The dictionary definition of holiday is a period of cessation from work or, a period of recreation. It is certainly not the sort of definition or description that most people would offer when asked the question but, in reality, it is broad enough to be accurate. You might choose a week in the West Country or the Lake District, perhaps a weekend in Paris or two weeks in Benidorm or even lash out on Florida, Bangkok or a cruise around the Alsakan coast. Whatever you decide to do and where to go it will be different from what you do at home and it will usually cost a lot more too!

Often, many months are spent saving for the holiday while the anticipation and planning generate a mounting feeling of excitement as the day grows closer. But the one thing which hardly anyone gives a second thought to is the planning of what to do if something goes wrong. It is only human nature, after all, to put a mental block against things that we do not like and illness and injury are usually the first things that are stored in the ‘don’t want to know’ file. After all, you have paid the insurance premium – you have haven’t you? – and so if things don’t go as planned it will be the responsibility of the metaphorical ‘they’, won’t it.

Very few people have even the slightest idea of what medical facilities are available south of Dover. The European Community is not too bad because of the reciprocal health care facilities that exist with our national health service. But once you go beyond, things change very rapidly. In America and Canada the standard of care is excellent but at a price. Something as simple as a throat infection can set you back $300 for the doctor’s fee and the drugs, and if you are unfortunate enough to suffer a heart attack someone is going to have to pay bills of between $5000 and $500,000, depending on the complications and the treatment you receive. Try back packing in Africa - without any doubt the sights and sounds are wonderful but if you are in need of a doctor I can assure you that they are as rare as zebras in the New Forest! And even when you manage to find one, the chances of getting the treatment you need for your complaint is very hit or miss. What about exploring some of the magnificent sites which have been hidden behind the communist block for so long? No doubt the experiences and momentos will be a talking point for years to come, but so will the ordeal you would go through if you were unfortunate enough to be taken ill. Outdated equipment, scarcity of essential drugs, sterilised old glass syringes and needles and a desperate shortage of everything will certainly be memorable!

But please don’t let me frighten you with these facts. Statistics show that only a small proportion of travellers need to seek medical help when they are on holiday and an even smaller proportion are sick enough to call for help. So the chances of your being one of the unfortunates is very small indeed but, even so, you do need to take precautions. Now I’ve already mentioned the insurance premium haven’t I? Just make sure that, before you set off on the journey, you have filled in the form honestly and paid the premium. At the end of the day, provided you have stuck to the rules, it is the insurance company that will be your friend in need and it is they who will be footing the bill for your medical costs. So where do I, as an in flight medical officer, fit in to the picture. Before I tell you that, let me describe the mechanism and machinery that gets into gear when your cry for help arrives and then I will tell you how that cry eventually comes down the line to me.

Let me describe the scenario when an unfortunate, well insured British traveller suffers a heart attack when on holiday. Naturally the first thing to do is to seek medical help quickly. At this stage don’t worry about bills and demands for payment because the first thing to do is think of yourself and the care that you need. The next thing to do is to ask your partner or friend to contact the insurance company on the emergency number that they gave you and answer all the questions. From that point on everything will be taken out of your hands – with a few exceptions, because not all insurers work to the same rules.

The insurance company will then pass on your details to what is known as a repatriation (repat) company. The principle is the same as when you dent your car; of course you will notify the insurer but they will then delegate the job to a specialist car repairer. The repat company are the specialists in monitoring your medical problem when you are abroad and, when the time comes, getting you, your family and your belongings home.

Our unfortunate patient slowly gets over his heart attack until the time comes when the repatriation referee – usually a doctor or a specialist nurse – decides that all medical criteria have been satisfied, the treating hospital is prepared to let him go and the airline company rules have been satisfied. This is where I fit into the jigsaw.

A telephone call will be made to ensure my availability, and this is usually giving me twenty four hours notice if I am lucky! All the medical details will be faxed through to me and I will make a second check to ensure that all the criteria have been met. All my in flight medical monitoring equipment is packed, my emergency tools and drugs are checked and I am ready to go. From this point on everything should go smoothly and the unfortunate patient is usually delivered to his home or hospital within a couple of days. Once again there are exceptions to this rule and things sometimes don’t go as planned; but this is where my experience takes over and the whole point of the exercise is to get the patient home without any responsibilities resting on his shoulders and is as good a medical condition as he was when collected

I have explained one particular type of scenario where a doctor is needed to accompany the patient home. This isn’t always the case because the involvement of the repat company depends on the type of illness or injury that is reported to them. Simple illnesses often just need advice as to what to do and where to go. Others may need a non medical escort to help the incapacitated patient through the immigration / emigration barriers and luggage carousels. here are those who need some more specialist assistance but where a nurse escort will be the best option. Depending on the circumstances and the country, the patient may be asked to foot the bills himself and reclaim them when he gets home. On the other hand the repat company usually provides a cost guarantee to the health care provider or, as often happens, the escort may have to pay the bills to the foreign hospital before they are prepared to let the patient out of their hands!

Whatever the scenario, the repat company are the ones who will be at the end of a telephone line ready to take over the many ramifications of health care abroad. Sick people are never the best ones to make critical decisions, let alone in foreign surroundings and faced with a babble of foreign languages. In this book I will share with you many of my experiences both from the viewpoint of the in flight medical officer and those from my earlier days when most of my flying was at ground level! I will tell you some sad stories and some very happy ones and, at the same time I will try to give you some personal impressions of the countries that I have had the fortune to visit.

Above all, I will try and reassure you wary travellers who have remembered to fill in the insurance form, that help is at the end of a telephone call should you be unfortunate enough to need it. But remember that the national health service stops at Dover. Wherever you travel it will be very different from what you are used to and I can certainly assure you that they don’t do house calls in Africa !

So let me start off by whetting your appetite with a couple of stories about repatriation exercises in which I was involved and which may raise a few eyebrows!

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Cruising Complications

One of the growth sectors of the travel industry at the turn of the century seemed to be cruising. From very basic three day boat trips around the Greek islands, through whale watching around the Alaskan coast to ultra luxurious round the world voyages where every taste is accounted for. Cruise liners seem to be getting bigger and bigger, offering more and more facilities to pamper and care for the passengers including health care facilities should the unexpected happen.

The provision of those on board health care facilities naturally varies according to the size of the liner and the distance that separates its route from shore based medical facilities. It also needs to be remembered that the bigger the boat, and the further it travels, the cost of the cruise begins to escalate. Accordingly the clientele then tends to gravitate to the more affluent and older travellers who are, by definition, more prone to the illnesses and injury which advancing years impose. Consequentially, the on board medical facilities expand in proportion, from a simple first aid box to full health care facilities including doctors, nurses and even minor operating theatres and intensive care units. However, at the end of the day, it must be remembered that whatever on board facilities are provided they are a finite resource. Should the ship’s medical officer feel that the illness or injury he is presented with exceeds his capabilities then the first thing he will recommend is that the patient be transferred to the nearest shore based hospital.

This is where the repatriation companies come into the picture. The cruise liner is certainly not going to wait in port while the patient recovers in the local hospital. After all they do have hundreds, even thousands, of other passengers who have paid their money and have little sympathy for the fate of the suffering fellow passenger. The ship sails on leaving the unfortunate one in the hands of local medical facilities with a faxed report to the insurance company and repatriation company asking them to take over the case.

On many occasions I have been asked to travel to foreign ports to assist these sick people. The ailments have varied from strokes, through heart attacks, cancers, psychiatric emergencies and major operations to something as simple as broken limbs. Fortunately, the majority of cases I have dealt with have been landed in places not too far from home in Europe, where the medical facilities vary from excellent to acceptable and where the repat company’s involvement is a simple ‘get them home’ exercise. Occasionally however, the poor patient is stranded many miles from civilisation and where the medical facilities are totally inadequate to deal with the presenting problem. This is where the repat company really has its work cut out and where I am sent on my way to just to assess the situation and the possible solutions. One case which springs immediately to my mind involved an Australian lady who had been cruising inside the arctic circle off the northern coast of Russia.

Coming to the end of a three month tour of Europe, the climax of my seventy six year old Australian patient’s and her husband’s holiday of a lifetime was a cruise in the Barents Sea off the north western coast of Russia. For some weeks she had become increasingly breathless until it got bad enough for her to ask to see the ship’s doctor. After an examination, and the use of the limited on board investigation equipment, a diagnosis of an irregular heart beat and heart failure was made. The doctor felt that her condition was more than he could cope with on the ship, and he recommended that she be transferred to a shore facility. What the ship’s doctor unwittingly failed to realise was that there, some one hundred and fifty miles inside the Arctic circle, there was nothing within five hundred miles that could equal what he had to offer. The end result was that the lady was stranded in a small Russian community whose medical expertise was significantly lacking for the condition affecting her.

The repatriation company immediately recognised this and, after urgent enquiries, pin pointed the nearest suitable hospital at a small fishing port and town in northern Norway. The poor lady then had to cope with a 250 mile ambulance journey over less than adequate roads, over mountains and fiords, until some eighteen hours later she was able to relax in a small but comfortable general hospital. After two weeks of investigation and treatment the treating hospital doctors felt that there was no more they could offer and cleared her for repatriation to Australia via London. The proviso they made was that the journey be broken in London for assessment by an expert cardiologist before the long leg of her return home to Melbourne in Australia.

My journey to the tip of Norway was, in itself, long and tedious. An early start from London’s Heathrow airport to Oslo in southern Norway, followed by an internal commuter flight to Tromso and finally on a small turboprop aircraft into the tiny local airstrip. After booking into my hotel I headed my weary way to the hospital to meet my patient and her husband.

The hospital itself was small but very well equipped and staffed. The doctors and nurses spoke excellent English and communication was not a problem. They were able to tell me what extensive investigations they had performed and what they had done to stabilise her condition but, not having a cardiologist to call on, they did not feel that they could do more for her. I did my own pre flight assessment and my findings concurred with theirs in that although the heart failure was well controlled, the irregular heart rhythm remained, and was a worry. We agreed that to go any further she needed to be transferred to the care of an expert heart specialist.

This is one of the decisions in aeromedical repatriation which is mine, and mine alone. An obvious and very significant medical problem which needs investigation but, on which side do the scales fall. Do I leave her there where the facilities are lacking, or do I take the risk of

inflicting a long and strenuous journey to a centre of excellence. In this case, the patient was significantly stable and cheerful enough to accept the risks and, after a long discussion with the duty doctor at the repatriation company, the decision was made to travel the next day.

The Norwegian town was a delightful small fishing town of about eight thousand souls. Pretty, brightly coloured houses scattered amongst wide open spaces and all around a fjord whose waters were cold enough to take your breath away. Wild reindeer were everywhere and, try as I might, I failed to see one with a red nose! My visit also happened to coincide with a carnival to celebrate the 150^th anniversary of the town and so the streets were packed with people taking advantage of the street barbecues, entertainment and bars. However, I must confess that at this stage, celebrations were furthest from my tired mind and, after a delicious meal of reindeer steak and trimmings, washed down with excellent local beer I retired to bed.

It was during the night that I experienced, for the first time, the land of the midnight sun. On waking at three in the morning I was totally disorientated to find it as light as day outside with the sun still low down on the horizon. My first thoughts were that I had overslept, and I was half dressed before I looked at my watch and realised that I could grab another three hours! Outside, the streets were still busy with revellers, bars were still open and the roads were as busy as they were when I first arrived! At breakfast I spoke to a very friendly waitress who told me that from July through to August it was daylight twenty four hours a day but from November through to March it was a permanent night! Pitch dark, freezing cold, deep snowdrifts, I’ll never complain about British weather again!

After breakfast it was back to the hospital to collect my patient. Because of her unstable heart I took the precaution of connecting all my equipment to her so that I could monitor it and be ready to act if anything went wrong. Fortunately, despite the three flights and a very long day to London, she remained stable at all times and I never needed to intervene. On the other hand, this happened to be one of those repatriations when, on the sector from Tromso to Oslo, another passenger decided to have a heart attack at thirty thousand feet and my work was cut out to keep things stable until I could pass him onto the paramedic crew on the airport tarmac.

My patient was delivered to a specialist unit in London where I discussed her condition with a consultant cardiologist. He agreed that the right decision had been made and that she needed extensive further investigation and stabilisation before the very long sector back to Melbourne in Australia. I must say that I was very relieved to be stood down at this stage because after two days, six flights and four thousand miles I didn’t look forward to another five days, four flights and twenty three thousand miles! When I rang the hospital some five days later, her condition had improved considerably, the specialist had declared that she was ready for the journey home and an Australian doctor was scheduled to arrive in London the following day to take her home.

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Moldova, where poverty is relative

August is usually a quiet month for me; unusual you might be thinking, because it is at the height of the holiday season and, surely, there will be many travellers needing my services. But, if you think about it, most high season holidaymakers are younger people, and young families and their children, the ones who don’t often suffer the types of illnesses and injuries needing the attention of a doctor. Of course there are many summer travellers who do need assistance, and who need to be brought home unexpectedly. But the great majority of them have non threatening complaints and are either accompanied by in flight nurses or those who can travel unaccompanied. It was therefore a pleasant surprise when I was asked to pick up my bags and to fly to Romania to accompany a fifty three year old American citizen back to England for treatment.

The story I was given was that he was a senior Salvation Army officer from Kentucky and who was working to set up that admirable organisation’s humanitarian service in that former communist block state. It was reported that he had a suspected ruptured spleen and that it was felt the medical facilities there were not sufficient to cope with his problem. He was to be brought back to a private hospital in London for the investigations and treatment which such a serious condition needed. The information I was given before I started off to London’s Heathrow airport were, so say the least, sparse, and I was even more confused when I collected the flight tickets only to find that I was in fact on my way to Moldova and not Romania. I couple of urgent phone calls to the repatriation company confirmed that although the original information had come through Romania, he was in fact in Chistinau, the capital of Moldova – another former communist block country a few hundred miles further east!

London to Frankfurt on a Lufthansa airbus to connect with an Air Moldova flight to Chistinau on a Yak 42 aeroplane, the old Russian equivalent of the BAC 111 which has long been replaced by airline companies in the west. Surprisingly, the Yak was a very comfortable aeroplane and the in flight service was superb. The two and a half hour flight was indeed a pleasant one and even more surprising was the countryside of Moldova we flew across. Mile upon mile of well cultivated fields, interspersed with hills covered with huge forests and vineyards stretching as far as the eye could see! The airport at Chistinau was modern and clean, and the reception I received was far more friendly than many I have encountered in western airports. It was almost a pleasure to part with the eighty American dollars I was asked to pay for a visitor’s visa!

When I arrived at my Hotel, my patient was sitting in the reception waiting for me and, for the first time, I was able to get a true picture of the problem over a glass of very good Moldavian red wine. It transpired that my patient had fallen at home in America some two months previously and, although he had not mentioned it to his doctor there, he had experienced a vague pain in his stomach ever since. This got worse after his arrival in Moldova and he had seen a local doctor who, after a series of simple investigations, had recommended an operation to explore his abdomen. I will tell you more about Moldovan medical facilities in a moment but, suffice it to say that my patient contacted his insurance company who asked the repatriation company to transfer him to London as soon as possible. The pre flight medical examination I did also raised the suspicion of problems affecting his kidneys which had not been previously mentioned. And so, it was with little hesitation that I agreed to transfer him to London the following day.

In fact my patient, although I suspected he was masking the underlying medical problems, was a remarkably cheerful and friendly man. Indeed at no time had he been admitted to hospital in Chistinau but had carried on with his normal activities and humanitarian duties. After completing the pre flight assessment, and having contacted the repatriation company with my thoughts and decisions, I had the pleasure of spending the evening with him and his wife and listening to them speaking about their work and thoughts about Moldova.

He had been working in Moldova for some four years, and difficult years they seem to have been. The Salvation Army has always been held in high esteem in my mind for the magnificent humanitarian work they have done throughout the world over many years. Having said that, they are still a religious organisation, beset with the sectarian divides which is responsible for more hurt and suffering than all other causes put together. My patient’s arrival in Moldova was met with stiff and violent opposition from the indigenous worshiping sects including the Russian Orthodox Church, the Muslim community and many others, who saw their worship of the same god in a different way as a serious threat. His life had been threatened, his property stolen or destroyed and his wife verbally abused in the streets. It speaks worlds of his admirable dedication that he even stayed there, let alone his success in the work that he was doing.

Although it did not appear immediately obvious, Moldova is a very poor country. For many years under the wing of the Soviet Union all their produce had been spoken and paid for, albeit for a pittance, by other Soviet states. However, once the communist block fell apart, their market had collapsed and demand for their produce had disappeared. This was no more demonstrated than by their wine producing industry which I was told had vast underground cellars, holding millions of bottles of high quality wine with no one to buy it. I have already told you about the excellent red wine I tasted, but when I tell you that I bought it at 20 pence a bottle you may realise what I mean!

Poverty is relative; relative to what you are used to and have been brought up to accept. My patient told me about the schoolchildren who attended the schools the Salvation Army had set up, and where the attendance hovered around forty percent. The attendance leapt to around ninety percent when, after a request to the Salvation Army in Scandinavia, two container loads of unwanted children’s shoes were bought at six dollars a kilo, shipped to Moldova and distributed. The children simply didn't attend school because they had no shoes to wear. I was told that on one occasion a young boy attended school in the morning but was noticeable by his absence in the afternoon. When asked why the following morning, he innocently replied that he was unable to because it was his brother’s turn to use the shoes!

Medical facilities in the country are also hopelessly inadequate by even the poorest western standards. Something as well cared for in western countries such as diabetes is, In Moldova, almost a death sentence. Not because of lack of knowledge or medical caring but rather because the supplies of insulin, syringes and needles vary between scarce to simply non existent. Death rates amongst children in Moldova would, in the United Kingdom, be regarded as catastrophic, but are regarded there as the norm. Once again because what we consider to be basic items, such as antibiotics, antiseptics and pain killers, are virtually unobtainable and, if they are, only at a very high price. Medical equipment for investigation of illnesses is rudimentary and very often only outdated cast offs from more modern and ‘generous’ countries in the affluent west. It was therefore small surprise to me that the decision to repatriate my patient to the United Kingdom for investigation and treatment had been made.

Having said all this, my reception in Chistinau was wonderful. I certainly couldn’t understand the Russian that was spoken but the whole attitude of everyone I met was friendly and courteous. The hotel staff welcomed me with open arms and the food I ate was superb. My evening meal started of with caviar, continued with fried sturgeon and local vegetables and concluded with a delicious local sweet. The whole was washed with a bottle of the excellent local red wine I have spoken of, and the bill at the end – the princely sum of six American dollars! Small wonder then, that when I left the waitress a tip of five dollars she burst out in tears. As my Salvation Army patient told me, I had given her the equivalent of a week of her normal wages!

As happens too often with my repatriation experiences, I had little time to really get to know the country I was visiting. My patient however was a mine of information and I left Moldova with a sense of despair to realise what I was leaving, and knowing what I was going back to. Readers of my first book will know that my opinion of the United Kingdom national health service is often critical but, having being given the opportunity to see how others simply exist, it is with a sense of relief that I started the journey home.

We started off early the following morning to catch the comfortable Yak 42 flight back to London via Frankfurt. Flight delays and an unusual lack of assistance at the airports meant a long twelve hour journey before my patient was comfortably settled into a good London hotel, there to wait for an appointment with a well equipped London clinic. At the end of the day it was obvious that he had tired considerably, was unacceptably breathless and in significant pain. I sincerely hope that his ailment will be settled soon because Moldova will be a sad place without him.

Before you join me on more of my travels to all parts of the world, perhaps a few words of explanation of how I got involved with aeromedical repatriation in the first place may interest you – along with a couple of stories which would probably be better in a comedy sketch.

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The Golden Hour

I am often asked by the patients and their relatives that I accompany on a repat, how it was that I got involved with such an interesting branch of medicine - how did I get into the world of ‘real’ flying doctors. The answer is fairly straight forward really, but I suppose it would be very boring reading just to say that. So let me give you a chapter of a resume of my medical career and experiences which led me through into the aeromedical world. My story may sound a little incredible, and even stomach churning at times, but I will work on the principle that if my wife and children could put up with me, why shouldn’t you.

After a hospital career, mainly in orthopaedics and accident and emergency medicine, I moved into general practice in South Wales. There I spent three years learning the hard way. Despite being in a five doctor practice, I was ‘on call’ every Tuesday and Thursday and every other weekend. The reason for this is that I was considered to be the ‘junior’ partner and was expected to do far more than my fair share of the work, for a pittance compared with the other partners. This was indeed a far cry from the comparatively comfortable life that modern general practitioners have to face in their trainee years. At the same time I had first hand experience of the way that the patients I dealt with in that part of the world had acclimatised themselves to and taken full advantage of the welfare state. As a fairly typical example, I was asked to do a house call on the sick child of a local councillor. Unusually, morning surgery was quiet, so I did the house call before surgery only to find that there was no-one in! Back to surgery, only to get a phone call an hour later when the councillor apologised for having missed me, but they had been out shopping and didn’t expect me so early and it was OK for me to come now! Needless to say a few choice words encouraged him to bring the child to surgery! Honestly, the work load was daunting to say the least, and I find it small wonder that parts of South Wales now find it very difficult to attract new family practitioners.

After those three years I rebelled and moved to live and work in the West Midlands. There I found that the grass really was greener on the other side. Equally shared on call commitments, patients who rarely abused the medical services and all this for a much better salary and standard of living. For what seemed to be the first time since I qualified, I had time to myself to spend with my young family and my own interests.

As I have said, I am a practical person rather than a theoriser. Perhaps this is why front line emergency medicine has always appealed to me. As well as settling down as a family practitioner in the Midlands I did regular sessions in the local accident and emergency unit and it was there that, in the mid seventies, I became aware of a glaring gap in the national health service. For those unfortunate people taken ill at home, a simple phone call to a family doctor meant that expert help was just around the corner. Similarly, once patients had overcome the waiting list barrier and were in hospital, specialists offered up to the minute solutions to medical ailments and injuries. The gap I mentioned affected those victims of accidents and emergencies who were thoughtless enough to suffer their illness or injury in the street, on the road, in the countryside or at work. Those people, often suffering life threatening conditions, had to wait for an ambulance to arrive only to find it manned by crews whose qualification was little more than an advanced first aid certificate. Fortunately, things have changed dramatically over the past 20 years and highly trained Paramedics and Air Ambulances have brought expert emergency care to the place where it is needed – the site of the emergency itself!

That crucial period, between the time of onset of the life threatening ailment and the time the patient arrives at the accident and emergency department, has often been referred to as the ‘Golden Hour’. In that short time, stopped hearts can be restarted, catastrophic bleeding can be stopped and breathing can be assisted. But such life saving measures need specialised equipment and the people who are trained to use it, vital ingredients which were certainly not offered by ambulance services at the time. It was at this time that I became involved with a national organisation called BASICS – the British Association for Immediate Care. In the short space of three months, four doctors and myself raised enough money to equip and offer an emergency medical flying squad which became known locally as ‘the flying doctor service’.

Since that time, and for over twenty years, I have carried a pager on my belt and been available, at the touch of a button, to respond to requests from ambulance control for assistance and to offer advanced medical equipment and expertise. In those years the ‘flying doctor service’ has turned out to many thousands of calls and there is no doubt that lives have been saved and suffering relieved. Also during those years we have seen the birth and development of the ambulance paramedic service. It certainly has been a pleasure and privilege to have been involved with the training of those paramedics and to work alongside them as professional equals.

Naturally, my involvement with such work has had marked influences on my family life. Many times excuses have been made for missed appointments and I can remember innumerable occasions when I have had to apologise to Isobel, my wife, for soiled and torn clothing – my dinner suit after one call out! I was even called to my children’s’ head teacher’s office one morning and had a reprimand from him after one particularly busy day.

On my way to the surgery each morning I dropped the children off at school, but carrying a pager and ambulance radio telephone meant that there was no getting away from crisis calls. The children were well strapped into the back seat when I was asked to attend a serious road accident involving two motor cyclists, a car and a lorry. It really was serious. One motor cyclist horrifically injured and dead and three others with multiple serious injuries. The end result was that we were over an hour late in getting to school, but I felt sure that the teachers would understand my predicament and not issue the children with poor punctuality red stars. I was a little surprised therefore to be presented with a letter from the headmaster a few days later, asking me to make an appointment to see him.

My first attempt to apologise for the children’s’ lateness was quickly brushed off with a grateful thank you and compliment for the work that I did, and that he fully understood why the children were late. ‘It’s not the punctuality that concerns me doctor’ he said, ‘it is the day diaries which we encourage the children to keep. Two of my teachers have had to report off sick with psychological problems after reading your children’s accounts of that accident you went to the other day!’. I went away with a smile on my face, not because of an inverted sense of humour but rather because, even at that tender age, I knew which direction my children’s’ careers would lean towards!

Not all the calls I got from ambulance control could be constituted as emergencies, indeed many of them were a complete waste of my, and the ambulance crew’s time. On the other hand, what would you think if a distraught mother said over the telephone one Christmas night, ‘my little girl has got a toy car stuck in her chest and she can’t breathe’. This was the message I received as I was about to sit down with a glass of Christmas port. Within minutes I was breaking all speed limits – fortunately on virtually empty roads – while my mind raced over the possible implications and whether I carried the right equipment to deal with them.

I was the first to arrive at the address given and must confess to being a little surprised to find an air of almost complete tranquillity as I rushed through the front door. The television was blasting away in the corner, father was snoring in his chair with a half empty bottle of whisky alongside him, mother was making tea in the kitchen and her teenage daughter sat slumped over the kitchen table. There is the patient I thought as I cast my eye around and saw a young girl lying flat on her face in front of the fire. I immediately turned her over into the recovery position and was in the process of pushing my finger into her mouth when a very loud ‘Oi, what the ‘ell are you doing?’ came from mother standing at the kitchen door, at about the same time as the youngster’s teeth closed on my unsuspecting finger. ‘That’s my grand daughter you’re messing with, this is my little girl here wot’s got the car stuck’ proclaimed mother as she pointed to the teenager still slumped over the kitchen table.

What had happened was that the teenage mother had been playing with her daughter and was showing her how to make one of those Christmas present friction drive cars go. You know, the type that after a couple of sweeps of the wheels you let it go and it races away across the floor. The problem arose when she used her chest as a surface to build up the speed of the car wheels but, unfortunately, forgot to let it go quickly enough. The end result was that a fold of skin from her chest quickly wrapped itself around the car wheels – ‘it’s stuck doc and it ‘urts me to breave’ was the tearful wail from the kitchen table!

At this point the paramedic crew rushed through the front door, burdened down with their resuscitation equipment, and fortunately I was able to halt their rush before they made the same mistake that I had. A few words of explanation and suggestion and within minutes a heavy duty cutter had relieved the teenage mother of her predicament. It was at this point that a well oiled voice emanated from the previously snoring father – ‘I ‘ope you vandals intend to pay for that car, it was the little ‘un’s Christmas present’.

Needless to say, a very rapid exit was the order of the day with the ambulance crew nearly falling over themselves with Christmas mirth. The only casualty of that incident was me, and I felt very sorry for myself as I returned to my port and my amused wife bandaged my very bruised finger.

Another flying squad call that sticks in my mind is when I was asked to attend after a man had collapsed outside the local bank. Whether it was because the machine ate his card, or he realised how overdrawn his account was, I do not know, but the message that came over my radio was that a man, had collapsed in front of the bank cash-point machine and that a first aid trained fireman was trying to resuscitate him. While the receptionist explained to a very busy surgery where I had gone, it took me just 4 minutes to arrive outside the bank.

