Medical evacuation, often shortened to medevac or medivac, is the timely and efficient movement and en route care provided by medical personnel to wounded being evacuated from a battlefield, to injured patients being evacuated from the scene of an accident to receiving medical facilities, or to patients at a rural hospital requiring urgent care at a better-equipped facility using medically equipped air ambulances, especially helicopters.

Examples include civilian EMS vehicles, civilian aeromedical helicopter services, and military air ambulances. This term also covers the transfer of patients from the battlefield to a treatment facility or from one treatment facility to another by medical personnel, such as from a local hospital to a trauma centre.

The first medical transport by air was recorded in Serbia in the autumn of 1915 during First World War. One of the ill soldiers in that first medical transport was Milan Rastislav Štefánik, a Slovak pilot-volunteer who was flown to safety by French aviator Louis Paulhan. The United States Army used this lifesaving technique in Burma toward the end of World War II with Sikorsky R-4B helicopters. The first helicopter rescue was by 2nd Lt Carter Harman, in Japanese-held Burma, who had to make several hops to get his Sikorsky YR-4B to the 1st Air Commando Group’s secret airfield in enemy territory and then made four trips from there between April 25 and 26 to recover the American pilot and four injured British soldiers, one at a time. The first medivac under fire was done in Manila in 1945 when five pilots evacuated 75-80 soldiers one or two at a time.

Most people derive their knowledge, or perhaps it is more accurate to say their expectations, of medical evacuation procedures from the media through highly publicized/romanticized television shows or so-called “docudramas”. One would not expect clients to arrive anticipating standards of performance and modes of implementation modelled on John Wayne and Tom Cruise movies … would they?

But when a medical evacuation has become necessary, and people are worried, anxious, scared and in pain, the time is not appropriate to explain the sensible reasons for the differences between cherished myths and an actual medevac. For this reason, the background planning that goes into supplying our clients with a careful and professional medical evacuation service is worth looking at in detail.

The main elements in a rapid and secure medical evacuation are careful application of medicine and safe transportation. To support these a large number of actions have to be taken after the go-ahead for the medevac has been given, including checks that:

• The medical director or manager of the patient’s company agrees to the evacuation
• The patient’s full name, nationality, and birth date are known
• The patient’s medical problem and medical history are known
• The passengers’ (if any) names are known
• The location of the patient is precisely known
• The patient’s passport is available, and that it as well as the exit permit are valid
• The destination country will allow the patient in
• The destination hospital is appropriately chosen, and has a bed and doctor available
• If the patient is a child, the destination hospital has a companion bed available
• The treating doctor is aware that the patient will be evacuated and will release the patient
• The patient’s hospital / medical expenses will be paid so the patient will be released
• The charter aircraft used is suitable for the patient, the route, the airport, and the weather
• The charter company have provided a fixed-price quotation
• A flight plan has been filed
• The medical crew are available
• The medical crew have been briefed on the patient’s condition
• Appropriate medical equipment is listed, checked, and packed
• The evacuation costs are covered by us OR another party guarantees the cost
• Money to cover the cost of airport and fiscal taxes is available
• Transportation is available for medical crew and patient to and from airports
• The plan of action takes into account delays and changes in time zones
• Family members have hotel bookings available after arrival at evacuation destination
• Local agents are available for ground assistance
• The flight plan is approved
• The destination airport(s) are open

Checking and preparing for items marked with an * can take a lot less time if companies and individuals make the effort to plan in advance for an emergency

Medical escort staff have to be called in at short notice. Doctors are needed who are experienced in preparing and executing medical evacuations. A medical escort should not be a doctor or nurse only used to working in hospitals who is unaware of the logistical and medical difficulties associated with transporting sick patients. Trained professionals are in short supply and cannot be waiting on call for when a medical evacuation is required. The only way this is feasible is when a large urban hospital in a highly-developed country, supported by taxpayers and/or private donations, is prepared to release its medical staff on a rostered basis for such work. Even then, these medical flights are almost universally limited to under 30-40 minutes from home base. (The Flying Doctor service in Australia is actually no exception; while medical teams cover a very wide area, they are solely employed in this service and funding is provided by both private and public sources). There is consequently a short and unavoidable delay, as medical staff cannot simply abandon their patients and their work.

The medical equipment needed is far from ordinary. Medical equipment specialized for use in the medical evacuation environments is also needed. All equipment must be light, compact, robust, and battery-operated, all specifications which mean that double or triple the cost of traditional hospital-based equipment. When two or more patients (or indeed two or more medevacs) need to be supplied at the same time, such equipment must be expensively duplicated, and then more sets bought and kept ready as backups. In a tropical environment, breakdowns are more common and equipment has to be sent overseas for servicing, increasing downtime. And then before each evacuation all medical equipment needs to be checked, as you can’t send out for spares while en route.

Patients, passengers and crew must still abide by the rules of civil and natural law on a medevac flight. The most important law is that of gravity. Time spent checking the aircraft pre-departure is not time wasted, as if the engines stop gravity cannot be reasoned with. Additional unnecessary passengers and luggage (as opposed to medical equipment) increase fuel burn and flying time. Civil laws are equally important. A medevac is NOT a mercy dash and authorities do NOT condone associated illegalities.

The fact that an aircraft is on a medical evacuation flight does not allow the patient, pilot and crew to ignore the laws of the country. There is NO regulation or agreement that allows visa- and passport-free entry into a country simply because there is a patient on board that aircraft. There IS a regulation that allows a pilot to declare a medical emergency and land in a country for which the plane and crew did not previously file a flight plan or carry visas – but ONLY if this emergency occurs and is declared in-flight.

If before take-off the patient or passengers do not have valid passports and exit/entry permits, at the very least there will be delays. In some cases, the medevac may be cancelled by the authorities and/or the aircraft and crew impounded. For this reason, passports should be scrupulously checked and we request copies or originals of passports be available as early as possible in an evacuation. Furthermore, observation of customs regulations often requires that all medical equipment leaving and entering a country be declared to the appropriate authorities.