RYAN COPELAND; RENÉ DE JONGH
Repatriation means returning the individual to his or her usual social, cultural and medical environment. If, after disembarkation for medical reasons and an appropriate initial clinical review, the seafarer is not fit enough rejoin the ship, the voyage or the fleet for the near future, repatriation may be necessary.
In certain medical conditions, this may represent the best chance of preserving a productive career for the individual, as well as retaining skilled and trained seafarers in the industry. Even if neither of these outcomes is feasible because of the severity of the underlying pathology, timely repatriation can help ensure the best possible outcome for the seafarer.
There will be individual cases where the patient returning to their home country will not result in the best outcome because of the standard of medical facilities and care in the patient's home country. Fortunately, these are rare and it is important to find the right balance between the benefit of ongoing relative isolation of the patient in excellent clinical facilities, and the inevitable disadvantage of staying overseas without family and social support and struggling to recover in an unfamiliar culture.
All stakeholders involved in making the decision as to when to repatriate a seafarer must be aware of the advantages of staying, and the advantages of going home.
D.11.2 Fitness to fly
Before travelling, all patients must be assessed as to whether or not they are “fit to fly” - whether they are to move by air, ferry, train or car. This is a risk assessment and must take into consideration the patient’s medical condition along with the medical capability of the current treating facility, wherever that may be. For example, if a patient is continuously bleeding in a location where there is neither surgery nor blood available, yet is deemed 'unfit to fly', they will inevitably die; if transport can be safely arranged then the risk of moving is less than the risk of staying. Conversely, if they are hospitalised in a location where surgery and blood are available, the risk of moving them closer to home before they have surgery is of course far greater than the risk of not moving them until after surgery and transfusion.
The risk-benefit calculation for repatriation is quite different. Patients should be medically stable before repatriation, and that is a clinical assessment.
D.11.3 Physiology of flight
Fortunately, modern air travel imposes relatively minimal medical stress on travellers and patients. The cabin of a commercial aircraft is pressurised to a maximum altitude of 8000 feet (2440 metres),  with a subsequent drop in pressure from 1 atm at sea level to 0.75 atm when flying. This fall in pressure has two significant physiological effects in humans:
- There is a fall in oxygen saturation i.e. the amount of oxygen carried around by the red blood cell. Whilst the air at altitude is still 21% oxygen the partial pressure of oxygen is reduced in line with the fall in atmospheric pressure and becomes 0.75 x 0.21 = 0.16 atm. Hence, a reduced amount of oxygen enters the lungs and consequently, the level of oxygen circulating in the blood is lower than at sea level. This fall in circulating oxygen is scarcely noticeable in normal passengers but may affect those who have an underlying cardiac and/or respiratory condition or where end organ oxygenation is critical. Fortunately the degree of that fall in saturation in people with pre-existing medical conditions is predictable, and can be corrected by having the patient breathe supplementary oxygen.
- . Boyle’s law states that at a constant temperature, the volume of a gas is inversely proportionate to the pressure’. Hence, in an aircraft cabin any gas will expand in volume as the pressure falls compared to at sea level. In the context of commercial aircraft this represents an increase of volume of any gas by approximately 30% at cruising altitude. Note the effect on a bag of crisps or a bottle of water. Drinking gassy liquids at altitude has a result that is predictable but manageable on a personal level. However if air is trapped inside the head, chest, abdomen, tooth or other places where it shouldn't be at all, or where it is present at larger than normal volumes, difficulties can result.
Clinicians aware of the physics and physiology of commercial flight can readily foresee the potential results of these changes. After assessment by suitably qualified physicians, appropriate recommendations for the transport of people who may suffer ill effects in flight can be made. Staff to be included in this risk assessment, after appropriate briefing, include the patient’s treating physician, the airline medical department, others responsible for the ongoing care of the seafarer and assistance company staff, if they are involved.
D.11.4 Practicalities of travel
The decision that the patient is fit to fly also needs to take into consideration
- the underlying nature of the medical condition, the response to treatment and ongoing care requirements.
- Is the condition as stable as can be expected in the near future?
- Has there been a good response to treatment to optimise the condition at the current time?
- Can any ongoing care requirements be met during the journey e.g. wound care, administration of medication, monitoring.