A quick assessment confirmed that his heart had stopped and, over the next five minutes, we inflicted heart massage, specialised artificial breathing and a vast array of drugs before he was brought back to the land of the living. We were more than pleased at our success and felt quite proud of ourselves.

What we didn’t expect however was the chorus of grumbles coming from the queue waiting to use the cash machine. ‘Have you finished yet, I’ve got my shopping to do…’ said one large lady while a man tried hard to negotiate the scattered equipment and step over the resuscitated body to try to reach the machine. At least the patient patients still waiting in the surgery gave a cheer when told the outcome!

I could go on for ages telling such stories but I think it’s time to go back to being an in flight doctor. It was just a few years after becoming involved with emergency flying squad work that I was reading the BASICS journal and happened to see a small advertisement which had been submitted by the St John Ambulance Service. ‘Volunteer doctors and nurses are invited to assist in the repatriation from foreign countries of sick and injured British citizens’ - a concept which appealed both to Isobel and myself very much indeed. Little did I know at the time that that small advertisement would mean a career change from being a land locked flying doctor to becoming a real one in every sense of the word!

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In a Desert in Saudi Arabia

Although it was not really part of my repatriation world, my first real experience of aeromedical work took place in what must seem like the very unlikely setting of a desert in Northern Saudi Arabia! I had applied for, and been accepted for a short term contract where I would be working as one of the site medical officers during the building of the King Khalid military city, just South of the border with Iraq (which is where, some 10 years later, the first Gulf War was orchestrated ).

There, in company with one other doctor, a dentist, an anaesthetist, a radiographer and six nurses, I provided general practitioner and accident and emergency services to some 6,000 building workers on a gigantic construction site. As you may well imagine, the workload was very heavy, twelve hours on and twelve off for six days a week! The variety of medical problems we experienced was certainly enough to satisfy even the most ardent medical workaholic. But the biggest problem we faced was that our medical and specialist backup and support services were some 400 miles away on the Persian Gulf coast at Dharan, which boasted the nearest multi-speciality hospital to our building site.

We were able to cope with the majority of problems quite happily and competently, but if anything more than fairly straight forward surgery was needed, or we were faced with major bone injury, then we had to call on the air crew for an emergency casevac to Dharan. I’m sure that you can imagine, with 6000 building site workers under our care, we had to casevac at least one patient a day.

I have already said, we were in the middle of the Ad Dibdiba desert in Northern Saudi Arabia but, and contrary to what most people think, there is an awful lot to see and do in a desert. One of my favourite pastimes (yes we did have some time to spare apart from stitching cuts, reducing fractures and listening to chests) was to sit in what was called the 'rock shop'. There I spent many hours using a gem cutters lathe to inexpertly cut some of the very low quality alluvial diamonds which could be found, in abundance, in the surrounding desert. I still have about 5 carats of my handiwork fashioned into earrings and cufflinks, and funnily enough they mean very much more to me than some of the better quality and much more valuable ones.

The local Bedouins were very friendly people and because we offered, without charge, our medical services to them as well as to the site workers, they went out of their way to repay what they felt was a genuine debt. I was invited as the guest of honour to the wedding celebration of a local sheikh’s daughter in one of the local Bedouin camps, and had the ‘pleasure’ of drinking milk straight from a camel, of eating delicious rice dishes by hand (right hand only of course, because the left one is used for other unmentionable things!). And, being one of the more important guests, I was given the privilege of eating the sheep's eye!

Now, I feel that it is very important for travellers to always respect local traditions and customs and this is especially so in some of the more devout Arab and Islamic nations. The trouble is, such respect often flies in the face of all the medical care, practice and ethics which I was taught in medical school. One evening I was on duty when a heavily pregnant Bedouin lady was brought into the clinic. She had been in labour for some considerable time and it didn't take long for me to work out that the baby was trying to come out feet first (breech delivery). This is where my medical training came into conflict with Saudi customs. Putting it simply, the Moslem husband, and his many other children, could not come to the terms with the concept of another male, and a western infidel male at that, casting his eyes on the private parts of his wife. On the opposite side of the argument, I was certainly not prepared to perform a breech delivery with those private parts well hidden under a blanket! Fortunately, I won the first argument, the blanket was removed and a healthy baby boy was delivered and I suspect that mother and son are still doing well. However, I lost the second argument and spent the rest of the night and following day in a Saudi police cell trying to explain my religiously unacceptable actions and I was only released after giving a written apology to the husband - who probably couldn't read or write anyway!

One of the local laws, which I’m afraid I cast a blind eye to, was the forbidden subject of alcohol! Months in a very dry and very hot desert was more than I could bear and I soon made friends with the Scottish dentist who had talents which were very popular in the expatriate community. On his bi-annual trips home, one of the things which he brought back to the desert were many packets of yeast and which passed the eagle eyed customs officials as necessary to bake ‘English’ bread. These, combined with the malted yeast which was somehow found in abundance in the site shop, and were the proud basis of a very potent brew! I’m sure that the Saudi police had a suspicion of what we were up to but, in accordance with our contracts, and in sharp contrast to the unfortunate building workers, the European expatriates had to be given twenty four hours notice of ‘a raid’. You can imagine, therefore, the activity which took place if the location of the proposed ‘raid’ happened to be on the building where the illicit brewery was operating! On the other hand, the American compound was treated very differently and their contract stipulated that there were no raids behind their walled compound. I’m not sure what ‘diplomatic’ bag methods they used, but one of the many highlights of my stay in Saudi Arabia was to be invited to dinner by an American where bottles Californian wine and single malt whisky were in abundance.

But to going back to my first aeromedical experience and, in retrospect, probably one of my most heart-rending. It was when a nine-month-old Bedouin boy was brought into the emergency room, when I was on duty, with a wicked pneumonia and dramatic breathing problems. Now, most doctors will readily admit that children's medicine is very different from adult medicine; things can go from poorly to life threatening in a matter of minutes and specialist help is absolutely essential. This happened to this child and, despite all my best efforts, his condition worsened very rapidly. The emergency casevac flight to Dharan was a nightmare and it was a great relief to be met on the airport runway by the flashing lights on a brand new American type ambulance. We quickly disembarked and were on our way, within minutes of landing, to the hospital some 40 minutes away.

The problem was that despite the ambulance being brand new and fully equipped, and the driver trying to exceed all imaginable speed limits, none of the unused equipment on board had been removed from its packing and none of its fittings had been checked and connected! The almost moribund child desperately needing oxygen was deprived of it, because we simply could not find and connect the equipment fast enough. Despite all our efforts the child died as we carried him through he hospital emergency department doors.

As far as my aeromedical life is concerned, Saudi Arabia taught me many lessons right from the start, but one of those lessons stands out from all others. Never, ever, travel with a patient unless you are fully equipped to cover all medical eventualities. This may well mean being burdened down with all sorts of equipment that is rarely used, but I know I would rather do that than to be faced with a life or death situation that could have been solved by one small simple instrument or drug.

The case of the child in Saudi Arabia also underlined to me the fact that the quality and type of health care provision on offer is never the same from country to country. I was also made very aware that the value and quality of life itself is regarded very differently by different races. As far as the father of the poor child was concerned, it was ‘Inshallah’ – it is God’s will. It has certainly convinced me that, despite all our frequent and often justifiable complaints about national health service inadequacies, we do have a service which meets the basic medical needs of the population – albeit at the end of a waiting list!

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Namibia in Southwest Africa

The loss or delay of luggage, bags or medical and nursing equipment can cause major logistical problems when dealing with a repatriation. Just like a jigsaw, the whole picture cannot be completed properly if there is just one piece missing. On the other hand, there are rarely times when backup procedures cannot be set into motion or replacement equipment begged, borrowed or stolen. But in the meantime, the poor unfortunate patient, not to mention the repatriation officer, may be left stranded many miles from home for goodness knows how long – but perhaps every story has two sides to it and this one is a prime example.

The 19 year man we were sent out to bring home in this case had taken one of those increasingly popular ‘years off’ between his ‘A’ level results and starting at university (otherwise known as extended vacations at parental expense). He had been back-packing around southern Africa and had joined a group of other like minded youngsters who had rented a minibus to travel across the Kalahari Desert between Johannesburg and Windhoek in Namibia. The long, long trek over many miles of featureless desert was going well, until a very tired driver picked a wrong time to doze off at the wheel, and the minibus collided head on with a lorry going in the opposite direction. Fortunately, most of the youngsters escaped with minor cuts and bruises, but our unfortunate nineteen year old, who was asleep and unbelted in the front passenger seat, was not so lucky. He was thrown through the windscreen and suffered numerous broken ribs, one of which punctured his lung but, even more important and significantly, he had fractured his spine quite high up in his neck. On the other hand, I suppose he could be regarded as fortunate in that, despite the bone of the spine being fractured, the spinal cord itself was not severed and therefore he was not paralysed in any way, although there is no doubt that a little rough handling could have had catastrophic results.

Our patient was indeed lucky in that a number of his travelling companions were trained first aiders. Their excellent and intelligent first aid care and handling of the patient, followed by the rapid arrival of a helicopter air ambulance from Windhoek some 150 miles away, meant that just two hours after the accident our 19 year old was admitted to the emergency ward at the Roman Catholic Hospital in the capital city of Namibia, Windhoek. Facilities there were not as extensive as we see and normally expect in some British hospitals who are geared up for such injuries, the care he was offered was, without question, excellent. Due to the first aid he had been given at the accident, his well splinted spinal cord was still intact and the admitting doctors continued that level of care. His spine was completely stabilised and immobilised using splints and sandbags, and the fractured ribs and air leak from his lung were appropriately treated. After just two weeks, his general condition had stabilised enough for consideration to be given to transporting him to a specialised hospital, where his fractured spine could be operated on and more securely stabilised. The choices were either to fly him into a university hospital in South Africa or back to a specialist unit near his home in Manchester in the United Kingdom. Finally, a decision was made to bring him back home after taking into account a number of factors. Firstly, having loaded the patient onto a secure transfer stretcher there would be little logistical difference between a six hour flight to Cape Town and an eighteen hour flight to London. Secondly, by sending out a fully equipped doctor and nurse team, all possible in flight care could be given and finally, because the insurance company were paying the bills, they naturally aimed for the cheaper option!

Off we went, armed with a spinal stretcher, mattress and full immobilisation facilities, special chest drain equipment and a host of other medical and nursing necessities for an eighteen hour flight. With everything packed into four big bags, a nurse colleague and myself set off on the eighteen hour journey to Windhoek, with a two hour stopover in Johannesburg. The plan was that we would arrive at Windhoek at 4 o’ clock on a Tuesday afternoon, grab a few hours sleep before collecting the patient and catching the weekly direct flight from Namibia to London the following morning. The very tight scheduling was necessary because, being so soon after the Christmas holiday period, very few long haul flights could spare the 11 seats necessary to accommodate our stretchered patient, the voluminous equipment the nurse and myself.

All seemed to be going well until, just an hour after arriving, we stood alone and staring at the empty baggage carousel at Windhoek airport, all the other passengers having long departed. Enquiries at the lost luggage department were not very fruitful apart from the news that there was no more baggage to be unloaded from the plane in which we had come. However, another flight from Johannesburg was scheduled to arrive later that evening, and there was a remote chance our equipment would be on board. We were advised to go to our hotel and wait there for news and, hopefully, the arrival of our equipment which would then be delivered directly to us. The rest of the evening was certainly not an opportunity for grabbing a few hours sleep. Rather it was a series of telephone calls to Johannesburg and Windhoek airports, to the airlines to try to enlist their help and to the repatriation company back in London to keep them informed of events – not to mention a visit to the poor patient to keep him updated. It was fortunate that I had taken my mobile phone charger with me because telephone bills running into three figures soon take a heavy toll on the battery!

We set ourselves a deadline. Either the equipment was in our hands by midnight or we would have no alternative but to cancel the repatriation arranged for the following morning. At ten minutes to twelve, a phone call came through from the hotel reception – ‘your bags have arrived sir’. ‘Thank goodness’ we thought, and while I started making calls to say that the following morning’s repatriation was GO, my nurse colleague rushed downstairs to check the bags. He was soon back upstairs with a very long face, and the news that two of the bags had arrived, but that the two carrying the special stretcher and transport mattress were still missing. The ensuing telephone calls were sadly to stand everything down, and to ask the office back home in the UK to start making the enquiries for new travel arrangements to be made.

The following day was spend sitting at the end of various telephone lines as desperate attempts were made to locate the aircraft space which would accommodate us for the long trek home.. The fact that the rest of our equipment arrived by lunch time the following day was now not so important because, as I have said, virtually every flight out of southern Africa was fully booked some six to seven days ahead. It was late afternoon that a first gleam of hope started to appear; it seemed that stretcher space was available on an overnight flight from Nairobi to London some two days away. The only problem was that somehow, we had to get the patient and ourselves the nineteen hundred miles from Windhoek to Nairobi to meet that flight!

I agree that when you look it up in your old school atlas, the two cities of Windhoek and Nairobi are only some two to three inches apart. But in real terms it meant a nine hour flight in the only air transport we could find in southern Africa at such short notice - a single engine and very noisy transport plane posing as an air ambulance. We would have to cover some one thousand nine hundred miles over a route which had to be meticulously planned to avoid African war zones. A very seemingly unconcerned south African pilot told us that there was every chance we would be forced to land, if not shot down, if we flew over those troubled countries! Once we got to Nairobi we would then transfer to our London bound jet and there would be a further 8 hours overnight flight. There being no other alternative, the go ahead was given to make the new arrangements for the repatriation some two days later. The good news was passed onto our long-suffering patient who, bless him, had not complained once during the whole unfortunate saga. This meant that there we were, my nursing colleague and myself, stranded in a far away land. What on earth could we find to do to fill in the two whole days before our journey home started!

Exploring Windhoek itself was a pleasure. Clean, well laid out streets and avenues that would put many in the UK to shame. Warm and friendly people of all shapes, sizes and colour who went out of their way to assist and advise us. And above all, no apparent racial overtones, which the western press in general would have us believe is rampant in this part of the world. A few enquiries soon had us looking towards a brief safari into the Namibian scrub land and desert for just £40 a head, and were treated to an adventure which most people see only as a television documentary.

The day started off with a visit to an ostrich farm where we were treated to a very informative tour and were invited to meet the livestock. Lunch was included in the cost of the day and the menu appropriately offered fillet of ostrich, which was delicious. The best part of the day started after lunch when we climbed aboard a 4-wheel drive jeep and toured a 1,000 square mile private animal reserve. Rhinos, giraffe, warthog, elephant, all manner of antelope and deer, birds of all shapes, sizes and colour that we would normally see in textbooks. It really was an afternoon of pleasure and excitement tempered only by the fact that I did not have a camera telephoto lens with me, and had to make do with some long distance shots. The day finished off with a very acceptable sundowner while we looked out over some magnificent countryside as the sun set over the reserve.

Our guide had been superb throughout the day, giving us a non-stop commentary on the land and its animals, the country and its people. He was in fact a German immigrant who had settled in Namibia after the second world and was indeed very knowledgeable about the country, its people and its wildlife. As well as a guided tour he gave us some frightening facts about the spread of AIDS in his country, and also his concerns about how large estates were being split up into smaller parcels of land and then given to the local people. Bad management of these small parcels was then apparently turning them quickly into desert and slowly destroying Namibia as he knew it. It was a memorable day and our guide certainly earned the generous tip we gave him at the end of the tour. Certainly a day to remember.

The following day started at 6am when we met the patient and the ambulance crew at the hospital with all our equipment. After completely stabilising and immobilising the patient’s spine our journey back to England started. I won’t bore you with the details of a very long and tiring day because it went completely without incident. After nine hours of a very noisy trip across the African continent the transfer to the comparative luxury of a jet at Nairobi went very well. Some 30 hours later, our very tired patient was delivered to a spinal injury unit in London. His condition was completely unchanged and his spine still intact. After a mutual back pat and handshake we wended our weary way home to relate our stories to an eagerly anticipating home audience!

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Don’t I know you ?

With a few exceptions, aeromedical repatriation is very much a loner’s game. The travelling to the airport, the waiting in the lounges, the flight out, the hotel that is booked for me, these are all activities which I usually do on my own and, apart from occasionally passing the time of day, there are very few people to talk to. Of course, there is the part of the repatriation when I collect my patient and their relatives and accompany them to their final destination. This is the part of the repat which I enjoy most, when a large part of my work is exercising my vocal chords and to reassure the patient with a non stop chatter!

But going back to the exceptions I mentioned. Of course there are the occasional repats where the patient’s medical and nursing condition means that both a doctor and a nurse are needed and, on occasions like this, it is a great pleasure to be able to recount and share experiences with a like minded colleague. But the type of exception I am really referring to is when, very many miles from home, I unexpectedly meet up with someone whom I know well, or someone from my dim and distant past and when the repatriation exercise almost turns into an old school reunion. But first, let me tell you a little about the particular case I was dealing with.

This is one of those repats where I was given just twelve hours notice to be at London’s Gatwick airport to meet up with a nurse for a flight to John F. Kennedy airport in New York. I can never really understand why such short notice is given because when I sat down and read the twenty pages of faxed notes it was very obvious that this case had been brewing slowly for a couple of weeks. But, there you go, mine is not to reason why but rather to say OK, and be on my way! The patient in this case was an eighty year old lady who had travelled to Connecticut to spend a few summer months with her daughter and son in law who lived and worked in that wonderful New England countryside. Her family doctor had declared her fit to travel and, apart from occasional arthritic aches and pains, she was a very fit lady who was perfectly capable of managing her life and affairs at home in South Wales. But, just four weeks after arriving in Connecticut, disaster struck.

She was taken by ambulance to a small local hospital after complaining of severe chest pain, and immediate electro cardiography and blood tests showed that she had indeed suffered a severe heart attack. She was immediately transferred to a specialist cardiology unit where, over the space of twelve hours, the diagnosis was confirmed, an angiogram located the blocked heart artery, balloon angioplasty opened the blockage and a small metal insert called a stent was inserted to keep it open. This was a perfect example of what is called aggressive medicine where, when faced with a problem, doctors take immediate and decisive action to sort it out.

In the initial stages everything went well for our patient. Unfortunately, just twenty four hours after having had her heart attack and having her arteries re plumbed, part of her heart muscle gave way under the strain and blood leaked into the sac around the heart. Once again, aggressive medicine was expertly practised, a tube was inserted, the leaked blood drained off and over the next few days she made a slow but good recovery. The end result, some twelve days after her original heart attack, was that my patient was discharged from hospital back to stay with her daughter in as fit, and at least as active, a state as she was when she first travelled to the United States.

Naturally, such aggressive and intensive medical care does not come cheap in the United States and the bills generated by my patient’s heart attack, and the subsequent procedures, had already passed the one hundred and fifty thousand dollar stage. Naturally, the insurers were wringing their cost analysis hands in despair. Also, by this time, the lady was well past her intended stay dates in Connecticut and so a decision was quickly made between the repat company and the insurance company to get her home as quickly as possible. Home into the passive medical hands of the national heath service, before anything else could go wrong, and where the insurers would no longer be responsible for paying any bills!

This decision was probably the reason for the sudden last minute rush, and the lateness of the call asking me to travel. With a farewell peck on the cheek to a very sleepy wife, the following morning at five thirty I was on my way from home to meet up with a nurse colleague for the ten o’ clock flight to New York. Now even at this stage, and from the paperwork that had been faxed to me, I knew that the patient had a very Welsh surname and that she lived in a rural part of South Wales. But, even as a Welshman myself, I certainly thought no more about it. It was only nineteen hours after leaving home and after arriving at the patient’s daughter’s home in Connecticut to do the pre flight medical assessment did some very old and very rusty memory cogs in my head start to grind together.

Naturally, when we met, and to put my eighty year old patient at ease, I used my very limited Welsh vocabulary to introduce myself and to ask her how she felt. She apologised profusely in English, explaining that as a child she had been brought up in a part of Wales where Welsh was rarely spoken. Indeed, as a youngster myself I well remember being told that I would ‘get nowhere if I used the Welsh language’! Further discussion and questioning soon brought out that we had in fact lived just a few miles apart back in the 1960s. The plot thickened considerably when the patient’s daughter arrived home and I realised that not only was she about the same age as me, but a very loud but old memory cell shouted loudly ‘I know who that is’. Yes we went to the same school, and of course she remembered the school badminton club evenings. It turned out that I had re met my very first date some three thousand miles away in America some thirty five years later!

It certainly turned out to be a very interesting reunion. We spent a lot of time discussing old friends and those we were still in contact with, about how our lives had moved on over the years, about our own families and of how our lives had progressed since that date many years before. It fact we spent so much time talking that eventually my nurse colleague and our patient had to interrupt and bring us back to the present time! A very memorable reunion indeed.

The pre flight medical assessment went very well and it was soon confirmed that, despite her very traumatic medical experience, everything was OK for the repat the following day. Travel details were discussed and by the time we were ready to go back to our hotel, my previously very nervous patient was almost looking forward to the flight home!

From my patient’s daughter’s home back to the hotel we travelled through some of the most beautiful countryside I can ever remember. Many people talk about New England in the fall but I can assure you that it is a magnificent experience at any time of the year. Wildlife was abundant with deer virtually ignoring us as we drove past. We were told that there are black bears in the region and that they were becoming a nuisance by raiding the soft touch dustbins and carelessly left open cars – I think I am happy to stick to the urban foxes we have in the United Kingdom. Once again though, there was little time for exploration on this repatriation exercise.

Back at the hotel, it wasn’t long before we were eating a superb meal, in a very colonial setting set in magnificent wooded surroundings. No room numbers at this hotel but rather names such as Stratford, Cambridge, Oxford, Worcester and Warwick, all superbly fitted out with period furniture and the discretely hidden modern accoutrements to make an evening away from home very comfortable. The meal matched the surroundings in excellence of quality and presentation - snails in garlic, followed by roast bison and finished with apple soufflé, and was quickly followed by an early bed to be ready for the long journey home the following morning.

Medically and from a nursing viewpoint the repat went without incident. A two hour road journey from New England to John F Kennedy airport in New York, a two hour wait there followed by a seven hour flight to London’s Heathrow airport. There we were met by a very comfortable patient transport vehicle and within an hour of landing were on our way to rural South Wales. Four hours later and our very tired patient was safely tucked up in bed in her local hospital surrounded by her friends. A total of sixteen hours from collection to delivery of a successful repatriation. But the job wasn’t finished; after handing over the medical report to the hospital, it was back on the road for a four hour journey to Gatwick airport where I had left my car, then a three hour drive back to home in the West Midlands. For me it had meant a total of thirty six hours without sleep. It wasn’t long after arriving home therefore that my head hit the pillow, leaving the telling of tales of an exciting reunion until the following day!

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Family doctors – Take note !

There is no doubt that aero medical repatriation is an exciting and, most of the time, a very fulfilling and rewarding job. However, there are definitely occasions when I feel very much like one of those characters in the Roger Hargreaves children’s books – Mr Angry!!

As a full time General Practitioner I was born into, and learned my trade under the protective umbrella of the national health service. It certainly taught me that, in line with the Hippocratic Oath, the patient’s needs came before financial gain. A very far cry from what we saw as the worm of fiscal priorities and a fee orientated work ethic which has eaten its way into the legal profession!

Now, having moved into a totally different type of health care provision I am able to stand back and watch my former GP colleagues from a fly-on-the-wall perspective - and I often don’t like what I see. I’m not talking about multiple murderers, body snatchers or inefficient and incompetent surgeons, but rather the inability of many general practitioners to see beyond the cosseted surroundings of their practices, and the often even more offensive money first, patient second attitude. Let me expand on my thoughts with a number of examples – and I hasten to add that they are only a small selection from the many that I have encountered!

I’m sure I don’t have to remind you that travel insurance companies are not charitable extensions of the national health service. They are profit making organisations and they go to great lengths to make sure that the rules are adhered to – in other words, the small print of the policy. The whole concept of travel insurance is to handle medical emergencies abroad and not to provide a quick and easy way of bypassing waiting lists at home. Break a leg or have a heart attack when you are abroad and the insurers are your best friends at a time of need; but to expect them to pay foreign medical fees for long standing pre existing medical conditions is another matter. This is why, when an injury or illness abroad is notified to them, the small print of the policy gives them the right to approach the GP at home to enquire about the patient’s previous medical history.

There is another very important reason for the enquiry. Very often, when someone is taken ill in a foreign country, the doctors there want to know more about the patient and any medication being prescribed, just in case it has a bearing on the illness which they are trying to deal with. For instance, a patient may be taking steroid tablets for a completely unrelated condition but which may have significant bearing on the current illness; asthmatics may be on a whole array of tablets and medicines, any of which could react badly to the treatment they want to offer.

I was asked to go to Toronto to repatriate a seventy year old gentleman who was spending Christmas with his son and, while he was there, the unfortunate man had suffered a heart attack. On his travel insurance form he had honestly declared that some six years previously he had suffered angina, was investigated in Ireland and subsequently had triple heart by pass surgery. Naturally he had paid an extra premium to cover any heart conditions while he was away and was therefore fully covered for the costs of medical treatment in Canada. At this point the repatriation company contacted the family doctor in Northern Ireland and asked for details of the gentleman’s previous medical history and for a list of drugs with which he had been treated. There followed eight days of frustrating telephone calls and pleading before the vital information was forthcoming.

For the first couple of days the messages left with the doctor’s receptionists and the numerous telephone calls, emails and faxes went unanswered. Eventually, a very curt email reply came back stating that, in spite of a signed consent form, he did not release information to insurance companies – and despite having already been told that the information required was for his patient’s wellbeing. More fruitless requests went by unanswered before another email was received stating that the doctor was prepared to divulge the information, but only on receipt of a fee of £50 in cash! By this time the repatriation company was being pressurised by the foreign doctors and the patient’s relatives for the information and agreed to pay the fee. But how does one get £50 in cash from London to Ireland? Easy enough to send cheques, wire transfers and money orders but hard cash in a hurry? – not so easy. However, by day seven the family doctor in Ireland had his cash but even then it took another 24 hours before he took the trouble to email the vital information through. The sum total of the fax was : Mr Edward Murray - !992 Angina, 1993 triple CABG (coronary artery bypass graft), Aspirin, Propranolol, Frusemide (the patients name has been changed and the italics are my explanation). A total of eleven words was all this money grabbing, unhelpful and thoughtless doctor could manage at £4.54p a word. Needless to say, when the repatriation exercise was completed the patient went home armed with all my criticisms of his family doctor, and my report contained many of the thoughts that I’ve shared with you.

That was just one example of the many ‘fee before fact’ general practitioners that repatriation companies are having to deal with. What is perhaps just as worrying is the huge number of GPs who hand out ‘fit to fly’ certificates like confetti at a wedding, and who give no thought to the implication of their actions. Where is the patient travelling to? What medical facilities are available there? Is the patient able to tolerate a long haul flight of up to 15 hours through many time zones and in the cramped confines of an economy class seat? What effect could flying at 39,000 feet have of the patient’s condition? All these are basic facts in the aero medical game. But not, it would seem, to many family doctors whose prime interest in foreign travel is how much money their foreign travel vaccination clinics can generate!

