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AssistanceRepatriation&

SUPPLEMENTJULY 2010

SOS: Assistance at seaCruises covered

Click for helpAssistance company innovation for 2010

2 ASSISTANCE REPATRIATION& 2 ASSISTANCE REPATRIATION&

contents

International Travel Insurance Journal

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INTERNATIONAL TRAVEL INSURANCE JOURNAL ISSN 1743-1522

Welcome to ITIJ’s fourth annual Assistance & Repatriation supplement!

Despite the ongoing repercussions of the economic downturn, the international assistance industry is still strong and, as is shown on the following pages, is continuing to innovate and push boundaries to provide cutting-edge solutions to travellers in need.

In this year’s supplement, we take a look at how smartphone technology is leading the way in something of a revolution in assistance delivery; we take to the water to investigate the logistics of assistance at sea; and we assess the liability risks that assistance companies face on a day-to-day basis. But what of the risks that are posed by operating in any given country? Our World focus in this edition centres on the Greek islands to give an in-depth analysis of the standards and access to care in this popular tourist region. Elsewhere, we look at why the MENA region should not be taken as a uniform operating platform; and we round up the latest news affecting commercial carriers and international funeral directors.

We also get up close and personal with industry veteran Thomas Buchsein in our Profi le section, and re-tell the fascinating story of an unusual repatriation that involves a thrilling ambulance ride and a hotel with bulletproof glass – but can you guess where they went?

We hope you enjoy this supplement!

Sarah WatsonEditor, [email protected]

Worlds apart 4

Repats business update 8

SOS: Assistance at sea 12

Liability matters 16

Mamma Mia! 20

To prescribe or not to prescribe 22

Goat soup and snail stew 24

That’s a fact! 26

Click here for help 28

Profi le: Thomas Buchsein 32

Hold the plane 34

Big numbers 35

4 ASSISTANCE REPATRIATION&

Lara Hilmi of Connex Assistance Middle East discusses the differences in medical treatment across the Middle East and North Africa

The term Middle East and North Africa (MENA) is commonly used to imply that the vast region stretching east from Morocco in Africa, to Iran in Asia is fairly uniform throughout. While there are similarities, there are also huge differences in language, culture, and standards of living that are often overlooked by companies that are suddenly expected to operate in that region. The 22 countries that make up this part of the world are, for the most part, more of a fragmented

‘mosaic’ than a uniform region. This means that an international company’s experience in these countries could vary massively, and nowhere is this more true that in the health care sector.

Medical mattersComparing medical services between Egypt and the United Arab Emirates (UAE) would show a stark difference in facilities, costs, and procedures. The difference between these two countries is obvious. Egypt has its own idiosyncrasies related to being a top tourist destination in a developing country, and the UAE is a relentless business hub with a constant flow of visitors both into and out of the country. However, if you cross the UAE border into another Gulf country such as Saudi Arabia, there will yet again be another way of doing things. In Egypt, any emergency case is transported to the closest governmental

hospital. The first 24 hours till the patient is stable can be assimilated into the hospital expenses if the patient cannot afford it. After this time, the patient or next of kin must take the decision about whether or not to continue treatment at the facility and pay the medical expenses,

public hospitals in Egypt try their best to economise on costs,

and quite often certain medical equipment may have to be hired

in by the hospital for certain cases

an international company’s experience in these countries

could vary massively, and nowhere is this more true that

in the healthcare sector

Worlds apart

ASSISTANCE REPATRIATION 5&

or alternatively, transfer to another facility. Government hospitals used to be free in the past, or at most charge a symbolic amount for treatment; however, this is no longer the case – although they are still substantially cheaper than private hospitals. Like most general hospitals anywhere, those in Egypt are overworked and overcrowded, and in rural areas, Egyptian government hospitals suffer from poor standards of hygiene. While patients can expect a friendly service and English-speaking doctors, the patient will generally have much more contact with nursing and paramedic staff, who are rarely able to speak the language, making communication more difficult. Privacy may also be an issue for patients, as certain general hospitals have large wards with several beds and few single rooms. Female and male wards are split so the next of kin of the opposite sex would not be able to stay with the patient, and may only be allowed to visit during the official visiting

hours – this practice would come as a surprise to many Western patients who have been in an accident while on holiday and find themselves in an Egyptian public hospital. There will also be differences in the type of hospital food served, which may not be ideal for European patients, and can cause problems. Visiting times are another area where there tends to be significant differences between Egyptian and western hospitals – they can be a hassle as there is a large volume of patients in any one hospital, and it is normal in the Egyptian culture to be visited by extended family, friends, neighbours, and even colleagues – causing even more overcrowding. This practice usually results in insurance companies or patients requesting a transfer to private facilities, which are much more expensive, but better equipped. Dealing with government hospitals from the point of view of an

According to Saudi law, hospital admissions are split between male and female wards, with

separate entrances for each sex

all medical reports can only be requested in person and received by hand, which can

often cause complications and delays


assistance company can be diffi cult – issues such as the fact that all medical reports can only be requested in person and received by hand can often cause complications and delays. Th e volume of patients may be so large that a medical doctor may be despatched to get medical information as the treating doctor would be busy seeing patients and might not have time to see the patient and provide a report. Furthermore, public hospitals in Egypt try their best to economise on costs, and quite often certain medical equipment may have to be hired in by the hospital for certain cases. Th ey may further economise on cost by, for instance, in the case of a heart patient, using streptokinase rather than agrystat, and non-drug-coated stents rather than drug-coated stents. In the UAE, meanwhile, you will fi nd an altogether diff erent experience. By law, all emergency cases must be transferred directly by public ambulance to a government hospital. Th ey are highly

equipped, well staff ed, and due to the cosmopolitan nature of population, doctors’ nationalities are mixed and nearly all the staff will speak excellent English. Most government hospitals do not

deal with foreign insurance companies; however, local insurance is accepted, and some local assistance companies can be used to make guarantees of payment to

certain government hospitals. Cash must be paid in person, and the medical report must either be requested by the patient or by the insurance company in person, at which point a small fee of 100AED is sometimes charged. Stabilisation of the patient is free at the point of care, after which charges continue at a much cheaper rate than that of private facilities, merely as a symbolic fee and not a real refl ection of treatment costs – with the exception of radiology. Male and female wards are again split; however, there are usually single rooms available, so the next of kin may stay with the patient, but if that is not the case they have strict visitor times that must be adhered to. Th e food is multicultural due to the nature of the mixed population, so it doesn’t pose as much of an issue as you fi nd in Egypt. Overall, the service is more familiar to the patient, but there is a lot of bureaucracy and red tape that may hinder the assistance company in handling the case as effi ciently as it might have done

had the same case happened elsewhere, as the hospitals insist on sending agents in person to collect medical information and for the payment of medical fees.

Just a border awayTh ere are clear diff erences between medical treatment in the UAE and Egypt. However, another Gulf country – such as Saudi Arabia – will pose its own challenges that have not been experienced in the aforementioned destinations. In Saudi Arabia, in the case of an emergency, the patient is transported by government ambulance to the closest hospital – whether it is public or private doesn’t come into it. At a government hospital, for the fi rst 24 hours, care is free to the user, and the hospitals are relatively well equipped, although they have a tendency to be overcrowded. According to Saudi law, hospital admissions are split between male and female wards, with separate entrances for each sex. Waiting rooms are segregated, and usually each fl oor is designated for either sex – even the intensive care unit is split into male and female areas. Visiting hours may be mixed; however, next of kin are not usually allowed to stay at the hospital, but can sometimes be permitted at the discretion of the hospital administration. Th is type of segregation extends to the medical staff . Most women ask for female doctors, and in the case that this is not possible, a male doctor may examine her but a female nurse must stay in the room while the examination is happening. Foreign insurance is commonly not accepted, except for few exceptions, and payments must be made in cash. Food can be quite oriental, but in most cases European food can easily be arranged. Importantly, during the time of pilgrimage, all treatment in government hospitals in the Mecca area, and Arafat, is free. n

Lara Helmi is the in-ternational network director and co-founder of CON-NEX Assist-ance Middle East, the leading provider of full service assistance in the region. Since its inception in 1999, Lara has led the company’s expansion to form three business units in Egypt, UAE, and Sudan and a network of pro-viders spanning 11 countries across the Middle East and Africa.

In the UAE … most government hospitals do not deal with foreign insurance companies; however, local

insurance is accepted, and some local assistance companies can be used to

make guarantees of payment

during the time of pilgrimage, all treatment in government

hospitals in the Mecca area, and Arafat, is for free


Repats business updateInternational repatriation, especially that of mortal remains, is a specialist field that is subject to a myriad of varying laws and requirements in different countries. ITIJ spoke to representatives from two international repatriation companies to ask about the most recent rule changes and trends affecting their business

Firstly, ITIJ caught up with Yves Pathinvoh, development and quality director for Anubis Assistance International, to pose some questions about the company’s business operations over the last year and any developments affecting the wider industry. Here’s what she had to say

Has there been an increase or a decrease in funeral repatriations over the last 12 months – has your company witnessed a decrease in business as a result of fewer people travelling?It is a fact that since autumn 2008, people are travelling less than usual. There are two main reasons for this. Firstly, the swine flu pandemic affected the global movement of people across the world, especially for

destinations in the Americas. Then, the global financial crisis happened, which is probably the main cause of the decrease in the number of people travelling. Since the world economy slipped into decline, we have assisted several companies – both small-to-medium enterprises and multinationals – that have failed and left many people out of work and needing to be repatriated as they couldn’t afford to get home.Over the last 12 months, these two issues affected both the tourism and leisure sectors, as well as freight and the wider repatriation industry. Our company has definitely witnessed a decrease in business as a result of fewer people travelling to long-haul destinations. However, in Europe, we treated more cases between France and the United Kingdom, and we also noted over the past year that there has been an increase in local and national remains repatriations, especially within France and Italy.

What effects have the increased security at international airports had on funeral directors?

The increased international security regulations have not really affected the funeral industry. Anubis still adheres to the same safety standards relative to coffin

storage or handling. As a rule, we tend to find that airline companies are more concerned by security regulations. They must, therefore, secure and implement stringent yet efficient processes for the transportation of coffins.

