Medical Evacuation Request Assessment Guidelines

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Overview and Purpose

Medical evacuation is a complex, high-cost intervention that requires careful assessment to ensure patient safety, appropriate resource allocation, and optimal outcomes. This guide provides International SOS assistance coordinators with a structured framework for evaluating medical evacuation requests and determining the most appropriate course of action.

A medical evacuation involves the transportation of a patient from their current location to a medical facility capable of providing the required level of care. Evacuations may be conducted via air ambulance, commercial flight with medical escort, or ground ambulance, depending on medical acuity, distance, and local circumstances.

Key objectives of the assessment process:

Ensure patient safety and medical appropriateness of evacuation
Determine the optimal timing, mode, and destination for evacuation
Verify coverage under membership agreements or insurance policies
Coordinate with treating physicians, receiving facilities, and local authorities
Manage costs effectively while maintaining quality of care

Initial Assessment Criteria

When a medical evacuation request is received, the assistance coordinator must rapidly assess several critical factors to determine if evacuation is medically indicated and logistically feasible.

Medical Necessity Evaluation

The fundamental question is whether the patient's condition requires care that is unavailable or inadequate at the current location. Assess the following:

Gap in local care: Does the local facility lack the necessary expertise, equipment, or services to adequately treat the patient's condition?
Medical urgency: What is the time-sensitive nature of the required intervention? Is this an emergency, urgent, or elective situation?
Medical stability: Is the patient stable enough to be transported safely? What are the risks of deterioration during transport?
Diagnosis clarity: Is there a clear diagnosis and treatment plan, or is the evacuation primarily for diagnostic purposes?
Treatment alternatives: Are there local treatment options that could stabilize the patient until evacuation can be arranged more safely or cost-effectively?

Patient Stability and Transportability

Medical stability for transport is assessed based on vital signs, consciousness level, and risk of deterioration. Use this framework:

Stability Level	Characteristics	Transport Considerations
Stable	Vital signs normal and consistent, no active deterioration, condition well-controlled	Can travel via commercial flight with or without medical escort, or ground ambulance
Stable but Critical	Requires continuous monitoring, IV medications, or oxygen, but not deteriorating	Requires air ambulance with ICU capabilities or commercial stretcher with critical care team
Unstable	Actively deteriorating, hemodynamically unstable, requires ventilation or vasopressors	Must be stabilized before evacuation unless evacuation is to achieve stabilization. Requires ICU-equipped air ambulance
Too Unstable	Transport would pose immediate life threat, maximal support at current facility needed	Evacuation contraindicated until patient stabilizes. Continue treatment locally

Coverage and Authorization Verification

Before proceeding with evacuation arrangements, confirm coverage and authorization:

Verify the patient's membership status and level of coverage
Review specific terms regarding medical evacuation benefits
Identify any exclusions, limitations, or pre-existing condition clauses
Confirm approval from the insurance provider or corporate client
Document authorization numbers and communicating parties
Clarify cost responsibilities and payment guarantees

Medical Information Gathering

Comprehensive medical information is essential for appropriate decision-making. Coordinate with the treating physician to obtain:

Essential Clinical Information

Current diagnosis: Primary and secondary diagnoses with relevant details
Chief complaint and history: Presenting symptoms, onset, progression, and relevant medical history
Vital signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation (current and trends over past 24 hours)
Current treatment: Medications, IV fluids, oxygen requirements, ventilator settings if applicable
Diagnostic results: Laboratory values, imaging findings, diagnostic test results
Surgical interventions: Any procedures performed, surgical wounds, drains, or devices in place
Prognosis and treatment plan: Expected clinical course, planned interventions, estimated duration of hospitalization
Mobility status: Ambulatory, wheelchair-bound, stretcher-bound, ability to sit upright
Conscious level: Alert and oriented vs. confused, sedated, or unconscious

Consulting with Medical Team

The assistance coordinator should facilitate consultation between the International SOS medical director (or on-call physician) and the treating physician. This discussion should address:

Medical justification for evacuation vs. continued local treatment
Optimal timing for evacuation based on patient's clinical trajectory
Special medical equipment or personnel required during transport
Risks associated with transport and mitigation strategies
Receiving facility requirements and advance notifications needed