We received a report that an eighty three year old lady had travelled unaccompanied to Los Angeles to visit her son, but that while she was there she developed a chest infection and was admitted to hospital. Now, for a start, we wondered how a lady of such advanced years could have tolerated a seven thousand mile flight in the oxygen depleted atmosphere of 39,000 feet, but I must admit that there are some very able and active octogenarians!. In the initial stages it proved difficult contacting the American doctor and so to hurry things along we contacted her family doctor to get details of any previous medical conditions which may have had a bearing on the case. The report we received was, on the surface, helpful concise and complete and gave no indication of any previous illnesses the lady had suffered. The doctor also declared that he had seen no reason for her not to fly to America and had accordingly issued a fit-to-fly certificate for insurance purposes. Fair enough we thought, with no previous medical problems the lady should recover fairly quickly from her illness in Los Angeles and make her own way home as scheduled. What happened next was a catalogue of catastrophe furthest from our thoughts.

When we eventually received a medical report from Los Angeles our initial thoughts were that we were dealing with a completely different patient. Severe pneumonia in a lady who had for many years suffered from chronic bronchitis, a heart that suffered 2 attacks and was now in serious failure, and a list of drugs that she was taking that would keep an average chemist’s shop in profit for years! And all this referring to the same patient who the family doctor had declared fit to fly! Needless to say, our opinion of him was critical to say the least.

The insurance company on the other hand were completely fair and honourable. They agreed that the fault in this case was entirely laid at the door of the family doctor and agreed to cover the costs entirely. Hospital bills to date $135,000; doctors bills $69,000 and all this before we could even contemplate bringing her home! And all because a thoughtless GP had said that this octogenarian with chronic bronchitis and heart failure was fit to fly to the west coast of America.

It was weeks before our patient improved enough for a very fragile window of opportunity opened to bring her home. A nurse and I were rapidly dispatched, with every piece of equipment that might be needed, to California but even at this stage I had serious misgivings about the case - and I was not wrong. When we arrived at the hospital we were taken to an isolation ward (!) to find our very breathless patient suffering from a very infectious diarrhoea. Even ignoring her heart and breathing problems there was no way that any airline would carry her in her condition. The end result was that the nurse and I flew home without the patient, with an extra £15,000 added to the insurers bill and hospital costs escalating faster than an express lift! And all this because of a thoughtless family doctor.

OK. Perhaps these two cases I have described are at the extreme end of a problem, but I can assure you that they are the tip of a very large iceberg. Never a day goes past when we do not have major difficulties in contacting general practitioner surgeries and even when we do, in persuading them to release the information needed to handle the case. Never a day goes past when we don’t sit there with feelings of exasperation in having to deal with travellers that should never be where they have gone to in the first place. The sooner GPs become a little more world wise and professionally empathetic the better, because until they do many more travellers will be left stranded in remote places and where there is nothing that can be done to help them.

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Who is in charge ??

My first meeting with my patient on this repatriation didn’t really augur well for a good doctor patient relationship; it was even less so, and with great ominous foreboding, when I realised that the relationship was going to be a 20 hour one from Singapore to England and at very close quarters!

‘Good afternoon Mr Calthorpe’ (names changed), I said as I knocked on the door and walked into his hospital room in a very hot and humid Singapore, ‘my name is Barrie Davies, and I’m the doctor who has come to accompany you home’. This is my usual formal introductory gambit and one which, nine times out of ten, attracts an expression of intense relief and gratitude and is often accompanied by copious tears (especially in the ladies section). The familiarity bits come later when a close and empathetic doctor patient relationship is created, and which puts the poor patient at ease during what is naturally a very stressful period.

Not so in this case. It could only have been compared to a gentle prod being replied to with a hefty punch. ‘Damn you sir, you are speaking to Lieutenant Colonel, not Mister Calthorpe and you will wait outside until I am ready for you’, was the reply I received.

Now, I am not an open critic of military command structures and indeed, I am the first to accept that there has to be a hierarchical chain of command in all aspects of everyday life. Indians and chiefs after all eh? But I was damned if I was going to take such a rebuke lying down, particularly as our Lt. Colonel was 20 years past his sell by date! Similarly, and apart from a period as a cub scout, I had never had to respond to a military command in my life. On the other hand, through training and experience, doctors learn to accept all sorts of patient, no matter what their often abrasive attitudes may be, and this was how it was in this case. ‘I beg your pardon Colonel’ I replied, ‘but as I am the doctor who is going to accompany you home on a very tight schedule I must insist on seeing you immediately’ (please note I left out the word ‘sir’!).

So our first encounter had got off to a very shaky start but, funnily enough, our relationship quickly developed a sort of hierarchical command structure. He gave the orders, which I repeatedly and resolutely ignored, and countered with suggestions to which he had no alternative but to agree !

But I must confess that this particular case had attracted a lot of red warning markers from the moment all the details were faxed through to me. For a start, what on earth was a seventy eight year old gentleman doing on a long cruise around far eastern countries on his own. The faxed report stated that, on the day he was taken ill, he had taken part in a day trip into Vietnam – a four hour coach journey over very rough terrain followed by a six hour trek through the jungle and rounded off by another three hour coach journey back to the cruise ship. The sort of venture normally associated with very active and fit younger travellers.

When he arrived back on the ship he complained of pain, swelling and inflammation affecting his lower leg and presented himself to the ship’s doctor. At the time, the affliction which was most in the public eye was known as ‘economy class syndrome’ – blood clots which frequently form in the legs of long distance airline passengers. So when the ship docked in Singapore my patient was quickly transferred to a shore hospital with a diagnosis of deep vein thrombosis. I will not go into great detail of the diagnosis and treatment. Suffice it to say that the wrong diagnosis had been made and what had happened was that, in a 78 year old with poor circulation in his legs anyway, he had developed a nasty looking and painful inflammation which had rendered him severely incapacitated. Incapacitated enough for the cruise line to refuse point blank to take him back on board and the only option available was to get him home to the UK - which is where I became involved.

At this point things started to become interesting. On talking to my patient, he went to great lengths to tell me how, during his stay in the hospital, he had managed to ‘bribe’ some of the staff to smuggle whisky in to him, despite a strict ‘no alcohol’ policy which the hospital operated. I mentioned this to the treating doctor who seemed completely unsurprised. He then went even further to tell me that Lt. Colonel Calthorpe was a fully fledged alcoholic, and had severe liver damage and blood circulation problems which contributed to his inflamed leg! However, ignoring the fact that my patient had probably broken every clause in his insurance policy, and the treating hospital had not forewarned the repatriation company, here I was, in Singapore, and somehow I had to get him home.

The following morning, bright and early, I collected him from the hospital and with various combinations of ambulances and wheelchairs got him to the business class lounge at Changi Airport in Singapore. Needless to say, his comparative immobility didn’t stop him from attacking the complimentary bar in the business class lounge. Within an hour of arriving he had managed to down two glasses of champagne, two glasses of red wine and a very large brandy – all this before 8 am Singapore time, midnight back home in England! I almost had to drag him away when boarding was announced! ‘I will sit in the aisle seat’ he announced as we settled into the Boeing 747; ‘no you are not allowed to, the medical escort has to sit there’ I replied as a spontaneously invented new regulation came to my mind. No way was I going to allow him unimpeded access to the galley.

Despite my efforts, a large gin and tonic quickly disappeared followed by a red wine before he had even finished his entrée. It was when he summoned the stewardess and ordered a glass of port and a brandy that I drew the line. ‘I’m sorry colonel’, I interrupted quietly, ‘I think you’ve had more than enough alcohol for the time being, and with a fourteen hour flight ahead of us’. At this point the Jeckell and Hyde transformation took place again. In a very loud voice, and using expletives that made me wince, he totally silenced any conversation in the business class section of the plane. While enquiring as to my parentage and nationality he asked what right I had to tell him what he could and could not do. I must proudly confess that I surprised myself with a calm, considered and quiet response which only he could hear. ‘Sit down and shut up. I am in command here and if you behave like that again you will not be allowed another drink for the rest of the flight’.

His response was what can only be described as a sulk! He turned to look out of the window and there he remained for a very peaceful thirty minutes, refusing to talk or to reply to any questions. It was only when he asked if he could go to the toilet was the ice seemingly broken before he disappeared behind the curtain, and I sat there mistakenly counting chickens! Mistaken because after all, even with age related flow problems, surely fifteen minutes is a long time? A quick inspection of the toilets found them all unoccupied, and a further search soon located him in the galley downing a brandy. It only took a severe frown before the drink was downed and, without a word, he retreated to his seat. OK I thought, the time has come to enlist some assistance in the shape of the aircraft’s cabin crew. No more alcohol without my permission, was the instruction gratefully agreed to by the flight attendants whose ears were still throbbing from the earlier outburst.

By this time most of the passengers had started to settle down to get some sleep and indeed, to my relief, so did my Lt. Colonel. With a blanket over his head and still suffering the symptoms of his earlier sulk, a couple of hours of peace reigned. We were somewhere over the Himalayas when he woke and announced again that he needed the toilet. Fair enough I thought, the crew have been warned and, with any luck, this call of nature would be a genuine one. It was less than two minutes later that the senior steward came to me and, with a large smile, gave me the next chapter of my patient’s exploits. It seems that after visiting every galley on the plane and having his requests for alcohol refused, he had taken to approaching any passenger who was still awake and asking them to order drinks for him! Once again a reprimand, followed by another burst of expletives which even woke the passengers in the economy class section, before he disappeared under his blanket in another sulk.

Now I know that alcoholics are generally regarded as metaphorical lepers in society for their antisocial and frequently aggressive behaviour. Like other drug addicts they lie, steal and will do anything to get their hands on the next drink. On the other hand, they are sick people with a serious illness beyond their control and which society in general, and the medical profession in particular, has a duty to help them cope with or cure. In the case of Lt. Col. Calthorpe however, I had to try and negotiate a tightrope hung between my professional duty to my patient, and my social duty to the enclosed community of four hundred people at 36,000 feet! To have allowed him unlimited access to alcohol would have resulted in a potential crisis in the air, and could have put many lives at risk. On the other hand, to have denied him his ‘fixes’ could equally have resulted in a very unpredictable passenger and the equally dangerous crisis I have spoken of.

And the answer? A negotiated settlement between patient and doctor which meant a can of beer hourly for the remainder of the flight! Certainly not his idea of what he wanted and certainly more than I would have been happy with under normal circumstances. On the other hand it needs to be borne in mind that this was a repatriation exercise, where my duty was not to try and cure the patient but rather, to help him through a very difficult period between Singapore and England. It was therefore with a sigh of considerable relief that I felt the plane’s wheels touch down at Heathrow airport.

My patient was a very disgruntled man. The original problem with his leg had almost been forgotten in the comic opera which stretched almost a third of the way round the globe. Between Heathrow and his home in southern England another two Jeckell and Hyde transformations took place and our final parting, although not acrimonious, was not the way repatriations should finish. I have no doubt that the moment his front door closed a bottle opened, but there was little I could do about it other than to submit a full and very honest report to his family doctor. They say that hope springs eternal but in this case, I have my doubts!

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A life on the ocean waves

There was a time in my earlier medical career when flying was a very long way from my mind and my main purpose in life was, literally, to make ends meet! Having qualified at the ripe old age of twenty five, and never having earned a penny in my life, I was thrown into the carousel of mortgage, marriage and money with very little experience and a very large bank overdraft to fall back on. My wife Isobel’s income as a midwife certainly kept our heads above water in the early stages, but it wasn’t very long before pregnancy and children soon dried up that source. Of course as time went on, so did the financial position begin to improve but I’m more than happy to admit that a lot of financial hurdles blocked the way in the early stages.

Holidays were certainly a no go area in those early days apart from occasionally borrowing an aunt’s caravan for a week on the beautiful Gower peninsula in South Wales. Most of my holidays were in fact spent doing locum work for other doctors and deputising services to earn enough to make inroads into my overdraft. Even bank holidays proved to be valuable extra sources of income, and I well remember one very busy, ‘flu ridden Christmas where three twelve hour extra shifts were more than enough to keep the bank manager happy.

However, as time went on so the finances improved and I was able to spend a little more time getting to know my young family! We were certainly not in a position to read the foreign holiday brochures, but at least holidays became a time away from work that we could share as a family. At about this time I moved from South Wales to work in a family practice in the West Midlands, where the work load was more manageable and the income certainly more rewarding! I was also very pleasantly surprised to find that an old friend from my grammar school days had also qualified in medicine, and was in a practice just a few miles down the road. This re birth of an old friendship certainly opened a whole new world for us because, all of a sudden, foreign holidays became a reality which we could afford – although with a few occasionally daunting provisos!

It turned out that my friend’s wife’s sister was married to a Greek, and lived in the port of Piraeus, not far from Athens. There, she was the personnel director of a Greek shipping line which operated very popular cruises around the many Greek Islands and popular Mediterranean resorts. Yes, you’ve guessed it; cruise liners carry passengers and, in times of unpredicted trouble, passengers need doctors! The deal was that as long as we found our own way to Piraeus, and I offered my services as a ship’s doctor, the cruise line would provide full on board accommodation for myself and my family, full restaurant facilities with the passengers and the opportunity to take part in all the shore excursions and activities. In addition they would offer a small amount of remuneration depending on the size of the ship and the number of passengers it carried. Once again, a working holiday but one with a very big difference!

The cruise line operated seven ships varying from a smaller day excursion vessel to the larger eight hundred passenger vessels. There was never a need for a ship’s doctor on the day excursions but always on all the other bigger boats. The cruises they offered started off with three day adventures around the most popular Islands, through four and five day voyages including places like Istanbul and the islands of Rhodes and Crete, right up to one and two week odysseys including the Holy Land, Cyprus, Egypt and the pyramids and as far as southern Italy. Of course, I was not the only doctor who had found this little holiday goldmine and of course, everyone wanted to cover the longer more exotic sailings. Fortunately, my contacts and my being in a position to plan well in advance, meant that over a period of about five summers my family and I saw every corner of the eastern Mediterranean!

There is no doubt that I was fortunate in having very thoughtful and accommodating partners who were quite happy for me to group all my annual holiday weeks together. Therefore it turned out that by October, I could offer four weeks of my time to the cruise line for the following summer. Usually, I worked on the ship for the first two weeks of each holiday without my family who then joined me for the second two weeks, which was more than enough for them. I know it sounds very strange, but more than two weeks on a cruise liner designed for three and four day cruises can be incredibly boring. Captain’s welcoming and farewell party twice a week, Greek night twice a week, identical meals twice a week, the same ports of call twice a week with just enough time to disembark but not enough to explore. I’m certainly not complaining though! Those summer holiday jobs were some of the best times we have ever had as a family and, in a way, they whetted my appetite for the foreign travel which I am now enjoying.

The work load on those cruises could hardly be described as over demanding. A one hour surgery each morning and another one each afternoon before dinner. Otherwise, I was expected to be on call for emergencies whenever passengers were on board – and if the passengers had disembarked on excursions, I naturally had to follow them in case my services were needed didn’t I! The cruises were certainly not cheap, and the majority of passengers were American who were ‘doing the Grand European tour’. And having paid for their ‘all inclusive’ package they took the words ‘all inclusive’ literally and made demands on my skills in some very diverse ways! Fortunately, most of my patients presented with fairly simple complaints – sea sickness, coughs and colds, hangover headaches and simple strains and sprains. Unfortunately, my contract stated that the passenger was always right, and I was frequently tending to ailments and conditions well outside my professional field including chiropody, physiotherapy and even psychosexual counselling!

On the other hand, the experiences were wonderful. As I’ve told you, we were able to join the passengers on the shore excursions and on board activities. The best part was, that as members of the crew, we paid only twenty five percent of the advertised prices (our bar bills as well!). On the four day cruises, Istanbul was included as an overnight stop and we were able to join excursions around the magnificent mosques, the fabulous Topkapi Palace and its incredible treasures including the three hundred carat Spoon makers Diamond. The bazaar in Istanbul was a day trip in itself. Acre upon acre of dimly lit narrow passageways selling everything from Turkish delight to hand woven carpets and ornate brasses. But I would warn any of you who feel adventurous – leave your credit cards on board because those Turkish salesman can be very persuasive, and your duty free allowance can soon be over its limit!

On the longer one and two week cruises we were fortunate in being able to visit the Holy Land on a number of occasions and were able to wander away from the beaten track a little. Nevertheless, organised tours are well geared to cover a little of everything in a short period of time and, having sampled the tasters, we were experienced enough to avoid some of the more interesting main courses! It would be totally inappropriate for me to be so presumptuous to try and describe the Holy Land in this book – suffice it to say that it was an experience that we will never forget. Similarly Egypt with its pyramids, museums and incredible poverty proved to be as interesting and memorable. It was in Egypt that I first encountered that irritating, and indeed offensive, habit prevalent in many Moslem countries – the expecting and even demanding of baksheesh, or tip, or gratuity, even when it was certainly not earned.

So what exciting medical experiences did I have in my days as a ship’s medical officer. Fortunately they were few and far between because the majority of the cruising tourists were fit and healthy – otherwise they would not have travelled anyway! Most of the consultations were, as I have said, simple ailments or injuries which didn’t really tax my medical skills. It also needs to be remembered that in the eastern Mediterranean we were never more than a couple of hours sailing from a major port, and it was the company’s policy that if I felt I was dealing with a major problem then the ship’s captain was to divert and transfer the patient to a shore based facility. There were a number of occasions when an acute appendix reared its ugly head and, although the ship’s operating theatre was more than sufficient to deal with it, they were taken off my hands very quickly.

Once, when we were half way between Crete and Cyprus, a small aeroplane was unfortunate, or perhaps fortunate, enough to experience engine trouble as it flew within a few miles of the ship. The captain quickly responded to the ‘MAYDAY’ and, as part of the emergency response team, I was soon dressed in a life jacket and bouncing across the sea in the ship’s inflatable. The injuries, although painful and disabling were not life threatening; two broken legs, lots of cuts and bruises and a broken rib which punctured a lung. The victims were soon rescued and transferred to my on board medical facility – without a shadow of doubt I had the busiest night I ever had as a ship’s doctor before we were able to transfer them to a hospital in Cyprus.

From a financial point of view those cruising holidays that I had with my family were a Godsend which I could never have otherwise afforded. After paying for airfares from London to Athens the only other expenditure was spending money – and not a lot of that was needed! I have already said that the Americans were usually the most demanding from a medical point of view but I should also say that the South American citizens were the most grateful for services rendered, and even for insignificant consultations I well remember having Mexican one ounce silver Pesos being ‘forced’ into my hand!

A very memorable early chapter in my medical career and one where the memories are very pleasant. Over the years since my days as a ship’s doctor with that cruise line, I have since read with a great deal of sadness of the sinking, with loss of life, of three of the boats I sailed in. Very much a case of my being in the right place at the right time!

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Around the World in 5 Days !

When, as a youngster, I read Jules Verne’s epic story ‘Around the World in 80 Days’ I naturally regarded it as an experience and challenge of gargantuan proportions. But despite the fertile imagination of childhood, at no stage did I envisage undertaking such a journey myself, in just five days! Of course, there is no way that I can compare any of my journeys with that of Phileas Fogg but, on the other hand, he did not have the luxury of twenty first century airlines and neither did he have to cope with the complexities of time zones and jet lag!

When the call came in asking me to go to Honolulu I had no idea of what lay ahead. It would be dishonest to say that the prospect did not excite me – a trip around Pearl Harbour, relive that catastrophic December morning in 1941, enjoy the less demanding pleasures of Waikiki Beach and to sample the delicacies of a culinary hub of Polynesian food. Yes, I accepted the job with open arms despite what I knew was going to be a very tiring schedule.

As usual, before I leave home I prepare myself for the case by reading all the ‘log entries’ of the case to familiarise myself with what may be needed. In this case, the patient was a seventy year old man who had left England to spend some time with his son who lived and worked in San Francisco. As a treat and as an exciting climax of his holiday, his son and daughter in law had arranged to take him to Hawaii. But they had travelled to that Pacific paradise without knowing, or even suspecting that there was a very serious health problem brewing inside my prospective patient.

After just two days on the island he collapsed in a restaurant, pulseless and not breathing. He was resuscitated by those excellent fast response American paramedics and was eventually admitted to the intensive care unit of the local hospital. I will not go into the intricacies of his problem. Suffice it to say that the major blood vessel leading out of his heart was already seriously blocked before he travelled to America, but the stress and excitement of a very long series of journeys proved the final straw. The blood supply to his brain, heart and body was cut off suddenly and it was only superb paramedical and medical care saved the day. The following morning he was sitting up in his hospital bed with more tubes and wire attached to him than a desktop PC, wondering what on earth had happened.

Now I have already explained that travel insurance companies work on the principle of stabilising a problem while the policyholder is abroad, then getting them back under the wing of the national health service as quickly as possible where their financial resources are no longer under threat. However, it soon became obvious from the log entries that the unsuspecting patient in this case was a time bomb waiting to explode in terms of high cost heart investigations and heart surgery. Naturally the insurers wanted him home as quickly as possible! With all this in mind, I was dispatched with an accompanying nurse and an arsenal of equipment for the long journey to Honolulu via San Francisco.

A ten hour flight to the west coast of America, where we switched to a six hour flight to the Hawaiian islands was going to be demanding to say the least. The prospect became even more demanding when I collected the airline tickets at Heathrow airport to find that the penny pinching insurer had booked us outbound all the way in economy class! More about this very vexatious point in another chapter; I rang the repatriation company with a few choice words and veiled threats before we were quickly upgraded to business class seats where sleep was possible. By the time we got to Hawaii we were some ten hours behind UK time, and where everyone goes to bed at the same time as our body clocks were telling us to get up! It is a very disorientating experience indeed to call my wife by phone to wish her goodnight just as I was sitting down to a breakfast of Hawaiian fried rice and eggs! However, the prospect of first seeing my patient, then trying to settle down for a night’s – or perhaps I should say a day’s – sleep was not too daunting. But we were certainly not prepared for what came next.

As with all American hospitals, the welcome and courtesy we were offered when we arrived was magnificent. But what was not so reassuring were the confused looks on the faces of the doctors and nurses when we introduced ourselves and explained that we had travelled some eight thousand miles to escort our patient back to England. ‘But doctor, he is in the operating theatre at the moment undergoing major heart surgery’ was the reply which left me and my nurse colleague with looks on our faces that made theirs pale into insignificance!

What had happened was that on the day we flew from London’s Heathrow airport, our poor patient had collapsed once again. Resuscitation was followed by immediate and complex heart investigations and he ended up on the operating theatre table having his blocked heart valves replaced on the day we arrived! It had all happened so suddenly that no one had had time to warn us before we left, and I can assure you that four hundred seat airliner captains don’t turn their planes round! Eight thousand miles, ten time zones away from home, and we were up the creek without a patient so to speak. For the rest of the day the airwaves between Honolulu and the UK proved a bonanza for my mobile phone service provider as the repatriation company went to great lengths to salvage what they could out of an unforeseen and very expensive situation. They went through their active log sheets checking the whole of the Pacific rim to look for other sick British travellers that needed to be brought home rather than let us come home empty handed. Their search was not in vain! ‘How do you feel about popping over to Brisbane, Australia to collect a man with a fractured spine’ we were asked. Well, I wasn’t quite sure that ‘popping over’ was quite the right choice of words as, having already flown some eight thousand miles, Brisbane was another six thousand miles away to the west over a very big ocean!

The logistics of the task at such short notice was daunting to say the least. We spent the whole day (night in England and when theoretically I should have been sleeping) wrestling with the complexities of finding airlines with spare seats, not only to get a doctor and nurse over from Honolulu to Brisbane, but also to get the doctor, nurse, patient and his wife back to England from Brisbane. While the repatriation company concentrated on the Australia to England leg, I spent my time (and £4000 on my American Express card) concentrating on the trans Pacific leg. Fortunately, my bit of the job turned out to be easy and by Honolulu lunchtime the flights were arranged for midnight the same day.

Now I know what you are all going to say, ‘go to bed and try to catch up on some hours sleep’. Would you really, honestly and truthfully do that? There was no way that, having travelled a third of the way around the globe, was I going to miss out seeing Pearl Harbour, which is now an American national monument and managed by the US Park Rangers. A film, a lecture, a boat trip around the harbour where many of those huge battleships still lie on the bottom, and finally a visit to the USS Arizona where nearly 1,200 sailors perished, and all for free! It really was a memorable couple of hours before I finally put my head down to catch up some sleep.

Now comes the confusing bit of the story, and I make no apologies if you find it so, because it was my sleep deprived mind that wrestled with the complexities of writing it! As I have already said, Honolulu is ten hours behind the UK. In other words, they are getting up in the morning just as England goes to bed on the evening of same day. When I called Isobel to keep her in the picture, I explained that we were just boarding a Tuesday overnight flight to Australia. ‘How long does it take and when do you get there’, was her next question, and which was followed by the answer, ‘tomorrow, Thursday morning’. You could almost hear her brain ticking away some eight thousand miles to the east. How on earth could a twelve hour flight end up with my being ten hours in front of her whereas when I left Honolulu I was ten hours behind her! And on top of that, I completely lost out on a Wednesday! Yes, you’ve guessed it, I had crossed the international date line and had literally lost the whole day completely – or had we gained a day ? I’m sure my poor wife began to wonder who needed to be brought home me, or the man with the fractured spine in Brisbane Australia! But at least I caught up on some much needed sleep on the long night flight from Honolulu to Brisbane.

This was really turning out to be an epic adventure of my own. Forty eight hours and some14,000 miles later and here I was in Brisbane Australia. Now did you know that the city of Brisbane was born in the 19^th century as a penal colony because of its accessibility by sea and remoteness from anything and anywhere else! On the other hand, this was furthest from my mind when I arrived there because Brisbane happens to be the home of one of my oldest friends. Terrence Patrick Sullivan McGuire, a brilliant and well respected children’s orthopaedic surgeon, and with whom I spent my formative medical training years when I was a junior orthopaedic registrar in Liverpool. Within an hour of landing I had been in touch with him, and made arrangements for what proposed to be a very exciting and long overdue reunion.

But, naturally, my first priority was my patient who was an in patient in the local university hospital. All the notes regarding the case had been faxed by the repatriation company to the hotel where I was staying and, having had a good night’s sleep over the Pacific, was ready to meet with him.

Now I have already told you that he had a fractured spine but things were not quite as simple as that! My patient and his wife had been on a golden wedding celebration world cruise from Southampton to New York, through the Panama Canal and up the west coast of America to San Francisco. It was there that the first inkling of a problem became apparent. He developed a pain in his neck spreading to his arm and which at first he tried to control with simple pain killers. Between San Francisco and New Zealand the pain became bad enough for him to approach the ship’s doctor who started him on much stronger pain killers and made arrangements for him to be seen by a specialist when they docked at Auckland. More pain killers, muscle relaxants and anti inflammatory medications were offered with limited success and it was only after arriving at Brisbane was it thought necessary to X-ray his neck! It turned out that two of the spinal bones in his neck had collapsed causing severe and painful pressure on his spinal cord. With such a major problem it was inconceivable that my patient could continue his cruise He, his wife and all their bags were left in Brisbane while the ship sailed on. And which is where the repatriation company entered the picture.

When my nurse colleague and I visited our patient in hospital we were given the opportunity to examine the case in more detail and discuss with the treating doctors the cause and proposed treatment. Things did not look too good at all. The fractured bone was not the sort of thing an injury causes but rather they thought that a secondary cancer deposit had weakened the bone so much that it had simply collapsed. Even further, the poor man’s weight had dropped some 25 pounds since he had started the cruise and an ultrasound scan of his liver had shown some very ominous shadows. All in all, things did not look good for him, and we agreed with the Australian doctors that the best plan of action was to get him home to England before the illness progressed too far for him to be comfortably moved. Fortunately, I had carried my full medical kit with me at all times since leaving home for Honolulu and I was therefore sufficiently well equipped to assist our patient in his long and tiring journey home via Singapore.