Were any repatriations affected by the volcanic ash cloud that covered Europe for nearly a week in April this year? What did you do to counter the effects?This situation affected both our assistance activity and international logistic services for a week. As everyone knows, all European aircraft space was closed. All

flights were cancelled and ticketing was not available. For that week, we managed and stocked several ‘stand-by’ coffins at Paris Charles de Gaulle, Paris Orly and Lyon-Saint Exupery airports in France, and we tried to limit the number of coffins in our logistic warehouses by reorganising our schedule plan.

Are there any countries that have become easier or more difficult to operate in over the last 12 months?Basically, the industry of international funeral repatriation has evolved well to cope with international logistics. Today, it is possible to carry remains out from most countries worldwide without too many problems or issues arising. However, we could note that repatriations from Western Europe, the US and even the West Indies are easier than repatriations of remains from some Eastern and Central European countries or Africa, in particular sub-Saharan Africa.

From which country does your company see the most frequent repatriations?Our most frequent repatriations are

the industry of international funeral repatriation has evolved well to cope with international

logistics


performed from France. In particular over the last 12 months, our company performed a great deal of repatriations between France and the West Indies – with Martinique clocking up the highest number of repatriations. There have also been a high number of repatriations of mortal remains between France and other European countries – the UK, Italy, Portugal and Spain; between France and Algeria and Morocco; France and the US; and even France and Africa, including a relatively high number of repatriations to Cameroon, the Ivory Coast, Senegal, Mali, and Guinea. We also managed a number of domestic transportation missions, so France-to-France repatriations, which form an important part of our activity.

The swine flu pandemic hit the entire world hard – what was the effect on international funeral directors?Contrary to what people might imagine, the swine flu pandemic did not really affect the activity of the repatriation industry either positively or negatively. Indeed, the number of registered deaths was not as high as had been envisaged, and no specific decision was taken regarding the transportation of people who died due to the swine flu virus.

What is the most frequent mode of transport that is used to repatriate people who have died closer to home? We used to organise flights to perform almost all repatriation of mortal remains missions – even between the closest European countries. Then, we flew around 85 per cent of cases we managed, mostly because an aircraft guarantees the best safety conditions. More recently in France

and Europe, we also do repatriations by road, as long as the journey is less than 1,000 km. Usually, if a person has passed away closer to home, we use a hearse. Essentially, though, the mode of transport depends upon where the person has passed

away. We can also use a sea-faring vessel, if necessary, or if it is the most sensible option for where the body needs to be repatriated to – for example, last month we managed a case between Dinan in France and the island of Jersey.

ITIJ also spent time with Melanie Walking, partner and international operations director of Rowland Brothers

International, to see how world events have affected her business and how the industry has learnt lessons from the happenings of the past 12 months

Over the last year, the single matter that has had the most obvious impact on the repatriation industry as a whole was the volcanic ash cloud that resulted from the eruption of Eyjafjallajokull in Iceland. An

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Over the last year, the single matter that has had the

most obvious impact on the repatriation industry as a whole was the volcanic ash cloud that resulted from the eruption of

Eyjafjallajokull in Iceland


irritant in more ways than one, the volcano delayed fl ights to and from Europe, which meant that it delayed repatriations on their homeward journey. Just when the family thought their loved one was coming home, they were faced with what could have been an indefi nite delay. However, in order to overcome this unfortunate situation and to eliminate further distress to families we arranged for the majority of repatriations to be returned by road, where possible, for example to Germany. Other families were disappointed but very understanding, and we were grateful for that. In truth, there was not much more that anyone could do but wait to hear from the Civil Aviation Authority about when fl ights would be back to normal.

Th ankfully, the swine fl u pandemic did not test contingency plans to the extent that had been expected. Emergency procedures were in place, but what a relief that they were, in the end, unnecessary. If projections of 50 per cent staff absence due to sickness had been true, businesses would have struggled to stay open. In terms of cargo security, there has been no change to regulations that aff ect our own procedures, but cargo screening is still high on the international agenda. In Canada, reports suggest they recently committed to spend CA$95 million on new security measures at their airports. Vigilance is crucial as an estimated 75 per cent of commercial cargo is carried on passenger aircraft. An annual transport security expo and

conference taking place in London this September will consider recent European Commission regulations and aspirations for a total cargo screening regime.

In terms of passenger security, we have reports that families carrying cremated remains onto fl ights have been refused permission to take them onboard – either because they did not have appropriate documentation, or because the ashes were

unsuitably packed, or because the airline policy was not to allow an urn in the passenger cabin. Passengers must check airline and consular regulations before they travel, and also be aware that these regulations could change at short notice, depending on security alerts. We don’t recommend packing the urn in checked baggage in case the luggage goes missing.In the UK, the Coroners Reform is still under way. Th e proposed system is for legally qualifi ed independent coroners to oversee all deaths, supported by medical experts, with increased medical scrutiny in the death certifi cation process. Th e Coroners and Justice Act 2009 came into eff ect in February 2010, but we

understand changes are unlikely to go live before April 2012. Th e appointment of a Chief Coroner, National Medical Advisor and a National Medical Examiner is anticipated this year. In the last twelve months, we believe we arranged more outgoing repatriations from the UK with interim death certifi cates than fi nal certifi cates. An interim certifi cate means the Coroner has opened an inquest and there may not be a fi nal death certifi cate for possibly six months or more.

Sudden or violent deaths in England and Wales are investigated to establish how, why and where the person died. It can take months to assemble all the information and witnesses HM Coroner needs at the inquest. If there is a criminal investigation – anything from a traffi c off ence to a murder – the inquest is adjourned until criminal proceedings are over, which could take months or years to conclude. Th en the Coroner reaches his decision and instructs the Registrar to register the death.Meanwhile, just the Coroner’s interim certifi cate is available, which often doesn’t contain a medical cause of death. Worst-case scenario is that the intended destination is one of the countries that needs this information to authorise the repatriation. We also heard that sometimes an interim certifi cate was not accepted when families tried to settle estate matters in their country of origin. One consular representative in London successfully resolved this issue for her citizens last

year, so now we can confi dently arrange repatriations with a legalised interim certifi cate to that destination.And fi nally, we were astonished by an attempt to repatriate a gentleman in a wheelchair to Germany who apparently passed away in England 24 hours before the fl ight. It’s hard to imagine standing in line at the EasyJet check-in with your deceased relative in a wheelchair. His travelling companions were his wife and stepdaughter, who were arrested on suspicion of failing to give notifi cation of a death. Th e gentleman was expected to be repatriated later by more conventional means. So have global fi nancial matters aff ected leisure travel? Will families decide that a stay-cation resolves their money worries? Travel stats suggest that in spite of the global fi nancial crisis, people still want to take a holiday and will still look abroad. In 2009, the number of outbound passengers from the UK reportedly fell by 11 per cent. Th is year, we hear there has been a package holiday revival, with a trend towards shorter holidays or short breaks, and increased interest in all-inclusive holidays. So passengers continue to travel abroad if they can fi nd a good deal. As long as there are passengers going on holiday, there will be a need for international funeral repatriations – whether they are paid for privately or through the person's travel insurance company. n

ITIJ would like to thank Rowland Brothers International and Anubis for their contributions to this article

Thankfully, the swine fl u pandemic did not test

contingency plans to the extent that had been expected


As cruise holidays become both more popular and more geographically diverse, Dr Tim Hammond, chief medical officer for emergency medical assistance and claims management company CEGA, examines the intricacies of cruise assistance

The cruising trend is fast gathering pace. The Cruise Lines International Association (CLIA) reports that its member ships carried a record 13.445 million passengers last year – in spite of the recession. This year, it expects this figure to rise to 14.3 million. CLIA also reports that its major lines are collectively spending $6.5 billion this year to launch twelve new ships and that, “looking forward, CLIA member lines have 26 new ships on order between 2010 and 2012. This represents a net increase in capacity of 18 per cent, or 53,971 beds.”Whilst industry analysts at this year’s Cruise Shipping Miami conference confirmed that the Caribbean (followed by Europe) was top of the list of popular cruise destinations, they also claimed that cruise lines are expanding deployments and placing newer and larger ships all over the world. They emphasise that the appeal of cruising is growing right across the globe; be it in Australia, Asia or Latin America. According to the Mobil Travel Guide, cruise lines now sail to all seven continents and drop anchor in over 100 different countries. As the popularity and diversity of cruising grows, so too do the challenges to emergency assistance providers.

The case for emergency assistanceWhen does it become necessary to offload a cruise patient to a shore-based medical facility? In many cases, with bigger and more sophisticated cruise ships comes a corresponding development in onboard medical expertise – often giving a sick

passenger a higher level of care than that available ashore – particularly given the remote areas that some cruise ships visit. CLIA claims that many of its cruise ship members, which include Royal Caribbean International and Carnival Cruise Lines, meet or exceed American College of Emergency Physicians (ACEP) guidelines. In practice, this means: “Medical facilities aboard ocean-going ships are staffed by trained and licensed medical professionals with at least three years of clinical experience, including minor surgery and emergency care.” It also means that ‘all doctors and nurses are fluent in English’ and that ‘infirmaries are equipped to provide emergency care and treat a wide range of medical maladies, from minor sunburns to fractures and heart attacks’. Onboard medics can generally investigate, diagnose and offer initial treatment to a seriously ill passenger – but, if the passenger is at risk, or poses a risk to other passengers or crew, he or she will need to be transferred ashore. Medical conditions that may necessitate this include complex cardiac problems; stroke; acute breathing difficulties; serious trauma; severe gastric illnesses and psychiatric issues.

