Coordinating Medical Evacuations During a Pandemic

Tune in now

Listen to gripping episode #10 of NAVIGATE, the travel podcast, where AMREF Flying Doctors reveal the many challenges of air ambulance evacuations.

For many of us, the outbreak of COVID-19 meant shifting to remote work and the end of “business as usual”. But for some, things became a lot more complicated – and dangerous.

AMREF Flying Doctors is the largest international air ambulances service and medical evacuation provider in East Africa and the Central Africa region. With close to 60 years of experience in the aeromedical transport industry to draw from, AMREF Flying Doctors has also safely completed over 300 COVID-19 patient transfers to date.

In the first of a two-part medical assistance podcast series, World Travel Protection’s Debra Harvey sits down with Medical Director, Dr Joseph Lelo, and Operations Manager, Maggie Kariuki, from AMREF Flying Doctors.

Based in Nairobi, Kenya, they share how they’ve continued to support their clients despite the complex environment created by the global COVID pandemic.

From managing the increased demand for evacuations as a result of the deadly virus, to coordinating care with hospitals at full capacity on top of border closures and constantly evolving regulations, they reveal how AMREF Flying Doctors overcame many challenges to provide valuable, life-saving healthcare to COVID patients – while keeping their medical staff safe, too.

What we cover: 

  • The valuable work of the AMREF Flying Doctors
  • Challenges of providing medical assistance and evacuations during COVID-19
  • The process of overseas medical evacuations

Managing overseas evacuations during COVID-19 – Part 1 | AMREF Flying Doctors:

Voice Over

0:00:00 – 0:00:19

Welcome to Navigate, the podcast that helps you safely and securely traverse the globe. Alongside travel industry experts and global travellers, we’ll gather insights and advice that help you manage any pitfalls or problems that may occur while you’re away from home. Our voyage of discovery starts now.
Debra Harvey

0:00:20 – 0:00:56

Hello and welcome to today’s Navigate podcast.  I’m Debra Harvey and I’m the Operations Manager, Clinical services of world travel Protection and I’m your host for today. I have the pleasure of introducing Dr Joseph Lelo, medical director, and Maggie Kariuki, operations manager from AMREF Flying Doctors who are based in Nairobi, Kenya. This is the first of two podcasts that I will be doing with AMREF. Today we’ll be learning about AMREF, what they do, and the impact of COVID19. So welcome, Joseph and Maggie. Thank you for joining us. It’d be great if you could tell us a little bit more about AMREF and the service that you provide.
Maggie Kariuki

0:00:57 – 0:02:09

Thank you everyone. As Deb has said, AMREF Flying Doctors is the largest, best known international ambulance services provider in East Africa and Central Africa region. We have been in the aeromedical industry for the last 60 years, acquiring huge wealth of experience, professionalism, and solid infrastructure. I would say that we were the first in the continent to be accredited by European Aero-Medical Institute, short for EURAMI, and twice the winner of the international air ambulance provider (ITIJ). So we have won that award twice, I think about 3-4 years ago and that award is the most prestigious award in the global travel health insurance industry and this is a true reflection of the exemplary effort put in by our highly trained staff. We are a social enterprise, owned by AMREF Health Africa, the largest health-based NGO in Africa, and all our profits are channelled to the NGO to support its vision of lasting health change in Africa.
Debra Harvey

0:02:09 – 0:02:17

And I know obviously in your business, which is quite important to us, is that you actually own all your aircraft, is that right?
Maggie Kariuki

0:02:17 – 0:04:01

Yes, we own our aircraft, so we have a unique blend of turbo props and jets. We own two PC-12s and two jets that are dedicated to our core business activity for aero-medical evacuation. We can evacuate patients locally, that is from the bush to the international airports regionally as well as to South Africa, Europe, Asia, Middle East by our private air ambulance or own commercial airline with our medical escorts. We have, ah, quite a range of the clients that is including and not limited to international insurances, assistance companies, corporates, defence forces, NGOs, government agencies and the public at large, including free evacuation on a charity basis to the poor community. All our medical activities are coordinated here in the office 24-hour Control Centre, which is accessible by telephone, mobile phone, e mail and fax. Even walk-in, allowing all our clients access to medical advice day and night. AFD owns four ground ambulances that complements our air ambulances. Three of these ground ambulances offer advanced life support and one of these is basic life support, which are used to transport the patient from the airport to the hospitals or vice versa within Nairobi. We also offer medical assistance services in the Greater Eastern Africa region to international insurances and assistance partners acting as a local and regional partner on their behalf in this regard.
Debra Harvey