Later that afternoon my old friend Terry McGuire picked me up at the hotel and gave me a fascinating conducted tour of Brisbane. Hardly the sort of city that until fairly recently had been a penal colony! Well laid out, clean and tidy and all designed around the beautiful Brisbane river. I can certainly see why so many people have made this part of Australia their home! Terry and I had a superb evening and over a meal and a few glasses of wine we caught up with family, friends and every other sort of news we could think of. An absolutely wonderful evening and when I retired to bed I quickly submerged into a fifteen hour sleep full of fond memories.

On the evening of the following day I donned my ‘official’ doctor’s tie and began a long repatriation exercise. Fortunately my nurse colleague and I were able to share the duty periods over the long 36 hour journey from our patient’s hospital bed in Brisbane to a national health service bed at home. As the journey went on we could visibly see him tiring and, although he hardly complained, the pain he suffered was very real. High power pain killers and sedatives made the journey much easier but without a doubt it was with considerable relief that we handed him over in his local hospital, with family and friends close by.

I finally got home some 122 hours after waving goodbye to Isobel and after travelling some 26,000 miles. When I left home I had no inkling of what lay ahead of me but without any shadow of doubt, I wouldn’t have missed it for the world !!!

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It takes all sorts, unfortunately

As a youngster in South Wales, I lived close to the factory where outside-halves (stand off half or fly half for you non rugby readers) were made, but life would be very boring if all people came out of the same mould wouldn’t it. Faces would be the same, opinions would always agree, illnesses would always present themselves the same way and personalities would be predictable before the mouths even opened! I certainly can assure you that medical repatriation would lose the appeal it has for me if this were the case, because the most exciting part of the work is its sheer unpredictability. No two flights are the same, no two illnesses are alike, every country is different and perhaps most important of all, none of the many patients I bring home can be likened one to another.

The great majority of the people I deal with are naturally very frightened of the situation in which they have found themselves, whether it be a heart attack in Spain or broken limb in Africa. They are enormously relieved and grateful when I arrive and announce to them that they can now sit back and leave everything to me to get them home. On the other hand, there are some customers who take the attitude that they have paid their insurance premium and that I am there at their beck and call. These types, I don’t usually find very difficult to handle because the complexities of a repatriation soon have them floundering. They are very often the ones who are most grateful at the end of the exercise and the most generous when it comes to thank you letters.

But the people I dislike most of all are those who use their misfortune as an opportunity to try and get as much as they can out of the insurance company, and almost completely disrupt what would normally be a well managed repatriation and happy homecoming. Thank goodness the case I’m going to tell you about in this chapter is the exception and not the rule, otherwise I’m sure I would have stopped playing this game a long time ago. And perhaps the lady from the Midlands, to whom I will be dedicating this chapter, will read this book and learn a few lessons.

Canada is a country that has always amazed and impressed me. It is so big that Great Britain can only be regarded as a drop in a bathtub in comparison. From the neat urbanisation in the east with its stark contrasts between the seasons, through the vast almost unexplored interior rich with animal wildlife to the beauty of British Columbia, the doorway to Alaska. I have been to Canada many times and fortunately, during different seasons. I have seen the beauty and magnificence of the forests in the fall, the oppressive heat of the summers and have been stuck in ten foot snowdrifts in their winters. Listening to my waxing lyrical, it will therefore come as no surprise to you if I tell you that when I was asked to do a repatriation job to Vancouver I had no hesitation in accepting.

On the other hand, my first suspicion that this case was what we call a ’hot to handle’ job, was when I looked at the flight schedules. My outbound flight had been booked with an airline which we didn’t normally use and, when I asked why, I was told that for some reason the patient was refusing point blank to fly with the airline company we are used to, and trust. There also seemed to be an extraordinary volume of paperwork associated with this case, far more than I would have expected.

I’m not going to bore you too much with all the medical details. Suffice it to say that the patient was a 58 year old lady who had suffered a small heart attack and, as is usual in North America, underwent an emergency angiogram where they examined the blood vessels around the heart. One artery was badly blocked so the treating doctor had stretched it and solved the problem very quickly by inserting stents. These are all fairly routine procedures and, apart from the airlines insisting that the patient has to have a doctor accompanying them in the air, they rarely cause any repatriation difficulties. So why the enormous amount of paperwork.

Now, having told you the brief medical details, let me tell you all about the patient herself. Our 58 year old lady was what is known as a ‘mature student’ who was attending Vancouver university and aiming to obtain a qualification in social work. I will probably encourage a few raised eyebrows and don’t regret it, but as far as I am concerned, social service studies is a concept with no beginning and no end, has very little in terms of a structured concept and content and, as such, is an is an ideal learning environment for those who don’t know what they are doing or why they are doing it! It also seems to fit in very well with someone who at 58 years of age is still studying and not working!

While studying at Vancouver, my patient was staying with her sister who lived in Canada. After the initial heart attack the medical side of the affair was soon on the right track and a proposed repatriation date some 16 days ahead was proposed. Not so, insisted the Canadian sister and the patient’s children who lived in the midlands, we are not happy for her to come home until she is completely recovered. There then followed many, shall I say, confrontational telephone contacts where the question of who made the repatriation decisions was ‘discussed’ at length. While all this was going on, the patient’s sister had submitted a bill to the insurers for car rental in Vancouver because, according to her, the hospital was a long way away and she had no other means of transport. This claim didn’t seem to make a lot of sense when other bills started arriving for the patient’s sister’s hotel bills at a very expensive hotel near the hospital (because she didn’t like driving home late at night). Laundry bills, restaurant bills, telephone bills to name but a few came in thick and fast, with the insurers and the repatriation company pulling their hair out trying to contain what was a rapidly escalating bill for the case.

By the time I arrived in Vancouver I had had plenty of time to read and absorb the story and all its implications. One of the last log entries was a veiled plea from the insurers asking the repatriation company to send out one of their more experienced staff to try and control the financial haemorrhage! After landing in that very attractive city after a long overnight flight my first thoughts were a hotel and a few hours sleep to prepare myself for the battle ahead.

Later that same day I took a cab to the sister’s home. The introductory pleasantries in fact went quite well and, for a short while, I began to wonder if all I had read was correct, and whether I had in fact come to collect the wrong patient! I should have known better because it was not long before I was subjected to a tirade of complaints of how beastly the insurers had been, how inefficient the repatriation company was and that no one was prepared to listen to their side of the story! They had even tried very hard to save the insurance company money by suggesting that the patient’s sister accompany the patient back to England, rather than send out a doctor, and which of course she would have done without any though of recompense. The fact that the sister inadvertently mentioned to me that she hadn’t been able to afford a trip back home to England for a long time was of course irrelevant!

Still being a little curious about the original flight schedules, I discretely enquired about their preferences as to which airline they normally used for their transatlantic crossings. It turned out that they didn’t want to fly with our preferred carrier because they held a frequent flyer card with the other airline and they wanted to collect the air miles! It really was a pointless exercise trying to explain to them that foreign travel insurance was just what it said on their policy document - to stabilise an illness in a foreign country and to get the patient back under the wings of the national health service when it was prudent to do so. But they were much too thick skinned to absorb any rational explanations such as these. The illness was someone’s fault and they intended to get their money’s worth out of it.

Fortunately, after many repatriation cases, thousands of flying miles and a whole encyclopaedia of personalities encountered, I know when and how to put aside personal thoughts and feelings and deal with the case in hand. After all, having taken out all the non medical parts of this case, I was still dealing with a 58 year old who had suffered a heart attack, had undergone heart surgery and who needed to be escorted back to the United Kingdom as quickly and as safely as possible.

The following morning the repatriation got off to a bad start. A cab picked me up at my hotel and off we went to collect the patient. Normally when I answer the front door at my home, the first thing I say to the visitor is something like ‘hello’ – certainly not ‘that cab is too small’! There, sitting in the hallway were two enormous suitcases, two huge packing cases and more hand luggage than the average family would generate. The explanation given to me this time was that it was approaching Christmas wasn’t it, and that things were much cheaper here in Canada weren’t they, and we were flying business class so we had a bigger baggage allowance didn’t we, and so on. I tried to explain to my patient, and her sister, in words of one syllable that I was not a pack horse, and that my job was to get the patient home safe and sound and not to act as a removal man! Much to their annoyance we finally took off with the two suitcases and numerous pieces of ‘hand luggage’ and leaving the packing cases behind.

At the airport things went fairly well and we were soon comfortable in the business class lounge. But somehow the conversation got round to my job as an in flight medical officer and finally gravitated towards duty free allowances and whether or not was I allowed a duty free allowance in my work. Yes you’ve guessed it! Please can I use your allowance if you are not using it - and we ended up with yet another piece of hand luggage full of wine, whisky and cigarettes. The flight home was really a non event. My patient ate a good meal washed it down with a couple of glasses of wine and was soon fast asleep in her reclining chair buried under a blanket. Similarly, the arrival in the UK went without any hitches, we were picked up by a chauffeur driven car and some three hours later my patient was duly delivered home with instructions to contact the family doctor the following morning. It was with considerable relief that I was able to contact the repatriation company and report that the case was now closed! But was it ?

Some six weeks later I received a letter from the insurance company. It was asking me to comment on an official complaint they had received from the patient. Virtually every aspect of the case was the subject of a vitriolic letter in which she was demanding compensation for the way she had been treated, and the psychological trauma to which she had been subjected. I was accused of having been rude, unsympathetic and lazy, I had refused to assist her with her luggage and had slept throughout the whole flight home.

Now I take a lot of pride in the work that I do, and I also go to great lengths to document everything contemporaneously during the repatriation exercises that I am involved with. Which is why I carry a small, lightweight but very powerful computer with me at all times. Within minutes of each case being closed a full report of the case is submitted, via the computer and a mobile telephone, to the receiving hospital or to the patient’s family doctor. Everything that happens during a repatriation is documented, even down to the time the patient goes to the toilet, and so it was little trouble for me to check back on all the aspects of the complaint. Needless to say, her complaint was dismissed by the insurers and nothing else was heard.

I said at the beginning of this chapter that life would be very boring if all people came out of the same mould didn’t I? I am more than happy to stick by that with one small amendment. I just wish that there was a quality control system of some sort whereby the seriously defective models are recognised and discarded right at the beginning!

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A frightening family reunion in Johannesburg

Very occasionally, I am asked to travel to countries and cities abroad where, over the years, to which either family or friends have moved, settled and set up home. Naturally, such an offer does not happen very often and so when it does, it adds an extra thrill of excitement when I am asked to travel there on a repatriation exercise. Of course, the time I am allowed to spend in those far off places is usually very limited and my first duty when I am there is to deal with the whole issue of getting the unfortunate patient back home. However, the thrill of seeing long departed cousins, uncles, aunts or friends really adds to the excitement of the job, and this is how I certainly felt when I was asked to repatriate a man, who had suffered a serious heart problem, from Johannesburg in South Africa to the North of England.

My first cousin and her husband emigrated to South Africa some forty years ago, well before the collapse of that infamous apartheid regime. Pam was a well qualified nurse and midwife and Mike, her husband, was a qualified mining engineer; I’m sure you will agree that their talents were very welcome in that troubled country. After moving around various places with very romantic and famous sounding names such as Pietermaritzburg, Port Elizabeth, Cape Town and Bloemfontein they finally settled in Johannesburg. And so, after I was asked to do the job, a very excited Pam had an unexpected telephone call from me asking if she could put up with a guest for one night.

At the time the insurance companies and repatriation companies that I work for had been making strenuous efforts to cut costs involved in bringing people home. One of the methods they had adopted was to cut back on the rest time that the in flight escorts were allowed before they made the return journey home. Admittedly this move had been tempered with the guarantee that all flights in excess of four hours would be in business class but, nevertheless, it was a move with which I strenuously disagreed, and still do.

However on this trip to Johannesburg, I was able to ask the repatriation company to send me out a day earlier than was originally planned, as I would be staying with a cousin who would naturally be charging me nothing for my accommodation or meals, with the result that the extra time I spent in the country would not mean any financial liability to the insurers. It was with building anticipation that I boarded a jet at Heathrow Airport for the eleven hour flight to Johannesburg. There, after a restful night in my ‘sleeper’ seat, I was met by an excited cousin and, after a very emotional welcome, we travelled the short twenty minute journey to her home, past innumerable gold mine pit heads, and mile after mile of gold mine waste tips!

And what a magnificent home it was! A four bedroom bungalow with two living rooms, a vast kitchen, a den, a family room, two bathrooms, a huge garden with a swimming pool, a sewing room, a study and last, but very significantly not least, a gun room! Looking further it was not difficult to see the eight foot high fence around the property which was topped with electrified razor wire. The gate to the drive was operated by a remote switch, and once we were inside I was asked to stay in the car until the gate closed behind us and was secure. It was only then that the remote switch to the garage door could be operated and be allowed to drive in, and once again, wait for that door to lock before we could get out of the car and deactivate the internal security system! This was a mere taste of what I was to see and hear over the next twenty four hours.

First, it was important to go to see the patient, make a full pre flight assessment and then inform the repatriation company of any changes that may have been needed to the original schedule. My patient on this exercise was a 67 year old man who had travelled to Johannesburg with his daughter and grandson to visit his other daughter. He had a very significant medical history which very nearly landed him in deep water because he had breached the insurance company’s terms and conditions.

Some six months before my patient had travelled to South Africa, he had developed a troublesome shortness of breath and his family doctor had diagnosed mild heart failure and had treated it accordingly. The problem got worse but, with the appropriate drugs, he had managed quite well while he was at home in a famous north western British seaport. When planning his trip to South Africa, he mentioned it to his family doctor who was unsure enough about the long flight for him to arrange a heart specialist appointment. The end result was a long report which gave him a very guarded permission to fly but with a long list of preconditions. The problem arose when, having filled in the travel insurance proposal form, he omitted to declare the shortness of breath, the mild heart failure or the appointment he had had with the heart specialist. He merely stated that he had a ‘fitness to fly’ certificate, without mentioning anything else. And off he went to Johannesburg.

What our patient did not know, and I’m sure his doctor or heart specialist at home did not even give it a second thought, is that Johannesburg is some 6,500 feet above sea level. And I’m sure that those of you that have travelled to exotic high places are very aware of the breathlessness and tiredness that high altitude can cause to us sea level people without weeks of acclimatisation. The end result for my patient – yes, you’ve guessed it – a previously well controlled sea level heart failure rapidly progressed into a very serious and life threatening high altitude illness. Within just twenty four hours of his arrival in Johannesburg, my patient was fighting for his life in the specialist cardiac intensive care unit of a very well equipped private hospital.

Normal policy checking when an insurance claim is made, includes contacting the patient’s family doctor to have sight of any previous medical history which may be relevant. In this case, as soon as the doctor’s report was received, the insurer took just one look and naturally immediately declined to accept any liability. It took over a week of frantic pleading telephone calls and faxes from the man’s relatives at home and in South Africa before the insurers agreed to reverse their decision and cover the costs. It was on the grounds that no original intent to defraud had been intended – another dire warning to those of you who think they can save a few pounds by missing out on travel insurance costs!

Following two weeks of very intensive and very expensive care that my patient had recovered sufficiently for his repatriation to the United Kingdom to be considered. The logistics of the job were formidable; the transfer of a sick, high dependence patient from a hospital in South Africa, a 5,620 mile flight to London, before his transfer to an internal flight to an airport nearest to a hospital in his home town. The patient had to be catheterised because his exercise tolerance was virtually nil, and even a few yards from his aircraft seat to the toilet was a major hurdle. He needed continuous oxygen at a high rate (British Airways need to be complimented on this because they were the only airline prepared to help) and, despite his slow recovery, he needed a host of vital drugs. From this point on, things started to go smoothly – that is until I arrived with the ambulance to collect him. The South African hospital had refused to accept the repatriation company’s guarantee to pay costs, and they were adamant that until the bill had been settled they were not prepared to discharge him! Once again, out came the gold credit card, and a sum equivalent to £5000 was deducted from my account with a promise from the repatriation company that they would reimburse it very quickly once I got home!

Finally, after a very long and tiring night flight, and very smooth connections in the UK, my patient was delivered some 21 hours after collection to the cardiac unit in a hospital near his home. Because of the extensive pre flight preparations by the repatriation company, everything had gone well and without any hitches. Indeed, he looked better at the point of delivery than when I had collected him. A satisfying feeling of a job well done after a very difficult, but successful repatriation exercise; but let me tell you a little more about my impressions of South Africa.

I have already spoken a little about the extensive security precautions at my cousin’s home, and after having spent two days with her I can understand why they were necessary. I also spoke to a number of her friends, to staff at the hospital, and I also had the opportunity to read a number of the Johannesburg daily and weekly newspapers and watch the local television news channels. The impression I was given is that the crime rate around Johannesburg is at phenomenal proportions compared with those here in the United Kingdom. House and property burglary, car theft, muggings, assault, murder are almost considered the norm rather than the exception (Cousin Pam and Mike regularly carry guns with them and dare never to go out at night alone). Drug related problems at astronomical rates and AIDS amongst the adult population running at about 40%. Poverty and begging makes the problems we have experienced at home a tiny drop in the ocean compared with theirs. Car crimes are such everyday occurrences that vehicles are fortified to centurion tank level and insurance is virtually impossible. Motor vehicle accident rates at levels which in the United Kingdom would be considered major disaster proportions. And above all this, a slow but steady march of what can only be regarded as reverse apartheid, where white people are being subjected to increasing levels of racial intolerance, violence and abuse.

Why does my cousin not consider returning home you may ask. It is simply due to financial considerations. In Johannesburg they can be considered fairly well off and afford a relatively high standard of living but should they return to Great Britain, their income and savings would be proportionately reduced to almost poverty level. To give just one example; as a thank you for having taken the trouble to put me up, and for having provided me with extensive taxi services while I was in Johannesburg, I took my cousin, her husband, daughter and two friends out to dinner (naturally on the insurance company’s expense account). A high class, substantial three course meal, including a couple of bottles of very good South African red wine, and other drinks for six people – the bill came to just £60. A similar meal here in Great Britain and I know I wouldn’t have had much change out of £200! For British tourists in South Africa, the value for money of their tourist pound is phenomenal That certainly cannot be said when South Africans travel abroad and encounter the prices to which we are accustomed.

A very exciting and enlightening repatriation exercise, which gave me the wonderful opportunity of meeting relatives whom I have not seen for many years. Now I know that there are many parts of that immense country which are designed for and naturally attract foreign travellers and, without doubt, prove to be exceptional and fascinating tourist locations. However, having seen what I have described in this chapter, and having had the opportunity to look at the country, well off the beaten track without any of the tourist industry frills attached, to live there permanently? No thank you …………….

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A Seven Mile High Crisis!

The majority of the repatriations that I accompany home are incident free, where most of my time is spent monitoring the patient’s condition and making sure that the arrangements go according to plan. In fact, the whole concept of case refereeing and management is to ensure that by the time the actual repatriation goes ahead, all risk factors have been assessed and eliminated. Why? Because if anything goes wrong with a patient’s condition it is far better if it happens on the ground, where hospital back up facilities are close at hand. Certainly better than at thirty six thousand feet where I’m on my own and limited to the equipment and drugs I brought with me.

Those of you who have read ‘The Winged Medic’ will also know that airlines have very strict rules and regulations as to whom they are prepared to carry and when. The repat company routinely liases very closely with the airline medical department, and the overseas treating doctor until a certificate known as a MEDIF is issued. This certificate certifies that in the opinion of all concerned, the patient is fit to fly. But even having said that, the ultimate decision always rests with the aircraft captain who is entitled, at the very last minute, to decline to carry the patient for whatever reason. Thank goodness this has never actually happened to me.

Taking all these factors into account is why the majority of the repat cases that I accompany home have been incident free. Most of my duties are spent in refereeing the case before departure, pre flight case assessment when I arrive to meet the patient, monitoring his condition during the journey and dealing with the repat logistics to make sure everything goes smoothly. Very occasionally however, and through no one’s fault at all, things can go very badly wrong and where all my training, repatriation equipment and drugs are put to the ultimate test.

I was already dealing with the repatriation of a fifty five year old man, bringing him home from a very hot Malta when my mobile phone rang and one of the other companies that I work for asked me if I was available to do another job. I was in fact scheduled to arrive back in London’s Heathrow airport early on Sunday evening and to drop the patient at his home in Middlesex. I had then intended to spend the evening with my daughter in Berkshire before travelling back home on the Monday morning.

Listening to the proposed new arrangements over my mobile phone, the second job fitted in well because it was scheduled to fly out of London Gatwick to Albuquerque in New Mexico, USA on the Monday morning. This just meant that instead of seeing my wife on that morning I would be winging my way to the United States instead (I routinely carry a good supply of socks and shirts!). Now I’m sure that you all know I have a very understanding wife, who has heard the same story a hundred times before, and I was therefore able to agree to the second job very quickly.

Sitting with my daughter and her husband on the Sunday evening, and sharing a bottle of very palatable Californian white wine, I was able to go through all the paperwork which had come through via my mobile phone and laptop computer. The case seemed a little strange right from the start.

The patient, a man from the Merseyside, was spending a holiday with his daughter, who was married to an American and who lived in New Mexico. The story was that without warning he had felt dizzy, complained of a pain in his arm, went a mottled shade of grey and passed out. His daughter, obviously having read her first aid manual, immediately assumed that he had had a heart attack and gave his chest a very hefty thump. It was then reported that he woke up with a very different type of pain in his chest (which was hardly surprising) and was carried off to hospital by the paramedic crew which had been summoned.

Naturally, the patient’s daughter contacted the insurance company immediately, and was then passed on to the repat company who took the details as I’ve described. The surprise came the following day when the case referee contacted the intensive care unit at the hospital and was told that the patient, having felt much better, had discharged himself! The doctor in Albuquerque said that they had been given very little time to perform all the investigations and tests necessary to make a diagnosis before the patient had walked out. He also said that under the circumstances he was not able to make any predictions nor was he prepared to issue a fitness to fly certificate. This left the case referee in an enormous quandary. By discharging himself against medical advice the patient had contravened the terms of his insurance policy, and the insurers were well within their rights to refuse to pay the hospital’s bills. Also, by having contacted the airline’s medical department, the daughter had stirred up a real can of worms because they were now not prepared to fly him home without the elusive medical certificate.

Fortunately, the insurers in this case were a well known company whose empathetic attitude always gives the customer the benefit of the doubt. They accepted the patient’s plea that he was unaware of the insurance terms he had contravened and quickly agreed to cover the hospital bills. This still left the vexed problem of the necessary fit to fly certificate. After intensive discussion between the insurers and the repat company, it was decided to send out a doctor to assess the patient, issue a certificate himself and accompany him home if all was well. This was indeed a far cheaper option than to have to readmit a very reluctant patient to hospital for extensive investigations and to obtain the necessary certificate from there. With all this in mind, I left my daughter’s home early on a Monday morning bound for Gatwick and a long flight to New Mexico.

The first thing that hit me when the plane landed in Albuquerque, New Mexico was the heat. One hundred and ten in the shade, at an altitude of five and a half thousand feet and I can assure you that within minutes my body, which is used to British weather at sea level, began to complain. Albuquerque is a city of half a million people at the southernmost end of the Rocky Mountain range resting in the high desert in the Rio Grande Valley under the shadow of Sandia mountain. I say ‘high desert’ because the climate is described as precisely that – warm days, cool nights and spectacular sunsets and in my very short stay there I certainly experienced all three.

On this repat I was given a rest day, essentially because the outbound and inbound flights were so long and tiring. The morning was spent visiting and assessing the patient then returning to the hotel to write up my notes. The discharge letter from the hospital, despite his very short stay there, was informative and full of investigation results, all of which found nothing wrong at all. My extensive pre flight examination came to the same conclusion: everything was normal including another heart test which showed nothing wrong whatsoever. I contacted the hospital doctor who had seen my patient and we both came to the same final diagnosis – a faint after a very stressful journey and a slightly low blood oxygen due to the sudden change in altitude. I contacted the repat company, explained my findings and said that I was happy to issue a certificate and that the repat could go ahead as planned. I then had the rest of the day to myself.

Fortunately, despite the short notice, I was able to book myself onto the longest cable car ride in the world. From the valley floor a breathtaking six mile journey, rising over five thousand feet to the summit of Mount Sandia. The scenery we passed over was rugged and spectacular to say the least and the view from the top over the New Mexico desert was breathtaking. Even more impressive was the spectacular array of colours which graced the desert sky at sunset. The trip concluded with a mouth watering meal of Mexican green chilli proportions at the mountain top restaurant. Certainly a memorable excursion and one of many that the region could offer – hot air balloon trips, a visit to Santa Fe, the oldest and highest capital city in the USA, inhabited Pueblo Indian villages, to name but a few. A memorable day indeed.

The following morning was spent preparing for the repatriation. Once again I met up with my patient, and a short chat and brief examination confirmed that he was as fit and ready to travel as the day before. Passports tickets and baggage were accounted for and it was not very long before we were on our way to Albuquerque airport to catch a shuttle flight to Dallas. Everything went well and just one hour after landing there we had transferred to the international terminal and were settled into the business class section of a jumbo jet for the second long leg of our journey from Dallas to London’s Gatwick airport.

Now what normally happens on these overnight flights from North America to the United Kingdom is that we take off fairly early evening, enjoy an in flight meal, then let the patient try to grab a few hours sleep before we arrive in England in the early hours. As the accompanying doctor I always make a habit of staying awake during this section of the repatriation to watch over and monitor my patient, and look forward to a few hours sleep when I get home. My habit proved to be right in this case because some four hours into the flight, I was reading a book and everything was quiet – except that is for a sudden very gentle gurgling sound from the patient alongside me!

It didn’t take very long, and not too many instrument readings to confirm that my patient had suffered a cardiac arrest in his sleep – his heart had stopped! From that point instinct took over, and ignored the fact that we were causing great disturbance and mutterings from the other three thousand pound a head business class passengers. Having called the flight attendants for assistance I dragged the patient from his seat into the aisle where there was more room to manoeuvre and emptied my equipment bag onto the floor. A heavy thump on his chest was followed by mouth to mouth breathing and chest compressions by the first aid trained girls as I prepared my heart defibrillator ready to try to restart the heart by shocking it. The aircraft captain had been informed of the emergency and had come down to offer any assistance, which was very timely as it is only common sense to ask his permission to fire off thousands of volts on a passenger jet at thirty eight thousand feet! The first shock did not produce any result and while the stewardesses continued their chest compressions and mouth to mouth, I put a needle into the patient’s vein and gave him a large dose of adrenaline to try and stimulate his own responses. A second shock followed at a much higher voltage and, within seconds, the trace on the heart monitor started to return to a normal rhythm. All this had happened over a period of some six minutes, but at the time it felt like a lifetime. Some five minutes later my patient had recovered enough to be able to ask what had happened, and why was he lying down on the aircraft floor in the aisle!