Location, location, locationRemote locations, extreme weather conditions and minimal onshore medical facilities can all complicate an emergency disembarkation. So too can a conflict zone, where hospitals may have been destroyed or made inaccessible, and security risks may be high. Some areas

even harbour the threat of piracy.These challenging characteristics can be found on cruise routes the world over; be it the limited medical facilities of the Faroe Islands, Mozambique and the Ivory Coast, or the war-torn zones of Yemen, the seas off the coast of Somalia and Sierra Leone. Even the Caribbean, most favoured amongst the cruise fraternity, has its share of healthcare limitations. Its larger, developed islands, such as Barbados and Martinique, boast a sophisticated healthcare infrastructure, but their smaller counterparts offer only the limited medical

provision typical of the developing world.But even getting ashore is a problem in some regions. No more apparent are the challenges of the environment than in Antarctica – the world’s most desolate landmass. Here, helicopters and air ambulances need to be robust enough to land in severe weather; onshore medical care may be limited to private units in research stations and military bases; and flights to hospitals in mainland South America can take as long as six hours. Where possible, the assistance process should ensure that a sick passenger is

SOS: Assistance at sea

Remote locations, extreme weather conditions and minimal

onshore medical facilities can all complicate an emergency

disembarkation

Cunard


given onboard care until such time as the ship is within easy reach of a benign environment and good medical facilities. Ideally, the ship’s doctor and the assistance provider will decide, between them, when and where it is best to offload the patient. On the rare occasion where there is disagreement here, the ship’s doctor, as the clinician on the spot, has the ultimate say, and the assistance company will then take over care of the patient once they have been disembarked. A passenger falling ill whilst cruising down the East Coast of Africa, near Ethiopia for instance, will benefit more from the care offered onboard than from that available in an Ethiopian hospital. Providing that there is no risk, an emergency assistance provider will request the ship’s doctor to delay offloading until the ship docks in Kenya. This minimises the number of patient transfers and maximises opportunities to access good medical care.

Overcoming the challengesAt times, a ship will offload a sick passenger without seeking advice from the assistance provider, or a passenger will need immediate disembarkation, regardless of the ship’s geographical position. In these cases, the assistance team will need to overcome the challenges presented by an imperfect location. To do this, it must have a thorough understanding both of the ship’s environment and of the patient’s condition.The proximity of the ship to the shore will be critical to the assistance process. Will the nearest port accommodate a large ship or will a tender be necessary? Will the ship be within flight range of a helicopter? Will it have a helipad or will a winch be available to lift the patient? These are just some of the factors that the assistance team may need to consider.Just as critical will be the suitability of onshore medical facilities in relation to a patient’s specific needs. If the patient has cardiac problems, he or she may need sophisticated investigation, or, if suffering from psychiatric issues, urgent hospitalisation. An effective assistance team should work with a global network of trusted agents and medical facilities to obtain the best possible onshore care, as quickly and economically as possible. If onshore medical resources are inadequate and the region is undeveloped, the patient will need to be transferred by air ambulance to an area with more suitable medical facilities, from where they can also be repatriated, if appropriate. The assistance team may need to use an aircraft that can withstand adverse weather conditions, fly long distances without fuel stops and land in restricted or unprepared spaces. It must also ensure that a medical team, skilled in emergency care, and with the appropriate in-flight medical equipment,

puts the patient in safe hands during a transfer or repatriation. Finally, if a patient is treated abroad, the assistance team should assess his or her ongoing care until he or she is ready to be reunited with a cruise or repatriated. The likelihood of rejoining a cruise will depend on the conclusion of a dialogue between the patient’s onshore doctor, the onboard doctor and the assistance provider’s medical team; all of whom will need to be satisfied that the patient is in a safe and stable state and of no risk to fellow cruisers. Throughout this process, the provider will be liaising with ship doctors, port agents, local medical facilities, hospital specialists and even the patient’s family; simultaneously acting as emergency medic, linguist, facilitator, cost controller and manager.

Counting the costThe unique nature of each cruise assistance case prohibits hypothetical cost calculations. A helicopter evacuation, for instance, can typically cost anything between £1,000 and £8,000 depending on the type of helicopter used, the

distance it needs to travel and the expertise of accompanying medical staff. This, however, is a rare expense, since a helicopter will only be used in a life-or-death situation. More commonly contributing to the expense of the cruise assistance process is the two or three-stage evacuation – for instance, from a cruise ship to a small Caribbean island with only basic medical facilities, on to a hospital in Barbados – and, from there, once the patient is stable and fit to fly, back to hospital or home in the UK. Costs can include an air ambulance, medical escorts, onshore medical care, flights and compensation for loss of holiday. How can these costs be reduced? The use of public hospitals wherever possible – providing that they offer the appropriate care – is an obvious answer. So too is the reunion of patient and cruise, if possible; particularly on a round-the-world trip, since this will relieve an underwriter of both holiday compensation and repatriation costs. What of reciprocal healthcare agreements? Once upon a time, these were widely used to cut the cost of cruise assistance – but that is not the case today. In countries such as Australia, cruise patients are considered to be ‘travelling to seek medical care’ and are therefore not eligible to claim the free care offered by such agreements. Most critical to the containment of costs is an assistance provider’s specialist medical knowledge and network of global contacts – if both of these are in place, it will enable an assistance company to ensure that a patient receives the right care, at the right time, at the right price.

Is there a typical cruise assistance case?With cruise lines offering onboard entertainment that ranges from rock climbing to ice skating and on-deck cinemas, it is no surprise that the profile of their passengers is edging away from the frail and elderly, who form the lion’s share of those people who need to be offloaded from cruise ships. According to CLIA, the average cruiser is now aged 46, although data released by CruiseMates suggests that the longer the cruise, the older its passengers. How do these facts translate into cruise assistance cases? Predictably, those needing emergency disembarkation generally fall into a significantly older age group; around the mid-70’s. Brittle bones that turn a fall into a serious injury, ongoing medical conditions that complicate an immediate medical emergency and the emotional vulnerability that goes hand in hand with old age, can all be characteristic of many cruise assistance patients.Often, cruise passengers will be attracted to a holiday at sea because they have

An effective assistance team should work with a global

network of trusted agents and medical facilities to obtain the best possible onshore care,

as quickly and economically as possible


been given medical advice not to fl y. If they need to be evacuated, this can have implications on their repatriation, when oxygen, medication and medical escorts may ease their potentially long fl ight home. Just as challenging can be the bulky mobility aids that accompany many cruise assistance patients; among them zimmer frames and mobility scooters, which may need to be offl oaded and repatriated along with their owners. Since scooter batteries are classifi ed as explosives by airlines, this can necessitate scrupulous organisation from an assistance provider.

The future“As medical technology advances, so too do our capabilities,” reports CLIA. “For example, many ships are now incorporating telemedicine – where onboard doctors use technology to communicate with specifi c specialists on land to off er the best medical care available to passengers.” Cruises are already an attractive option for those challenged by poor mobility and health, but will these increasingly sophisticated onboard medical facilities attract more and more passengers with health problems? Will this put pressure on assistance providers, or will the advanced onboard care reduce the need for

emergency assistance?Micky Arison, chairman and chief executive offi cer of Carnival Corporation, says: “I believe the biggest change for cruising in the UK over the next ten years will be that it will become just like North America, off ering cruises of just about any length and suitable for just about everyone.” As cruises across the world become more ‘suitable for just about everyone’, off ering ever more diverse facilities, such as family water parks and full-sized boxing rings – will we see a wider range of emergency assistance cases, including sport-related injuries and childhood illness? Only time will tell on this one, but certainly the increasing range of activities onboard cruise ships present more opportunities for cruisers to hurt themselves.One fact is undisputed: with a universally predicted growth in the cruise sector, there is likely to be an increase in the number of emergency assistance cases.

Th is will put the quality, not the quantity, of assistance providers to the test. It will emphasise the necessity of a provider’s penetrating global reach, its expertise

in hostile environments and its trusted network of contacts that is co-ordinated by fast-acting, highly experienced, teams of specialists. n

Dr Tim Hammond MB, BS, MRCP (UK), MRCGP did his medical training in London and has since worked in hospital medicine, general practice and medical assistance, both in the UK and overseas. He joined CEGA in 2004, leading the medical team in their UK offi ce, and also con-tinues to do aeromedi-cal repatria-tion work for them.

What of reciprocal healthcare agreements? Once upon a time, these were widely used to cut the cost of cruise assistance – but that is not the case today


When sending their staff out on an assignment, assistance companies are exposing themselves to various liabilities. Thomas L. Hudson, senior vice president and general counsel for Medex, analyses these and offers advice on how to manage your risk

What is the liability of an assistance company that sends someone to provide assistance? First, what is the liability exposure to the provider of the assistance services if he/she sustains injury on the job? Second, what is the liability exposure for the conduct of the service provider if he/she injures the client? The answers may surprise you, because the liability of the assistance company is rather limited.

Assistance means ‘emergency’Assistance companies provide assistance in many dicey situations – and often in an emergency. The client (maybe a traveller or an employee of a client) needs help.

The emergency can be of a medical nature or involve personal security, or both. To render assistance, the assistance company needs people to provide assistance services. The variety of cases described below shed light on the types of liability an assistance company could expose itself to as a result of a third-party provider:

Medical emergencies* In January 2002, during a flight to Tokyo, an executive experienced dizziness, nausea and pain in his ear. By the time the plane landed, he was extremely ill and getting weaker. A colleague drove him to a hospital in Narita and contacted the assistance company. In discussions with the treating physician, the assistance company medical director realised that a number of critical tests had not been performed. The medical director dispatched a local medical consultant to the patient’s bedside. This physician reported evidence of a slight right-side paralysis, facial drooping and weakness in the patient’s grip. Without

a concrete diagnosis but fearing a stroke, the assistance company recommended an air ambulance evacuation with a physician escort. Because of the distance, two flight crews were needed. The result was a patient maintained in stable condition

during the flight home to a hospital that successfully treated the patient. The service providers included the assistance company’s local physician advisor and the flight crew and medical crew of the air ambulance company.* In June 2004, a couple’s vacation in Mexico was suddenly transformed into a medical emergency. The husband was bodysurfing when he was driven

headfirst into the sea’s sandy bottom by a large wave. Paralysis was the result, and the wife called the assistance company. While doctors at a local hospital had administered drugs, taken x-rays and immobilised the patient, more was needed. The assistance company decided to evacuate the patient as soon as possible to a facility that was better equipped to treat spinal cord injuries. An air ambulance was secured and dispatched. The assistance company had to convince airport officials to permit the plane to land on a private runway because the main airport was shut down at night. Ground ambulance services were arranged on both ends, and the patient woke up in a hospital near his home. The service providers included the flight crew and medical crew of the air ambulance company and the ground ambulance service providers.