0:04:01 – 0:04:32

Yes, I guess for us it’s that peace of mind that you do own your own aircraft. They are permanently configured as air ambulances. They’re not just private jets that have then had a medical team put on it. And absolutely, as you said you have a 24-hour business, so your speed of response and action, and that you’re fully accredited. So that gives us as a partner and your experts in East and Central Africa real peace of mind for our customers and our clients.
Dr Joseph Lelo

0:04:32 – 0:06:19

Allow me to add something there, Debra. We’re also proud to announce that we are acquiring a new jet. So it will be a medium size jet, that would be a Cessna sovereign. So with the medium range, it’s much faster and bigger and can take two patients so the acquisition should be complete towards the end of this year, so we’ll have extra capacity to be able to offer your clients more choice and a faster, more spacious aircraft to get them to the tertiary care that they so desperately need.

Let me add something about our staff. We have a fully dedicated, full time employed team of nurses who have an intensive care background. So they’re the ones who coordinate and manage patients on each and every flight. So this has been actually one of the challenges in that has been brought to us by this new outbreak of COVID that you realise that you simply never have enough staff. So we’ve had to expedite a recruitment, we’ve had to train even more. We’ve had to push longer shifts at times. So actually, COVID has brought in a challenge that our team has been able to meet quite well to be able to continue offering services. To date, we have carried out almost 300 COVID patient medivacs. So on average, we do about 900-1,000 medivacs per year. So the COVID bit is quite significant. On some days, we do five flights. So it is, it has become quite busy. There’s a lot of new challenges with regards to getting hospital space now. A lot of the hospitals we traditionally use are full, over 100% full. So it is a big challenge, but through our networks we’re able to secure beds for our clients in the region.

Debra Harvey

0:06:19 – 0:06:55

Absolutely. We found the same thing in terms of in our region organising any aeromedical retrieval or any transfer, COVID 19 has added an extra complexity and challenge, especially in terms of clearances, border closures and obviously getting an admitting facility. It sounds like with your network, you’ve been able to overcome those challenges and even been able to increase your resourcing and staffing with the impact of COVID 19. Is that right?
Dr Joseph Lelo

0:06:55 – 0:08:14

Yes, that is absolutely correct. I think that COVID is bringing out the best in some some sectors. So we have been quite busy, and I think we have a lot to be grateful for. Another challenge we face with COVID is a need for COVID testing for everybody. So there’s a lot of running around at midnight trying to get COVID tests for an emergency flight because the crew needs a negative test to be able to go to another country. Some countries are very, very strict with regards to testing and even for the patients as well. So whether you’re COVID negative or positive, a lot of authorities will insist that you have a test done within 72 hours before arrival, so this actually brings in a whole new aspect of having to get this test and coordinating and managing it and making sure that all members of staff and all patients have their tests quite challenging. Although we seem to have found a way to work around it. We have very good support from the AMREF lab so very fortunate that we do have a lab in our backyard that’s able to help with a lot of these tests. So again the challenge came and we rose to it and met it.
Debra Harvey

0:08:15 – 0:08:18

So you have your own lab. Is that right? For COVID testing?
Dr Joseph Lelo

0:08:18 – 0:08:48

We have a lab because AMREF is a big family. We are part of the greater AMREF which is our healthcare NGO so the healthcare NGO is right next door to us. It’s so to speak, it’s a parent of AMREF Flying Doctors, they’re the owners so they have a lab which we have a priority access to. They really help us a lot to do our testing. You can walk in now and get our results out before we get home.
Debra Harvey

