December 02, 2019 -
On water, on land and in the air - the ambulance service of the ADAC brings injured and sick patients from all over the world home. For the most urgent cases, aircraft equipped with intensive medical care take off from Nuremberg. Always on board: flight doctors from a pool of 80 experienced specialists.
When a new inquiry arrives, the specialists begin to collect information. Many of them have already worked as paramedics or nurses. Next door to the doctors, it is then a matter of getting a well-founded picture of a situation that is often one or two continents away. This is where the web-based telemedicine system Case.iocomes in. The previous version of Case.io was originally developed as a second opinion system for the several projects of the Swiss government, the UNFPA, and LuxDev, model country was Mongolia. An adapted version is in use on the computers in Munich. Doctors from Indonesia to South Africa can upload files directly. They receive an email link that they can use exactly once and exactly for this purpose, which guarantees data security.
MUNICH. The Learjet 60XR is a state-of-the-art aircraft that can fly up to 860 kilometres per hour and up to 3800 kilometres. It is the fastest aircraft with the longest range in the ADAC international flight service flight pool. There is also a Beechcraft Super King Air 350 and two Dornier Fairchild 328-300 jets. They are provided by Aero-Dienst GmbH & Co. KG in Nuremberg. At least two aircraft of the ADAC-Ambulance Service are on the move every day, often all four of them. The passengers, however, usually don't notice anything of all this.
Because in such a machine only sick or seriously injured fly, whose condition makes a flight employment necessary. Heart attacks, strokes or serious injuries are particularly common. Then one of the intensive care airplanes takes off from Nuremberg and picks up the patient so that he can be treated in a clinic close to his home.
Andreas M.'s reason for flying was a severe infection. Breathlessness, weakness, organ failure - suddenly the 43-year-old Upper Bavarian's trip to Mexico became a life-threatening exception. In spring 2016, an ambulance pilot took him to the University Hospital in Erlangen, where he was taken to intensive care. He was one of the few who received Extracorporeal Membrane Oxygenation (ECMO) during the flight.
That saved his life. Only since 2012 the On Board ECMO is possible with newer, smaller devices, and only in the Dornier Jets. Flight physician Dr. Michael Meyer was in Mexico with some colleagues. It was a successful mission, he sums up. At an event day at the ADAC headquarters in Munich, he gave insights into his work. Ambulance operations are also coordinated in the triangular high-rise tower with its colored windows.
Meyer has been on the international flight service since 1993 and has accompanied more than 1000 flights. He has been in charge of the service since 2009 and coordinates the work of about 80 doctors. He himself now flies less frequently, and there are still about 25 missions per year. "Someone has to organize the whole shop," he says and laughs.
Half the time, Meyer is senior physician at the Anaesthesiology Clinic of the University Hospital Erlangen. This is similar with most other flight doctors. They have a lot of experience, they get extra training for the airy special missions. In 2016 alone, flight doctors, paramedics and pilots brought more than 1250 patients home. That is only a fraction of the foreign care. At 55,000, their number was higher than ever before. There were 2750 scheduled home flights accompanied by doctors, several thousand ambulance repatriations, but the most frequent were on-site care abroad.
All this requires a comprehensive deployment network. It is coordinated in the Ambulance Service Offices on the second floor of the Munich ADAC headquarters. Processing, the medical area and flight scheduling are next door. In total, there are about 100 employees, and 23 doctors work shifts in the medical area. There are general practitioners, orthopaedists, heart surgeons, paediatricians and many other specialists. They are networked throughout Europe with 14 other colleagues in smaller emergency centres, for example in Greece, Croatia and Turkey. This simplifies language matters, and local knowledge is also helpful. The physicians have years of clinical and practical experience. In the head office, they use a computer mouse and telephone receiver instead of a scalpel or ultrasound.