Determining Evacuation Mode and Destination

Modes of Medical Evacuation

Select the appropriate evacuation mode based on medical acuity, distance, and logistical factors:

Mode	Appropriate For	Typical Cost Range
Air Ambulance (Fixed Wing)	Critical patients, long distances (>500km), require ICU-level care during transport	USD 25,000-150,000 depending on distance and medical requirements
Air Ambulance (Helicopter)	Short distances (<300km), areas inaccessible by road, time-critical emergencies	USD 8,000-30,000
Commercial Flight - Stretcher	Stable patients who cannot sit upright, require monitoring but not intensive care	USD 15,000-40,000 (cost of blocking seats plus medical escort)
Commercial Flight - Medical Escort	Stable ambulatory patients, require medical supervision but not continuous intervention	USD 3,000-8,000 (escort fees plus business class tickets)
Commercial Flight - Fit to Fly	Stable patients who can self-manage with minimal assistance	Regular airfare only
Ground Ambulance	Shorter distances (<500km), road accessible, various acuity levels depending on ambulance capabilities	USD 2-5 per km plus medical team fees

Destination Selection Criteria

The destination facility should be selected based on several factors:

Medical capability: Facility has the required specialties, technology, and experience to treat the specific condition
Geographic proximity: Closest appropriate facility that meets medical requirements, minimizing transport time and risk
Bed availability: Confirmed acceptance and appropriate bed type (ICU, general ward, specialty unit)
Language and cultural factors: When possible, consider patient and family preferences for language and cultural environment
Cost considerations: Balance quality of care with cost efficiency, particularly for prolonged hospitalizations
Repatriation logistics: Consider future repatriation needs and ease of follow-up care coordination
Family accessibility: When medically equivalent options exist, consider family's ability to visit and participate in care

Common Evacuation Destinations by Region

Southeast Asia: Bangkok, Singapore, Hong Kong (depending on patient location and condition severity)
Middle East: Dubai, Doha, Amman (for regional cases), or Europe for complex cases
Africa: Johannesburg, Nairobi (for Sub-Saharan Africa), Cairo (for North Africa), or European evacuation for serious cases
Latin America: Miami, Panama City, Buenos Aires (depending on patient location)
Remote locations: May require staged evacuation with interim stop at regional center

Special Considerations and Contraindications

Absolute Contraindications to Air Evacuation

The following conditions generally prohibit air evacuation until resolved or stabilized:

Untreated pneumothorax (trapped air will expand at altitude)
Recent thoracic or abdominal surgery (<10-14 days) with risk of dehiscence
Uncontrolled bleeding or high risk of hemorrhage
Severe respiratory distress unable to maintain oxygenation at cabin pressure
Active seizures or status epilepticus
Severe behavioral disturbance posing safety risk to crew or other passengers
Infectious disease requiring isolation beyond capabilities of transport (e.g., viral hemorrhagic fever)

Relative Contraindications Requiring Special Arrangements

Pregnancy: After 36 weeks (32 weeks for twins), airlines typically prohibit travel; medical clearance required
Recent myocardial infarction: Typically wait 3-7 days post-event if stable; requires cardiac monitoring during flight
Post-surgical patients: Timing depends on surgery type; generally 48-72 hours minimum for major procedures
Fractures in casts: Cast must be split or bivalved due to swelling at altitude
Mental health crises: May require sedation, restraints, or additional security escorts

Pregnancy Considerations

Pregnancy requires special assessment for evacuation:

First trimester (weeks 1-13): Generally safe if uncomplicated; morning sickness and fatigue may affect comfort
Second trimester (weeks 14-27): Safest period for travel; lowest risk of complications
Third trimester (weeks 28-36): Travel possible with medical clearance; requires documentation and monitoring
After week 36 (32 for multiples): Most airlines prohibit travel; evacuation requires air ambulance
High-risk pregnancies: Require obstetric consultation and may need specialized air ambulance with neonatal capabilities

Pediatric Evacuations

Children require special considerations:

Newborns under 7 days: Generally not suitable for unpressurized cabin; may require special arrangements
Parent/guardian accompaniment: Always arrange for at least one parent to accompany; consider impact on other children
Medical escort experience: Ensure medical team has pediatric experience and appropriate equipment
Receiving facility: Confirm pediatric capabilities at destination
Anxiety and fear: Children may be more distressed by evacuation; consider comfort measures and communication strategies