Needless to say, and despite a feeling of achievement at having managed to restore the stopped heart, there remained the worry of a further four hours of flying time before the patient could be deplaned and moved to an intensive care unit on the ground. The captain and I discussed the options of diverting, but at the time we were half way across the Atlantic ocean and so there was little point in turning back to the United States. Similarly, I did not feel there was much advantage in our diverting to Glasgow or Manchester as the time gained would be minimal. We finally decided that the captain would continue on to Gatwick, radio ahead and ask for priority landing status (in other words, straight in and no queuing) and to make sure that a full paramedic emergency team and ambulance were ready and waiting for us.

The rest of the flight was comparatively uneventful! All my monitoring equipment remained well attached to the patient, he was given appropriate medication, the intravenous drip was set up properly and secured, and at no stage did I let him doze off again! The stewardesses managed to restore a sense of calm and quiet to the other passengers with liberal doses of brandy and port, and the captain was able to report that the plane was still flying perfectly well despite the shocks! And the patient – well, he remembered nothing apart from eating a meal then waking up to find himself on his back in the aircraft aisle.

After landing the patient was taken off the plane and into the paramedic ambulance within minutes. Shortly after that he was off my hands and being cared for by a very competent hospital team who took it all in their stride, blissfully unaware of the pandemonium just four hours before. The ambulance took me back to Gatwick where, and with considerable difficulty negotiating my way through officialdom, I managed to get back to the plane to put my equipment back together. Two of the flight attendants and the aircraft captain had remained behind to wait for me and, even though it was just six thirty in the morning, a large glass of champagne was the order of the day.

It took a long time for my own adrenaline surge to settle down, which was fortunate because I still had a three hour road journey back home to the West Midlands. Naturally, once I arrived home, Isobel my wife wanted a full and graphic account of the trip and its ‘exciting’ events, and the repat company itself was on the telephone very quickly once the faxed copy of my report had arrived on their desk. The airline also wanted a report filled in and the receiving hospital were quickly on the line wanting their copy. All in all the sleep I had promised myself did not come until much later that evening.

Looking back on the case, the question soon arose’ ‘where did I go wrong?’. Why wasn’t I, or the hospital in Albuquerque, able to foresee the events despite numerous investigations and examinations. The answer is simple; the cardiac arrest that my patient had suffered in flight was not predictable and was nothing whatsoever to do with the symptoms he presented with originally in New Mexico. It boiled down to the fact that it can happen to anyone at anytime, and that it was fortunate that my patient’s original symptoms were enough to ensure that he had a medical escort with him at the right time!

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Come Fly With Me

I knew it! It was bound to happen sometime

For years and years I have been travelling around the world to rescue or repatriate sick and injured tourists and businessmen and, after each mission, I have returned home with stories ranging from the incredible to the enchanting. I have brought back photographs and souvenirs including views taken of Everest and Ecuador in the same week, and have carefully carried home ostrich eggs (empty of course) and reindeer skins. My wife, Isobel has always loved the stories and really has been the inspiration for me to put pen to paper and tell you all about them

So, what has happened? Well Isobel has decided that enough is enough. She has become tired of listening to my stories and looking at the pictures and has decided that she wants some first hand experience rather than to get it second hand from me. She has joined the world of aeromedical repatriation as an in flight nurse!

Up until recently, she has worked as a nurse practitioner in general practice for some 20 years. She has become an authority in diabetic and hormone replacement clinics, and advanced to the stage where she was a Community Practice Teacher (nursing). But, having achieved the In Flight Nursing award some years ago, and having completed many air ambulance repatriations on an occasional basis, she is theoretically more qualified than I am. This was the second string to her bow that she has now fitted and wants to use. Isobel has retired from her general practice position and is making herself available, and on call for nursing repatriation duties.

Being an in flight nurse is a completely different world to that of an in flight doctor. Yes, we all travel around the world picking up sick and injured people, and yes, we all collect air miles and spend many nights in strange hotels and of course the logistics of the cases we are involved with are similar. But that is where the similarity ends because, like any other branch of health care, nurses nurse and doctors doctor! As a medical officer, I repatriate those unfortunate travellers who need medical care, back up and skills which can only be offered by a doctor. Isobel will be dealing with those cases which demand nursing skills and which I readily admit are totally alien to me.

For a start, the equipment carried by a nursing officer is very different to that carried by a doctor. In ‘The Winged Medic’, I explained to you the equipment which I carry, and which I decided to purchase myself rather than have to rely on the equipment provided by the repatriation companies. Isobel has also decided to provide her own equipment and will therefore be as self sufficient and as independent as me. There is logic to this argument; by owning our own medical and nursing equipment, our availability and ability to drop everything and travel at a moment’s notice is much improved. In a similar vein, once we have been notified of a job we can go straight from home to airport without having to divert to company equipment stores to collect the necessary bits and pieces. At the end of the day, we are in a position to be able to agree, and to accept (and sometimes reject!) a job and we can respond quickly and be on our way to airports at a moment’s notice. Such immediate availability of a doctor, a nurse and all the appropriate equipment also means that our time is much in demand.

OK, let me tell you a little about the nursing equipment that Isobel has to carry. Basically, the intrinsic difference between a nurse assisted repat and one which involves a doctor is dependant on the fine dividing line between a condition which may be life threatening and one which is not. Nurses generally bring home patients who, although past the immediate danger period, still need significant nursing and paramedical skills. The equipment that the nurses carry is therefore selected with these pre conditions in mind.

Stretcher cases are prime examples. In order to transport a bedridden patient from a hospital bed in a foreign country to a hospital at home, Isobel will need to carry a folding aluminium stretcher and a special mattress which will provide comfort as well as support. To compliment those there are sheets, blankets, pillows and a host of straps, pads and waterproof covers. And what about toileting facilities – after all, bedridden patients are not usually able to go to the toilet, least of all to the claustrophobic cubby hole toilets on aircraft. Bedpans, bottles, and an array of waterproof add-ons and tubes are standard pieces of equipment.

When I have told friends of the amount of equipment that a nurse often has to carry, I am met with an incredulous ‘but surely, if the patient needs all that, surely they should be transferred on an air ambulance’. Unfortunately, such an ideal world does not exist. I recently travelled with a nurse to Melbourne, in Australia, to bring back a young man with a fractured spine, and when the logistics of using a Lear Jet air ambulance were looked at. The eleven thousand mile journey would have meant six refuelling stops, four overnight stops, three changes of aircraft crew and a total bill to the insurance company of around fifty thousand pounds! And don’t forget the medical and nursing cover! Compared with this, the roomy surroundings of a jumbo jet, on a journey of just thirty hours are much more favourable as far as the patient and his carers are concerned.

As well as the stretcher equipment I have described, Isobel also carries a full nursing bag with all the usual bits and pieces essential to normal nursing care – and I have no intention of exploring her bag to tell you more about it! Also, modern nurses are a long way from the Nightingale variety and carry special monitoring equipment such as stethoscopes, blood pressure monitors, blood oxygen monitors, blood sugar testing kits and a host of other bits and pieces. Drugs are an important part of a nurses kit. The kit is very different from the one a doctor carries and carries a wide selection of items which the nurse is used to, and confident about using. Taking everything into consideration, whereas a doctor may well carry what can be regarded as a mini intensive care unit with him, nurses carry almost the rest of the whole hospital ward – excluding the sink!

Over the years I have been accompanied by nurses on many combined doctor / nurse repatriation missions. Cases such as these can usually be classed as the seriously ill where both nursing and medical care may be needed over many hours of a transfer. It also means that on some of the long intercontinental repatriations the caring, monitoring and treatment of the patient can be shared with a colleague, allowing the other to get some rest but be immediately available if needed.

As I said, I knew it would happen one day, and that day has arrived. It also means that on those repatriations where a doctor and nurse are required there may perhaps be the opportunity of us flying together ………………. !

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Can I take you upstairs please?

I have had a lot of wide ranging experience in the aeromedical world and it has taught me many, many useful lessons. Just to give you some examples, I know when to give gratuities (tips to most of us) and how much I need to give when I need favours; I know how to persuade airport check in staff that my overweight baggage is just within limits; and I nearly always know, within a matter of minutes, what time I will be arriving home after a five day trip to the other side of the world and need a large scotch! But one thing I have certainly learned about the countries that I have visited, is that the lower down the socio/economic developmental ladder it is, the more difficult and more expensive it is to get into that country!

The minute I was asked to travel to Nigeria, to repatriate a Scottish oil worker, I knew that my outbound flight timings were dependant on my getting an entry visa for that country. Exactly why countries like Nigeria insist on travellers having a visa to enter the country I am not very sure. From a professional point of view, and apart from their oil and precious stones, there is nothing much in Nigeria to attract legal, let alone illegal, immigrants! And I’m pretty sure that there are more people who want to get out rather than in! But, I needed a visa to go in and rescue my oil worker, and which is why at six O’ clock on a Monday morning I left home with plans to spend a long day at the Nigerian Embassy in London.

And a long day it was indeed. Despite the repatriation company having contacted the embassy beforehand, and despite having being assured that I would be given as much assistance as possible, it was still some eight long hours after submitting my application before the embassy relieved me of seventy pounds, and returned my passport with the visa duly stamped inside.

The difficulty in getting a Nigerian visa was just one of the many problems that this particular case had generated. The patient was in a Port Harcourt hospital with a report that he had suffered a heart attack. Unfortunately, the only long haul airline (Air France) who flew into Port Harcourt had declined to provide the oxygen needed for the transfer, and the only airline who were prepared to supply oxygen (British Airways) only flew into Lagos some three hundred miles away. And then surprise surprise, there were no available air ambulances to transfer our patient to link up with that flight. A road transfer from Port Harcourt to Lagos was completely out of the question - when you have read the rest of this chapter you will understand why! We finally decided that the only viable solution was a costly air ambulance from the UK to Port Harcourt and back again!

The aircraft which had been chartered for this repatriation was an HS 125, a nine seater executive jet with enough seats taken out to provide the space for a stretcher. The flight was due to leave Gatwick airport at 8 the following morning so there was little point in my driving back to the Midlands after a long day at the Nigerian embassy, and then to have to be up a 4 the following morning to drive back to Gatwick. A very boring and expensive night at the airport hotel was the end result, but at least I had the opportunity for an early bed, a good night’s sleep and a lie in until 7 the following morning!

The first two hour leg of the journey the following morning took us from Gatwick to Alicante where we refuelled for the long second leg over the Sahara desert. Did you know that the Sahara is the biggest desert in the world? After all, when we looked at maps and atlases in school it didn’t look that big did it? But when I tell you that the flight from Alicante to Port Harcourt took us nearly seven hours, at five hundred miles an hour, the concept of size becomes apparent. It is virtually as far as it is from London to New York. The difference is that in a commercial airliner there flight attendants tending to all your needs, as much food as you need and at least one modern film to watch. Air ambulances are a little different and mile upon mile of sand dunes interspersed with coffee and sandwiches can be a little boring!

Some ten hours after leaving Gatwick, our HS125 started descending to land at Port Harcourt. There is one thing about this part of Africa, and one which rings warning bells as loud as Big Ben. It is the fact that malaria is endemic here, and a particularly nasty form of that dreadful disease too! Unfortunately, medical repatriation is one of those occupations which does not fit in with the prescribed way that anti malarial drugs need to be taken – for one week before you travel, during your stay there and then for four weeks after you return home. But having said that, there are other ways of fighting the mosquito which don’t involve any drugs and which have proved effective for me during my numerous visits to affected areas. First, despite the heat and humidity, wear clothes that keep as much of your skin covered as possible. Long sleeved shirts, long trousers and long socks (tuck the trousers in the socks if you are not too vain) and make sure that the clothes you wear are dark in colour, because light colours seem to attract those bugs like magnets. And secondly, carry and use anti malarial bug sprays on every bit of skin that is exposed and also a lot of those bits that are not! I can assure you that the level of protection is excellent, even though the opposite sex may comment that your after shave is a little unusual!

When the door of the plane was opened, the heat and humidity hit us like a brick wall – and lots of mosquitoes met their doom as they tried to enter our repellent laden atmosphere. The next two hours were spent on the airport tarmac while the immigration staff went through our passports and checked every piece of medical equipment we were carrying. They seemed very concerned that we were going to illegally import equipment but, at a later stage of the repatriation, and having seen what Nigerian hospitals had to offer, they should have been happy letting it in! In the end, we were allowed into the country after agreeing to leave everything on board the locked aircraft until we flew out, a small price to pay to get to the air conditioned airport hotel.

By this time it was eight o’ clock and pitch dark everywhere. Our main concern at this point was to try and contact our patient and, if possible, get him to us at the hotel so that we could get clearance for an early flight out the following morning; but it was not to be. Our handling agent in Port Harcourt refused point blank to drive us the twenty miles from the airport to the centre of the town where the hospital was located. Too far, he said, too dangerous, the roads are too bad, we will be attacked and robbed were just a few of his excuses and reasons which convinced me that he knew what he was talking about, and that a night in the hotel was advisable! Ok I thought, a phone call to the patient to let him know what was happening was the next step, but even that was fraught with difficulty. Despite the hospital and the hotel being only 20 miles apart, it took the hotel switchboard nearly an hour to make a connection, and even then our conversation had to be at such a level of decibels that I’m sure if I had stood outside the hotel door, Gordon, our hospitalised oilman would have heard me! Eventually however, I was able to reassure him that we had arrived and, one way or another, we would be picking him up the following morning.

The next stage was to try and contact the repatriation company back home in the UK and let them know what was happening. This turned out to be a real comedy of errors, and a major exercise which involved everyone from the hotel receptionist, through the porters and kitchen staff and, finally, the hotel manager who was called in from home. Using a bunch of keys, which would have made the Beefeaters at the Tower of London proud, he led me through a series of corridors to his office where, on his desk, sat the well labelled ‘international telephone’. Suffice is to say that the message finally got through to London and, with my tongue hanging out, I made my way to the bar to join the flight crew for a well deserved beer.

And a very busy hotel bar it was. The gas and oil industry in Nigeria depends mainly on European and American experts for its running, and it seems that there is a very high turnover of personnel. There were certainly a lot who had just arrived on a scheduled flight and others who were catching the same plane out the following morning. All in all, getting a beer at the very inadequately air conditioned bar was a battle of almost epic proportions. One waiter took the order who then passed it on to a clerk who wrote the it down; the paper was then passed on to another waiter who took the cap off the bottle of beer and handed it, and the slip of paper, to the first waiter. The order was then delivered to me for my signature and finally the slip of paper was passed to yet another, much more senior staff member who played with the keys on his till as if it were a piano!

It was during this game of ordering beer that another, much more interesting aspect of Nigerian nightlife revealed itself to me. From the start I had subconsciously noticed a large number of very pretty girls around the bar, but my need for a beer took priority before all else. It was while leaning on the bar trying to catch a waiter’s attention that I had the unexpected sensation of a hand moving across my thigh and starting to pull my trouser zip down! Now, there are two natural ways to react to such a sensation; you either panic and leap away with arms flailing and uttering loud expletives or, you adopt a more conservative frame of mind and go absolutely rigid while turning your head slowly in the direction you felt the sensation had come from. As a guest in Nigeria, and not wanting to cause a scene, I of course took the second option.

There, standing right beside me, and with her hand still working at my zip and checking that my manhood was intact, was one of the prettiest girls you could imagine. ‘This feel good’ she said, ‘can I take you upstairs please?’. Now I am very world wise and I know how to cope with virtually any unexpected eventuality, but I must admit that this situation left me a little short of ideas. I slowly removed her very inquisitive hand and, without wanting to offend her, asked her if she would like to join me for a drink – which the barman passed on to her a lot quicker than I was able to get mine.

I’m sure you will understand why I declined her original invitation but I was quite happy to sit with her for a very interesting hour while she explained how the hotel ‘hostess’ system works and why she was part of it. She was just fifteen years old and trying to continue her schooling, but the problem was that schooling in Nigeria costs money and neither she nor her parents had any. Prostitution was the only way she could earn enough to buy the necessary books and pay the school fees. It seems that the twice weekly international flights into and out of Port Harcourt were the best nights and, if she was lucky, she would find four clients on one night and earn herself the grand total of $20! How much of what she was telling me was true, I don’t know but I could see no reason why she needed to tell lies. After another drink I gave her three $10 notes and told her to have a night off! The rest of the evening was then spent drinking a few bottles of warm beer with the flight crew and watching a continuous stream of very pretty girls escorting their arriving and departing oil industry customers in and out of the hotel lift doors!

The following morning I was up at the crack of dawn to meet with the handling agent at the hotel reception. He insisted that we waited until it was well light enough before we started the journey to the centre of Port Harcourt where we were collecting Gordon the oilman from the hospital. It was soon obvious why he wanted it to be light and why he had been so reluctant to collect the patient the previous evening. The road from the airport to the city was horrendous; partly paved, partly dirt track; potholes that could hide a whole car; livestock, including humans, wandering haphazardly; a random system of drive on the right or left depending on mood; huge lorries taking up the whole road and forcing everyone else into ditches and a system whereby if someone offended you, you just drove into them! By the time we arrived at the hospital I was wondering who needed to be repatriated most, me or Gordon!

But we got there. Gordon was sitting in his room dressed and ready to go. Now usually when I repatriate people I go to considerable lengths to get as many discharge documents as possible and speak to the treating doctors and nurses. The reason for this is that I try to make the transfer from the hospital abroad to the hospital at home as seamless as possible, so that the new doctors know as much as possible about what has gone on before. But in Gordon’s case there was nothing apart from one electrocardiograph strip! No doctors or nurses to speak to, no blood test results and no other test results, or treatment reports. Also when I repatriate people, I take a case history and perform a pre flight medical to make sure my patient is well enough for the long journey ahead. In this particular case, Gordon seemed so fit and well that my thoughts of who needed to be repatriated most came back to me!

The repatriation went very well indeed. The final case report that I sent to the receiving hospital questioned whether Gordon had had a heart attack at all and my suspicions were confirmed when I rang the hospital a week later! As far as Gordon was concerned, he had had a very welcome break from his oil drilling job at the insurance company’s expense, and planned to return to Nigeria three weeks later. From the insurer’s viewpoint it was some £35,000 spent for a false alarm, but a situation that was unpredictable and unpreventable. And my thoughts? Well, there are many places I repatriate people from, and I often come home full of exciting stories and plans to go back there on vacation with my wife. Nigeria won’t be one of them!

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Bad News is Never Easy

Working as an in flight medical officer often has many rewarding and happy moments, but equally there are times when neither care nor compassion can overcome the sadness generated by some of the cases that I handle. It is important to remember that, on every trip to far off countries, I am dealing with people who have been poorly enough to need the help of a doctor and, despite the incredible advances in modern medicine, not all ailments can be cured. Sometimes, when reading all the documents relating to a case, I get a sinking feeling when I realise that I will be bringing someone home to an uncertain future. But even then the importance of being a small part in the handling of the case is my driving force. I have said it to many of my patients – it is bad enough being ill at home, but when it happens in a foreign land, far away from friends and relatives and where language is an insurmountable obstacle, it can be devastating.

Let me tell you about a case which Isobel and I were involved with. One which was heart rending from the moment we were asked to cover it as a doctor and nurse team. The repatriation company asked us to travel to western Australia where a 23 year old man called Alan was in hospital. He had been back packing with friends around that wonderful country when he had suddenly experienced severe stomach pain and presented himself at the local hospital casualty department. It became obvious to them very quickly that Alan was not suffering from something as simple as indigestion or appendicitis, but rather he had a severe inflammation affecting his whole abdomen – peritonitis. Extensive surgery and investigation were needed very quickly to find the cause of the problem and the findings were not very happy ones.

Unbeknown to him, Alan had a small cancer hidden and growing in his bowel before he even left his home in Scotland on the adventure of a lifetime. As time went on, he put the stomach problems he experienced down to strange foods or to traveller’s diarrhoea, but even the pills and potions he took with him didn’t help. It was when the cancer finally and suddenly ate through his bowel wall did the awful truth become apparent. At the operation, not only was the cancer which caused the peritonitis found, but also that it had spread to other parts of his bowel and to his liver. The treating doctors did their very best by taking out the parts which were worst affected, and by making sure that no more blockages or infections could happen, but there was no question that the disease was going to be fatal and that time was the only unknown factor.

Isobel and I made sure we had all the equipment which might have been needed. Stretcher, mattress, bedding and all the straps to hold it together, full nursing kit, full doctors kit and a whole chemist’s shop full of drugs – just in case! It looked as if we were moving house when we started out for Heathrow airport to start our long journey to Perth in Western Australia. It was when we arrived at the airport and went to collect out tickets that we hit our first problem, one which is happening more and more often as insurance companies try to tighten the financial screw tighter and tighter.

The tickets we were given were from Heathrow to Singapore and then on to Perth, a twenty one hour journey including nineteen hours flying. This was to be followed by just thirty six hours on the ground before we repeated the journey back to home. And the reason for our discontent? The outbound flights were booked in economy class! Isobel and I have always been proud to do a good job in the repatriation industry but neither of us is prepared to be the fall guy in the insurance industry’s continuing unempathetic efforts to cut costs. The class in which we travel on short haul flights around Europe is unimportant because journey times are so short, but long haul flights are a very different matter and rest is absolutely vital. It was with this in mind that we stood our ground at the ticketing desk and contacted the repatriation company. Harsh words flew but we stood our ground and were finally upgraded to business class – I can see dark ominous clouds of dispute looming on this subject in the not too distant future!

It was some twenty four hours later and with eight hours of time zone disorientation that a very tired doctor and nurse finally disembarked in Perth and hired a very big taxi to take us, and our voluminous equipment, to the hospital where Alan, and his parents who had travelled out to be with him, were waiting for us.

Despite his having been told the bad news, and that he was in a great deal of pain, Alan was in remarkably good spirits. He was able to discuss with us what had happened to him, how we were going to manage to get him home and how sorry he was for having caused everyone so much trouble! At no stage did he ask for sympathy or pity or to complain about his misfortune. In fact, the only thing which had upset him was, that on the day he had been admitted to hospital, he had booked and already paid for a skydiving adventure in the desert outside Perth.

We spoke to the doctors and nurses at the hospital where the level of care had been magnificent. As we listened, it became more and more obvious that the outlook for Alan was grim indeed. The cancer was so virulent that they had not even been able to determine where it had come from. What they did know was that it had spread like a bush fire fanned by the wind. It had invaded many parts of his intestine causing blockages and bleeding, to his liver from where it was quickly spreading to other parts of his body and they even suspected that there were small deposits in his brain. It became obvious that if we were going to be able to repatriate Alan to his home town then it would have to be done quickly, despite the difficulties that such an exercise were going to involve.

Time to catch up on some sleep – not an easy thing to do as we were going to bed in the middle of the morning when everyone else was up and about and hard at work. Fortunately in the aeromedical repatriation world one learns how to cat nap at a moment’s notice and, although an overdraft of sleep hours soon starts building up, it is enough to manage on. Even more ammunition in my argument with the insurers about travelling in business class on long haul flights! We certainly didn’t see much of Australia on this trip.

Despite his obvious disability and pain, Alan was still insistent in getting out of bed and moving around. We therefore decided that it would be better for him to travel in business class on the long journey home rather than be confined to a stretcher the whole time. It would mean that he could, with assistance, go to the toilet rather than be catheterised or have to use a bottle. He could pass the time watching a choice of films rather than spend long hours staring at the ceiling. And perhaps most important, he could have a choice of meals, although it was very obvious that he was eating very little indeed and even had to be encouraged to drink small amounts of water.

We arranged with the Australian hospital that the needle that they had put into one of Alan’s veins be left in place. This would give me the opportunity to inject pain killers at very short notice if they were needed. It was finally with many tearful farewells with the doctors and nurses at the Perth hospital that Alan was carefully loaded onto a stretcher for the journey to the airport for the long flight home. The ground handling staff there had been forewarned and they were magnificent in their efforts to get our patient on board with the minimum of fuss and bother. It wasn’t very long before Alan was resting comfortably in his business class seat, although he was at pains to tell the flight attendants off for fussing over him too much.

The long flight home with a stopover at Singapore went very well indeed. With appropriate sedatives and pain killers, Alan had a very comfortable and uneventful flight, he slept for long periods and remained pain free for most of the time. At Singapore he insisted that I get off the plane and buy him a huge bunch of orchids so that he had something he could give to his girlfriend when he got home in Glasgow. Isobel and I took it in turns to sit alongside him to monitor his progress and tend to his needs while the other tried to grab a few minutes of those invaluable catnaps! Once again though, the biggest problem we had was in trying to get him to eat even tiny morsels of food and even plain water was hard to get into him.

We arrived at London’s Heathrow airport in the early morning. The next stage of the repatriation to Scotland had been thought out long in advance and it had been decided that, rather than go through the hassle of deplaning and transferring to the airport medical centre to wait for the next flight to Glasgow, an air ambulance was more appropriate. This meant that the customs and immigration formalities were done on the aircraft followed by a short ambulance journey from the Boeing 747 to a Beechcraft King Air dedicated air ambulance. Within just one hour of landing at Heathrow, we were in the air for the ninety minute flight north to Scotland.

Once again the ground handling at Glasgow was excellent and the road journey to the hospital uneventful. The ward were expecting him and so, some thirty hours after collecting him from the ward at the Perth Hospital, we were handing him over to the ward at the Glasgow hospital. The journey, despite all our efforts, had taken a great deal out of Alan and he looked desperately tired. Despite this, he was still uncomplaining, still apologetic for all the trouble he had caused and grateful for everything we had done for him during the long journey home. It really was a heartrending farewell when we said goodbye to him and his parents as we left for the final stage of our repatriation exercise to our home and a much needed bed.

Repatriation medicine is nothing like working in general practice or in hospital, in that the whole concept is theoretically a job and finish exercise. We are notified of a case to be covered, we fly out, we collect the patient and then care for them during the journey home and then we hand them over to a hospital or to the patient’s general practitioner. Once they are handed over, it is theoretically the end of the job for us, and there is officially no reason for us to be involved any more. But we are human aren’t we! We do try to keep in touch and, by giving the patient our visiting cards, hope that they will keep in touch with us to tell us how they are progressing. In Alan’s case however, we almost felt afraid to keep in touch with the hospital or his parents.

It was just two weeks later that, while on another repatriation mission in the Canary Islands, my mobile telephone rang and a familiar voice spoke to me. It was a very tearful Alan’s mum to give me the news that just ten days after arriving in Glasgow he had very peacefully passed away – just eight days before his 24^th birthday. He had remained conscious and uncomplaining right up to the last few days when, to ease the pain, the doctors had administered strong pain killers and sedatives. He had had the opportunity to talk to all his family and friends and, as his mother said, he was eternally grateful to Isobel and I for giving him the opportunity to do that. Despite this I felt dreadful and very inadequate indeed. There is no doubt at all that bad news is never easy to tolerate, and it is at times like this that I question the fairness of life itself and the almost illogical faith that many people hold dear.

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The Southernmost City in the World

Since I started in my aero medical repatriation career, I have flown many hundreds of thousands of miles and have had the opportunity to visit every continent. Naturally though, my travels tend to follow you tourists and businessmen, so the more of you that go to cities and countries then the more likely I am to follow you! Having said that, the continent to which I have travelled fewer times than any other is South America, which perhaps gives a suggestive nudge to the tourist industry towards that spectacular unexplored territory.

It therefore goes without saying that when I was asked to travel on a repatriation case to the southernmost tip of Argentina, I accepted immediately, and without any question as to the medical details. And when they told me that this was to be a doctor and nurse repatriation, and would my wife Isobel be available to accompany me, things looked even better - it was certainly an opportunity too good to refuse.