Security emergencies* In December 2008, a hostile takeover of Bangkok Airport stranded over 50 client employees in the city. The

Liability matters

If an independent contractor is deployed, the assistance

company is not responsible for the welfare and safety of the

service provider


assistance company offered the option of harbouring the affected people in place with protection or moving them out of Bangkok to Phuket with secure transportation and escorts. All of the employees chose to leave, and the assistance company co-ordinated the evacuation from different locations throughout the city. To provide services, the assistance company used security personnel and ground transportation personnel.* During the summer of 2006, the assistance company provided safe housing, local transport, protection and assistance during Israel’s attack on Southern Lebanon. Over 100 evacuees included employees of corporate clients, a television production team, and students. The aviation evacuation option was eliminated first by the Israeli Air Force. Evacuation by sea was eliminated soon after by an Israeli naval blockade. The assistance company’s on-the-ground intelligence revealed that transportation overland was unacceptable from a safety perspective due to strategic bombing by the Israeli Air Force. Faced with these issues, the assistance company secured a safe haven north of Beirut and moved the evacuees. On a frequent basis, the assistance company’s local agent and an evacuation team briefed the evacuees on the military situation and rehearsed plans to evacuate at a moment’s notice. Soon, government-sponsored evacuations began and the assistance company’s team escorted the evacuees to a designated naval vessel for evacuation. To provide services, the assistance company used security personnel, in-country agents and ground transportation personnel.

Medical and security emergencies* In November 2008, the assistance company received a frantic phone call from one of its clients who was trapped in a hotel under attack in Mumbai, India. The assistance company advised the caller on how to protect himself. Other calls were received. Once initial recommendations were given, the assistance company deployed on-the-ground agents to contact and protect its clients until sufficient intelligence was obtained to assess the situation. The assistance company’s agents moved its clients to a secure location, assisting them later to gather their personal effects. In addition to travellers, the assistance company provided protection to several expatriate employees of clients. Two travellers sustained relatively minor injuries. After the crisis, the assistance company escorted travellers to the airport. To provide services, the assistance company used security personnel and ground transportation personnel. * On 19 January 2010, an earthquake hit Port-au-Prince, Haiti, with devastating consequences. Within hours, people

entitled to emergency assistance services contacted the assistance company – some with relatively minor injuries. In an unusual twist, the assistance company chartered a plane to transport a US-based news

team to Port-au-Prince. After seeing the devastation and the breakdown of civil authority, the news team requested security

personnel, who were then flown in by the assistance company. In the following days, to provide medical and security evacuation services to its clients in Haiti, the assistance company managed over 50 flights into and out of Port-au-Prince and arranged over 40 overland relief convoys to transport people to the Dominican Republic and bring supplies into the disaster areas. To provide services, the assistance company used aircraft pilots and crew and security personnel.

Liability for injury to service providersIn each of the examples, the assistance

company has a round-the-clock team of assistance co-ordinators who can respond to medical emergencies and personal security situations such as the ones described above. They take the first call, open the case file and analyse the facts – all without leaving an emergency call centre (or ‘ERC’) with its high-tech telecommunications. Critical analysis and decision-making takes place in the ERC, and the decisions are usually implemented by service providers in the field. The assistance company could send an employee to provide the assistance, but it is more likely that an independent contractor would be used. A vital point

assistance companies must be careful about indemnity

provisions in contracts


to note is that: if it is an employee, the assistance company would be responsible for the welfare of its employee. If an independent contractor is deployed, the assistance company is not responsible for the welfare and safety of the service provider – unless the assistance company acted in a negligent manner in connection with the assignment. For example, if the assistance company had special knowledge about the risks inherent in the deployment and failed to impart that knowledge, the assistance company could be liable for injuries sustained by the otherwise independent contractor. In the usual case, the service provider – who may be a medical consultant, a trained security professional, an in situ agent, or a provider of air or ground transportation services – knows more about the attendant risk than the assistance company, and they act accordingly. Independent contractors do not act under the control of the assistance company. They are not employees. It is the lack of control authority that distinguishes the assistance company’s liability for employees versus service providers who are independent contractors.

Liability for acts of service providersThe flip side of this liability issue is the assistance company’s liability for the acts of those service providers who

are independent contractors. A typical service agreement between an assistance company and a client usually contains an indemnification provision. A typical provision may state that the assistance company is responsible for claims arising from the conduct of its employees and sub-contractors. If the assistance company agrees to be responsible for the acts of sub-contractors, the potential liability can be substantial, and it is unlikely that the assistance company’s professional

liability insurance covers the conduct of independent contractors. Accordingly, assistance companies must be careful about indemnity provisions in contracts.Service providers, not employees, are most often used by assistance companies to render direct services to travellers or expatriates. Service providers can include the physicians and staff of a hospital to which a sick or injured client is admitted,

The risk emanates from the duty to vet and credential each

of the service providers that are contained in the provider

database used by the assistance company


as well as ground ambulance providers, air ambulance companies and security personnel. It is not reasonable to impose responsibility on an assistance company for the conduct of these independent contractors. Th e assistance company can in no way be described as controlling the driver of the ambulance, the pilot of the aircraft or the surgeon who operates on the patient. Yet, a client might well ask the assistance company to assume such liability. In such cases, the answer must be ‘no’.In refusing to accept liability for the acts of independent contractors, the assistance company nonetheless still has some exposure. Th e risk emanates from the duty to vet and credential each of the service providers that are contained in the provider database used by the assistance company to provide services in an emergency. A failure to adequately credential a provider could lead to an unqualifi ed provider injuring a client. Th e failure – if it rises to the level of negligence – can form the basis for liability on the part of the assistance company. As examples, negligence may be using a ground ambulance company that has a poor safety record or arranging for an air evacuation using an air ambulance company that does not have an aircraft suitable for the fl ight plan that the patient needs. Vetting physicians and surgeons as well as hospitals is an important function of the provider relations department of any assistance company.

In conclusion, the nature of emergency assistance – both medical and security in nature – requires a global network of service providers. Th ese service providers are not employees of the assistance company, and unless the assistance company is somehow negligent in assigning the provider to perform the service, the assistance company is not liable for injuries sustained on the assignment. Assistance company liability for injuries caused by a service provider is also limited. While the assistance company has a duty to credential and use only qualifi ed and competent service providers, the assistance company cannot control how the service is provided because the service providers are independent contractors. Assuming an adequate vetting process is in place and followed, the assistance company would not be liable for claims arising from a service provider’s conduct. n

Tom Hudson is the senior vice president and general counsel of MEDEX Global Group, Inc. He oversees the legal and regula-tory affairs of MEDEX Global So-lutions for medical and personal security services and products.


Lambros Maridakis, travel and new business development manager at Mondial Assistance Greece, outlines the challenges and solutions for providing medical assistance to the increasingly popular smaller islands

Despite the recent high-profile financial problems and issues involving violence that have been seen throughout Greece, the beautiful and secluded small islands remain popular with fans of the Mamma Mia! movie as well as those looking to truly get away from it all. The remote and sparsely inhabited islands provide travellers with a chance to bask in unspoilt beauty away from the bustling nightlife and crowds of the mainland cities and tourist hotspots. However, the most remote and untouched islands do pose greater challenges to travel insurers and assistance providers, as

many of the islands have no hospitals and limited transport options in the event of an emergency. Most islands without a hospital do have, instead, a small medical centre or occasionally a private general doctor living locally. The medical centres are often operated by general doctors who have recently graduated from medical school, and are waiting either to undergo their speciality training or to be hired by a city hospital.

Greek healthcareAs stated by the UK’s Foreign & Commonwealth Office, the Greek national healthcare system provides a basic medical service to Greek nationals. This is also available to visitors from Britain, thanks to a reciprocal agreement with the British National Health Service. There are many public and private hospitals and medical centres throughout Greece, including on the islands, standards of which do, of course, vary. Doctors and facilities are generally good, but assistance companies should be aware that the standards of nursing and aftercare, particularly in the public health sector, do lag behind what is normally acceptable in the UK. Furthermore, the public ambulance service, which will normally respond to any accident, is unfortunately rudimentary and there are severe shortages of ambulances on some islands. The state facilities provide emergency services and treatment at no or a very low charge, while private doctors’ charges may be higher than those of mainland doctors due to supply and demand. Therefore, assistance and repatriation must often be arranged privately, which can, of course, increase costs for the insurer quite dramatically.Greek pharmacies generally offer an excellent level of service, many having a trainee doctor or other trained medical physician available for advice and diagnosis of common or minor conditions. English is widely spoken, although medicines can be relatively expensive. For those holding a European Health Insurance Card (EHIC), medical treatment is available as if they were a Greek national. Prescriptions can therefore be provided easily by doctors or dentists, with consultations and treatments being free of charge.Throughout Greece, there is a free,

24-hour emergency telephone service, through which information is provided in English, French and Greek.

The issue of transportThere is always a local doctor on the smaller islands, who is available for minor treatments. However, if there is a more serious illness or injury, particularly if it requires surgery, or is likely to require further treatment and possibly a hospital stay, this will necessitate a transfer to the nearest major island or mainland city.

While major islands and cities are not very far away in terms of distance, scheduled transportation options consist of either ferry or air travel, which mean that journeys could take a long time – the longest by air being approximately 40 minutes. Therefore, transfers for medical treatment are usually arranged by the state social system, which uses a Super Puma helicopter. While this is quicker than scheduled ferry or air travel it is still a relatively slow and vastly expensive way to handle emergency situations. Sometimes, though, it is the only option and the insurer or assistance company must make the call to use the service. Mondial Assistance Greece’s network covers a large number of remote area and island locations, supporting the local municipalities and medical centres. In addition, it has in place contracted priority services with all Greek air

the most remote and untouched islands do pose

great challenges for insurers and assistance providers, as many of them have no hospitals and limited transport options in the

event of an emergency

There are many public and private hospitals and medical centres throughout Greece,

including on the islands, standards at which do, of

course, vary

Mamma Mia! Assistance Needed!


ambulance companies (both small planes and helicopters). Th e company has also recently launched its own branded road ambulances in Greece. Th ese are initially available only in Athens, but eventually the service will expand to serve almost the entire country. Th is service is very important for the islands, because it guarantees a consistently high level of care for policyholders, as the company is able to handle all transfers – to, from and between airports. To ensure patients receive the best possible care at all times, Mondial selects its crews very carefully and monitors the quality of service at all times.