Logistical Coordination and Documentation

Pre-Evacuation Coordination Checklist

Ensure all of the following are completed before evacuation proceeds:

Medical coordination: Treating physician informed and provides transfer summary; receiving facility accepts patient and has bed ready; medical team briefed on patient condition
Aviation/transport: Aircraft or ambulance confirmed and en route; flight plan filed; fuel stops arranged if needed; ground transportation coordinated at destination
Documentation: Passport and visa requirements confirmed; medical certificates completed; fit-to-fly or transfer forms signed; insurance authorization documented
Medications and equipment: Sufficient medications for transport plus contingency; medical equipment tested and ready; oxygen supply calculated with reserve
Patient and family: Patient and family informed of plan; consent obtained; personal belongings prepared; family travel arrangements made if accompanying
Financial: Payment guarantees in place; cost estimates provided; insurance pre-authorization obtained
Communication plan: Contact numbers exchanged; progress updates scheduled; emergency communication plan established

Required Documentation

Compile and verify the following documents for every evacuation:

Medical summary from treating physician with diagnosis, treatment, and current status
Laboratory and imaging results relevant to diagnosis
List of current medications with dosages
Fit-to-fly certificate (for commercial flights) specifying any special requirements
Consent for treatment and transport signed by patient or legal representative
Passport copies for patient and accompanying family members
Visa requirements checklist for destination country
Insurance authorization and guarantee of payment letter
Contact information for treating physician, receiving physician, family members, and employer/client

Non-Evacuation Alternatives

In many situations, evacuation is not the most appropriate intervention. Consider these alternatives:

Specialist Consultation

Arrange telemedicine consultation with specialist at regional center
Deploy specialist physician to patient location for assessment and treatment
Coordinate with local specialists who may be available at other facilities in the area

Enhanced Local Care

Supplement local medical team with International SOS physicians or nurses
Provide specialized equipment or medications not locally available
Coordinate with regional International SOS clinics for outpatient care
Arrange private duty nursing for closer monitoring

Delayed Evacuation

Stabilize patient locally first, then evacuate when safer
Wait for appropriate weather conditions or transport availability
Complete initial treatment phase locally to reduce evacuation risks
Arrange commercial repatriation after hospital discharge instead of acute evacuation

Alternative Facilities

Transfer to better local or regional facility that doesn't require international evacuation
Utilize private hospitals or clinics that may have better capabilities than initial facility
Consider regional centers that may be closer, cheaper, or more appropriate than long-distance evacuation

Post-Evacuation Follow-Up

The assistance coordinator's responsibilities continue after the evacuation is completed:

Confirm arrival: Verify safe arrival at destination facility and patient handover to receiving medical team
Update stakeholders: Inform family, employer, and insurance provider of successful transfer
Obtain receiving physician report: Get initial assessment from receiving facility within 24 hours
Monitor ongoing care: Maintain contact with receiving facility to track patient progress and identify any additional needs
Coordinate repatriation: Begin planning for eventual return to home country when medically appropriate
Financial reconciliation: Compile all costs, process invoices, and close financial aspects of case
Case documentation: Complete detailed case notes including timeline, decisions made, and outcomes for quality assurance and future reference
Quality review: Assess evacuation process for learning opportunities and areas for improvement

Case Decision Framework Summary

Use this decision tree approach when assessing evacuation requests:

Is there a medical necessity? (Gap between local care capability and patient needs) → If NO, decline or suggest alternatives
Is the patient transportable? (Medical stability adequate for safe transport) → If NO, stabilize locally first or provide enhanced local care
Is evacuation covered? (Membership/insurance verification) → If NO, discuss cost responsibility with patient/employer
What is the appropriate mode? (Based on medical acuity, distance, and logistics) → Select most appropriate and cost-effective option
What is the appropriate destination? (Medical capability, proximity, availability) → Confirm bed availability and acceptance
Are there contraindications? (Medical, logistical, or regulatory barriers) → Address or plan workarounds
Is documentation complete? (Medical, legal, immigration, financial) → Ensure all requirements met before proceeding
Proceed with evacuation → Coordinate all parties and monitor throughout process