Normally, a doctor and nurse are asked to travel together when the patient who is being repatriated has both medical and nursing problems. Examples are perhaps road accidents, where the patient has chest injuries needing a doctor and limb injuries needing a nurse; or it could be someone who has had a stroke who needs the doctor to look after the medical side of things and the nurse to deal with continence difficulties. However, there are other types of illness and injury which could, under normal circumstances, be managed by one pair of hands, but where the sheer logistics of the case demand more than one person. This was a repatriation which fitted into the latter category. It was a diagnosis where the patient needed constant attention during three flights, over ten thousand miles and some thirty hours traveling – certainly an exercise which just one person could not manage alone.

Our patient turned out to be a sixty six year old lady named Lorna who had been disembarked from a South American cruise liner with a provisional diagnosis of severe anxiety and depression. Now, I’ve already spoken to you about the way that doctors on cruise liners will quickly wipe their hands of any patient whose illness could upset or offend the other passengers; and this was certainly so in Lorna’s case. There is no shadow of doubt that mental illness of any sort gives most people, and doctors (including me!), the heebie jeebies, and this is obviously why our patient was now stranded, alone and friendless, in a hospital in Ushuaia, the southernmost city in the world some 10,000 miles from home. The cruise doctor had certainly solved his problem with one quick and easy decision, and the other 1,999 passengers had wended their happy way up the east coast of south America without the offensive presence of a psychiatric case on board.

When I read all the case notes it was very obvious that there was more to Lorna’s problem than met the eye. She was on a spectacular cruise which had set out from Panama, through the canal to the Pacific ocean, then down the western side of South America. There, they were scheduled to travel through the Beagle Channel in the Tierra del Fuego (the Land of Fire) at the southernmost tip of south America, stop off at Ushuaia (the southernmost city in the world and main departure point for Antarctica, some 600 miles away) before travelling north along the eastern coast of south America to Jamaica. The cruise holiday was scheduled to take place over three months and to stop at countless countries and ports that most people can only read and dream about. I don’t even dare to think about the cost of such an adventure but I’m sure you will agree with me that it must run into mega bucks!

But why had Lorna booked her place onto such a wonderful cruise holiday alone, and with no friends or family to share the excitement with her? Why, as the case reports detailed, had she spent most of the first half of her epic journey through the Pacific alone in her cabin, having all her meals sent to her? Why had she made so many visits to the doctor’s office on the ship, matched only by the number of requests that he visit her in her cabin? And why, as the cruise progressed and her mood deteriorate, did her threats of self harm, including suicide, become more and more frequent? Small wonder therefore, that the ship’s doctor took his first opportunity to rid himself of a patient who was causing him endless worry, and who was disrupting what was supposed to be the voyage of a lifetime for many. But before I go into more details of the medical aspects of this case, let me tell you more about our journey to the southern most city in the world.

Modern air travel certainly has revolutionised the concepts of distance and the time it takes to get to your destination. Just a hundred years ago, a voyage to Australia could have taken between two and three very uncomfortable months, and the costs involved meant that those who decided to go must have had little desire to return. Now, in the 21^st century and for just a few hundred pounds, the more hardy of us can contemplate a holiday anywhere in the world almost as easily as a trip to Majorca or Benidorm in Spain! But who on earth would want to go to Ushuaia, a city of just twenty thousand souls, some three hundred miles from ice bound Antartica, ten thousand miles from London and whose claims to fame are wildlife and almost year round snow! I say this to try to explain why there are just not enough travellers to justify direct flights from London to Ushuaia! Rather, our flight plan involved a complicated and lengthy schedule of flights from London to Madrid with British Airways, from Madrid to Buenos Aries with Iberia and finally from Buenos Aries to Ushuaia with Aerolineas Argentinas.

Having said that, it really was an exciting outbound journey. London to Madrid in business class was fairly routine but the next stage to Buenos Aries was an unexpected pleasure when Isobel and I were upgraded to first class. That twelve hour sector was a dream literally as, after a magnificent in flight meal, we electrically converted our seats to beds and slept through most of the twelve hour flight. Buenos Aries itself was like any other Spanish city as we travelled by taxi through from the international to the domestic airport. But the most exhilarating part of the journey was then continuing our flight over the southern half of the continent, over the spectacular rain forests and magnificent river Amazon, over snow capped mountains (and valleys too!) and over incredible glaciers and snowfields as we went further and further towards our destination, some ten thousand miles from home.

Naturally, the first thing we did when we arrived in Ushuaia was to go to the hospital to visit and assess our patient. This is always important because, very often, the long distance reports we get from foreign hospitals and doctors leave a lot to be desired to say the least. Shortage of medical details, some facts held back and others exaggerated and the curious (that doesn’t make sense) phenomenon which language barriers impose. For example, where just one letter can cause untold damage when translating reports; to tell an Italian man not to work should come out as non lavora, but if just one letter is changed and you say non labora, you would be telling a very surprised macho male not to go into labour! However, I’m wandering away from poor Lorna in hospital in Ushuaia.

Using my schoolboy Spanish, we were directed to Lorna’s small room in the hospital which was securely double locked. The first thing we saw when the door opened was a very small window heavily barred – literally our first introduction to a very remote Argentinian psychiatric ward! But much to our surprise, Lorna herself was the complete opposite of what we had been led to expect; a very articulate, well orientated and well spoken lady who, when she realised we spoke English, subjected us to non stop chatter where we could hardly get a word in. In the space of a couple of hours we listened to a catalogue of her family problems and the ensuing acute anxiety state which had resulted in her running away and cruising on her own. This was followed by a sense of total isolation on board the cruise liner, with no friends to talk to and surrounded by strangers who all seemed to be enjoying themselves. Small wonder that the end result was a very unhappy lady who made a desperate cry for help to the only person she thought could ease her woes. But the last thing she thought the ship’s doctor would do was to put her off the ship very quickly and in an alien environment many, many miles from home. Now, the relief of having someone to speak to and who would listen to her and could empathise with her problems was almost a cure in itself. And when we sat down and explained the repatriation plans back to the UK which would start just 36 hours later, the transformation was almost complete. Certainly not quite the sort of psychiatric problem we had been expecting.

We were in Ushuaia in early January which is in fact right in the middle of their summer. The weather was quite pleasant with blue skies and a sun struggling to keep the temperature around 10C. The Beagle channel was just a few yards from our hotel and we were able to watch Antarctic supply ships loading and unloading at the docks with supplies for those who were even more adventurous, and who wanted to travel even further south! All around us were the most spectacular rugged mountains and peaks covered in snow and which, when the sun set, explained why southern Argentina earned its name Tierra del Fuego – the Landof Fire. Pony trekking in the summer and skiing in very cold winters add to the attractions of this very spectacular place full of very friendly people.

Not so many years ago, in the midst of the economic depression in the late 1920s and early 1930s, many Welsh people emigrated to such far away places as Wolverhampton, the Black Country and Birmingham just looking for work. Many never returned and blended into the local population where names such as Pugh, Jones, Pritchard and Evans became commonplace all over the UK (and I hasten to add that Isobel and I emigrated to the Midlands very much later than the 1930s!). So what on earth has this got to do with a repatriation trip to Argentina you may well ask!

Well Isobel, was an Evans before I was lucky enough to find her and, the Evans family seemed to have a lot more adventurous spirit than most, and some of her father’s cousins went a little further than the West Midlands looking for work. They travelled to Patagonia whose mountains and never ending pampas plains are part of the spectacular sights I have just been telling you about. Apart from a few letters, which petered out during the war years, nothing has ever been heard since of the Patagonian side of the Evans family. Naturally therefore, while being presented with one of the best steaks I have ever had the pleasure of eating, our thoughts wandered to that long lost branch of Isobel’s family - and where was the best place to look? The telephone directory of course.

Not that we had the time nor the wish to go trekking into the mountains to meet these long lost relatives (and I am assured that many of them still speak fluent Welsh) – although I’m sure we would have had a very warm welcome and a host of stories to take back to Wales if we had. There was of course the possibility of a phone call perhaps? But, having explored the phone book, it became very clear that our relatives had blended into the local community as quickly and as well as had their West Midlands counterparts. There were five Evans staring at us from the Ushuaia directory – Domingo Evans, Pablo Evans, Julio Evans, Jesus Evans and Magueritta Evans. Like the Mayan and Inca nations of south America, the Evans family had been swallowed up by the Spaniards!

The repatriation the following day got off to a very good start. The ticketing had already been done, Lorna was packed, ready and waiting for us in her hospital cell – sorry, room and the first leg of the journey to London via Buenos Aries and Madrid took off on time. At Buenos Aries we took a taxi for the 20 mile journey between the domestic and international airports and, perhaps because we took a different route this time, we saw the contrasts between the incredible poverty and spectacular affluence which is the hallmark of many south American cities. The Iberia flight to Madrid went well with a mildly sedated patient sleeping most of the way and on the final leg to Heathrow airport we patiently tolerated Lorna getting more and more excited the nearer we got to home.

Some 4 weeks later Isobel took a phone call from Lorna’s daughter to say that her mum was doing very well. Despite there still being a lot of personality clash obstacles to overcome, the family seemed to have accepted the very expensive ‘cry for help’ very well and were rallying around her.

Although this was not the longest repatriation I have been involved in in terms of distance, it certainly was in terms of travel logistics. It was also a ‘psychiatric’ case which did not fit into an expected pattern and one which Isobel and I didn’t mind doing. All in all, an exciting exercise and one in which a page of the Evans family book could finally be closed!

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An Unexpected ‘Holiday’ in Hong Kong

I have told you before about repatriations where things go wrong but, thank goodness, these are the exception rather than the rule. Good case handling by the repat company means that everything should be firmly in place long before medical and nursing escorts are dispatched around the world, with the intention of returning home very quickly with the patient. But, as I said, there are exceptions to every rule and occasionally unexpected complications disrupt schedules completely. From the insurance company’s cost effectiveness point of view, not a good thing to happen, but for the ‘stranded’ medical escorts, one of the perks of the trade so to speak!

Isobel and I were fortunate to have travelled to Hong Kong some 10 years before the handing back of the colony to China although, on that occasion, it was to attend a conference on pre hospital medical care. To be asked to travel back there on a repatriation, after the hand over, was a really exciting prospect. It would give us the opportunity to enjoy its incredibly busy lifestyle again and to see for ourselves the changes that communist rule had imposed.

But first of all, let me tell you about the case itself and introduce the patient to you. Graham was a 60 year old who was in Hong Kong as part of an expensive package cruise holiday covering many far eastern places including Thailand, Vietnam and Malaysia as well as Hong Kong. He and his wife were coming to the end of their holiday when something, which had been bothering him for some months, suddenly got much worse. Graham had been losing weight unintentionally for some months, and during that time he had also noticed that he was finding it more and more difficult to swallow his food. One morning he woke up and was frightened to find that he couldn’t even swallow his own saliva. A visit to the ship’s doctor was followed very quickly by a journey to the local hospital in Hong Kong where the excellent medical care which Hong Kong can offer soon took over.

To cut a long story short, within twenty four hours of being admitted to hospital, Graham had undergone an extensive series of investigations. And the diagnosis? Yes, many of you will already have guessed, Graham had developed a nasty cancer which had slowly grown until it had completely closed his gullet and prevented him from swallowing anything. Naturally the cruise liner had long gone on its way, leaving Graham and his wife to the care of the local doctors and to the repatriation company whose job it was to get him home to Middlesex at the earliest appropriate time for continuing care.

Discussion between the treating doctors and the repatriation company continued on a daily basis until finally the Hong Kong doctors felt they had done all they could and that Graham was stable enough to tolerate the long journey to a hospital near his home. They were insistent that he needed a doctor and nurse escort and, although he was reasonably mobile, he would need to be able to lie down for most of the journey. It was estimated that it would take some 24 hours from hospital bed to hospital bed, including a thirteen hour flight – a very tiring and stressful exercise for the fittest of us but even more arduous for someone who was as weak as this patient. Accordingly, the insurance company agreed that the best alternative was for Graham to make the return journey in a first class seat where he could lie down and where there was plenty of room for him to be cared for.

As soon as the decision had been made to get him home, Isobel and I made arrangements and were soon settling into business class seats on a jet for the long flight covering 6,100 miles and seven time zones to Hong Kong.

The first thing different we noticed when we landed in Hong Kong was the airport. Putting it simply, it was a completely different airport from the one we remembered from our previous visit to, the then, colony. For many years the first impression, for anyone of arriving by air in Hong Kong, had been one of flying between skyscrapers looking into living rooms and bedrooms as the plane touched down at the old Kai Tac airport. Now, the new Hong Kong airport on Lantau Island was fully operational, and we were given the opportunity to experience a purpose built 21^st century facility rather than the added-on-extra-bit concept which most airports offer. Having said that, we had already been forewarned and given the benefit of a hands-on experience of the new airport by Norman, a very close friend of mine, who is the foreign sales director of a Worcestershire company which had been given the contract to carpet the new airport – and a very good job they had made of it too! Wide spaces, friendly faces, incredible shopping opportunities and ground transport to get us to Hong Kong Island within minutes temporarily overcame the tiredness of the 13 hour flight.

Hong Kong was certainly as we remembered it. An incredible number of high rise buildings packed into a very limited space, a road system built on multiple levels just managing to cope with an endless volume of traffic all hours of day and night and the most incredible array of multi coloured signs and lights that I have ever seen in all my travels. Shopping in Hong Kong is an experience in itself as we found on our first visit. State of the art, high tech electrical goods at bargain prices that make you weep; tailors and seamstresses that can turn out made to measure suits and copies of creations, that have just appeared on Parisian catwalks, within a matter of hours; street markets where you can buy anything from illegal ivory carvings to look-alike Rolex and Omega watches that have never been anywhere near Switzerland.

But, as in all our travels, we were there to work and the scheduling in this case left us little time to re experience the memories we had of our previous visit – or did they? More of that in just a minute. Our first thoughts were to go to the hospital, visit our patient, speak to the treating staff and to confirm the repatriation arrangements. It was when I telephoned the hospital to arrange a convenient meeting time that I had the first warning that there was a problem, and was told that the treating doctor wanted to see me as soon as possible. Now having worked in the repatriation business for a long time, and knowing the gravity of Graham’s complaint, I was fully aware that even minor changes in a patient’s condition can affect the medical clearance which airlines have to give before we fly. It was with not inconsiderable concern that Isobel and I made our way to the hospital.

It turned out that during an attempt to widen Graham’s gullet to enable him to swallow just a little, and while we were on our way to Hong Kong, a tiny perforation had appeared in the gullet wall and some air had leaked into the wrong part of his chest. The tiny hole had sealed itself but nevertheless, the leakage had major implications when the reduced air pressure at 36,000 feet was taken into consideration. After visiting our patient, speaking to the treating doctor and then phoning home to the repatriation company we quickly came to the decision that things would have to be put on hold. The major question was how long things would have to be put on hold.

It is important to remember that insurance companies are not charities and that repatriation companies have to charge for their services. Similarly, Isobel and I don’t work for nothing and airline companies don’t accept excuses in payment for tickets! In short, up to this point, the repatriation had run up bills close to £10,000 on airline tickets alone, and the question was now to find the least expensive solution to an unforeseen problem. Graham would certainly have to wait another 9 days at the earliest before we would be able to bring him home, so what was the best solution? Well, the first alternative was to bring Isobel and I home and then reschedule the whole exercise – that would mean many thousands of pounds having to be written off. The second was to ask Isobel and I if we would be prepared to stay in Hong Kong until Graham was fit to fly. Of course, it would mean having to pay us at a reduced rate, and also paying hotel and subsistence costs but it would be a lot cheaper than bringing us home and then rearranging the whole exercise. Guess which alternative we decided on – despite the fact that we would soon run out of underwear!!

So, for just over a week, we were able to relive our first experience of Hong Kong. Stanley Market, the floating restaurants in Aberdeen Harbour, the peak, Kowloon and the New Territories, Macau, Canton (Guangzhou) as well as all the million attractions of Hong Kong Island itself. It was no different from our earlier exciting experience - except for one very important factor - prices! There was little doubt in our minds that living costs (for tourists at least) had risen out of all proportion during the time scale involved since our first visit. Yes, electrical goods were still incredibly cheap and the local markets were no strain on the purse. But hotel costs, restaurant bills, taxi fares and so on had gone up into mega proportions. A reasonable meal for two in an average restaurant set us (sorry, our expense account) back $S700 – about £60, and even a half pint of beer (on my own account!) in the hotel bar gave no change out of $S50 – about £4. Taxi meters appeared to have gone into turbo charged overdrive although the famous Hong Kong trams were still there and very cheap. All in all, an incredible opportunity to re-live previous experiences but fortunately for Isobel and I, at someone else’s expense. We would certainly recommend Hong Kong to anyone (despite its current political leanings), but with the provisos that the bank manager is warned before you travel and you keep any unwelcome opinions to yourself!

Each day we were there, we revisited Graham in his hospital room and were very pleased to see the small leak into his chest slowly disappear. He was a remarkable man who was fully aware of the implications of his illness but he never, at any stage, complained or appeared down hearted. On the contrary, his biggest worry was the inconvenience that he felt he had put us to! No further attempts were made to widen his gullet and feeding him was by means of a special solution being injected into one of his major veins. Fortunately, he was able to allow tiny trickles of fluid down his throat so one of his biggest pleasures at this time was to suck ice cubes. The plan was to get him to a hospital near his home where an operation could be performed to insert a plastic tube to replace his gullet and to allow him to eat and drink of his own accord. With all the previous arrangements slowly fitting back into place the repatriation was rescheduled.

As I have told you, despite his problems, Graham was fairly mobile – although a couple of weeks in a hospital bed weakens most people! Accordingly, getting him from the hospital to the airport and then onto the aeroplane went very well. The special feeding tube into his vein had been left in place and every hour, on the hour, Isobel and I injected 50ml of the special feeding solution which the Hong Kong hospital had provided for the journey. One of Graham’s biggest grumbles when we visited him at the hospital was that, for many years, he had enjoyed a couple of glasses of scotch every day and that since his admission, he had been denied that pleasure. Now there are many rules and protocols in the aeromedical repatriation world and one of them is that the people we are repatriating should be discouraged from drinking alcohol. But the opposite side of the coin was that I was dealing here with a request from a man with a terminal illness and what right had I to deny him such a request! The question was already answered. I’ve told you already that Graham was able to swallow the small trickles from a melting ice cube and it didn’t take long to use the aircraft’s frozen food compartment to make some malt whisky and water cubes. If you could have seen the face of that man when, having asked for a plain ice cube, I popped one of the ‘specials’ into his mouth. It seemed to make everything worthwhile.

It was a long flight and it was a very tired patient that disembarked to meet the ambulance for the road journey to the hospital in Middlesex. The journey was very short and we had been assured by the repatriation company that his admission had already been arranged so that Graham didn’t have to hang about for too long. But that was not quite the welcome we received! ‘Sorry, the doctor who accepted this case has gone off duty now’ ; ‘sorry the last bed has been taken, you’ll have to wait in the accident department until one becomes available’ ; ‘nobody told us to expect this case’ ; ‘we’re very busy at the moment, just sit over there and wait your turn’. These are all the standard phrases which I meet regularly in UK casualty departments after many hours and many miles of travel. And this is what happened in Graham’s case. Fortunately I am used to the problem and as a doctor will go to considerable lengths to protect my patient’s rights – which is what happened in this case. I’ll not repeat the words or threats used, suffice it to say that within an hour of arriving, Graham was tucked up in bed and getting the treatment he urgently needed.

In fact, Graham lived for just six weeks after arriving home but at least during those six weeks he was comfortable and well cared for. Right up to the very end he kept telling people about his ‘whisky cubes’.

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Things Don’t Always Go According To Plan

’ve already told you that before any repatriation can go ahead, an enormous amount of logistical work and support usually known a case refereeing, takes place first. It involves the repatriation company, in the shape of its doctors and nurses, analysing every aspect of the case, contacting everyone involved and weighing up all the many pieces of information which come from many sources. The whole point of the refereeing exercise is to try and ensure that when the repatriation does go ahead, every piece of the jigsaw fits perfectly into place. It is to make sure that when the in flight doctor, or nurse, arrives to collect the patient, no piece has been left out of place which could result in delay, confusion or, at worst, having to abandon the repatriation exercise.

Unfortunately, no matter how good the refereeing, no matter how meticulously the information has been analysed and no matter how many fail safe mechanisms have been put in place, there is always the occasional case where a spanner is thrown into the works. There are some medical conditions and complications which slip through the referees net and which, through no-one's fault, leave me to have to break the news to the patient when I arrive at the foreign hospital bed and have to say, 'sorry, I just can't take you home".

There was no reason why the 36 year old lady should not have gone on holiday to one of the Greek Islands. She was just 28 weeks pregnant with her first baby and this was probably the last holiday that she and her husband were going to have on their own for many years. The pregnancy was going well, her doctor was quite happy for her to travel and she fitted in very well with the guidelines that airlines write with mothers-to-be in mind. Things went blissfully well for the first few days - but then disaster struck.

Following a small, threatening bleed she went to see a Greek doctor who immediately admitted her to hospital. He put her on appropriate drugs and started a series of investigations and scans to determine the cause of the bleed. The answer came back very quickly; part of the unborn baby's lifeline - the afterbirth - had separated from the mothers womb and had caused the bleed. This was the worst possible cause because, just like a tear in a piece of cloth, a weak spot had opened and could easily open further. The unborn baby was unaffected at this stage and continued to move around, blissfully unaware of the danger it was in. The immediate treatment - complete bed rest, to try and prevent any further separation of the afterbirth in the hope that the damage could heal itself. And the most frightening scenario? If the afterbirth separated completely, both the mother and her baby could literally bleed to death within minutes unless appropriate emergency help was close at hand.

For ten days the repatriation company and the case referees kept a daily review of the situation by contacting the patient, her husband, the treating doctor and the hospital staff. All went well, there was no more bleeding, the scans seemed to show that the separation had healed and that the baby continued to progress well. Talk started about repatriating the prospective parents to a specialist maternity hospital near their home in the UK, and all the wheels started turning to determine the best options.

After further four days a direct air ambulance flight was decided as the best way of transporting her the 1,700 miles to home with the least possible number of flight changes and movements. Enough equipment was loaded to cover all emergency scenarios including an incubator in case the worst came to the worst. Despite all these precautions, there still remained a deep sense of high risk and everyone who had been involved with the case kept fingers tightly crossed that we could get her home.

The first outbound leg of the flight went well to Rome where we stopped to refuel. A mobile phone call to the patient in her hospital bed from the tarmac in Rome met with an excited response and which quickly demonstrated how much she was anticipating getting home. No, she was not getting any tummy pain and no, there was no more bleeding since the first time and yes, she continued to rest in bed all the time. The worries that we were still faced with a life threatening problem were still there, but the clouds were lifting a little as we moved into the sunshine of the eastern Mediterranean.

We landed late evening, and as soon as I switched on my mobile telephone it bleeped with a message asking me to call the repatriation desk at home at the earliest opportunity. My concern was immediate; these ‘contact asap’ messages usually came only if there had been a change of plan, and one which needed immediate attention. The message I was given was to please go directly to the hospital where the unfortunate mother-to-be had started bleeding again and I was to make an on the spot assessment.

When I walked into that hospital room the look on the faces of the expectant mum and dad was heart-breaking. They knew what had happened but were hoping against all hope that I could reassure them that all was well, and that they were going home. But no, the drug treatment had restarted and a new scan showed a very small further separation of the afterbirth. Despite the small size of the separation and the bleed, the implications of two road journeys, the loading and unloading of an aeroplane and a six hour flight at thirty thousand feet were all too threatening to even contemplate. Despite the late hour, and to confirm my findings and thoughts, I contacted a senior obstetrics doctor at home. The immediate answer was as I had expected - don't touch, keep your hands off; insist on complete bed rest for at least another four weeks until that baby has matured enough to stand any chance at all.

The response from the prospective parents surprised and heartened me immensely. Despite the very obvious disappointment and tears when I broke the news to them, their reaction was one of deep gratitude that by insisting that they remain where they were for a long time, it was giving their very precious baby a better chance. After discussing my decision with the treating Greek doctor, I contacted the repatriation company and gave them the bad news that the repatriation would have to be aborted, and that this case would have to remain on their 'active' list for some time to come.

We were now left in the unfortunate position of a doctor, a nurse, two pilots and a very expensive air ambulance stranded on a Greek Island with nothing to do! Now, I can hear you all saying 'lucky devils, wish that could happen to me'. But basically, we had all travelled with a job to do and were in a work, not holiday, mood. On top of that we had limited supplies of under wear, no swim wear and were on tightly managed expense accounts, and so the holiday mood was a long way away! It was therefore a welcome relief when the message came through asking if we were properly equipped and prepared to divert to a remote part of Turkey to pick up a lady with a broken leg, and to transfer her back to Manchester. Admittedly, such a well equipped and very expensive Air Ambulance would not normally be used for such a simple injury but in this case it would at least help lessen the financial penalty the insurers would have to face after the aborted mission - and so it was Turkey, here we come.

None of us had ever heard of the town in central Turkey we were asked to fly to, and we certainly wondered what our 60 year old prospective patient and her 62 year old husband were doing in what appeared to be such an isolated place. After flying over mile upon mile of what appeared to be very mountainous and desolate Turkish countryside we were pleasantly surprised when we landed at what appeared to be a very modern and well appointed airfield in, literally, the middle of no-where! We were even more surprised when the whole complement of airport staff turned out and lined up to greet us, and the airport manager himself came out on the tarmac and to shake everyone's hand.

The more unpleasant surprises came when the pilots were asked to pay the airport landing fee of $900 in hard cash – sorry sir we do not accept cards! And it was just as unpleasant when the refuelling costs, again in hard cash, put UK fuel costs in a minor league. It took a major pocket searching and foreign exchange exercise before we just managed to put together enough to ensure our departure with enough fuel the following morning - but even then they tucked our passports in the airport safe to make sure every last penny could be accounted for!

Fortunately, the hotel we were booked into was a little more trusting, and they were happy to accept our various credit and debit cards. And indeed it turned out to be a superb hotel with incredibly varied and very tasty catering facilities. It was also at the hotel that we were able to learn a little more about the area we had ventured into, and it soon came as no surprise to us why our unfortunate prospective patient had travelled so far into the wilderness.

Cappadocia is in the central region of Turkey. It is renowned for its archaeological sites with very great emphasis on early Christianity. Indeed, looking at the guide books, Christianity was here long, long before Islam, and its influence on future events in the Christian world appeared to have much greater significance than anything that went on in what we now call the State of Israel. Its history, alongside incredibly weird rock formations, multi storey houses carved into the rocks and vast underground cities certainly make Cappadocia a paradise for those who look for a little more than sun, sea and sand. Small wonder indeed, why our patient and her husband had come to this remote spot.

As I have already told you, a simple injury as a broken leg does not normally warrant such an expensive repatriation exercise involving an air ambulance. In fact, our patient was truly very well spoilt as she winged her very comfortable way home to Manchester via Austria. Similarly, there was little for myself and my nurse colleague to do other than hand out the canapés and Coca Cola. On the other hand, what had started as a two day exercise had stretched into five and had severely stretched my limited supply of clean shirts and smalls! A hot bath and a change were more than welcome when I arrived home and waited for the next telephone call.

As an addendum to this story, I kept closely in touch with the case of the mother to be on the Greek Island and was truly delighted to hear that some six weeks after my aborted mission the story had a happy ending. Baby Lucinda weighed in at four pounds two ounces at thirty four weeks and, just two weeks later, was well enough to accompany her mum home on a scheduled flight, and looked after by one of my nursing colleagues.

