Air evacuation of patients

It is 2016. We are lucky. A tourist in the executive class vacated his seat after declaring, “I can sit anywhere.” He moved to one of our seats in the economy class. An executive class seat has more space to accommodate our medical equipment. Unfortunately, the family of the patient was able to arrange only two seats in the executive class. The father had the baby on his lap fixed to a board. I had the breathing equipment in my hand with the oxygen cylinder strapped on my back.

We thanked the gentleman and settled down on the three seats that were now available to us. The father moved the armrest back as I unhooked the oxygen cylinder and handed it to the ground staff as we are not allowed to carry an oxygen cylinder on commercial flights. The airhostess handed me the onboard oxygen cylinder that we had booked in advance. However, there was a problem. The piping on our machine did not fit the new oxygen cylinder. The other oxygen cylinder had already been removed from the aircraft. I asked the airhostess for a blade. She looked at me suspiciously and said, “Blade on an aircraft?!” She then approached the pilot who emerged from the cockpit to give us the required permission. The airhostess took out a small box that contained articles such as bandages, a scissor, and a blade. I noticed that the pilot kept an eye on me as I took the blade and waited till I handed the blade back to the airhostess after cutting the pipe and fixing it to the new oxygen cylinder. We made it to New Delhi with no incident.

Fast forward to 2021. The neatly dressed officer in an air force dungaree declared, “We don’t have an oxygen cylinder on board! We do not have a stretcher either. You can carry whatever you want!” The nurse and ambulance driver who had dropped us to Leh air force base wanted to take the stretcher and cylinder back as it was in their ‘charge’ but I was not in a position to part with either. Finally they pleaded, “Doctor-saab, please bring the stretcher and cylinder back to Leh.” It was a smooth flight in the C-17 aircraft from Leh to Chandigarh. Later, the father used a private transporter to send the cylinder and stretcher back to Leh.

These are just two stories of air evacuation of sick patients from Ladakh for treatment that is not available here. Such cases require a lot of effort by the patient’s family along with intervention by the administration and help from the airline/air force. It is difficult to arrange such an evacuation at a short notice. There have been hundreds of such evacuations from Ladakh in addition to commercial air ambulances that cost in excess of INR 7 lakhs (INR 700,000).

We must constantly work to improve our healthcare system. COVID-19 has shown that a fine line separates life and death. This reality was driven home for me when I watched four of our doctors admitted to the COVID-19 ward during the second wave in 2021. Similarly, a fine line separates a patient and a healer too. A senior physician once told me, “It is for us, nono!” after I congratulated him when we acquired an ECHO machine and added that it would benefit patients. This is when he explained that it was not just for patients and that healers can become patients anytime. I saw a lot of wisdom in his words.

There are two district hospitals in Ladakh: Sonam Norboo Memorial Hospital (SNM), Leh and District Hospital (DH), Kargil. Both of them have recently undergone a major change in their status. They were two of 24 district hospitals in the erstwhile J&K state and are now the main hospitals of UT Ladakh. Since we do not have many facilities in these hospitals, referral is an important approach to treat many cases. This is also important when we provide care to high profile delegates who visit Ladakh.

There are plans to have a doctor and medical facilities in every corner of Ladakh irrespective of the population size. This is in contrast with Sri Lanka, which has a centralised system. Though Sri Lanka is a developing country, it has a good healthcare system. They have very few tertiary care centres and referral units function as stabilisation units. These units do not have doctors and are staffed by trained paramedics. These units are connected by an efficient transportation system, which includes helicopters and air ambulances to transport patients to well-equipped tertiary care centres.

Another approach is to use commercial aircrafts for patient evacuation. I am told that every flight from places such as Port Blair has nine seats reserved for patients at a nominal cost. Such a system would benefit people who cannot afford an air ambulance. Nine seats provide enough space to carry a patient on a stretcher along with a doctor, a nurse, and a relative and is much cheaper than an air ambulance.

We need to streamline the referral and evacuation system, as we cannot have every facility at our hospitals. It is simply not cost effective as many of them are not required on a regular basis. There have been instances in India in the recent past where patients have been referred to foreign hospitals by the government to receive treatment that is not available in the country. The Nirbhaya case was one such example. Thus, services provided by any hospital can never be ‘complete’.

At present the government has a state-sponsored referral system to the nearest tertiary care centres in Kashmir. However, we need to expand this to create an efficient air evacuation system, especially when we have no surface connectivity in the winter. The government currently pays for the air ticket of a patient and an attendant under the Janani Shishu Suraksha Yojana (JSSY). However, we need to streamline the process. At present, the army and the air force provide support to transport critical patients. However, their aircrafts are often not equipped to transport critical patients. At the same time, it requires a lot of paperwork to use commercial airlines including provision of basic facilities such as an onboard oxygen cylinder. It thus makes sense to have a more streamlined referral system for air evacuations from Ladakh with possible subsidies and support from the government.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

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