Storms at seaAny island, but particularly the smallest ones with limited facilities and services, can fall victim to the weather, with storms able to cut them off completely for days at

a time. Occasionally, when the weather is at its most severe and dangerous, and an island with no doctor available cannot be reached by air or sea, the only solution is to give medical advice via telephone. With this important lifeline front of mind, Mondial Assistance has developed a telephone assistance solution for Greece, by working together with key expert providers as well as developing its own local resources. A suite of 24/7 solutions has now been created for over-the-phone medical assistance at any time. Th e call centre used is operated only by doctors and supplemented by telemedicine equipment, allowing a fast and accurate diagnosis to be made remotely.Fortunately, intense storm situations arise only one or two times per year and don’t last longer than a few hours in the summer and for a maximum of two days in the

winter. However, an exclusive contract with a company providing repatriation using sea vessels gives Mondial Assistance constant access to remote islands that have no airports or landing facilities and the ability to repatriate even in adverse weather conditions. In the event of a life or death situation, the Air Force and the Navy are called upon to transport the person in need, no matter how extreme the weather conditions.

Meeting the challenges head onMondial Assistance Greece has developed and continues to develop a national network of over 3,000 physicians and private medical facilities across Greece. It is prioritising the introduction of direct and responsible local medical services on the islands, whether these are at a local hotel or in a dedicated medical offi ce or centre. In addition, the company is affi liated with private medical facilities and has a strong relationship with the state medical system. Th is allows it access to state ambulances, hospitals and medical centres, as well as giving it the opportunity to ensure that policyholders receive only the best quality treatment, whether inpatients or outpatients.Greece is also one of the European countries where sometimes it has been noted that private clinics can have a

tendency to infl ate hospital bills, so it is important for assistance companies operating in the country to combat this practice. Th us, Mondial has put agreements into place with local providers for the lowest possible costs in all our services. Th ere are always obstacles and challenges to deal with when it comes to providing social medicine, no matter where you provide it. However, the role of an assistance provider is to deliver solutions and tackle any challenges head on, while off ering the best access to medical care and support that is available. In the Greek islands, this can be a challenge, but not one that is insurmountable. n

While major islands and cities are not very far away, in terms of distance, scheduled transport consists of ferry and air travel, which

means journeys could take a long time

Any island, but particularly those smallest ones with limited facilities and services available, can fall victim to the weather, with storms

able to cut them off completely for days at a time

Lambros Maridakis is the travel and new business development manager at Mondial Assistance Greece. He has worked in the region for almost 20 years, gaining signifi cant experience in the market. Joining Mondial Assistance in 2005 to launch travel insurance in Greece, Lambros is now also responsible for expanding and managing medical assistance services in the country.


To prescribe or not to prescribe…

Gerry Bolger, chair of the Royal College of Nursing In-flight Nurses Association, discusses the issue of administration of medicines by British in-flight nurses overseas

The practice of using registered nurses by assistance companies to repatriate patients is well established. This article discusses the complex issue of safe administration of medications to patients in transit. This article is written from a UK nursing regulatory perspective and reflects the guidance and regulatory requirements from the Nursing and Midwifery Council (NMC), the regulator of registered nurses and midwives. As such the solutions proposed may not be transferrable to nurses on the nursing registers of other countries.

Regulation, regulation, regulationUK registered nurses transferring patients are required to comply with their regulatory requirements regardless of where they are located. In the UK, the NMC was established to safeguard the health and wellbeing of the public and is responsible

for setting the standards of education, training and conduct for nurses and midwives. The NMC has issued standards for medicines management, which clarifies many issues, including the related

legislation and best practice for medicines. However, because of the nature of in-flight practice, further guidance has been written by the RCN In-flight Nurses Association (now the Critical Care and In-flight Nurses Forum) in conjunction with the NMC, the government’s Department of Health and pharmacists to advise its members of the issues related to in-flight practice, and to offer solutions to the problems that commonly arise in this field. This work is quite detailed, and as such, this article will outline the main issues and solutions.

With the in-flight administration of medicines, the issue becomes more complex because there is also the need to consider the law of the country being visited, especially in relation to the carriage of some medication. In each country, some medicines are restricted and having them in one’s possession can result in stiff penalties locally. As such, good clinical governance by in-flight assistance companies should reduce such risks. In the UK, medications fall into four categories:

General Sale List (GSL) – these are •simple over-the-counter medications such as paracetamol, which can be bought without any prescription and without the input of a pharmacist;Pharmacist only medicines (P’s) – these •can be supplied without a prescription but require the authority of a pharmacist;Prescription Only Drugs (POMs) •– these are the majority of drugs, which require a prescription from an independent prescriber. In the UK, some nurses can obtain ‘independent prescriber’ status following the

appropriate training and supervision, and record that qualification with the NMC. Doctors and dentists are also independent prescribers;Controlled Drugs – these are medicines •that are restricted drugs as laid out in the Misuse of Drugs Act 1971, which both classifies their restriction against their habitual risk and some storage conditions.

There will be very few circumstances when a registered nurse should be carrying a controlled drug in-flight, as these require a Home Office license. Failure to declare any controlled drugs – especially on re-entry into the UK, or in fact any country, without the appropriate documentation and local permits – is likely to result in arrest, and potentially prosecution locally

the assistance company or underwriter could be exposed to a claim, and pose the nurse

to regulatory investigation should anything go wrong

In each country, some medicines are restricted and having them in one’s

possession can result in stiff penalties locally

©CEGA


and may result in the nurse facing a regulatory investigation, which would be undertaken by the NMC. Across Europe and in many other countries, there are variations on the restriction of some medications, relating to both the strength and the legal classifi cation. As such, this can be a minefi eld for an assistance company and their in-fl ight nurse. Th e simple fact is that it is best to check. Some nurses have traditionally carried a small but varied range of medications, but this could mean that a nurse could inadvertently fall foul of the law of the country they are in, or transiting through.

Should in-fl ight nurses carry any medication?For an in-fl ight nurse to administer any medicine, it must fi rst be prescribed to the named patient. Once a medicine is prescribed, it can be administered by anyone. Even giving paracetamol to a patient without a prescription is technically prescribing. Although in the UK some nurses can become an independent prescriber, and these nurses are allowed to prescribe a wide range of medicines, this is not common across Europe or other countries. Without the appropriate independent prescribing training and the possession of a registered independent qualifi cation or other appropriate mechanisms – such as the medicine being prescribed, or homeley remedy protocols (homeley remedy protocols allow a nurse to administer an extremely limited list of medications that are GSL list and P-classed medications only) – the assistance company or underwriter could be exposed to a claim, and pose the nurse to regulatory

investigation should anything go wrong; for instance, an anaphylactic reaction

So how can nurses safely administer medicines?Firstly, as the guidance recommends, a doctor must prescribe all medication that the patient is discharged with from their overseas care setting. As the patient is crossing an international boundary back into the UK or other country, the nurse requires a written authority to administer the medications. Th is should be sent with the nurse by an appropriate independent prescriber who works for the assistance company. Th is can be faxed to the nurse or even to the clinical setting and collected at the time of discharge. Secondly, should a patient require supplementary medication, such as simple analgesia, the nurse can carry other GSL medications but they will still require to be added to the list of medications prescribed. Or if a stronger medication is required this is dispensed locally with the patient. Th is protects both the nurse and the assistance company. Th irdly, homeley remedy protocols, can be put into play. Some assistance companies may think this is overly bureaucratic, but this is in fact best practice, because unless the nurse is an independent prescriber, which requires appropriate training and supervision, companies will have to have a clear awareness of the medication needs of the patient. Th e authority to administer is similar to having a PGD, which is an authority for a nurse to supply and to administer a medication in the absence of a doctor in accordance with the requirements on the Medicines and

Healthcare Products Regulatory Agency (MHRA) website. However, because assistance companies are not National Health Service employers, or not registered with the Care Quality Commission, PGD regulations would not normally apply. In the UK, it is recognised that many patients live with long-term conditions and are on long-term controlled drugs, and as such the HMRC (UK Customs) has issued guidance on controlled drugs and on the amount of drugs that can be brought back into the UK without an import license. Th e key issue is that the medication MUST be accompanied by a letter from the prescribing doctor, confi rming the drug details (name form – e.g. liquid or capsule; strength; and total quantity) and should follow the guidance in the HMRC Guidance Notice 4, 1998. Liquid medications, such as insulin, and hypodermic needles and syringes, or other such medicines, equally require a doctor’s letter stating they are required or risk being impounded by airport authorities. By applying these straightforward approaches, the assistance company, underwriter, nurse and, ultimately, the patient is protected.

In summary:Nurses must comply with the •requirement of the regulatory body of the country of registration; as such, this will diff er country by county. UK registered nurses must administer •

medicines in line with NMC requirements.All medication must be prescribed prior •to administration. Prescribed medication belongs to the •named patient.In-fl ight nurses should carry an •authority to administer a named medicine to a named patient. Controlled drugs need a separate letter •from the prescribing doctor as do liquid medicines and needles. Assistance companies should have good •clinical governance in place to support practitioners, and manage medications and equipment requirements across international boundaries.

Gerry Bolger is the pro-gramme di-rector for the Quality in Caring work within the Chief Nurs-ing Offi cer’s (CNO) Directo-rate at the Department of Health in England. As well as being a registered nurse, Gerry holds a Masters’ degree in health management. He has led the Royal College of Nursing In-fl ight Nurses Association as their chair for eight years and has been involved in clarifying issues on medicines adminis-tration in that role.

Liquid medications, such as insulin, and hypodermic needles … equally require a doctor’s letter stating they are required

or risk being impounded by airport authorities

Failure to declare any controlled drugs … are likely to result in arrest, and potentially prosecution locally and may result in the

nurse facing a regulatory investigation


Glamorous shops and restaurants, exquisite cultural artefacts and breath-taking scenery – all aspects missing from this mission. Sue McPherson, part of AXA Assistance’s UK-based medical team, shares the story of a repatriation that wasn’t the average run-of-the-mill excursion. What was the destination? Answer at the bottom of the page

Double-nurse trips are always fun – well, usually. A better description for the trip I was assigned to, along with Craig McColm, would be ‘memorable’! But where in the world were we setting off to? You may – or may not – recognise it.Checking this country’s website confirms that we need visas. When I call the country’s embassy, the switchboard bids me to press various buttons, which take me back to the original message. The website says visas take seven to ten days, and we need to travel in two. This is not looking good.On the Internet, we find a company that purports to arrange visas in one day. The call is answered by a girl in the middle of a coughing fit, who eventually says that the man who arranges the visas is on holiday until May. For this service, I am robbed of £9.42 in premium call charges. We resolve to go to the embassy in London, armed with all the correct paperwork, some

dodgy photos and consummate charm. All for a stamp in our passports.