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September 11^th 2001

The dreadful act of terrorist murder at the World Trade Centre in New York didn’t involve me in repatriating any of the victims or their relatives. Having said that, I do know of a number of doctors and nurses who were stranded in America for up to a week until the airlines managed to get their act together . But that dreadful event certainly does have very significant and serious ongoing implications in my travels around the world as you can imagine. I’ve told you before about the difficulties I often experience in getting my complex and valuable medical equipment through airport security checks. Those difficulties have now been magnified a hundred fold and are certainly making my travels a headache of varying proportions depending on what countries and airports I am travelling to and from. Osama Bin Laden and his grotesquely warped mind had a lot to answer for in more ways than one!

I’m sure that those of you who have flown since September 11^th will be aware of the heightened security arrangements at airports. Lists of items banned from carry on luggage are displayed everywhere and are endless, including everything which can remotely be described as having a cutting, stabbing or any injury causing capability. Pen knives of all shapes and sizes, razor blades, nail files, cork screws, needles, scissors, no matter how big or small they are and whatever their intended purpose, letter openers, knitting needles, bats, snooker cues – the list goes on and on.

Like you, I’m certainly not in disagreement with the increased security because, looking at it logically, if anything does go wrong at 36,000 feet it’s a heck of a long way to fall! On the other hand, what does annoy me very much is the vast variation in the level of security and efficiency I experience at airports in different countries. Similarly, there is the almost total lack of understanding and empathy with the work that I do and the equipment that I carry. After all, I fly some 500,000 miles a year, am a fully qualified and documented in flight medical officer and I carry a home office international drug licence. I don’t know about you, but am totally in favour of computerised national identity cards which not only carry your personal and medical details but also a degree of security clearance according the job you do and the environment that you work in. The civil liberties campaigners who complain about infringement of their privacy can only do so if they have something to hide and I have no patience with them.

Before I go into some of the check-in security stories I have to tell, let me go through my medical equipment and the implications it could have in terms of airborne piracy. For a start I carry a heart defibrillator which can deliver shocks equivalent to thousands of volts. Not only could it seriously disable any unfortunate recipient, but its effect on aircraft instruments is not very well documented – and after all, if they even insist on you switching your mobile phone off on aeroplanes, just imagine the defibrillator being switched on !!! Until very recently, I always carried a small operating kit with me because there are certain conditions where rapid surgery can be life saving. It included several pairs of forceps, scissors, scalpel handles and blades, and stitching materials. You may have read of a young lady travelling from Hong Kong to London who needed a special drain put into her chest, otherwise she would have stopped breathing; the operating kit would have been perfect in those circumstances. But yes, you’ve guessed it, sorry sir, you can’t take scissors on board. And this is despite the fact that it is obviously an operating kit designed for a specific purpose and carried by a doctor. The silly thing is that despite not allowing me to take the scissors on board, the security staff are usually quite happy for me to keep my scalpel handles and the blades which are sharp enough to almost decapitate someone with one stroke! I do actually carry a full chest drain kit which has certainly proved life saving in the past, but there again, the kit includes two razor sharp chest drain needles, as thick as knitting needles and some 20 cm long – lethal weapons in the wrong hands. On the lists of banned items seen at the airports it specifically allows hypodermic needles for personal use (and I’m talking about diabetic and other medical uses !!) but, as you can imagine I carry many needles varying in size from 1 cm to a drip needle some 6 cm long. These are not for personal use

but must be classed as tools of my trade – you can imagine the implications here, to the extent that flights have been delayed while my kit is examined and arguments go to higher and higher levels. The same unempathetic logic applies to my mid-wife, wife Isobel’s delivery kit which contains enough essential tools to cause havoc in the wrong hands. You will certainly agree with me that my medical kit would provide an arsenal of hijacking tools but, in my hands they are the absolutely vital tools of my trade and I cannot even contemplate accompanying a patient without them.

Casting blame and ‘I told you so’ utterances after September 11^th is both pointless and unfeeling, and it would be a bit harsh to say that one learns from one’s mistakes and talks of horses and stable doors. But there is no doubt in my mind that the very lapse and lightweight security at US airports at the time was greatly to blame. The pendulum has now swung so far in the opposite direction, those security facilities can now only be described as draconian! Before September 11^th, relatives were regularly allowed into American airports as far as the aircraft boarding gates to wave goodbye to their departing relatives. Unaccompanied baggage was often loaded on aeroplanes while its owner caught another flight and despite the technology being widely available, scanning of hold baggage was rarely done at US airports. Poorly paid and uninterested security staff were often seen discussing their date the night before, or tonight’s ball game rather than watching the scanning X-Ray monitors. I could go on and on and on, I’m not making this all up, I have seen it with my own eyes and experienced it myself many times. Things have changed, although as I implied, an expensive mistake to have had to learn from. Now, as well as routine and thorough Xray scanning of both hold and hand baggage, security checks are random and frequent, relatives now have to wave goodbye at the kerbside and no one is allowed to park their car anywhere near a terminal. National guardsmen are very noticeable in their combat fatigues, bristling with weapons as they patrol every part of the US airports and regularly stop and check travellers. But, having said and commended all these changes, aren’t they the very precautions we have tolerated and indeed encouraged at airports in the UK for many years? Perhaps it is because we are more used to terrorist acts here in the UK and accept high level security as the norm.

One of my other worries is the inconsistent approach to security adopted by staff at different airports in different countries throughout the world. I will certainly fly the flag because British airports are the gold standard when it comes to baggage and individual security. Security staff are polite, but firm and display significant empathy when it comes to dealing with individual cases. On each repatriation exercise I explain what I’m carrying and why, I present my identification documents and cards and remain polite and co-operative at all times. Sometimes I have to go up and down various ladders of security levels but, touch wood, up until now I have never had a problem in British airports. On the other hand, not so far from home in some very popular holiday destinations for British tourists, airport security can be as lax as the elastic in a pair of worn out knickers!

Even a month after September 11^th airports in the western Mediterranean seemed to have missed the security boat. I remember bringing a stretcher patient back from one of the Canary Isles via mainland Spain and, from the outset, felt that no one seemed to care let alone have learned anything from New York. The ambulance which took us to the airport was allowed through the airport security gates and onto the tarmac with no checks on us, or on the considerable baggage we were carrying. We all boarded and took off with absolutely no security personnel having been in sight at any time nor an immigration officer to check our passports. When we landed in Spain later than we were scheduled to, we were taken off the first plane with all our baggage and rushed through the airport - once again with not even a cursory security check. Within an hour of landing were taking off for Gatwick. I could have been carrying anything on board, bombs, weapons – I could even have had an illegal immigrant on the stretcher rather than my patient! The irony of that case was that when we landed at Gatwick, the customs officers went through everything with a fine tooth comb looking for cigarettes and liquor over the limit – and no, there weren’t any! In a slightly different vein, Isobel my wife went through the same airport on an air ambulance, travelled to the hospital to collect a patient, travelled back to the plane and was not stopped once – despite the fact that she had left her passport at home !

On a recent repatriation to Portugal I was assisting my patient through the Xray machine when there was a lot of noisy activity just behind me. I was asked to stand aside while someone, who was obviously very important and was accompanied by a very attractive lady, jumped the queue. Of course the body scanner bleeped loudly and the security staff very apologetically asked him to empty his pockets. Lo and behold, there was a Swiss army knife big enough and complex enough to need a university degree to operate it! And what did the security staff do – they gave him the knife back and told him to carry on! When I protested about it, I was told that he was an important government official and that because he was flying on a private jet it was OK for him to carry what can only be described as a very offensive weapon. When I protested that he was carrying it into a secure area and could hand it over to any passenger flying on any aeroplane I was told to carry on and mind my own business. Well, I don’t know about you but I do consider it my business when there is a possibility of dangerous weapons in unidentified hands coming onto my aeroplane! In Portugal it seems that there were rules for some people but not for others!

I could go on and on and tell you dozens of stories about lax or over enthusiastic security at airports but they all come under the same basic umbrella. The security precautions are designed only after an event has taken place and are meant to stop it happening again. But where there are mindless fanatics, terrorists, religious perverts, mentally ill people and all manner of troublemakers, they will always find a way of causing trouble no matter how many barriers we build to try and protect ourselves. It is a very sad reflection of humanity in general that we have to think and act this way.

My job as an in flight medical officer has certainly become more complex and difficult over the years, and I can only surmise that it will become even more so for my successors. I am quickly coming to the stage where the pendulum of age, complexity and sheer exasperation will swing to the other side and I will sit back and let others do it while I enjoy my cans of Budweiser on a beach in Florida!

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A Reverse Repatriation !

There is no doubt that working as an in flight medical officer (IFMO) means using skills in a very different way to that which most doctors are used to. Family doctors are highly skilled professionals who are used to recognising and dealing with a whole host of illnesses and diseases and, when more specialised care is needed, they refer their patients to hospital consultants. Flight medical officers however are trained to deal with emergency situations in a closed community, at a moments notice and with no specialist back up to call on. They also need to know how to deal with what are usually simple illnesses at ground level but, the low oxygen environment seven miles up in the air, can become life threatening.

Let me try to explain it from a different perspective and to go some way towards explaining why in flight medical officers are a fairly rare, and often eccentric breed. We all know that family doctors work within the community that they serve. They get out of bed in the morning, wave goodbye to their loved ones, travel to their surgeries, see patients, deal with the presenting problems, sometimes even do home visits and, at the end of the day, are able to go home and spend time with their families. On the other side of the coin, their flying colleagues are given an assignment, pack their travel bags and, depending on their destination, may be away from home and family for anything between two and five days. If I told you that I spend about 150 nights a year in a hotel bed or on an aircraft seat you will get a better idea of what I’m talking about.

You will no doubt agree that working as an IFMO is simply not compatible with normal family life. It is certainly not suitable for young married doctors with young families. Similarly, it is a stressful life living out of a suitcase and demanding logistical skills far beyond those which most doctors need. Accordingly, and despite it being an essential service, it is not a branch of the medical profession which is attractive to many doctors – perhaps eccentric is therefore an understatement! Perhaps this explains why repatriation companies are continually facing problems in finding suitable doctors to cover the escalating number of patients in far off countries who need to be escorted home, because airlines simply refuse to carry them without such an escort.

So why am I silly and eccentric enough do it? Well, as a family doctor, I certainly enjoyed hands on emergency medicine including sports medicine, accident department work and emergency medical flying squad calls out where you get your hands dirty at the cutting edge so to speak. It was in my spare time that learned the skills of repatriation medicine as a volunteer working for the St John aeromedical service while at the same time, my wife Isobel became equally attracted to in flight nursing. It was therefore an almost natural progression, when the children grew up and left home, to switch from family medicine to in flight medicine in the winding down years before the question of retirement needed consideration.

I’ve already explained that repatriation companies have a constant headache in finding enough doctors to cover the cases they are presented with. Perhaps this is why, while enjoying the balmy sunshine and cans of Budweiser in Florida, the telephone rang and very stressed voice blurted ‘I know you are on holiday doc, but we’ve got a problem and I was hoping you might be able to help!’

The company that was calling me has, what might be called, four ‘full time’ doctors, even though those doctors are self employed and can accept or refuse repatriations depending on their commitments – I fit into this category. They also use a bank of ‘part timers’ who have regular jobs and accept repats in their spare time as a way of topping up their income. The part timers are usually only available at weekends and during their holidays. The problem they had was that that since I had gone on holiday the work load had almost doubled, and they were finding it increasingly difficult to find the doctors to cover the work within an acceptable timescale.

It was explained to me that a 74 year old man had been on holiday with his family, enjoying the sights, sounds and excitement of the busiest holiday destination in the world – Orlando. The excitement and the busy schedule must have been a bit too much for him because he was unfortunate enough to have suffered a heart attack, and the damaged heart muscle gave way under the strain. He went into heart failure, had severe breathing difficulties and for some time it was touch and go! Cecil was a fighter though and over the next few weeks had made a good recovery. He now fitted into the guidelines to allow him to fly the 4,500 mile, 8 hour journey home accompanied by a medical escort. The problem was that the repat company were so hard pressed that they could not provide a doctor to do the job for another 7 days! As you can imagine, after the forced extension of his holiday, Cecil was very unhappy – he simply wanted to come home to his family. And the insurance company was even less happy because as long as the patient was in the USA he was adding to their bill which had already passed the $50,000 mark! And of course, there was always the possibility of another heart attack or heart failure which would cost them even more!

Naturally, I did not want to spoil my holiday and I won’t even dare to publish Isobel’s comments! But on the other hand, I felt a degree of loyalty to the repat company and agreed to do the job on the condition that the scheduling fitted in with my wishes. Now I always carry my medical equipment with me wherever I go, so that was not a problem. I also carry my laptop computer at all times and was able to receive a 30 page email detailing Cecil’s problem Having rented a car, and at 8 o’ clock on very sunny Tuesday morning, I waved goodbye to Isobel to set off on the 200 mile journey from the Gulf Coast of Florida to Orlando.

A couple of years ago I brought another patient back from Orlando, a lady who had had serious breathing problems. I remember meeting her and asking her how she had enjoyed her vacation - despite the medical hang up! She was effusive in her praise and told me that if it hadn’t been for her illness she would have managed to see the whole of Florida. Now this confused me somewhat because, prior to her admission to hospital, she had only been in the state for 9 days, hardly enough to even scratch the surface I thought. It was when I asked her where she had been did the real story come out. The Magic Kingdom, Epcott, Sea World, Universal Studios, the Great Wall of China – the list went on! As far as that lady was concerned, Orlando was Florida and she had never set foot outside the city boundaries. Going even further, she had never heard of the Everglades, the Florida Keys, St. Augustine, the Gulf Coast, the Spaceport at Cape Canaveral and so on!

I found this very sad but, must confess that my and Isobel’s style of holiday should not be compared with that of others. Everyone to their own after all! We love exploring the Florida Everglades, by foot or by boat, and seeing, close at hand, a wealth and diversity of wildlife that is awe inspiring. To drive down the Florida Keys to Key West, over the many long bridges and small islands which make up the chain, is breathtaking. And to finally arrive at Key West and be a fly on the wall watching their life style is an experience never to be missed. And what about the first established city in North America, St. Augustine? The list of things to see and do in Florida, while at the same time enjoying their wall to wall sunshine, is endless. Despite what that patient thought, you certainly can’t see Florida in 9 days!

Which is why I enjoyed the 200 mile drive from the Gulf Coast to Orlando. Wide roads and very little traffic compared to the almost permanent congestion experienced on British roads. Egrets, osprey, herons, hawks and vultures as common as the crows and Magpies back home. The three hours it took me to get to the hotel where Cecil was staying were a pleasure and went by very quickly.

To say that he was pleased to see me was an understatement. After spending 6 days in hospital having his medical condition stabilised, he had been discharged to a hotel. The problem was that just 4 days after his being admitted, the rest of his family jumped on an aeroplane and headed home at the scheduled end of their holiday, leaving him to fend for himself. A little bit cruel I thought, particularly when insurance companies are always prepared to cover the cost of one relative staying with the patient wherever in the world it is. It ended up that a poorly Cecil had spent the last 8 days alone in a foreign country with no one to talk to but the hotel staff.

As I said Cecil was excited to see me, but that was more than I felt about seeing him when I did the pre flight assessment. The medical details that the case was based on were from the treating hospital – where he had last been seen just over a week before. In theory he fitted in with airline regulations – it was more than 10 days since his heart attack and the heart failure – but without regular assessment his condition had not been monitored, and things were not as good as they should have been. In simple terms, his heart failure was borderline, probably exacerbated by the fact that he had a poor memory, and I was unconvinced that he had been taking his medication properly and regularly. It was with great trepidation that I sat down and explained things to him and explain why I was putting the repatriation off for 24 hours while I adjusted his medication. Naturally he was devastated, and was only consoled by the fact that I was going to stay with him to watch over his heart condition. I contacted the repat company to explain the situation who, in turn, made the appropriate changes to the scheduling. My job was to call Isobel down on the Gulf Coast and tell her that the ‘quick out and back’ repat was beginning to stretch like a piece of elastic!

By increasing his water tablets and adjusting his heart failure medication I committed Cecil to a day in his hotel room and toilet! But the ploy seemed to work. The following morning he was up and about and as bright as a well polished button. The heart problem seemed to be well under control and his breathing was good enough for him to take a walk with me and enjoy a good breakfast. It was my pleasant duty to tell him, then the repat company that it was GO on that evening’s flight. There was one snag! I was not prepared to decrease the tablets which made him pass water and reduce the strain on his heart. But those of you who have flown before will be well aware that on aeroplanes there never seem to be enough toilets – do you understand my implication! The problem was solved four hours before the flight when I took him to the local hospital and, for the princely sum of $259, Cecil was catheterised!

From that point on everything went well until the early hours, some 3 hours from Heathrow airport. Despite my medication juggling, despite the catheter and despite Cecil being on Oxygen for most of the flight, as a precaution, things started to go wrong - he started to become agitated and his breathing became more laboured. Listening to his chest and it was soon obvious that he was slipping back into heart failure despite my efforts. The answer was to use medication directly into his veins to increase his kidney function and open his lungs. Within 30 minutes his condition had again improved dramatically and his catheter bag was working overtime! The rest of the flight went well and, as you can imagine, the relief on my face when we touched down was obvious. The pilot had radioed ahead and a paramedic crew were waiting on the tarmac to pick up and transfer Cecil to the nearest hospital with a heart department. I went with him to explain the situation to the admitting doctors and say goodbye to my patient who, despite the fact that he was still some 100 miles from his home in Birmingham, felt much more at home. Just 3 hours after landing at Heathrow I was checking onto the same plane, but with a different crew, back to Orlando!

I don’t remember much about the flight after my adventures the night before. As soon as the plane was on its way the ear plugs were in, the eye shields were in place, the business class seat wound down and I disappeared under a blanket! Some 7 hours later I was woken by a very pretty flight attendant who offered me a cup of tea and told me that we were within an hour of landing. I collected my rental car, once again enjoyed my 3 hour drive back to the Gulf Coast and by 6 o’ clock Florida time, just 58 hours after leaving, was enjoying the wall to wall sunshine and a can of Budweiser! And of course, a bottle of duty free perfume soon wafted away Isobel’s objections to my leaving her!

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A learning exercise in more ways than one !

It wasn’t long after Isobel joined me in the aeromedical industry as an in flight nurse that we were asked to repatriate an 86 year old man from Tortola in the British Virgin Islands. The prospect of a trip to the Sunny Caribbean was very appealing, and even more so now that it meant our first trip together, not just as an in flight doctor and nurse, but also as husband and wife!

Our 86 year old patient, Norman, and his lady friend, had been enjoying a cruising holiday when he was taken ill with a chest infection which rapidly developed into a pneumonia. Even though the medical facilities on the ship were very impressive, the decision was made that he needed more intensive care and he was quickly transferred to the shore hospital in Tortola, the capital. Reading through all the notes on the case it was clear that it had been touch and go at one stage, but that excellent medical care and his own determination had pulled him through. After a very stormy illness he had now recovered enough to be brought home.

This is an appropriate point for me to make some comments about British family doctors and their almost total ignorance of travel medicine and its implications, In Norman’s case he had asked his doctor if it was OK for him to go on a Caribbean cruise and he was given permission without even a cursory medical examination. The problem was that Norman had, for many years, suffered from chronic bronchitis and, after being given the go ahead by his doctor, he didn’t even bother declaring it to the travel insurance company! The end result was that the insurance company declined to accept liability for Norman’s pneumonia and his family were faced with a bill closing on £60,000!

Family doctors in the United Kingdom really do need to brush up on the subject of travel medicine but, having said that, there are only two very simple rules that they need to follow. The first is to sit down and think about the holiday destination that the patient has decided on, and than to balance the patient’s medical history against that destination. In the case in question, I would question the intelligence of the doctor who let an 86 year old man, with severe lung disease, fly some 5,000 miles to meet up with a ship whose medical facilities were very limited and whose itinerary included places where medical facilities were rudimentary to say the least!

The logistics of the repatriation were daunting indeed. The airfield on the British Virgin Islands is quite small and certainly can’t accommodate aircraft big enough to fly across the Atlantic. It therefore meant that both the outbound and the homeward sectors were going to be long and tiring – hence the decision that a doctor and nurse were needed on this case to provide backup for each other. With all this in mind a very heavily laden husband and wife left for Heathrow airport for a very demanding but potentially exciting repatriation.

There is certainly no doubt that the outbound sector was daunting. British Airways London to Frankfurt where we linked up with an Avianca Columbian airlines flight to Puerto Rico and there to board a small commuter American Airlines flight to the British Virgin Islands. Three flight sectors, six thousand miles and a total of eighteen hours travelling. On the first leg to Frankfurt we were told that the plane was absolutely full and restrictions on the amount of hand luggage which was allowed were very strict indeed. It was therefore with considerable trepidation and concern that I watched my medical kit disappear down the chute, along with the evacuation stretcher and mattress, to be classed as hold baggage and labelled through to the Virgin Islands. My concern was that the content of my medical kit included equipment worth about £8000, and a variety of drugs necessary in repatriation work and which I rarely leave out of my sight. In this case I was given no choice.

The journey from London to Frankfurt to San Juan in Puerto Rico went without incident but, as Puerto Rico is part of the USA, we were obliged to collect our luggage, pass through customs and then re check it in to our final destination. It was here that my concerns about our equipment started to come to fruition – after a long wait at the carousel nothing appeared. Despite our loud and long protestations, no effort was made to find and unload our bags and we had to helplessly watch as the Columbian airlines plane took off for Bogota in Columbia. We could do nothing but fill in a lost luggage form at the Columbian airlines desk and carry on to Tortola in the British Virgin Islands on an American Airlines commuter jet.

On arrival, our first task was to report the missing bags to the American Airlines desk at Tortola. To be fair, the staff there were very empathetic and immediately went to lengths to try and locate the missing bags, but at that stage of the evening it was a fruitless task. All Isobel And I could do was to hail a cab and make our very weary way to the hotel into which we had been booked to catch up on some sleep.

The following morning our first task was to go to the nearest store to buy some clothes and toiletries to replace the ones which were in our bags somewhere in South America – always a pleasure to buy new clothes when you know someone else (the insurance company) is paying. Next, it was over to the hospital to meet up with Norman, our patient. It really was a pleasure to meet him because, despite his unfortunate illness, he was one of the most cheerful octogenarians I have ever met. Chatty, uncomplaining, complimentary towards everyone and absolutely effusive in his gratitude to Isobel and I for having travelled all that way just for his benefit. When we explained that things may have had to be delayed a day or two because of the lost luggage it didn’t affect his mood. ‘You’re here and you won’t go home without me will you? So I’m happy now’, were his comments.

Next, back to the airport at Tortola and to the American Airlines desk where we were given the good news that our bags had been located in Bogota, Columbia. They would be loaded onto the next available planes and, with a little bit of luck, they would be with us on the evening of the next day. Of course this meant delaying our scheduled return to the UK but at least we now had a target time to aim for. Back to the hospital to give Norman the good news and then Isobel and I had some time to ourselves to see some of the British Virgin Islands.

Despite the difficulties in getting there, I can honestly recommend the British Virgin Islands as a holiday destination. The people there are incredibly friendly to an extent which we reserved Brits can almost find embarrassing. Nothing is too much trouble for them and they go out of their way to offer assistance at all stages. There is no doubt in my mind that the BVI people are a very different kettle of fish to those which we normally meet in some of the other Caribbean islands, where you are asking for trouble if you stray outside the closely guarded holiday resorts. A typical example was when Isobel and I decided to walk from our hotel to the town. Before we had gone a hundred yards, a car stopped and sounded its horn. Naturally we were apprehensive until we approached the car and a very old head yelled out of the window with ‘ where you go man ‘. ‘To town’ we replied, and were met with, ‘ you get in then’. The elderly driver had simply seen us walking towards town and offered us a lift! Just imagine a similar set of circumstances in London or Birmingham!

The sea around the BVI is a multitude of shallow beaches and coral reefs which are a magnet for water sport enthusiasts. Neither Isobel nor I are strong swimmers but both of us are happy and confident at snorkelling. I have even donned full sub aqua equipment on many occasions – with an instructor of course – to explore the deeper parts of the ocean. Here it was incredible; the coral reefs were teeming with sea life that are only seen normally on the Discovery channel on television and the fish so ‘friendly’ that they were quite happy to literally eat out of your hand, I drew the line though when I was offered the opportunity to go on a boat trip to some of the outer reefs where the bigger fish lived!

The restaurants were brightly lit, the waiters and waitresses informative, friendly and welcoming and the menus – well, they were mouth watering to say the least. Isobel and I were fed like kings and queens and enjoyed every morsel. Talking about queens, and no, don’t jump to conclusions, I have read that our queen takes her own food and chef with her wherever she goes just in case she picks up any foreign bug. Well, all I can say is that I feel sorry for her, to be missing out on the local delicacies which are on offer in some parts of the world. But, there again, I don’t suppose she has ever suffered from travellers diarrhoea has she!

The following evening it was back to the airport to collect our missing bags. The flight came in at 10 pm and within 30 minutes all our bags were appearing on the carousel. The story we were given was that the bags were indeed on the Frankfurt to Bogota flight but that they had omitted to taking them off at Puerto Rico. Consequently, they had spent 24 hours sitting unclaimed and unguarded in Bogota airport! Yes, you’ve guessed, they were well and truly broken into and raided. From my medical bag was taken everything that could be quickly pocketed; a blood gas machine (£1000), an electronic stethoscope (£200), a miniature heart monitor (£1500), a digital camera (£600) and a blood sugar monitor (£150). From Isobel’s bag she had also lost her blood gas machine, her electronic stethoscope and her blood sugar monitor. In all, some £4,600 worth of equipment. Certainly not the end of the world but what it meant was that we were not in a safe situation to bring poor Norman home without the equipment. The silly thing is that the electrical chargers were left in the bags leaving all that very expensive equipment totally useless.

Urgent phone calls to the repatriation company resulted in a spare set of equipment being urgently sent out to us, but that meant a delay of another 2 days before we could go ahead with the repatriation. There we were, stuck on the BVI for another 48 hours before we could return home. OK, I must confess that it wasn’t the worse place in the world to be stranded, and yes, we did manage to squeeze in a bit more water sport, but it also meant hours of sitting in airline offices and police stations reporting the losses to ensure that the insurers had all the recommended documentation to make a valid claim.

Two days later, the vital equipment arrived and we were able to go to the hospital to give Norman the good news that we were ready to go. I have already told you about the difficulties in getting to and from the BVI and we had decided that the most acceptable way to get back to the UK was by air ambulance to Barbados to link up with a scheduled flight to Heathrow. After four very uncomfortable hours on a Beechcraft King Air, transfer to a stretcher on the British Airways jet and by the early hours the following morning we were in London. Norman had a very comfortable journey and didn’t cause us any problem at any time. Some 22 hours after leaving the BVI, he was comfortably tucked up in bed in a Portsmouth hospital. All’s well that ends well you may say. But let me give you some of the ongoing implications.

All the equipment that Isobel and I carry belongs to us. This meant that after all the pieces sent out to us were returned to the repatriation company, we were not in a position to accept any other jobs. Yes, we could borrow the company’s equipment again, but that would mean a 200 mile journey to collect it before we could travel again. Replacing the equipment was not a problem and just 5 days after returning home, we were ready to go again. But, until the insurers were forthcoming with the cash, we were some £4,600 out of pocket!

