The transfer of psychiatric or non-specifically agitated patients can be challenging and fraught with complications not elsewhere seen in the field of retrieval medicine. Retrieval by road is often possible, but the distances mandated by a remote or offshore environment, the expected duration of transit, the relevant geography and terrain, and the urgency of transfer may dictate that flight is the only option for retrieval [1].
Air retrieval is a highly stimulating activity involving a restrictive and inherently unfamiliar environment. As a result, many of the physiological and psychological effects of transfer, the assessment tools, and the management strategies outlined in this document do not exclusively apply to patients with a psychiatric diagnosis. Anyone travelling by air may become agitated in transit, due to personality traits, organic brain disease, pre-existing phobias, withdrawal from nicotine and other drugs, or delirium from an underlying illness or injury. We have all seen the videos of people absolutely losing their marbles once trapped inside that aluminium tube.
Retrieval for a primary psychiatric issue is also much more common than is appreciated. 7023 US military personnel required aeromedical repatriation from Iraq or Afghanistan for psychiatric illness in the period between 2001 and 2013, as did 178 UK military personnel from Iraq between 2003 and 2009. This was not, as you would expect, the result of post traumatic stress disorder (PTSD), but more often due to mood and adjustment disorders precipitated by separation from family and loved ones [2,3]. These stressors are common to any deployed setting, meaning it is crucial that medical professionals working in support of expeditionary operations have an approach to managing them.
Contemporary evidence is minimal, but historically it has been shown that delaying transfer in favour of slower modes of transport, in some specific contexts, did confer unnecessary morbidity and mortality [4]. This paucity of evidence, combined with such a heterogenous patient population, means that there can be no clear guidelines in the way that guidelines exist for the retrieval of trauma, stroke, or acute coronary syndrome. Instead, determining who requires transfer by air and the degree of urgency must be evaluated on a case by case basis.
Legal and ethical considerations:
The treatment and transfer of involuntary patients is complex. Whether a patient has the capacity to provide informed consent or not, it remains best practice to consult patients on treatment decisions and explain all interventions. This is not only a more ethically responsible manner in which to conduct clinical care, but also improves doctor-patient rapport and maximises co-operative behaviours. Requesting that a patient take medication voluntarily is preferable to forcible intramuscular injection, just as the patient boarding independently is preferable to stretcher loading. All patients should be informed of the reasons for transfer, and have explained to them what they can expect in terms of restraint measures.
Any patient who requires urgent aeromedical evacuation due to the severity of their illness, to the extent that they are considered a danger to themselves or others, are by definition a significant hazard in the aviation environment. Ultimately, while on-board the responsibility for the safety of the aircraft and its occupants lies with the pilot-in-command. Civil aviation laws in most if not all jurisdictions dictate that in order to ensure the safe operation of the aircraft a pilot may refuse the carriage of any passenger that they deem to pose any significant risk to such safe operation. This could potentially lead to refusal to transfer these patients to their own detriment, and so these factors must also be balanced against the patient’s right to having minimally restrictive interventions imposed upon them [5].
Risk assessment:
The probability that a patient will become significantly agitated en route, and thereby disrupt the safe operation of the aircraft, needs to be assessed in advance. Stratification of risk will allow the planning of mitigation strategies, appropriate staffing, and handover requirements. The Royal Flying Doctor Service (RFDS) use a risk assessment matrix, which we have adapted below - though it should be noted that no tool should entirely substitute for clinical judgement.
There are a number of validated tools that can be utilised to assess the degree of agitation and the effect of sedation, usually by quantifying responsiveness as a metric along a sedation-agitation scale. The RASS is a commonly used scale familiar to many clinicians and has a high interrater reliability. An ideal score lies between 0 and -2 [5] but a RASS score of -4 may be appropriate for a short period of time on engine start up or patient handling [6].
Team composition and competencies
As described above, those patients who are designated as high or medium risk should be accompanied by a two person medical team. Between them they should possess advanced airway skills and be capable managing a mechanically ventilated patient. RFDS guidelines also recommend that a doctor is present for the transfer of any patient aged <16.
Any patients in the custody of forensic mental health staff may require corrections staff to also be present. Escort by other law enforcement officers, such as police, can occasionally be required and should be considered on a case-by-case basis. Any carriage of firearms or non-lethal weapons requires discussion with the pilot and crew well in advance and will be governed by local laws, which may be subject to change depending on whether the aircraft crosses state or country borders with differing police jurisdictions and legal systems.
Use of mechanical restraint
One must attempt to minimise the use of mechanical restraint as far as is reasonably practicable, though the RFDS risk matrix that we have based the one above on always recommends implementing mechanical restraint regardless of risk level. Restraints are scalable however, and this may at times be negotiable, depending on clinical context.
If physical restraints are going to be used these should be applied prior to boarding, as entry and egress from the aircraft can be stimulating. Whenever restraints are required, there should be clear documentation regarding all aspects of their use.
Once the aircraft is in motion, it is strongly recommended that restraints are not removed, even partially [5].
Use of chemical restraint
Pre-departure checklist:
Any easily reversible causes of agitation should be treated prior to flight. To optimise patients for transport and pacify patients as best as possible prior to transfer, the following pre-departure checklist can be utilised:
Emergency plan:
A pre-determined emergency plan should be discussed with all members of the transfer team, including aircrew, in order to identify what actions should be taken in the event that disruptive behaviour arises. This plan should cover the identification of patient deterioration, any escalation of restraint that will be used, routes of communication that will be employed both within the team and to the ground, and the potential for aircraft diversion. Prior preparation should include drawing up and appropriately labelling additional medications that may be required. Consider the ready availability of additional mechanical restraints, even if not initially intended for use.
Credit:
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References:
[1] Le Cong M, Finn E, Parsch C. Management of the acutely agitated patient in a remote location. Med J Aust. 2015;202(4):182-3.
[2] Turner M, Kiernan M, McKechanie A, et al. Acute military psychiatric casualties from the war in Iraq. Br J Psychiatry. 2005;186(6):476-9.
[3] Peterson A, Hale W, Baker M, et al. Psychiatric aeromedical evacuations of deployed active duty U.S. military personnel during operations enduring freedom, Iraqi freedom, and new dawn. Mil med. 2018;283(11-12):e649-58.
[4] Jones D. Aeromedical transportation of psychiatric patients: historical review and present management. Aviat space environ med. 1980; 51(7):709-16.
[5] Royal Flying Doctor Service Western Operations. Clinical Manual Part 1 Clinical Guidelines. 2020. Available from: https://files.flyingdoctor.org.au/dd/magazine/file/Part_1_-_Clinical_Manual_-_March_2020_-_Version_9.0f97.pdf?_ga=2.189544107.1497741517.1587882809-1818519623.1587882809
[6] Royal Flying Doctor Service Queensland. Clinical Practice Guidelines Manual. 2010. Available from: https://www.broomedocs.com/wp-content/uploads/2012/08/Final-Draft-sedation-protocol-1802101.pdf
[7] Soomaroo L, Mills J, Ross M. Air medical retrieval of acute psychiatric patients. Air Med J. 2014;33(6):304-8.
[8] Le Cong M, Gynther B, Hunter E, Schuller P. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J. 2012;29(4);335-7.
[9] Pritchard A, Le Cong M. Ketamine sedation during air medical retrieval of an agitated patient. Air Med J. 2014;33(2):76-7.
[10] Piper M (2015) Withdrawal: Expanding a key addiction construct. Nicotine Tob Res. 17(12):1405-1415.