Ground ambulance options

The repatriation of a patient is a complex process that involves decisions by many different parties in the assistance chain. While we often talk about the air ambulance sector within ITIJ as part of this process, Mandy Langfield explores its ground-based counterpart, the road ambulance

Not all terrains and geographies lend themselves well to ground repatriation services, but others are remarkably well adapted. Where road networks are of a good quality, the ground ambulances that use them are basically rolling intensive care units, and the care provided by the medical personnel onboard is the same as you would expect in an air ambulance. Across the world, ground ambulances are commonly used to repatriate people or move patients between medical facilities, where this is a logistically feasible and cost-effective transport option. ITIJ spoke to Jane Hegeler of Tangiers International about how the company views ground ambulance transports differently in various parts of the world: “There are areas in the Middle East and Africa where flying restrictions, or no fly zones, may result in ground transfers. When air travel is contraindicated by our medical team, but the patient needs to seek treatment at a higher level of care facility, we would opt to use ground transportation.  Every case is different, and decisions are made depending on individual circumstances and the origin and final destination. For example, there are some cases in remote areas that do not have a nearby operating air field, where we are left with no choice but to move patients by ground to a destination where they can continue by air.”  The decision on whether or not to use a ground ambulance, she said, are both medical and logistical – primarily, it is the medical condition and security aspects of the case that are considered first, and then logistics are worked out on that basis.

The ground ambulances that use road networks are basically rolling intensive care units ” 

For US-based Gateway EMS, the last few years have seen an increase in the number of insurance and assistance companies seeking its services. Oliver Muller, CEO, said: “We have seen a consistent growth for over seven years now in volume.  While we would like to think that a big part of this is due to our excellent customer service, we are also realistic and aware that the economy has been going up sharply in the last [few] years, leading to more business and leisure travellers.  In turn, there is a higher percentage of possible travellers falling ill or injuring themselves.” The current economic climate means he is cautious about the future, though: “At the same time, we are watching the economy closely as there is prediction for a slowdown in 2019 which will likely lead to fewer travellers and we need to prepare for this as well.” In certain seasons, there is a spike in the number of insured clients being moved by road ambulance, according to experts who contributed to this article. Muller explained that seasonal holidays have a significant impact on patient volume, and on the type of injuries for which these patients need care: “Whether it is the snowbirds going to Florida, the Caribbean or other islands, or skiers from all over the world going to the Rockies or Canada, the type of illnesses or injuries we see is very cyclical.” Christoph Ullrich, Senior Manager of International Network for ADAC Ambulance Service in Germany, pointed out that the sheer size of his company (20 million members and counting) means that there is a less noticeable shift in terms of assistance cases in different seasons, but that the locations to which the company is called certainly correspond to tourist activity. “Of course,” he explained, “Switzerland, Austria, the French Alps and northern Italy contribute the main volume in winter season, whereas in spring/summer southern France, Italy, Croatia, and so forth, are the main countries.” Christian Nagiller of Austria-based Medi-Car confirmed that for his company, 90 per cent of all transports performed during the winter season are from ski resorts in France, Switzerland, Austria and Italy, with the main injuries being fractures of the lower leg and ruptured ligaments. He added: “During the summer season (from June to the end of September), it changes completely; the pick-up places move to the south of Europe, especially Italy, Croatia, Spain, France and Austria, and the problems are more serious like stroke, heart attack and other internal problems.”

In the US, there has been a real increase in the number of patients being driven, rather than flown, home ” 

Those providing such services in Europe may not have the same logistical – or security – concerns as those in other areas. As Hegeler of Tangiers International told ITIJ, when it comes to using a ground ambulance in a high-risk area or war zone, risk mitigation measures have to be taken to ensure the safety of the crew and patient. She explained: “We always try to use an experienced ambulance company in the area where the transport is taking place and use the support of our own network of field agents on the ground that can assist with additional logistics, as well as the services of armed escorts and security where necessary.”

Going the distance

There are pockets of the world where ground ambulance services aren’t practical – for instance, in areas where the roads are in a particularly poor state of repair and a bumpy journey wouldn’t help a patient with severe injuries. The decision to repatriate a patient by road has to take into account the distance travelled as well as the local topography. Ullrich told ITIJ: “Usually, we travel a maximum distance of between 800 km and 1,000 km, always depending on the geography, infrastructure and the condition of the patient. For instance, covering 400 km in southeast Europe is definitely more challenging than travelling 700 km within central Europe.” Muller said that although the company doesn’t keep data on the maximum distance it has ever transferred a patient, he said that long-distance transfers are undertaken ‘as long as it is safe for the patient from a medical perspective and safe for the ambulance crews from the perspective of duty times’. “Some of the transfers,” he said, “can be up to 10 or 12 hours, and have several crew members involved or overnights before getting to the patient.” There is no ‘typical’ condition of patients, with critical care transfers being common for patients suffering an injury after a car accident, or cardiac or even cerebral issues.  Nagiller has noticed that, over the past few years, he is being asked by clients to perform more and more long-distance transfers, as well as trips from islands such as Mallorca, Ibiza and Elba. “In our opinion,” he told ITIJ, “it is better for the patients to bring them back home by ground ambulance with a doctor escort if the distance is not too big.” The maximum distance he has transported a patient is around 3,000 km, which certainly underlines the fact that a flight is not always necessary across Europe.  While not all patients are fit to be transported by ground ambulance, according to Muller, almost every patient that can be flown by air ambulance can also be transported via road. When it comes to critically ill patients, according to Nagiller of Medi-Car, a high number of his patients are intubated and ventilated. “Usually,” he told ITIJ, “there are two different kinds of ICU transport – patients who had a car/bike accident, so most of them have a polytrauma; and patients who have internal problems.”

Declination

Inevitably, it is impossible to transport all patients by ground ambulance transportation. Ullrich said that for ADAC, this occurs ‘only if the patient’s condition is not stable enough, or there is no proper insurance coverage and the patient, or their family, won’t cover the cost of the transport’.  Mueller at Gateway EMS explained: “As the provider that organises the ambulances on behalf of the air ambulance or assistance companies, we ourselves do not decline. We provide the medical information to our preferred and vetted ambulance providers who will then make an assessment if it is safe to transfer a patient via ground ambulance. It is very rare for an ambulance company to decline a patient, especially if for example the air ambulance medical crew is going bedside. When transfers are declined it may be due (but not limited) to factors such as distance. For instance, maintaining a vented patient via ground should only be done for a certain period of time, or for psychiatric patients where the safety of the medical crew may be in question.”  Medi-Car’s leading doctor assesses every case the company is tasked with, and if the patient is not stable enough to survive a transport, then the mission is declined. Nagiller told ITIJ that although this isn’t a frequent occurrence, it happens around three to five times a year.

Sustained growth?

Most of the companies ITIJ spoke to for this feature reported a general increase in enquiries from insurance companies about ground ambulance transportation for their clients – some significant, others less so; it seems there is a geographical divide. In Europe, demand for such services has been strong for some time and remains consistent. In the US, there has been a real increase in the number of patients being driven, rather than flown, home. For Tangiers International, Hegeler reported that less than 15 per cent of repatriations are completed by ground ambulance, and this has been the same for some time, as the company has always worked in areas of conflict and transfer by air is a more typical option in such regions.