0:08:48 – 0:09:00

Obviously we’ve used you for a lot of air ambulance retrievals into Nairobi. Why do you think there was an increase in the amount evacuations for COVID into Nairobi?
Dr Joseph Lelo

0:09:01 – 0:10:25

Nairobi is uniquely placed in the region in terms of being an advanced centre for health care. So you got, compared to the other cities in the region but a lot of private hospitals, very high standard accredited facilities. I think the facilities are JCI accredited so it’s as good as any hospital in the US. So a lot of our clients seeking advanced tertiary care at an accredited centre will want to come to Nairobi. Even ah patients within Kenya who need something advance for a serious medical condition will want to come to Nairobi.

So historical Nairobi has been the destination within the Eastern Central African Region even for actual central Africa. A lot of clients come from Central African Republic, Uganda, Tanzania, South Sudan, Ethiopia, Somalia. You’re welcome to Nairobi – even from the Indian Ocean Islands from Comoros, Madagascar will come to Nairobi for care. So we have been serving these clients traditionally but now with the strain on resources that COVID has brought into these neighbouring countries, it has increased which is unfortunate here. And also that has led to the hospitals in Nairobi now being overrun.

Debra Harvey

0:10:25 – 0:10:35

And are you still able to organise, obviously you do have the the private hospital facility and you’re able to organise beds quite easily with your network?
Dr Joseph Lelo

0:10:36 – 0:11:02

It’s not as easy as it used to be because the beds now are being given out on a first come, first serve basis. So if there’s a bed. But we have a lot of our colleagues working in this hospital so we seem to have a priority to be able to get these patients, once we have one, we’re able to coordinate that much quicker, and I’d say we have a bit of an edge to push more clients to get a bed.
Debra Harvey

0:11:02 – 0:12:07

Absolutely. I think in all the times that we’ve been working together and we’ve moved a lot of patients into Nairobi with your assistance that you’ve always been able to secure, I guess a bed and a specialist, what’s required for the patient. Because air ambulances, you’re not doing these for people who are not unwell or don’t need higher level of care. There is urgency for any aeromedical because it’s not without risk when you’re moving unwell people as you know, but I think that’s that speed of response and that you’ve got a bed and a specialist and if any surgery’s required, it’s done in that very fast response time.

So I guess we’re all aware of how complex aeromedical retrievals are from the time we make the decision that someone needs to be moved medically to a higher level of care in an emergent situation. We send you, activate you guys by sending you an email. Can you talk us through what happens from the moment that you receive our activation and providing a quotation?

Dr Joseph Lelo

0:12:07 – 0:13:53

From the moment we receive a request from the client in this case, WTP, the request would come in through email or on phone, and our 24 hour control centre staff will be able to pick up this email and escalate it to the relevant department. Our 24-hour Control Centre has got a medical side as well as an operation side. So we’ve got 24 hour medical teams as well as the operations team that look at every request and begin the logistics. The medical team will look at what it takes medically whether the patient is fit to be flown. If there’s any special requirements, we look at getting the right specialists and the right hospital, getting the right team on board the aircraft to be able to move the patient.

So whilst that is going on, the operations team will look at the whether the airstrip is open, whether the aircraft is available, whether there’s any special landing permits needed or any clearance needed. They will also look at any security requirements or security challenges that maybe exist in that particular airfield. So while that goes on, there’s a lot of communication internally and also outside to WTP regarding the patient. And once the movement has begun, WTP will be updated at all stages of the movement to ensure that they’re also able to communicate with their client on their end, make sure that everybody’s on the same page with regards to efficiency and coordination. And once a patient is handed over at the destination hospital, we will provide the summary of the movement and send this work to WTP and also we’ll be open to receiving feedback as well.

Debra Harvey

0:13:54 – 0:14:45

Absolutely. I guess that’s what we find as well, it’s obviously the medical once we’ve made the decision that someone needs to be to be moved emergently. It is the logistics of all the things that you were talking about that have to be done correctly, or obviously it can all end up not a great place in terms of obviously, you’ve got the extra complexities in Central and East Africa and certain locations where you are expert. So you understand all of those, the security night landing, payments of hospitals who won’t accept the guarantee from overseas insurance. So it’s that local knowledge and local expertise is really important.