- the mode of transportation and length of transfer.
- How long is the total journey time and therefore the total time away from full medical care?
- Can appropriate care be received in any destinations en route if necessary?
- Can the patient’s needs by met in transfer airports, ports etc.
- the mobility of the patient and their ability to self-care, see below.
D.11.5 Who should make the decision?
There will often be several stakeholders involved in making the final decision and each will have an opinion. That said the final decision as to whether someone is fit to fly is always that of the seafarer - or the relatives if the seafarer is unable to give informed consent. It is both fair and appropriate that he should be informed about the options and risks, and give informed consent. In addition, that the transport should be carefully arranged from logistics’ and medical points of view, to keep the seafarer safe, comfortable, and eliminate avoidable risks.
Relying solely on the treating specialist for his or her opinion about the seafarer’s fitness to fly home can be problematic. There is no specific training during undergraduate and postgraduate medical education for doctors and nurses about transporting patients by air and/or over long distances, unless they have specifically obtained experience in aeromedical transportation. The treating doctors’ medical expertise on the condition he or she is treating the patient for must be respected. However, recommendations for the timing, mode, routing, and medical or non-medical accompaniment on the repatriation flight should be made by people familiar with risk assessment in these circumstances and with the knowledge of the logistics, aviation and clinical limitations of flying patients. This is important because there is a considerable inconsistency even among specialists in their own field of expertise, about appropriate timing of travel after medical procedures.
D.11.6 Options for repatriation
When medically appropriate and feasible, utilisation of scheduled airlines is typically the preferred method of repatriation. Repatriation planning includes assessment of the medical condition and related inflight monitoring and treatment needs, any mobility related restrictions and any airline specific medical acceptance guidelines. Repatriation options could include:
- Commercial airline seated and unescorted
- Commercial airline seated with a non-medical escort
- Commercial airline seated with limb elevation, with or without a medical escort
- Commercial airline with flatbed, with or without a medical escort
- Commercial airline with stretcher, medical escort/s mandatory
- Air Charter flight with appropriate escorts
- Air Ambulance flight
D.11.7 Airline guidelines
Well-managed airlines are understandably averse to unpredictable medical outcomes on board their flights. In the interests of helping people travel for whichever reasons the traveller desires - including travelling to medical care, and travelling home after care – airlines usually have their own comprehensive guidelines on medical fitness to fly. Since there is plenty of time to plan repatriation (as opposed to an emergency evacuation) there is always time to get airline medical department clearance for repatriation of the ill and injured seafarer.
The majority of the top-tier airlines publish online the forms that are required for the assessment of the intended patient transport by their in-house or out-sourced medical advisors. In addition, they also provide online a set of guidelines accessible to all doctors involved with the seafarer's care, and of course, easily read by seafarers themselves, family and friends. The guidelines do differ quite considerably between different airlines even for identical pathologies, so it is best to identify the preferred airline early in the process and meet their requirements. Generally, using the airline of the seafarer's own country is a good idea if it is feasible. Many airlines see helping citizens get home as part of their duty as their nation's flag carrier. It also means that the seafarer will be back in a somewhat familiar language and cultural environment once they board the aircraft.
Usually, the airline requires the treating doctor to complete the MEDical Information for Flight Form (MEDIF) and that doctor carries the responsibility for ensuring the airline medical department has all the information they need to approve travel.
The International Air Transport Association also publishes a medical manual that provides a very detailed overview of some these considerations and specific airline clearance recommendations.3
D.11.8 Mobility and assistance issues
As well as any medical issues that may affect the passenger on board, the airlines are also concerned with the mobility and independence (or lack of) of travellers and patients. Airlines advise that all travellers need to be responsible for their own safety as well as health on-board. Cabin crew are not medically trained, the very basic airline medical kits are not available for access by passengers on demand, and very specifically, passengers need to be either independently mobile, or have a travel companion who can assist them physically in and out of their seat and moving around the cabin.
In the event of an emergency, all personnel and passengers must completely evacuate the cabin within 90 seconds. The crew will be more than fully occupied getting the passengers moving, and cannot be responsible for helping individuals to the exits. Although this is a highly unlikely scenario, it is a significant part of the reason why passengers who cannot manage their own mobility must provide a medical or non-medical escort to help them.