The embassyThe front door is smart, but a grubby notice directs us down a side-street, where a shabby door descends down a staircase festooned with electric cables. The room at

the bottom is windowless. At 9:00a.m., it is heaving with confused adults and crying children. We take a ticket and sit down.The filthy floor is littered with discarded food and crisp packets. At one side, the floorboards are ripped up and piled against the wall (health and safety considerations are obviously not an issue here). Red ‘scene of crime’ tape cordons off one area – we ponder what might have happened. The toilets are indescribable.Eventually, our number comes up. As I start explaining why we need the visa today, I am treated to a withering look

and a curt response: ‘I am able to read the paperwork’. So, I hand over £142 and am given a slip that says to return at 4:30p.m. hrs. Elated, we leave the dingy building to while away the hours before collecting the passports, now stamped with the precious visa.

Time travellersThe next day, we enjoy the luxury of the lounge at Heathrow Terminal 5 before our Boeing 747 delivers us to our destination, but this is no tourist resort. Our correspondent will take us to the hotel. I ask how far away it is. ‘Not much far’ is the reply, but gridlocked traffic means it takes an hour and a half to drive 15 miles. Horns continuously blast in fruitless attempts to get from A to B. Curiously, there are many large executive four-wheel drive vehicles with blacked out windows: clearly, there is money here. The roads are a series of craters, interspersed with the odd bit of tarmac. When it rains, the craters fill up, so it is like being

on a dead slow roller-coaster as the cars lurch into murky water. Rain in potholes – the closest thing our hotel came to a swimming pool!

All mod consEventually we arrive at the rather dubious looking hotel, our preferred option being full. I ask to see the rooms before committing ourselves. The narrow corridors are painted orange, and a sticky brown carpet covers the floor. The large rooms have thick bars across the windows. We are assured that the glass is bulletproof, so we will be very safe.The bathroom boasts ‘complimentary’ hot water. There is a bank of UK-style, three-pin plugs, a kettle, tea bags and

Goat soup and snail stew

we hit at least one car and bounce off the central

reservation – and no one but us notices

The embassy is heaving with confused adults and crying

children


coff ee, but a stern sign says ‘not to be used for appliances’. Th e telephone permits outgoing calls, but it is broken.We visit our patient. Th e hospital is modern and our patient has been beautifully cared for. We meet a very polite doctor, assess our patient, talk to the family about the journey and return to the hotel.

A night on the townTh e restaurant is a fug of smoke and deafening noise, the TV blaring with an English football match. Th ere is nowhere else to go, so we order our food – everything is ‘freshly cooked’, a euphemism for a ‘long wait’. When the food arrives, one hour later, it is cold. A bottle of decent red, extortionately priced, helps to lift our spirits.Time for bed. My colleague has a room with a window overlooking the stairwell; mine faces the front, aff ording a cacophony of motor horns and screeching brakes all night. No gunshots though.

Day trippingBreakfast is a prolonged aff air, and we take the time to plan the day. Cloudy skies above and the absence of a swimming pool scupper my plans, and my mood lowers. Someone suggests shopping, and our driver takes us to a mall where there is ‘everything you could possibly want to buy’. It takes 10 minutes to circumnavigate the entire place and discover there is nothing worth buying. We have a very passable coff ee and tart in a smart cafe, however, although it sets us back US$21. Th ere is a cinema, but despite lots of fi lms advertised, everything we fancy has ‘just fi nished’.Returning to the hotel, we decide to have a nap and then meet up for lunch, but it is fumigation day, so we are not allowed back into our rooms. We return to the

restaurant, where the menu proposes ‘goat soup’ and ‘shredded snail stew’. We become instant vegetarians and opt for spiced rice with a piece of bone described as ‘chicken’.

Down to workFortunately, it’s time to return to the hospital and on to the airport. Th e ambulance is clean and well equipped, but the driver thinks he is Michael Schumacher as we squeeze through the traffi c. Blue light and siren blazing, nothing moves for us. In fact, cars try

to cut us up. We hit at least one car and bounce off the central reservation – and no one but us notices.It is quiet and peaceful in the plane. Th e British Airways crew are excellent, and we have an uneventful fl ight home. We ponder the next destination – safe, dependable Benidorm sounds grand.So where were we? If you haven’t guessed, check the answer below. n

Article courtesy of RCN Critical Care and In-Flight Nursing Forum

Sue McPherson and Craig Mc-Colm work for AXA Assistance (UK). After spending time in the primary healthcare set-ting in the UK, Holland and California, McPherson joined Alpha Assistance in 1997 as a medical assist-ance nurse co-ordinator and repatriation nurse. She moved to AXA Assistance in 2003 to become part of the company’s in-house repatriation team.

it is fumigation day, so we are not allowed back into

our rooms

Answer: The destination was Lagos, Nigeria.


That’s a fact!Canada• 18.9 million Canadians

visited the US in 2008, spending a total of 146.6 million nights away

• 12.5 million US citizens and 837,000 Britons visited Canada in 2008

US• Over 2,500 Americans are

arrested abroad annually• Around 6,000 Americans die

outside of the US each year• Around 54.9 million

travellers visited the country in 2009

• The US saw 19 fatalities from skydiving accidents in 2009

Italy• Italy sees more than 43.7 million

tourists every year and is the fi fth most visited country in the world

• Italy has more than 400 ski areas – from Mount Etna in Sicily to the central Apennines

UK• 29.7 million overseas tourists

visited the UK in 2009• 69 million visits abroad were

made by UK residents in 2008• The FCO dealt with nearly

2.1 million consular assistance enquiries in 2008/09 – including 5,500 deaths, 7,000 detentions and 3,100 hospitalisations

• 372,106 passports were issued overseas from 120 FCO overseas posts in 2008/09

Germany• 67.2 million visited the

country in 2009• In 2009, Germany was

the eighth most visited country in the world

Dominican Republic• 39 cases of rabies in animals were

reported in 2007 and 95 in 2008• Over 1.8 million people visited the

DR between January and May 2009• 343,779 cruise passengers visited

the country in 2009

Brazil• The country saw fi ve million visitors

in 2008 – Rio de Janeiro alone attracts 500,000 visitors every year

South Africa• 8.4 million people visited the

country in 2006• 19,202 people were

murdered in the country in 2006

Morocco• A number of foreigners were

expelled from Morocco in April and May 2010 for proselytising

• An average of 10 people die and 200 are seriously injured every day on Morocco’s roads

Mexico• There were over 200 drug-related

murders in Tijuana, Baja California, between January and March this year

• The region of Chihuahua saw more than 2,600 murders in 2009, and 500 reported violent deaths – up until mid-May 2010

• 2008 saw three shark attacks along the Pacifi c coast, two of which were fatal

• The Mexican Ministry of Health shows over 59,000 confi rmed cases of (A)H1N1 with 452 deaths since last April’s outbreak

• According to the WHO, there were over 31,000 cases of dengue fever in the country in 2008


Greece• 16.5 million tourists visited

Greece in 2008• In 2005, Greece was voted

as the Chinese people’s number one choice as a tourist destination – in 2006, Austria also announced that the country was the favourite destination for its citizens.

• In 2005, six million tourists visited the city of Athens alone

Turkey• Over 500 tourists required

consular assistance between January and November 2009

• 45 cases of sexual assaults, including rape, were reported to British consular staff in 2009

• 30,929,192 people visited the country in 2008

Russia• In the fi rst quarter of 2008,

the number of outbound tourists reached 1.8 million

• 9.36 million Russians went on holiday abroad in 2007 – 1.9 million to Turkey and 1.2 million to Egypt

China• 80 tourists died and 391 were injured in

accidents in the country between January and September 2008

• China saw 131 million inbound tourists in 2007

• The China National Tourism Administration predicts100 million travellers spending 100 billion US$ will turn China into the world’s number one international tourism source market by 2015

• 71 per cent of Chinese holiday visitors travel to New Zealand on pre-arranged group tours

• 147 Chinese nationals died abroad in 2008 according to CNTA

Thailand• The country welcomed

more than 14 million international tourists in 2008 – four million from Europe

• 700,000 Australians visited the country in 2008

• 600,000 foreigners sought medical treatment in Thailand in 2007

Japan• 5.3 million Japanese

nationals travelled abroad in 2009

• 6.7 people visited the country in 2009

• The country is aiming for 30 million international visitors by 2019

• Fewer than one case of Japanese encephalitis per year is reported in US civilians and military personnel travelling to, and living in, Asia

Australia• Over 25,000 cases involving

Australians in diffi culty overseas are handled each year – over 1,200 hospitalisations, 900 deaths and 50 evacuations of Australians to another location for medical purposes.

• There were 900 confi rmed cases and one death from dengue fever in 2009

• Over 600 tourists are rescued from the country’s seas each year

• Over 1,000 Australians die overseas each year through illness or accident

• Nearly 1,000 Australians are arrested overseas and about 220 are in prisons overseas at any given time

Egypt• Over 600 tourists required

consular assistance between 1 April 2009 and 31 March 2010 for a variety of reasons, including death, arrest and rape/sexual assaults

• Air/sea rescue can exceed US$4,000 an hour

• 16 cases (fi ve fatal) of avian infl uenza have been confi rmed between January and March 2010

New Zealand• 1,383 cases of dengue fever between October

2006 and May 2007• 1,914 New Zealanders required consular

assistance abroad in 2009 – fi ve of which required emergency responses

• In 2009, the Global Peace Index rated the country as the world’s safest travelling destination

India• More than 450,000 foreign

patients sought medical treatment in India in 2007

• Over 40 tourists died in Goa in 2008 – many of these deaths were attributed to drugs or alcohol abuse


There’s no let-up to the challenges facing assistance companies – from helping clients caught up in hazardous situations abroad, to attempting to prevent client crises in the first place. But how are their services evolving to meet changing demands … and customer expectations? David Kernek reports

With smartphones becoming, for many, a part of the travel kit that’s as basic as passports, payment cards and toothbrushes, assistance companies determined to stay ahead of the competition are looking to mobile applications that enable people in trouble to get help by clicking on an icon – whether their car has broken down on the highway or they’re having a heart attack at a mining site in Papua New Guinea. This harnessing of new technology, together with some exciting product innovation and some much-needed self-promotion, is helping assistance companies to raise their profile. Here we talk to a handful of international providers to get the latest on their innovative offerings.