Now Maggie, recently you assisted our Canadian assistance team with a really interesting case. Can you tell us a bit more about that?

Maggie Kariuki

0:14:45 – 0:18:31

Thank you, Debbie. Now just to add on what Joseph has said, it is important to know that the Kenya government allowed a lot of foreigners to come into the country for medical attention, including those who are COVID 19 positive.

So I’ll go through the case we had with the Canadian office – Bagram to Entebbe. We experienced a lot of the difficulties with this case, and especially in Uganda, where they were not allowing anybody, including their nationals, back home. And you had to go through a series of permits. We had to obtain a landing permit from Uganda’s Civil Aviation Authority, Minister of Health, Ministry of Transport, public works and military. This would take a couple of days because our agent had to walk from one office to the other and I think it took approximately four working days.

Now the other challenge we had was most of the countries were not allowing any foreigners, even flight crew, to direct stop in their country and the reason why we did this flight with another provider. So they picked the patient brought to us in Oman and we picked the patient from Oman. We couldn’t even be allowed to make a stop in Entebbe or in Uganda. So the crew had to drop the patient and turn back to Nairobi. Now, this was challenging because of crew duty time, which is very limited. But we had no choice in this case and the crew went over duty. But obviously there are regulations that took care of that, which is what we applied in this case. But the most difficult part was even by ground ambulance to pick up the patient was the one that was coordinated by the COVID 19 coordinator and the patient was picked by military ambulances. To put all this together would take time and there were a lot of logistics required.

And just maybe to add to that, we also did a similar case again from Bagram. I mean, Bagram in Afghanistan, back to Nairobi. And this time we’re coming to Kenya. So clearances we would take care of them but on the other side of Bagram and Oman. We had a lot of challenges to be allowed to do our wing to wing with a COVID positive patient and the authorities demanded that the wing to wing provider who was bringing the patient from Bagram – where again, you cannot be allowed to night stop in Bagram, it’s a military air base, and they wouldn’t allow, normally they do, but this time they wouldn’t allow because of COVID 19 protocols and we had to do it to the wing to wing provider. Now, in Oman where we were doing this handover of the patient from the aircraft to aircraft. They said we will allow you if the patient will not leave the isolation pod, meaning we take the isolation pod to our aircraft and they take ours, which it’s not possible. It’s not even compatible, so again we had to go through so much negotiation with authorities on both sides. There were challenges in getting beds because within East Africa it is only Kenya that was accepting foreigners to come into the country who are positive. So therefore, hospital beds in this case, were a bit off a challenge. But because of our connections with hospitals, with the government, we have tremendous support from the Kenyan government and this would enable us, though uphill task for us to deliver.

Debra Harvey

0:18:31 – 0:19:09

I think it sounds like your experts at overcoming the challenges with logistics of moving COVID positive patients, especially when you’re dealing with multiple countries, borders, legislative requirements. So it sounds like, obviously, just moving people normally who are unwell by air Ambulance is complex, but COVID has added that extra complexity to any case, especially when you’re moving people who are critically unwell and you need to move them to a higher care acuity level.
Maggie Kariuki

0:19:10 – 0:19:57

Thank you, Debbie. I’d say it’s true, we’ve become experts and we have a lot of support with a lot of the government and even innovation industry. They understand medivac, and there is, as they support from all the providers in the field. But when COVID hit in a lot of people, including the industry providers there were some challenges no one knows what happens and they put a lot of regulations and protocols that you had to meet before even moving a patient to a next, then the authorities will ask, send us the pictures in the SOPs that you’re going to use bringing back patient into other country. But most of the challenging part was normally with allowing you to night stop in their country.
Debra Harvey

