The Planning and Approach to Transporting a Patient on Extracorporeal Membrane Oxygenation Across the Globe
In August 2021, AirMed International set out to complete a transport that most would consider impossible. They needed to move a COVID-19 patient on extracorporeal membrane oxygenation (ECMO) from the West Coast of the United States almost 8,000 miles to the United Arab Emirates – in the middle of a global pandemic. The trip required 14 days of planning and a whole lot of oxygen. This article tells the story and revisits the challenges and lessons learned from what could easily be considered the world’s longest ECMO transport.
Part of the Global Medical Response family of solutions, AirMed International is a leading air medical transportation company. They operate a fleet of customized and medically configured jets across three main locations – Birmingham, San Antonio, and Las Vegas as well as a floating fleet of aircraft out of Ypsilanti, Michigan – and their teams travel the globe providing care at a moment’s notice. AirMed’s flight crews consist of highly skilled pilots, flight nurses, flight paramedics, flight respiratory therapists and physicians who are trained to provide specialized medical care from bedside to bedside. AirMed also partners with renowned hospitals and specialty transport teams throughout the United States to provide an expanded scope of clinical care, including ECMO transports.
Two Weeks of Planning and a Whole Lot of Oxygen
Caring for an ECMO patient is a balancing act. From heart rate and blood pressure to oxygen levels, blood gases, and anticoagulants – every aspect of the patient’s heart and lung function must be carefully monitored and controlled. To move a COVID-19 patient on ECMO is even more of a balancing act – especially when it’s a 30-hour journey across five countries in the middle of a global pandemic when there are shortages of medical supplies and oxygen, international travel restrictions, and space limitations due to the size of the aircraft.
Planning the transport took two weeks. In July of 2021, Dr. Djaoued Bedjaoui, a senior officer at the UAE Embassy in Washington, D.C., contacted AirMed International to inquire about their abilities to transport a patient from the West Coast to Dubai. Brandon Bates, senior director of global strategy for AirMed would take the challenge along with the entire AirMed team on planning the logistics of the transport. Bates immediately connected with Dr. Bedjaoui to review the complexities of the case and the needs for the transport.
“The patient presented an extremely challenging clinical case which included COVID-19, pneumonia, acute respiratory distress syndrome, pulmonary embolism and pulmonary hypertension as well as bilateral pneumothorax,” said Bates. “In addition to the clinical presentation, we were facing a whole host of other challenges related to the pandemic and the amount of equipment the transport would require.”
The AirMed team worked quickly to piece together a very complicated puzzle. Working alongside Bates to plan each detail of the transport was Amber Payne-Gregory, director of Medical Operations for AirMed; Michael Doty, program manager for AirMed; the AirMed Clinical Coordination team; Chief Pilot Josh Kalil; Flight Nurse Jeremy Fails; Respiratory Therapist Xavier Ritchie; multiple pilots; the AirMed Dispatch and Global Operations Centers; Dr. Bedjaoui of the UAE Embassy; and the ECMO Transport, LLC., team led by Dr. Jeff DellaVolpe.
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The team meticulously mapped out the 8,000-mile journey, making sure to account for the pre-positioning of flight crews, landing permits in each of the five countries, COVID-19 testing for every passenger per individual country guidelines, and of course, oxygen consumption. Oxygen was a primary concern. The patient’s COVID diagnosis and the ECMO device and ventilator dependency meant that oxygen usage would be high.
Additionally, resupply along the route would be especially challenging due to COVID-19 restrictions, oxygen shortages and limited cabin space in the aircraft.
“COVID patients consume a lot of oxygen during normal processes, but you add in the ECMO modality, and that consumption increases significantly,” said Payne-Gregory. “So much so, that a lot of times that is the reason these patients can’t be transported. Not every service provider has the liquid oxygen capabilities that we do. Specifically, not the capabilities to perform a 30+ hour long transport.”
As Payne-Gregory and the clinical team worked to address oxygen concerns, the team at ECMO Transport had to develop a plan for downsizing their equipment and ensuring that placement in the aircraft was streamlined for providing care during the flight.
“As we planned the logistics of this transport, it quickly became apparent that space was going to be a challenge,” said Bradford Anderson, lead perfusionist for ECMO Transport, LLC. “We flexed and downsized our equipment as much as safely possible. We also developed a plan to stage our bags in a way that would allow the medical teams to quickly deploy additional equipment if needed.”
While the team worked out the logistics needed to complete the transport successfully, they also needed to account for the potential that the patient’s condition could deteriorate quickly during the flight. If that happened, they would need to divert to the nearest hospital facility. However, with ECMO capabilities not being widely available, developing a secure set of contingency plans would be difficult. When considering diversion stops, international healthcare systems had to be considered as others are not as advanced as the United States.
The AirMed team worked through every detail of the transport while the embassy made final preparations of their own. Within 48-hours of receiving confirmation from the embassy that they were ready to proceed with the transport, every piece of the puzzle fell right into place. The AirMed team had all necessary plans, briefings, and travel approvals completed.
One day in early August, the AirMed flight crew departed Birmingham, Alabama, and headed for San Antonio, Texas. In the lone star state, they picked up Dr. DellaVolpe and his team and continue their journey westward to pick up their patient.
A 30-Hour Journey
After a crew rest period upon arrival on the west coast, the team conducted a pre-transport visit to the hospital to ensure the patient was stable enough for transport and that they were prepared for what the next day and a half would bring.
“On the day of the transport, it took us a significant amount of time and effort to get the patient prepared to even leave the hospital,” said Fails. “Once we were ready, we departed the hospital in an ambulance and headed for the airport where we would load the patient onto the aircraft.”
As soon as the wheels were up, the AirMed Global Operations Center began the meticulous process of tracking every aspect of the flight.
“Our global operations team was responsible for monitoring all aircraft movements, reporting all take-offs and landings, technical stops, and providing patient updates to our customer,” said Bates. “Their constant communication ensured that the embassy remained informed, and the clinical and medical operations departments could provide remote monitoring and reporting on the patient’s condition to the receiving hospital.”
The team planned the journey in four legs. At each stop along the route, they refueled, refilled needed oxygen supplies, provided critical patient updates to the global operations team as well as the clinical coordination team, completed necessary pilot rotations and have meals. From Minnesota, the crew headed to Newfoundland, Canada –- and then on to Ireland and Greece —before arriving in Dubai. In total, they completed three pilot rotations and 30.5 hours of continuous patient care.
The complexities of planning this transport meant that the AirMed and ECMO transport teams were prepared for any possible scenario and that resulted in a completely unproblematic transport. After nearly 31 hours of travel time, they touched down in Dubai where they accompanied the patient to the receiving facility and successfully transitioned care to the hospital providers.
AirMed, like all air medical providers, are known for successfully managing bedside-to-bedside transportation for critically ill and injured patients on an international scale. However, the pandemic has added several complex layers to what was already considered a detailed and intensive process. AirMed must now account for travel restrictions, COVID-19 testing, supply shortages, oversaturation at hospitals and a whole host of other issues. When all those factors are added to a complex clinical presentation, the stressors of coordinating and completing a successful transport increase significantly.
However, with comprehensive planning, proper preparation and the right resources, complex and long-distance transports can be completed safely and successfully, even during a global pandemic. In the case of the longest ECMO transport, having the input and oversight from internal experts in aviation, clinical, operations and dispatch along with the expertise of the perfusionists from ECMO Transport, LLC., was vital in accomplishing this mission. With no clear end to the COVID-19 pandemic in sight, providers must continue to evolve its processes, planning and training to support the realities of providing care during these uncertain times.