Dr. Irmgard Seidl knows that this is not necessarily easier. "It is incredibly difficult to assess anything by telephone contact," she explains. Seidl's desk is at the head end of the open-plan office. She has been in charge of the medical department for six years and has built it up considerably herself. She has been with the ADAC for two decades. Often there are many hurdles between the doctor and the information that allows him to make a diagnosis. There is the distance, the language, the fragmentary details that have to be checked and often put together step by step.
It is not always a matter of life and death when a telephone rings and the case is passed on to the physicians after the basic recording. But they always have to reckon with that. "If a patient in Albania has a heart attack, but the catheter laboratory there is broken, we have to fly there immediately and fetch him," said Seidl.
Depending on the country, situations can also become dramatic that could easily be solved elsewhere. In Central Africa, a broken arm can be a difficult problem. To guide the affected person to the doctor quickly becomes a mammoth task due to the poor infrastructure. Seidl is currently having acute headaches with a Sri Lanka traveler with severe dengue fever. The doctors in the country are generally able to treat the disease well. But the patient first has to go to a suitable place. Once again, the main problem is the infrastructure. "You can't even imagine that, and patients often can't even imagine it beforehand," says Seidl.
Again and again doctors have to deal with avoidable situations. Traveling to La Paz at an altitude of 4000 meters with a severe, chronic lung disease? Not necessarily ideal, says Seidl. In her time as a resident internist, she urgently advised patients against such a thing. But many didn't even tell their family doctor that they were going away, let alone where. "I'm wondering," she says.
When a new request arrives, the staff begin to gather information. Many of them have already worked as paramedics or nurses. Next door to the doctors it is then a matter of getting a well-founded picture of a matter that is often one or two continents away. This is where the CASE IO system comes in. It was originally developed as a second opinion system for the World Health Organization (WHO), model country being Mongolia. An adapted version is in use on the computers in Munich. Doctors from Indonesia to South Africa can upload files directly. They receive an email link that they can use exactly once and exactly for this purpose, which guarantees data security.
However, modern technology does not change the fact that information sometimes drips only sparsely. In other cases, the doctors receive everything that is possible without personal patient contact - results of imaging procedures, photos of injuries, even catheter videos were already included. All this should help to decide: to treat on site or to collect? When it comes to transport: When, where and how?
The means are many, be it an island boat transfer in Thailand or a flight in a seaplane in the Canadian wilderness. A mule once dragged a hiker from a remote region in Norway to his car. The man could no longer walk well because of a blood blister. The helicopter he first asked for was classified as disproportionate. But the ADAC could borrow the mule of the hut owner for 150 Marks. "The helicopter doesn't fall from the sky everywhere", Seidl concludes. After all, every ambulance flight means costs in the five to six digit range.
An internal database documents the care situation in thousands of clinics worldwide. Each doctor assigned internationally answers evaluation questions in order to classify the clinic. When Seidl travels, she likes to take a look at one or the other hospital. Because if you didn't take quality seriously, almost everything would be treatable almost everywhere - and it would hardly ever be medically necessary to pick up a patient.
The Ambulance Service takes into account medical care, nursing care, hygiene, equipment, specialisation and therapeutic standards when deciding whether a patient needs to be picked up or not. So it can be that a patient is picked up from clinic A of a metropolis, while he can stay safe at hospital B.
If a flight is scheduled, hurdles can still arise. "It happens that an official with the patient's passport disappears at customs and no longer appears," reports Claudia Dickhäuser. The dispatcher coordinates flight routes. Clocks for all time zones hang next to her on the wall, a map of the world on another. The Follow Me car can also become a hurdle if it takes a long time. Without it, the ambulance can't get on the airport taxiway, the patient can't get on the plane.
Sometimes it is the flight doctor himself who stops a flight. Namely when it might otherwise be too dangerous for the patient. An unexpected complication, a need for special equipment - in such cases it is necessary to weigh up and, under certain circumstances, re-coordinate. After all, the aviation physicians are responsible from the moment they are taken over. "They are alone on site and have to decide everything on their own," says Meyer. "Such things are, of course, highly complex.