More likely, individual travellers may require assistance with normal in-flight activity such as getting to and out of the seat to go to and from the lavatory or galley. This can be challenging for people who are long-term disabled but not convalescent; it can be much more difficult for people who are acutely immobile and convalescent. Many such patients also require access to the lavatory more often than usual, plus physical help inside the lavatory, as well as medication inflight. An experienced, competent and willing person travelling in the same class as the passenger and seated next to them must provide any assistance. It is not the responsibility of cabin crew.
Outside the aircraft cabin, physical assistance is readily available. Both by law and by custom, airlines are well set up to provide on the ground assistance to people who find it difficult to move about an airport easily. Special assistance is easily available to passengers who may need help such as the elderly, those people with a physical disability, such as wheelchair users and people on crutches. This help should be requested at the time of booking, and is especially but not only useful during layovers or short-time connections.
A small but not trivial percentage of repatriations involve surface transport by boat/ferry, plus train and car. Mobility and hygiene issues do not disappear because the patient is not in an aircraft; so the plan should account for every support and activity needed for the patient to travel safely and comfortably, just as for air transport.
D.11.9 Medical care in flight
In certain circumstances a medical escort may be recommended to accompany a returning seafarer depending on the medical condition, mode of transportation and geographical distance to be travelled. Medical escorts are recommended for specific medical needs that may include:
- Administration of intravenous and/or oral medications
- Monitoring of key vital signs typically during flight to assess any changes due to the physiological challenges described previously
- Support with medical interventions during transportation (such as suctioning of secretions, changing of wound dressings, administration of intravenous fluids)
- Supervision and support of safe mobilisation for those seafarers with reduced mobility
D.11.10 Role of medical assistance companies
Numerous considerations need to be addressed when planning for the repatriation of a seafarer. It is critical that the coordination of these steps is carried out in a methodical manner to allow for the safe, considerate, coherent and cost-effective transportation of seafarers from the hospital of first admission after disembarkation, to their home. The seafarer, family, employer and receiving medical team also benefit from effective, frequent and accurate updates to ensure a successful transfer of care. The key decision points that need to be addressed include:
- Confirmation that repatriation is medically appropriate and reasonable
- Confirmation of fitness to fly/travel recommendations
- Consent for repatriation
- Identification of the most suitable mode of transportation
- Confirmation of medical clearance for travel
- Allocation of appropriate medical escort/s and any equipment that may be required during the repatriation
- Arrangement of appropriate receiving care in the home country if the seafarer cannot return home
- Confirmation of required travel documents including visas if required
- Financial approval for repatriation
To ensure continuity of care it is very important to confirm that appropriate arrangements are in place for the returning seafarer. The requirements will vary depending on the nature of the underlying medical condition and the need for ongoing care. The seafarer’s family doctor may fill this function, or, more acutely, the arrangement of an inpatient admission to a ward with an appropriate specialist and/or multidisciplinary medical team to resume both active treatment as well as long-term placement and rehabilitation, may be necessary.
The role of the arranging physician and team needs not only to focus on the medical needs of the seafarer and the resultant recommendations around the requirements and rationale for repatriation, but also taken into account numerous logistical and insurance related considerations.
Medical assistance companies are in a unique position to arrange and manage such events. They often have offices and agents around the world, access to appropriately trained medical escorts with the necessary equipment, extensive knowledge of the logistics required and, of course, this is their business. Without this expertise, the risk of a step being missed or poorly coordinated is much higher, as care is often fragmented and responsibilities are scattered through different countries and across different time zones.
(1) Civil Aviation Authority. CAP 393 Air Navigation: The Order and Regulations. London: Civil Aviation Authority, 2003
(2) Federal Aviation Administration. FAR Code of US Federal Regulations. Parts 25, 121 and 125. Washington, DC: US Department of Transportation, 2004
(3) International Air Transport Association. Medical Manual 11th Addition. IATA Publications, 2018. https://www.iata.org/publications/Documents/medical-manual.pdf
 Civil Aviation Authority. CAP 393 Air Navigation: The Order and Regulations. London: Civil Aviation Authority, 2003
 Federal Aviation Administration. FAR Code of US Federal Regulations. Parts 25, 121 and 125. Washington, DC: US Department of Transportation, 2004