Harnessing a needIn the UK, the latest technology has been harnessed by Mondial Assistance whose

Direct Assist service is for iPhone and other smartphone users. Drivers needing roadside help and warranty services launch their manufacturer-branded mobile phone application, select the service they require and enter their vehicle details. Using global positioning technology, the customer’s exact location is pinpointed, the nearest assistance point is identified and alerted and the iPhone app sends a message to the driver giving an estimate of how long he or she has to wait for help to reach them.

If roadside repair or towing isn’t necessary, the application uses the phone’s GoogleMaps feature to give drivers a list of the ten nearest workshops or dealers. iPhone users can automatically contact these providers or map the route to get there.“Direct Assist is a white-label product that is being offered first to our motor

manufacturer clients as part of the warranty and pan-European assistance packages we already provide to their customers, but we also see this service becoming an excellent cross-selling opportunity for our travel industry clients and their customers, and we are exploring many insurance and assistance opportunities within this market,” says Ben Smart, corporate and travel sales director for Mondial Assistance in the UK, “The service is likely to be included in these packages at no extra cost to consumers, yet will offer a new level of assistance in the palm of the hand.”In the niche travel insurance sector, Mondial has worked with mobile network provider 02 to produce the 02 Flow policy, which allows customers to change the level of cover they need – and the premium they pay – to meet changing travel plans and circumstances via their mobile phone. With the rolling 02 Flow monthly contract, which can be terminated at any time after the first six months, customers pay for increased cover – for expensive holidays and activities requiring exceptional cover – only when they need it. “Companies must look to new avenues, innovations and markets in order to stay ahead of the game and keep their

customers coming back time and time again,” says Smart, “We are constantly looking at ways to add value to our propositions and are excited by the vast range of opportunities available through technology, which has opened up in the last few years.”Other Mondial innovations include Insurance for Life and Banking for Life, pick-and-mix packages designed to improve customer loyalty in the bank and insurance sectors – and Wander UK Student Travel Insurance, which provides tailor-made cover for undergraduates planning their first parent-free holidays.

Help meElsewhere, Europ Assistance (EA) and 0800 helpme offer a ‘one-call-sorts-it-all’, 24-hour, global personal emergency service for insured customers in trouble after the loss or theft of mobile phones, keys, credit cards or other essential personal items. One call to 0800 puts customers in touch with providers to cancel lost or stolen cards, disable stolen mobile phones, and to arrange for fund transfers, locksmiths, transport, and help in a medical emergency. It can also help with replacement passports and traveller cheques, and put travellers in touch with interpreters and lawyers.The 0800 emergency line follows EA’s 2009 launch of NetGlobers, a community website that centres on health and risk travel information covering 193 countries. The site is packed with daily updated information – in English, French, German, Italian and Spanish – provided by both Internet users and official sources.Furthermore, for today’s eco-minded motorists, EA has organised a pan-European green roadside assistance network offering alternative transport such as electric and low-emission cars, green taxis and bicycle rentals. It is also developing a comprehensive assistance package – the launch of which is planned for the end of this year – specifically for owners and users of electric cars.

All in good timeIn the South Pacific region, the Australian assistance company Customer Care (CC) is using smartphones and Internet-enabled laptops to help expatriate mining staff in Papua New Guinea. CC’s critical care teams in Sydney – 1,700 miles away – can get real-time readings of a patient’s electrocardiogram, blood pressure and

The challenge around the leisure traveller is one of education, and getting the customer to understand the risks and to

contact their assistance company first when they need help

Using global positioning technology, the customer’s exact location is pinpointed,

the nearest assistance point is identified

[Click here] for help


other vital signs, and see videos of the patient’s condition.Th e smartphones and laptops used have

unique identifi ers on them, so that when an evacuation is necessary, GPS co-ordinates can guide the medical helicopter to patients in remote terrain.Th is high-tech diagnosis and treatment service can also be used to monitor patients in a critical condition on aircraft and at sea. “Vital signs monitoring is a natural extension of our emergency medical, evacuation, risk management and security service,” says the company’s sales and marketing manager, Louise Heywood.Other new CC services include: the Odyssey mobile phone application, which sends maps, routes and journey time calculations to travellers and expatriate staff who need to get to the nearest clinic or hospital in remote areas such as Fiji and Papua New Guinea; real-time security news and information sent to mobile phones by SMS or email, alerting policyholders to terrorism, kidnap and other crime-risk ratings in 185 countries and major cities, plus protection staff who can escort customers from trouble spots to the nearest safe port of departure; and risk mitigation training for employees prior to travel or overseas postings. “We believe that successful assistance companies will be those that are not just reactive but pro-active, and provide the highest level of customer service, expertise and value,” says Greg Brown, Customer Care’s general manager.

Education is keyCEGA – a UK-based assistance

company – points to work being done in all three of its key travel insurance markets: mainstream leisure holidays, corporate travel, and high risk hostile environments. Many people, says Rob Upton, CEGA’s director of sales and marketing, don’t think about the risks involved when planning holidays. Many consumers still have the idea that travel insurance is only about lost luggage and fl ight cancellations. When faced with a medical problem, they tend to overlook their insurer’s assistance company and instead ask the hotel’s concierge for advice on where to get help or look around for the nearest clinic. Th is approach often results in yet more trouble for policyholders and insurers, even in mainstream Mediterranean resorts that have well-developed tourism infrastructures.“Th e challenge around the leisure traveller is one of education, and getting the customer to understand the risks and to contact their assistance company fi rst when they need help,” says Mr Upton. CEGA is encouraging its insurance company clients to ‘promote

the assistance company as a fundamental benefi t of the travel insurance policy’ – a message also featured in the Foreign and Commonwealth Offi ce’s Know Before You Go information videos on YouTube. In addition, the company is working on plans to send safety information via smartphones and other GPS-enabled devices to corporate travellers when they arrive in high-risk territories, and it can provide people – such as news and fi lm crews, charity workers and mountaineering expeditions – in remote or high-risk areas with telemedicine services. Th ese include portable visual diagnostic units – the size of a bulky laptop – for direct communication via webcam with CEGA’s medical staff .

Immediate actionInternational SOS is now off ering corporate clients a mobile version of its TravelTracker service, which helps organisations to act immediately during critical events by identifying and communicating with at-risk staff through smartphones. Employers can get instant information about their employees’ travel plans, a consolidated snapshot view of travel information alongside current health and security threats and risks ratings, and interactive risk maps by continent,

mobile technology enables companies to be sure

customers are where they say they are when applying for

covereCall help on hold

One high-tech roadside assistance plan that’s crawling along in the very slow lane is the European Union’s (EU) eCall system, which would enable vehicles involved in crashes to report their own location to emergency services. Using the European Galileo satellite navigation system, devices installed in new cars, trucks and buses would send wireless signals to emergency services, telling them where the accident had occurred and the nature of damage to the chassis and, possibly, drivers and passengers. The European Commission estimates that it would cut accident response times by half in rural areas and up to 40 per cent in cities, saving up to 2,500 lives a year across the EU. Implementation – with the signal transmitters fi tted into all new cars – was originally planned for this year, but problems involving costs for car manufacturers, interoperability across the EU and varying degrees of enthusiasm among member states have pushed the commission’s target start date back to 2014.


country or city.Also new from International SOS is a mobile membership ‘app’ that puts travellers anywhere in the world in touch automatically with the network’s nearest alarm centre, giving them access to alerts and updates relevant to their location. When an employee arrives at, for example, Mumbai airport, the app will display any relevant medical and security alerts for India, providing them with the right information at the right time.

No time to wasteCount yourself lucky if you’ve never, ever, turned up at an airport two hours before your scheduled departure time to find that your flight has been delayed or cancelled, whether due to volcanic ash clouds, strikes, security alerts or those always unexplained ‘technical’ problems. The delay costs for passengers, airlines and insurers can be huge, but Andrew Bud –

executive chairman and founder of mBlox, an Anglo-American mobile network that handles up to 3.5 billion transactions annually and wireless payments worth US$500 million – says the best way to cut these costs is to strike at the cause. Some airlines, including Virgin Atlantic, do this by sending text messages to passengers who sign up for alerts about flight delays and cancellations, eliminating unnecessary journeys to airports, unbudgeted hotel stays and compensation payments. A spin-off benefit for airlines from SMS flight alerts – based on a service provided by mBlox for a UK rail company in the 1990s – is a database of passenger phone numbers that can be used cost-effectively for marketing text messages. It’s cheaper than direct mail and, says mBlox, more effective than email.Furthermore, mBlox is currently working with an insurance company that plans to sell last-minute, pay-per-use travel cover via mobile phones. Using SMS and WAP, the transaction would be completed in less than five minutes. An advantage for the insurer is that, once privacy issues have

been resolved, mobile technology enables companies to be sure customers are where they say they are when applying for cover. Believe it or not, there are people who try to buy travel insurance and make a claim after they’ve had their skiing accident in Switzerland.Text messaging is also being used by CallUma in its Tag ‘n’ Traq baggage tracking service. Travellers arriving at an airport buy – for £3.95 – a set of luggage tags carrying a unique tracking number,

which is stored on CallUma’s database along with the customer’s personal contact details. “If your luggage is lost,” says the company, “you let us know that it’s missing or text us with the words ‘lost luggage’ and your luggage tracking number. We do the rest just as fast as we can. As soon as we find your luggage, we’ll contact you via text message, phone or email with its location to arrange for its convenient return.”In conclusion, it seems that assistance

companies around the globe are trying their best to come up with innovative ways to help their clients, no matter what debacle they find themselves in. As technology and mobile telephones continue to evolve and code writers continue to develop new and more exciting ways for insurers or assistance companies to interact with their policyholders, the marketing opportunities that result from such contact will also be invaluable to the industry. n

the marketing opportunities that result from such contact will also

be invaluable to the industry


First of all, let’s start with some background information: where were

you born, where were you educated and where do you live now? I was born in Garmisch-Partenkirchen, a resort town in the Bavarian mountains, close to the Austrian border. When I was six, my family moved to Munich, where I went to school before attending medical schools in Berlin and Munich. I am now living in Aying, a small village south of Munich.

What is the most memorable part of your childhood?