Certainly an exciting repatriation exercise but not without its problems. Norman was certainly happy to be home and spent a further two weeks in hospital seeing his family and friends before he was discharged. Unfortunately, just two weeks later he suffered a massive heart attack and passed away.

You know what I found to be the most incredible part of this whole exercise ? I’m sure you know that Bogota in Columbia is one of the foremost drug capitals of the world, where narcotic trafficking is the rule rather than the exception. In my medical bag were drugs which, on the streets of the UK, would have been worth many thousands of pounds – in Bogota they were not touched! I suppose that if there is plenty of something available at little cost, it’s not worth stealing is it !!!

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Should I Fly or Shouldn’t I ?

Although this book is not really intended as an advice manual for travellers, it does seem reasonably appropriate to give you some guidelines on the relationship of illnesses to air travel, holidays and insurance cover. As well as you having to use a little common sense before, during and after your flight, airlines have quite strict and rigid rules as to who they will carry, whether special pre conditions need to be met and who they will not carry under any circumstance. All the headings in this chapter are certainly not meant to be a comprehensive list but rather, general advice. For more specific help the appropriate people to contact are your family doctor, your travel clinic nurse, the airline itself and sometimes the travel insurance company.

The disabled. Airlines will usually go out of their way to accommodate people who have mobility disabilities. Remember, airports are very big places and passengers frequently have to negotiate a maze of signs and travel long distances before they get to the actual aeroplane. If for whatever reason you feel you will need help, it is important to contact the airline, with whom you will be travelling, well in advance. They will then discuss your needs and arrange whatever assistance is necessary, whether it be help with your luggage, wheelchairs to whisk you through the terminal or even a ride on one of those buggies which are often seen beeping their way around airports.

Vaccinations and Disease Prevention. I am not going to give you a list of illnesses and diseases which are endemic in parts of the world because there are many books which specialise on this subject. The best place to get particular information is again at your family doctor’s travel clinic or at the specialised travel clinics which some airlines operate. Suffice it to say that once you venture abroad there are exotic diseases and illnesses that your body has fortunately never met before, ranging from those that just need a lot of toilet paper to others which can have grave consequences. Just to give you some examples; did you know that malaria is responsible for nearly half the deaths in the world since the world began, and there is still no guaranteed treatment for it; tuberculosis still rampant in many places around the globe and, as a result of government cost cutting, vaccination in the UK is a very hit and miss affair. Japanese encephalitis, Dengue fever, Meningitis, Rabies and Yellow Fever – the list could go on and on. Most of these, and others, can be avoided by very simple measures but, I will say again, talk to your family doctor or travel clinic nurse for up-to-date advice. Remember too that with the advances in modern air travel, germs and viruses, and the insects and humans that carry them, can travel all around the world in just 24 hours – frightening isn’t it!

Smoking, Fresh Air and Bugs. Those of you who have travelled by aeroplane will have noticed that most airlines have completely banned smoking on board. ‘And so they should have’, bleat most of you, ‘I don’t want to breathe other people’s smoke’. Fine, I will not argue, and neither did the airlines, because it was an instant opportunity for them to cut back on their running costs and make more profits. What they were able to do, without the tobacco smoke contaminating the atmosphere, was to dramatically reduce the number of times a minute that they needed to change the cabin air. In other words, the no-longer-cigarette-smoke-polluted-air didn’t smell and so it needed changing less often. From a physical point of view no one will notice that they are breathing the same air more often, but what about those nasty little microscopic inhabitants who are now being recirculated around the cabin more and more often !!!???

Everyone carries germs with them at all times, but most bugs are completely harmless. But what about that poorly old gentleman returning from the Far East with that nasty hacking cough? Of course he may have a simple bronchitis, the germs of which he is generously sharing with everyone but remember that tuberculosis is endemic in that part of the world where he has just come from! And what about those snuffy, spotty children who won’t stop crying and who are ruining the in flight movie for their neighbours? After all, not everyone is immune to simple things such as measles, mumps and chickenpox. It is a fact that the less the air in the cabin is refreshed, then the more likely it is that other people will pick up those bugs. And the answer? If you, or your relatives, have any sort of infectious illness then you should not be travelling.

Economy Class Blood Clots. Most of you have read all the stories in the press about those unfortunate people who developed serious blood clots in their legs after long distance flights. The opportunistic fee hungry lawyers certainly have because airlines are already facing court action because of the ailment. The problem is medically known as a deep vein thrombosis (DVT) where a big blood clot forms in the calf, and sometimes a piece of it breaks off, travels through the heart and then gets stuck in the small blood vessels in the lungs. Many DVTs go unnoticed but the ones that hit the headlines are when the traveller suddenly experiences a horrific chest pain and, not infrequently, dies.

The mechanics behind this drama are quite simple. The heart pumps blood to the body through arteries and it is then returned to the heart through the veins. But veins don’t have their own muscles to pump the blood back and rely largely on other muscles to do the work for them. The muscles are those which are usually squeezing and relaxing when we walk, run jump and kick but, when we are sitting for long periods, they are inactive. When on an aeroplane we just sit for long periods and are usually completely inactive while watching the movie or dozing. The blood in the legs becomes stagnant and, as is usual with stagnant blood, it becomes much more likely to clot.

But is this problem confined to aircraft passengers as the lawyers and some of our national newspapers loudly tell us? Of course it isn’t. Secretaries sitting at their desks for long periods; coach passengers on long road journeys; elderly people who spend many inactive hours sitting in front of the fire; computer fanatics whose only working muscles are their fingers as they surf the web. DVT is a crisis which can affect anyone and it is hardly fair to blame air travel and the airlines. Similarly, it is ridiculously inaccurate to label it ‘economy class syndrome’ because it affects business class and first class passengers in equal proportions. The simple answer is to keep those legs moving, get up and walk about frequently, drink plenty (of water not Gin!), wear tight airline socks (available at most pharmacies) to keep the blood thin and, if it gives you more reassurance to have done something, take half an aspirin before you travel.

Boyle’s law and gas expansion. OK, OK, don’t worry, I’m not going to go too deeply into the laws of Physics. To put it in simple terms, the harder you squeeze something the smaller it gets. At sea level, air pressure squeezed by gravity, is constant and the gasses that are all around us – oxygen, carbon dioxide, nitrogen etc – occupy what our body regards as a normal amount of space. On the other hand, if we go a mile or two up into the clouds and gravity gets less, air pressure falls and the air expands. ‘So, what on earth has this got to do with travel medicine’, I hear you saying; why should the laws of physics interfere with my holiday. But, before you throw the book away, read on a little more to learn how even a simple toothache can become a major incident!

Although it is physically possible to keep the air pressure in an aircraft cabin at sea level air pressure, it is prohibitively expensive. Accordingly, airlines pressurise the cabins to what we would find at about 6,000 to 8,000 feet – not quite what bodies are used to but, on the other hand, sufficient for them to cope with for limited periods without our noticing. Remember, the air has significantly expanded at this pressure, and certain illnesses and conditions can be affected if there is nothing and nowhere that that air can expand into!

Let’s say you had a tooth filled the day before you travelled and the dentist left a microscopic amount of air trapped below the filling. No problem at ground level but, as you climb higher and higher into the sky, that air expands and it has nowhere to go. The resulting toothache is something you will never forget! And what about that simple cold which has blocked your sinuses? Apart from sounding as if you are talking with a pinched nose no one would notice. But, at 6,000 feet, the expanded air in the sinuses would make you feel as if you had been hit very hard in the face with a frying pan. When the plane is going up or down, most of us know how to cope with the popping ears. Hold your nose and blow, suck a boiled sweet, yawn – these are some of the ways to equalise the air pressure between our ears and the outside world. But what if a recent ear infection has blocked those tubes?

These are some of the simple but painful consequences which Boyle’s law is responsible for. There are many others which the repatriation industry copes with every day. Plaster casts on broken limbs, recent operations and head injuries, air getting into the wrong part of the lungs are just some of the more serious air pressure problems which can happen. Fortunately, most of you will never encounter such things but rest assured that if they do, they will be coped for on your behalf!

Heart problems probably account for about 70% of the repatriation missions I am involved with. I think therefore it is only fair for me to give you some guidance on what to do, and what not to do before and during your holiday.

Airlines and insurance companies have very well documented and very strict rules and regulations regarding who can fly and those that should not. From the outset, whatever you do, don’t try and hide anything because, if anything goes wrong, you will be found out – and a very expensive finding out that can be. Basically, if you have anything relating to a heart condition then you need to declare it. Blood pressure, angina, a heart attack ten years ago, circulation problems and even the most insignificant of breathing trouble due to mild heart failure. And look at the medication your family doctor has given you – even the simplest medication tells a story.

Whatever heart problem you have encountered, there are guidelines to follow. For example, someone who has had a heart attack is unwelcome on an aeroplane for some four weeks after that attack – unless they have a fully equipped in flight medical officer with them, and in which case if there are no problems, they can fly 10 days after the attack. And when you get home, don’t think you can be on your way again a few weeks later, because you will not find any insurer who is prepared to cover you. Perhaps some three months later you will be allowed to travel fully insured, but only after paying a weighted premium. I will remind you of it again because it is absolutely vital to declare a problem. I have accompanied five heart attack victims home who had not declared their previous heart problems to their insurers. Having failed to comply with the insurance terms and conditions they were thrown adrift by the insurers and ended up footing the bills themselves. The most expensive was a heart attack followed by angiogram and heart surgery in San Francisco - £210,000. The cheapest was a heart attack in Cyprus with an uncomplicated recovery – a mere £5,600.

I really could go on and on about medical conditions which have a direct influence about who can and who cannot fly on scheduled aircraft. But you would become bored very quickly. I will remind you that if you have a medical condition of any sort – and that includes simple things like pregnancy, any recent operation, psychiatric problems and eye problems – you should consult your doctor or travel clinic nurse before you leave home. After all, it just boils down to your using common sense in remembering that an aircraft is a closed community of up to 450 people, sometimes seven miles up in the air and thousands of miles from land. There is no casualty department on board, and there is no guarantee that there are any doctors, nurses or paramedics close at hand. Prevention before you travel is always better than cure – and that is presuming, of course, that a cure is readily available!

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All good things come to an end – but how !

I often talk to other doctors and nurses about the work that Isobel and I have done as an In Flight Medical Officer and nurse. Their first reaction is to fantasise and enthuse about the exciting lifestyle it must offer, and their second is inevitably to ask for advice as to how they can get involved with such work. Well, our response may surprise you because it is the opposite of what you might expect and it is usually to discourage them from even thinking about getting involved! Without a shadow of any doubt, medical and nursing repatriation work is a concept totally incompatible with family life, and to even consider any sort of social life would be the door to a fools paradise.

Just last year alone, I spent some 40 per cent of my time away from home travelling all over the world to rescue sick and injured holidaymakers and businessmen. For 163 out of the year’s 365 nights, I slept either in someone else’s bed – on my own I hasten to add - or in the business class section of an aircraft! Bearing all this in mind, to try to organise a meaningful social diary was a pointless exercise. After all, no one ever plans to be sick or injured do they ? Likewise, I have never been able to plan my work or social calendar because I never know when I will be called out or when I will be arriving back home. Just imagine a young doctor with a young family fitting into such a demanding and unpredictable schedule. And I assure you that unless there is an already well developed social circle of good and understanding family and friends then it would be an ideal recipe for a loner!

Medical and nursing repatriation work appeals to two groups of doctors and nurses. Probably the biggest group are the part timers who squeeze in trips on weekends off, and during their holidays, to try and augment their income. The repatriation industry could certainly not do without them but, they are far from ideal because their availability is unpredictable and usually they can only offer enough time to do short trips. The second group, to which Isobel and I belong, are the ones who have managed to break free from the demands of the national health service early, and use repat work as an exciting wind down towards full retirement. Our children have grown up and left home and we have a very understanding circle of long term friends who take us as we are, and literally expect us when they see us! Isobel and I have often been asked how we have managed to stay together for so long, how on earth has our marriage survived such unpredictability. Our answer is simple – we are never together for long enough time to argue, and are always looking forward to seeing each other again and sharing experiences!

The unpredictability and anti social nature of the job was highlighted by a couple of weeks in January and February this year when neither Isobel nor I knew whether we were coming or going, or where and when we would be travelling to from one day to the next. In fact, January and February are usually the quieter months when it come to repatriation work because fewer people tend to go on holiday in those dull and dreary months between Christmas and Easter. But, having said that, many older people fly off this time of the year searching for the sun or visiting relatives in far off places, at a time when because of low demand, airline ticket prices are cheapest. It certainly wasn’t a quiet period for Isobel and I !

It was a Wednesday morning and I had just come back from a day trip to Nantes in north west France to find a message waiting at home for me. We have a trip planned to Mauritius on Friday, are you available? After checking that I had nothing already scheduled (and that there were no rugby internationals on the television!) I agreed to do it. The scheduling meant an overnight flight out of Heathrow airport, the sort that I like because it always means a late lie in and most of the day at home before I set off. But, it was not to be. Friday morning came and the office was soon on the line to tell me that the Mauritius trip was off because the patient had been readmitted to hospital and was not yet fit to fly. ‘But in the meantime doc, could you do a quick one to Benidorm this afternoon’. All systems were now on go because it now meant that I had to be in Heathrow by lunchtime to catch the Iberian airlines flight. Bang went the lie in and lazy day!

On the other hand, I must confess that I do like Benidorm. On this trip I would be seeing the winter face of the city, where it would be packed with older, heat seeking British holidaymakers, all drinking at Paddy’s, Mick’s and Taff’s bars and eating at Fred’s Fish and chip shop! Where the busiest shops are the pharmacies and tea rooms and wheelchair races on the sea front are the afternoon entertainment. Benidorm is easy to get to via Alicante airport, it is friendly and has a superb medical system and certainly makes my job much easier. But on this particular trip, no sooner had I arrived at Alicante airport and was climbing into a taxi when my mobile phone chirped in my pocket. ‘How are you fixed for you and Isobel to do an Australian trip the day after you get back from Benidorm?’ Again, a quick check on the diary and a call to Isobel to find out her commitments before if I said yes on behalf of both of us.

But even that one fell through the following day but for a very different reason from the Mauritius trip. It was what we call a reverse repatriation where, instead of bringing a sick Brit back home to the UK, it was to take an Australian lady back to Sydney. I still don’t know the intricacies and the background to the case but, suffice it to say that, it was a 39 year old lady who had outstayed her welcome in the UK and was, much to her displeasure, being deported by the immigration authorities. She had a long history of heart problems, including a heart pacemaker, which was the basic reason for her needing a medical escort. But, because of the times and long distances involved, and her very fragile personality, it was felt that a doctor and nurse escort were needed. So why did this one fall through? Well, it transpired that the lady was a professional cellist, and her travelling companion was a 300 year old very, very valuable cello. Wherever she had travelled, he cello had always accompanied her in a business class seat of its own but, in this case, the immigration authorities who were footing the bill didn’t feel inclined to pay. The impasse meant that the repat was stood down until an amicable agreement could be reached.

The result for Isobel and I was that instead of Australia when I got back from Benidorm, I flew off to Cyprus while Isobel went to – you’ll never believe it – Benidorm. But of course, the Australian trip was still in the pipeline and we were lucky enough to have a long weekend off duty together before arrangements were made to finally meet up with our deportee and her cello at Heathrow Airport on the following Tuesday evening. But even at this late stage the story got more complicated. While we were enjoying our weekend together it transpired that there was a recovering heart attack in Dunedin, New Zealand and a threatened miscarriage in Manilla in the Philippines. ‘As you and Isobel are down that way, would you mind diverting after the Sydney trip and bring them home’! Naturally, we agreed although it meant splitting up and going our separate ways, once again, after the Australian part of the trip

The Tuesday evening came and, in fact, we were very pleasantly surprised to find that the lady we were taking back to Australia was a very nice lady, who was naturally very protective of her £10,000 instrument. But I didn’t blame her because, having seen the way that airline baggage handlers in various parts of the world treat our hold luggage, I wouldn’t want my cello thrown into the aircraft hold. She stood her ground and, with just 30 minutes before we were scheduled to take off, the end result was patient, doctor, nurse and – as it said on the boarding card – Mr Cello settled comfortably into business class seats for the long flight to Sydney via Bangkok.

The repatriation went off very well. There were no problems from a medical and nursing viewpoint and, apart from her virtually talking the hind legs off a donkey for much of the flight, our patient was no problem at any time. Some 23 hours after taking off from London we touched down in Sydney Australia where we parted company with our patient and Mr Cello!

We actually arrived in Sydney at 6.30am their time, which was in fact the UK equivalent of 7.30pm the night before. It had been a long and tiring 24 hour journey with only a minimum of broken sleep. It was not very long after a couple of beers and a steak – despite the hotel insisting it was their breakfast time - before Isobel and I got our heads down in a local airport hotel to catch a few hours sleep before making our separate ways back to the airport, and then on to New Zealand and Manilla. Little did we foresee the events of that night which were to change our lives very significantly and bring to a close the repatriation lifestyle which we had both enjoyed very much for many years.

Both of us woke in the early hours and, because of the time differences and our body clocks, we found that at 3.00am Australian time we were as bright as buttons and ready to go. By 4.00am we were up, dressed, showered and enjoying the first cup of tea of the day when, without warning, things started to go wrong.

I felt a strange sensation in my chest which, over a period of about 15 minutes, developed into quite a severe pain. The pain itself was difficult to describe but suffice it to say that it became more and more discomforting and disorientating and had soon spread to my jaw and to my left elbow – funnily enough it was the pain in the elbow which troubled me most and is probably the part which I will remember most! Things became somewhat confusing from that point and all I can say is that I was indeed fortunate to be on a combined repat with my wife because she took control of everything. I vaguely remember being loaded into an ambulance by 05.00 and having an oxygen mask put on my face. I also certainly remember having a number of chocolate flavour nitrate tablets being put under my tongue, although they certainly did nothing to relieve the pain which seemed to be getting worse at this stage.

It seemed only minutes before I was being wheeled into a casualty department, being stripped off and having enough wires and tubes attached to me to service a small block of flats! Blood was being taken from my veins at the same speed as a bath tap and at the same time other fluids were being pumped into the other arm. What they were pumping in, I didn’t know at the time, but suffice it to say that a warm feeling started in my arms, spread to my head and neck and finally to my chest where the pain faded away to leave me in a blissful slumber. When Isobel finally reappeared after handing in all my details to the clerk I almost felt like saying that I was OK now, and we’d better get going because we had to be at the airport by 9.00am!

But that was not to be. It seemed that the electrocardiograph reading they had taken was suspicious of a heart attack, although when they let me see it I’m not sure I agreed. Perhaps it was because I just didn’t want to hear the diagnosis they were making. But, having said that, I was hardly in any position to argue, particularly with Isobel standing over me! Finally, about 3 hours after feeling the first pain, the consultant cardiologist who had taken over my case came to give me the plan of action. Yes, they felt that my symptoms and their findings were strongly suggestive of a heart attack but no, they didn’t want to give me any clot busting treatment. Rather, they wanted to take me to the cardiology department, do an immediate cardiac catheter angiogram to investigate and treat whatever they found.

Well, even at this confused stage I just could not believe what I was hearing. Here I was, just a few hours after having had my first chest pain, being wheeled into the cardiac catheterisation theatre. I was experiencing aggressive medicine at its very, very best. And all this some 10,800 miles from home!

The angiogram was an enlightening experience in very capable hands. I really didn’t feel anything at all and was indeed privileged not to be given any sedation so that I could lie there and watch what was going on, and be given a running commentary as the dye was squirted into my heart arteries. Over the years I have dealt with many patients who have had a coronary arteriogram and I am reasonably able to read the results. In my own case, I just could not see anything wrong! It was not until the cardiologist began pointing out the salient features that I became aware of the irregularities that he was seeing. Most of my heart arteries were in pretty good shape but there was one small one which just would not fill up. This it seemed was the offending vessel which had blocked off and caused the chest pain that I had experienced. Yes, it was a small one and yes, there were lots of other arteries in that area which would do its work quite well. But there it was, there was no doubt about it, one small artery had blocked off and caused the pain just a few hours before.

From that point it was back to the cardiac recovery ward and then on to the coronary care unit where Isobel was waiting for me. More tablets and injections to steady the heart rate, thin my blood, lower the blood pressure and relieve any pain that came along. Didn’t I feel sorry for myself. There I was after some 20 years in the job of repatriating heart patients now experiencing the whole scenario from the opposite point of view. After being relied on for so long to provide a shoulder to lean on, and take people home, I was needing those very things myself! As I said, I really felt sorry for myself.

The cardiologist who looked after me was superb. His empathy with my problem was outstanding and at all times he was encouraging and optimistic, while at the same time warning me that my future progress was in my own hands. One comment he made, and which amused us very much, was that the heart attack I had had was indeed very small, but that it should be taken as a warning. Indeed, he said that it was so small that in many cases muscular Australians would have taken 2 indigestion tablets and carried on with their day – after experiencing the pain I wasn’t so sure about that. His plan was to keep me in hospital some 4 days stabilise all the treatment I needed and then discharge me to a hotel where I would wait to be repatriated back to the UK. As far as he was concerned, leave it a week then go back to work full time !

The most fortunate thing about this whole unexpected episode is that Isobel was there with me. Out of the 80 or so repatriations I do each year, Isobel is with me in about half a dozen of them – thank goodness this was one of them. I just don’t know how I could have managed without her from the moment she called for that ambulance. She looked after all our cases and equipment and stayed for many sleepless hours holding my hand while I went through the mental and physical hell which I previously thought was for other less fortunates only. I’ve said it before and I will say it again – it is bad enough being ill at home, but when you are ill many miles away from home with no one to lean on, it is a disaster. I was indeed fortunate that I had Isobel’s steady hand to lean on.

The repatriation company back home in the UK was superb and, in a way, it was an enlightening experience to observe them at work from a totally opposite viewpoint from what I was used to. Naturally Isobel told them what had happened and, from the word go, they were reassuring and supportive. They liased with the Australian hospital regarding the costs and with the treating doctor regarding the case handling and treatment. They spoke to my family doctor in the UK to confirm that I had never experienced heart problems in the past and that I was not on any treatment. They arranged for Isobel and I to move into a hotel in the centre of Sydney after I was discharged from hospital, and while waiting to travel home, and they arranged with the airline who was going to fly me home to issue the appropriate tickets. And finally, the most devastating part of the exercise as far as I was concerned, they organised an in flight medical officer to accompany me home!

Just 4 days after being admitted to the Prince of Wales hospital in Sydney, Australia, I was discharged to spend a few days in a very acceptable hotel. You may remember me telling you that airlines and repatriation companies have very strict rules regarding who can fly and when and, for the first time in my life, I was now the subject of those rules, rather than acting as their enforcer! Heart attacks, no matter how big or small, run a high risk of repeating themselves in the early days – not something which airlines want their crews to be faced with at 36,000 feet. This is why the rules say that, without an accompanying doctor, you cannot fly unaccompanied for 30 days after a heart attack, but with an accompanying doctor and with the airline’s permission you can fly after 10 days. This was the category I fitted into. I was told to sit back, relax and enjoy the sights and sounds of Australia for another 6 days until the repat company sent out a colleague to accompany me home! I can imagine what you are all now thinking – the lucky devil; an unplanned holiday with his wife in a four star hotel in Sydney Australia, with flights, accommodation and food all paid for. Nothing, but nothing, could have been further from the truth!

The first problem that Isobel and I faced was that, when we left the UK shores with our cello carrying patient, we were planning to be away from home for just 4 days. This had already stretched to six and we had run out of spare smalls to keep us in a clean and acceptable condition! Not a problem really, and a very good excuse to do some shopping to tide us over for the week! Another problem I personally faced, and had difficulty in coming to terms with, was that Isobel was wearing kid gloves and treating me like an invalid – something I was certainly not used to! But it was at this stage that I experienced, and became very aware of, the reasons behind a complaint which I have heard so many times before from people who I have repatriated back home. ‘Why do I have to stay out here? I want to go home’.

And want to go home I certainly did. Although I was reasonably mobile (I’ll tell you more about that in a moment) and able to get about, I just wanted to get back to familiar surroundings, be close to family and friends and sleep in my own bed. What was now happening was not a pre planned and eagerly anticipated holiday, but rather an enforced and unintended stay in a foreign land. The luxurious hotel room became a prison, the repatriation company and the airlines became the prison officers and I was the prisoner who had no control over what was happening. The only consoling fact was that I was sharing my cell with another prisoner with whom I got on very well – Isobel. OK, I am being a bit melodramatic and things were not quite as bad as all that. But I certainly did want to go home and can now clearly understand and empathise with the feelings of all those other patients before me.

When I was discharged from the hospital, the doctor there had told me that my lifestyle would have to change to ameliorate any cardiac risk factors which I had abused in the past. Weight, diet, exercise, alcohol and the occasional cigar, which I had enjoyed, would all have to be seriously looked at and my habits changed where appropriate. Most of these would have to be managed once I got home but the one which was most appropriate at the time was the exercise – and Sydney was an ideal place to start.

What a magnificent city! All built around a picturesque harbour – or rather, series of harbours, the stunning harbour bridge alongside the futuristic Sydney Opera House, the fun filled Darling Harbour tourist paradise and Chinatown alongside. Sydney was an incredible place which Isobel and I walked around for those six enforced days and, despite our homesickness, enjoyed very much. But bear in mind that we hardly moved out from the centre of this incredibly friendly and remarkably clean city. Reading all the tourist guides it soon became obvious that if we were there six months, rather than days, we would still hardly scratch the surface of New South Wales, let alone the continent as a whole. And, to cap it all, we had the great pleasure of seeing that great old lady, the QE2, arrive and dock in Sydney Harbour when we were there.

A pastime which Isobel and I have become very good at over the years is the art of people watching. Where are they from, where are they going, what language are they speaking, what are they wearing, what are they eating – the variations are endless and intriguing and are an absolute mine of imaginative speculation. Australia is the perfect location for such a hobby because it is so cosmopolitan. But the difference here in Australia compared the immigrant population in the United Kingdom is that everyone here seems to proudly regard themselves as Australian. Yes there are Chinatowns, Vietnamese enclaves and many others but they still regard themselves as Australian. Perhaps there are few tips to be taken from them! Another trait which I found fascinating and amusing was the way different nationalities take pictures. We Brits see something, be it an animal or building, and we take a picture. If a Japanese takes a picture then he, his wife, his children and sometimes the whole family have to be there in the picture alongside the building or the animal!

We stayed in contact with the repatriation company on a regular basis and eventually the statutory ten days had elapsed. Two cardiology trained nurses were being sent out to accompany me home and to ensure that I behaved myself medically while flying home. The eleven thousand mile journey from Sydney to London via Bangkok went completely without incident and I finally arrived back in the UK some 2 weeks after having left there. A long time when all my original plans and scheduling anticipated my being away from home for just four days! A chauffeur car was there at arrivals at Heathrow Airport waiting for me and, just three hours after landing, I was delivered to my home in the West Midlands.

Well, was it the end of the line? Had my days in the exciting world of aeromedical repatriation come to an untimely end? Well, they have as far as the travelling side of things are concerned. However, and with the experience I have had over the years, and the fact that I can speak French and Italian, there is no reason I cannot do a good job at case refereeing in the office. But is that going to be as exciting and stimulating as the repatriation side of things ……………………..

Let’s wait and see !!

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