Electronic ISSN 2287-0237
Thailand is located at the center of the Indochina peninsula in Southeast Asia, bordered to the north by Myanmar and Laos, to the east by Cambodia and to the south by Malaysia. There are many migrants in this region, and the countries have also attracted a number of expatriates from developed countries. In 2007, Thailand had 14.5 million visitors, excluding those from neighboring countries. According to the Tourism Authority of Thailand, 55% of the tourists in 2007 came from the Asia Pacific region. The largest groups of Western tourists come from the United Kingdom, Australia, Germany, the United States and Scandinavia. Medical tourism has become a growing segment of Thailand’s tourism and health-care sectors too. When travelers or expatriates become ill or injured, urgent air evacuation to the nearest well equipped medical facility is needed, to preserve function and save lives as well as subsequent repatriation to the patient’s home country.
Fewer than 0.5% of all travelers actually require medical evacuation.1 It is estimated that in Thailand thousands of aeromedical evacuation and repatriation are performed annually. The decision-making process surrounding emergency aeromedical transport is based not only on the patient’s clinical condition but on many other factors as well.2 Due to rapid increasing fuel prices over the last decade, the costs of aeromedical transport have increased.3 Analysis of epidemiological data of aeromedical transportation will support efficacious decision-making of the modes of transport and health care facilities. In a certain subgroup of relatively stable, ventilated patients, transport on commercial airlines offers advantages in terms of cost effectiveness and reduced transport time and acceleration/deceleration trauma as a result of multiple fuel stops.4 Former literature indicated using helicopters was economically unjustified for transport exceeding 100 miles when an efficient fixed-wing service exists.5
Data was collected from the Aviation Medicine Center of our tertiary care hospital which operates a helicopter and fixed-wing aeromedical transport service. While handling the data, the regulations of the Ethics Commission of Bangkok Hospital Group were fully respected. Institutional review board approval was obtained, and informed consent was waived. A retrospective electronic medical record review was performed, and the epidemiological data of medical evacuation and repatriation cases were collected from January-December 2011. Data included age, sex, nationality, diagnosis, flight time, mode of transportation, type of aircraft, and cost per flight hour. Data were collected and entered onto a standard spreadsheet format. The median value was calculated.
Patient data
Three hundred and two patients were included in the study, 201 male (66.5%) and 101 female (33.5%). There were no exclusion criteria. Patient’s age ranged from 1 day to 105 years, the average age was 50.2 years (y) (median 54 y). The top five nationality of patients were Thai (n = 93, 30.8 %), Myanmar (n = 29, 9.6%), British (n = 19, 6.3%), German (n = 18, 6%) and Cambodian (n = 16, 5.3%) as shown in Figure 1.
Medical Data
The top five diagnoses were Stroke (n = 51, 16.6%), Multiple trauma (n = 41, 13.40%), Acute MI (n = 30, 9.8%), Cancer (n = 27, 8.9%), and Cerebrocranial trauma (n = 26, 8.6 %) as shown in Table 1 and Figure 2. The most frequent types of cases were classified according to the following specialties: cardiology (n = 58, 19%), neurology (n = 55, 18%), trauma surgery (n = 41, 14%), orthopedic (n = 32, 11%), cancer (n = 27, 9%) as shown in Figure 3.
Operational Flight Data
The average flight time for air ambulance was 1.1 hours, for helicopter 1.3 hours, for a regular seating 7.36 hours and for a stretcher 4.1 hours respectively, as shown in Figure 4. Most cases of stretcher and regular seat on a commercial flight were repatriation cases and the flight times ranged from 1 hour to 25 hours. All of the helicopter and air ambulance cases were evacuation cases. Most evacuation sites were in Thailand and Indochina countries such as Myanmar and Cambodia.
Mode of transportation
Of the total 302 cases, 209 were evacuation cases (69%) and 93 repatriation cases (31%). Most cases were transported by air ambulance (n = 104, 34%) but the helicopter (n = 84, 28%), scheduled aircraft with regular seating (n = 60, 20%) and a stretcher in a scheduled aircraft (n = 54, 18%) were also used, as shown in Figure 5.
Type of aircraft
Five different types of aircraft were used in air ambulance cases. The top three were ATR-72 (n = 66, 63.5%), Caravan (n = 12, 11.5%) and Beechjet400 (n = 12, 11.5%) as shown in Figure 6.
Financial Data
The cost per flight minute (min) were calculated for an air ambulance to be $ 202.5/min, for a helicopter $ 87.55/min, for a stretcher in a scheduled aircraft $ 40.1/ min, and for a scheduled aircraft with regular seating $ 9.37/min respectively as shown in Table 2 and Figure 7.
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Figure 1: Nationality of cases.
Table 1: Diagnosis of transported cases (n = 302).
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Figure 2: Diagnosis of transported cases. (n = 302).
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Figure 3: Diagnosis classified according to the specialty of transported patients (n = 302).
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Figure 4: Average Flight Time (hour) of transported cases.
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Figure 5: Mode of transport of transported cases.
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Figure 6: Type of aircraft in air ambulance cases (n = 104).
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Figure 7: The cost per flight hour of transported cases.
Table 2: The cost per flight minute and flight hour.
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As the demand for medical air transportation is likely to continue to go up in the future due to increased globe trotting and medical tourism,3 skilled physicians and nurses must be available at all times. Monitoring devices (ECG, blood pressure, pulse oximetry, capnography), defibrillators, pacing devices, ventilators, aeronautical oxygen systems, infusion devices, mattresses, medication including resuscitation drugs must be available 24 hours a day.2 All equipment must be certified for aeronautical use, and a permanent logistics team ensures its preventive maintenance.6 Cost-effectiveness is likely to be of the utmost importance for insurance companies and health care systems when determining appropriate form of air transportation. The flight physician has to determine that the patients not only receive quality medical care but the mode of transportation is most effective in terms of safety, time and cost-effectiveness, even though the most appropriate medical response should be the the main factor in the selection of an appropriate form of air transportation. Patients with neurologic conditions need even more timely and careful aeromedical transport than those with other diseases.7
From our data, neurologic diseases comprised 25% of the patients that required medical transportation. Most cases of evacuation were transported by helicopter or air ambulance and flight time was about one hour; most cases of repatriation were transported by stretcher or regular seat in commercial aircraft. Most evacuation sites were in Thailand and Indochina countries such as Myanmar and Cambodia. The diagnosis of cases varied from diseases to trauma but most cases (n = 99, 33%) were from accident and trauma, with multiple or severe injuries that needed surgery.
By comparing the costs per flight time, we showed that a stretcher in a scheduled aircraft is significantly cheaper than air ambulance and a scheduled aircraft with regular seating (first, business and economy class) was cheapest. The data also showed that the helicopter was significantly cheaper than air ambulance especially in the context of air evacuation within one hour.
Limitation: Data was collected from only one aviation medical center in the year 2011.
Transport of patients with various diseases or trauma, either by air ambulance or commercial flights, can only be safely performed by well-trained medical escorts and with comprehensive logistic arrangements. Medical air transportation is very costly, and continuing the trend of the last decade, its frequency is likely to further increase. The physician who is in charge of transport planning must communicate effectively with the patient, with the physician on-site, with the patients’ relatives and with the patients’ insurance company to determine and evaluate needs and determine the most suitable mode of air medical transport.