The early years in Garmisch! My father managed a US-American ‘Ice-revue’ – this warrants a brief explanation: it is an ice-skating event, much like the popular ‘Holiday on Ice’ – which belonged to the US Armed Forces Recreation Area. We lived in a tiny apartment ‘backstage’, from where I could listen to the swing music of the fifties all night long. Cool or what?!

Now, back to business: how did you become involved in the travel

insurance industry in the first place, and to your current role in particular?The simple answer to this is: step-by-step – my career, more or less, has been a perfect storm of coincidences, combining private pilot activities, an interest in

emergency medicine, rescue helicopters, travel medicine and assistance. I began by flying on the ADAC rescue helicopter, Christophe 1, then progressed to flying on air ambulance jets. Eventually, I became increasingly involved with the back-office part of the air ambulance, assistance and insurance businesses.

What aspect of your work do you enjoy the most?

I think my favourite part of the several jobs I have – working for AXA Assistance, working one day a month in a hospital and keeping my hand in at FAI rent-a-jet – is that they allow me to find and make new friends and colleagues all over the globe. I thoroughly enjoy not having a full-time office job, as I much prefer staying in touch with ‘real’ medicine and real patients – after all, it’s what I was trained to do and what I garner a great deal of satisfaction from. I see my role as an assistance company CMO as helping the company to put into action what the insurance product has promised. This can be quite challenging but the assistance industry brings me closer to people and their individual problems and unbelievable stories. It’s satisfying to find acceptable and affordable solutions that still fit into often dry, standard contract wording.

What do you find to be the most difficult part of your role at AXA

Assistance? I would have to say that the part I found, and continue to find, most difficult and least enjoyable is when the problem I am dealing with is not purely a medical one. I find it hard when the work is closer to insurance than to assistance, and every time I have to advise AXA against covering a particular incident.

How closely does AXA Insurance and AXA Assistance work together?

When I started with AXA Assistance, all they shared with AXA Insurance was the logo. I never really understood this and I’m happy to now see them starting to really use their obvious synergies. By using the same systems, it means communication between the insurer and assistance company is more comprehensive and the clarity of information can be improved. The result of this should be that a better service can be provided to policyholders.

Is it difficult to balance what is best for the patient with the cover on their

travel insurance policy? Yes, this is always an incredibly difficult balance to maintain. However, it can be achieved, and a ‘good’ company will always strive to stretch the terms and conditions of the policy rather than the patient … and I find this attitude at AXA.

Moving onto some more personal information, what is the worst job

you have ever had, and how long did you last at it? I think the worst job I have ever had would have to be when I was working on the ‘private’ ward in my hospital. I quite simply couldn’t cope with all these ‘wanna-be VIPs’. After a hard stint of six weeks, the head of the medical department understood and relocated me to the intensive care unit, where I was much happier.

If you could do any other job in the world, other than the one you have

right now, what would it be? It might not be the most normal secondary vocation for a doctor, but my choice would be playing the saxophone in a band!

A medical high-flyerITIJ spoke to Thomas Buchsein, chief medical officer for AXA As-sistance, about his time in the industry, what he enjoys most about his work, and why – in another world – he would be playing saxophone in a band. Read on for his explanations

a ‘good’ company will always strive to stretch the terms and conditions of the policy rather

than the patient

Garmisch-Partenkirchen


What is your favourite TV series, and why?

I am very keen on TV shows such as ‘The Simpsons’ and ‘Little Britain’, because I have high respect for well-staged bad taste and political incorrectness.

What motivates you in your life?I must admit I have a small

but developed weakness for praise and recognition.

If you were having a ‘dream’ dinner party, who would be there – apart from

your family? That is a difficult one, but I would have to say that I would really like to see all the fantastic colleagues and friends I have worked with over the years, and Carlos Santana would provide the music.

What are you most proud of – apart from your family?

That quite frequently I hear people say, “He doesn’t look like a doctor at all!”

Please complete the following sentences:

My favourite journey is … down the Mekong river on a longboat to Luang Prabang.

My favourite holiday destination is … The Aegean island of Paros, chilling out in the Magaya Beach Tavern.

Have you ever had the need to claim on your travel insurance?

Not yet thankfully.

Who is your favourite author? Isabel Allende. I love the low voice

and calm flow of words and colours in her books, which often tell the most terrible and tender, cruel and imaginative tales of death, love and passion.

What’s your favourite animal? My border collie, who is called Del.

If you could implement a law across the whole world, what would it be?

Mean your smile, break the rules, kiss slowly, forgive quickly and love truly.

Have you got a party trick? Beware – if the answer is yes, we shall expect

a demonstration at the next ITIC!I can make a coin pass (quite painfully and takes a while!) all the way through my blood vessels and tissues from my left hand to my right hand – and back! I can also juggle with one ball!

What do you miss most when you are away from home – either for

leisure or business travelling?My kids and my wife – what else could I say?!

What is you favourite food? Thai green curry.

Where do you stand on the issue of global warming?

On a thin sheet of arctic ice.

If you could be a stand in for any actor in any movie, who would you play?

Robin Williams in Dead Poets Society.

What was the first album you ever bought?

Deep Purple in Rock (I still have it!)

Who is your favourite band?Dire Straits, Ladysmith Black

Mambazo, Santana, Norah Jones. n

The Mekong River


Commercial repatriations come with their own set of ups and downs. Turbulence aside, ITIJ spoke to various international medical escort companies to discover the latest news on which airlines are easy to work with and which airports should be avoided at all costs

Th ere will always be a few airlines that are easier to work with than others, and these have been recognised by the people whose job it is to organise stretchers, escorts, oxygen and extra leg room. Th ose airlines currently in favour with this important cog in the travel insurance wheel include British Airways, Virgin, Lufthansa and Turkish Airlines. By making themselves more accessible to repatriation companies, these airlines are making a valuable contribution to travellers in need. Just one European carrier has changed its stance on the provision of stretchers in the last 12 months – Olympic Air – formerly Olympic Airways – which has now said it will not carry stretcher patients. Undoubtedly, this has aff ected how easy it is for an assistance company to organise a medical repatriation from Greece. At the moment, the problem is being solved through the use of Lufthansa aircraft departing from Athens airport. For those patients who are stuck on one of the smaller Greek islands, the patient will need transportation to Athens, and this normally has to take the form of a relatively expensive air taxi. For more information about how to evacuate patients from the more remote Greek islands, please see our article on the topic on page 20.Meanwhile, where are the worst-case-

scenario airports? Where do you least want to have a client that needs a medical repatriation? Th ere are several choices – Goa was highlighted as being particularly diffi cult to operate in, while

certain places in the Caribbean – Cuba and the Dominican Republic – were also mentioned as being somewhat more complicated for what could seem to be a

relatively simple and straightforward case. In Europe, the popular Spanish destinations of the Balearic and Canary islands off er their own unique challenges, as there are no direct business-class options available for the patient who just needs that little bit more space for a broken leg/arm. Monarch Airlines does off er premium seating, which has more leg room and can be used for patients who just need oxygen, or have a less serious complaint than, for instance, a broken leg. Th e majority of the airlines serving these islands are low-cost carriers, such as BMI Baby, Ryanair or easyJet, who do not off er any sort of business-class option. Another country where it is more diffi cult to service stretcher patients is Ireland – again, diffi culties arise due to the fact that it is only really serviced by low-cost airlines.When asked if there are any parts of the repatriation process that could be made easier for call handlers who are tasked with co-ordinating commercial carrier repatriations, it was noted that dealing with outsourced or centralised call centres was particularly diffi cult. Th e companies consulted were also asked about how they dealt with problems relating to the repatriation of people

suff ering from suspected or confi rmed swine fl u. In most cases, the experts were asked to extend hotel stays, and they had to make sure that the client was able to stay in the same hotel – and even the same room – due to some countries enforcing quarantine laws. Th e patient would then have to be re-booked onto another fl ight to their destination when it was confi rmed that they were safe and fi t to fl y.Th e eruption of the Eyjafj allajokull volcano caused days of delays to intended repatriation fl ights. With European air space closed for seven days, the backlog of cases that had to be found new fl ights left many assistance companies in diffi culty. No fl ights meant that alternative accommodation had to found for high-end insurance

clients and those medical patients that were well enough to be released from hospital.Concerning the provision of oxygen on commercial scheduled fl ights, although the situation has, by and large, remained static over the past 12 months, the people ITIJ spoke to said that Monarch Airlines had improved its systems, making medical clearance and oxygen provision more straightforward and quicker. In addition, UK-based travel fi rm Th omson, which has its own fl eet of aircraft, is now providing oxygen to customers free of charge, making life for the assistance company that little bit better. n

Airlines that do take stretcher patients:

LufthansaAir France

KLMIberia

Tap Air PortugalSwiss Airlines

Turkish AirlinesEmiratesEtihad

Jet Airways IndiaAir New Zealand

Air MaltaCyprus AirwaysCroatia Airlines

Egypt AirGulf Ai

Kenya AirwaysAlitalia – it was noted that although the airline Alitalia – it was noted that although the airline Alitaliasays it will take a stretcher, the reality is that it is

often very diffi cult to gain the necessary approvals from them

Hold the plane!

Just one European carrier has changed its stance on the provision of stretchers in the last 12 months – Olympic Air – formerly Olympic Airways – which has now said it will not

carry stretcher patients

Monarch Airlines had improved its systems, making medical clearance and oxygen provision more straightforward

and quicker

1,000,000,000

ITIJ offers a snapshot in figures of the repatriation and assistance industries

Cost of an air ambulance from the US east coast to the UK in US dollars

The number of beach rescues performed in Australia every year

The cost of an economy class flight, with medical escort, from Australia to the UK in euros

The number of road deaths in New Zealand in a year

The average number of people killed everyday in Thailand in motorbike accidents

The estimated number of people suffering from neglected tropical diseases worldwide, according to the World Health Organization

Estimated number of skiers worldwide

The number of injuries on the slopes dealt with by the Association of Mountain Doctors in France in 2008/09

The number of fatalities that occurred out of the 56.9-million skier/snowboarder days reported during the 2004/2005-ski season (according to the NSAA).

An estimated number of UK citizens travelling abroad for medical procedures in 2006

The number of Czech tourists who died whilst abroad in 2008

Big numbers

52,000 15,00024,000366

38 200,000,000

140,000 4550,500 52

assistance repatriation · 2017. 5. 24. · assistance &repatriation 5 or alternatively,...

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