the way from Austria, the Tyrol air ambulance arrived in Keflavik right on time at 10:00 a.m. local time (GMT). The Fox Flight air ambulance arrived just 20 minutes later. While the two planes refueled, the Canadian medical team handed the patient over to their Austrian counterparts and provided them with an update on his condition. With the transfer complete and the planes refueled, both crews resumed their respective journeys less than an hour after arriving in Iceland.
The very rapid turnaround times in both Goose Bay and Keflavik put the Fox Flight crew in a good position to get back to Canada. The weather was in their favour and, as on the way over, the last technical stop in Goose Bay took just 20 minutes. While the Fox Flight crew was in the air on the final leg of their journey, the Tyrol crew landed in Innsbruck and transported the patient to a local hospital to complete his recovery. The Fox Flight air ambulance arrived back at base at Pearson International in Toronto at 1:00 p.m. (EST) on March 24 to complete the mission – about 25-and-a-half hours after the first crew departed for Cuba the previous day.