0:19:57 – 0:21:14

I guess no one ever anticipated the impact of COVID 19 on our businesses. I remember in December hearing about potentially the COVID 19 and thinking oh this will pass in maybe a month or two and then as it then got declared a pandemic and global travel basically ceased, which I’ve never seen in my 20 years in the business. But I think it’s made us more resilient as assistance companies, in terms of you can really see our strength in terms of finding a solution. If there is a need, I think we will always try and find a way of assisting our customers so they get the care in a timely manner in an emergency situation. So I guess that has changed during COVID in terms of risk management, because before COVID air ambulances are not without risk when you’re moving people who were critically unwell, who are coming from very basic care to needing higher level of care. What do you think has changed for you with the pandemic in terms of risk management and all the extra complexity that evacuations now involve?
Dr Joseph Lelo

0:21:15 – 0:24:27

I think maybe on a positive note, I’d like to add that the difficulties we faced with these Bagram cases are no longer no longer the situation currently because I think the the governments we were dealing with at the time became more more reasonable. And actually I think with more knowledge and the information streaming across about COVID and actually with COVID being now in almost every corner of of Africa, I find there’s a bit more acceptance it’s just that the health care infrastructure is really not ready to cope with a huge influx patients. And I think that was the intention of these governments was trying to protect by locking down and shutting out the people who might be infected from coming back in. So the situation has changed. I think improvements are being done everyday now, a lot of capacity being built in terms of intensive care, oxygen generators that so there is hope. It’s not moving as quickly as we would like, you know, our neighbouring countries. But I think it’s a positive thing that COVID did show where the weaknesses were. A lot is being done in that respect with regards to risk management. I think we’ve had a lot of internal review of our SOPs with regards to risk, we’ve recently reviewed our risk matrix and incorporated all these new risks presented by COVID. We also see some opportunities. But there has been a lot of documentation and review of the risk management procedures with regards to operating in this new environment. Now I think it’s it’s the new normal. So there’s, I think, one of the risks. I would put across at this point on being unable to move a patient simply because a country in between where you need to stop for fuel has said no, you cannot fuel here, so it’s a lot of risk, a lot of long crew duty. As you may be aware the crew are limited to not more than a 15 hour shift.

So if you already stretching that shift to go pick up a patient and come back without an overnight stop at the other end. You’re basically at limits, so you tend to go to 16 hours and fatigue, crew fatigue, is also a risk, so there’s a lot of risk mitigation. Risk avoidance procedures that we have put in place. The trend to reduce the risk of this kind of stretching we do. The fatigue is compounded by the fact that the crew have to wear PPEs, you know, keeping a mask on all the time. So it is a big challenge, especially to the pilots who have to speak on the radios wearing these N-95 masks. But there’s reason to it and they’ve really improved. And I think the efficiencies that we’re seeing now as a result of COVID I think I’ll take that away as a positive because we’re working as a well-oiled machine now. We’re proud to be able to serve our clients in these challenging times.

Debra Harvey

0:24:27 – 0:25:55

I say the same thing to our team. If we can get through a pandemic with all the challenges, we can get through anything because I think nothing has challenged our business and our team as much as COVID 19 has. I think it has been a very difficult 12 months, but it’s good to see that I think we’ve had this time and been able to prepare and strengthen our teams and our processes and be very confident that we can move patients during a pandemic. And I think it’s amazing in terms of Kenya still keeping their borders open, taking foreign nationals where the other obviously other countries in Africa weren’t comfortable doing that. And I think it’s a testament to the service you provide that you’ve done what over 300 COVID 19 missions. So I guess I think thank you for your time today and I really look forward, there’s a lot more to talk about it. We’ve just kind of touched on the services that you provide. The impact of COVID 19 it’ll be great when we catch up next time that we’re focusing, obviously, in terms of Central and East Africa aeromedical evacuations, the assistant services you provide that we touched on briefly, I guess as travel resumes what you need to know if you’re going to be travelling for our clients, our customers and employers. So thank you.
Dr Joseph Lelo

0:25:55 – 0:25:58

Thank you Debra, it’s been a pleasure.
Voice Over

0:25:58 – 0:26:25

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