Questions/Answers

Despite advances in medical sciences, residents in remote parts in Thailand still have difficulty reaching health facilities. Medical transport of emergency patients from these areas must be timely and efficient. Tak, a small province in the northwestern Thailand, consists of various rural areas where a road transport to district hospitals may require up to 6 hours while an emergency patient transfer to the provincial hospital with physicians of medical specialties may take up to 10 hours, resulting in a tragic loss of life and disabilities among patients. National Institute for Emergency Medicine (NIEM), in collaboration with Royal Thai Armed Forces, Royal Thai Police, Ministry of Agriculture and Cooperatives, and Thai private sector, has initiated an aeromedical transport system in 2009. In Tak, such system was implemented under a project called “Sky Doctor” in 2012 with an aeromedical emergency crew from Somdejphrajaotaksin Maharaj Hospital. The project’s objective is to enable patients residing in remote, mountainous areas, some of which are not reachable by a road transport but primarily a water transport, to efficiently access emergency medical care at public health facilities. Regarding challenges under the “Sky Doctor” project, since the only possible means of air transport in Tak are helicopters owned by provincial divisions of Royal Thai Police and Army, requesting a helicopter for an emergency medical air transport can take time. Additionally, these helicopters are not medically equipped, while the project is financially constrained: medical practitioners are remunerated around 2 to 5 dollars per hour. Besides, when the project was initiated, there were only 3 nurse practitioners with basic aeromedical emergency training from NIEM on the crew. Improvements to the operations of the project, however, have been continuously made to address the challenges, and the crew has been expanded through advanced trainings with doctors, nurses, and other health practitioners included.

The “Sky Doctor” project enables access to emergency medical services for patients in remote areas with emergency medical conditions regardless of being insured under healthcare schemes or not. The team’s medical crew treat patients without discrimination against gender, race, or ethnicity. Meanwhile, the aeromedical service is patient-centered and no service fee is collected from patients using the service, which can be conveniently requested through the national emergency medical care hotline number 1669. After approved by NIEM, the crew from Somdejphrajaotaksin Maharaj Hospital can pick up patients seeking emergency medical attention not more than an hour after each request is made.

The SDGs that the “Sky Doctor” project run by Somdejphrajaotaksin Maharaj Hospital answers are as follows: Goal 3: Good Health and Well-Being The targets of the aeromedical service under the project are emergency patients in remote areas, including ethnic people or marginalized citizens or aliens. Critically ill child patients and pregnant women with labor risks are the two groups seeking and benefiting from the service the most. The interventions of the multidisciplinary aeromedical service crew to reduce maternal mortality, terminate preventable cases of neonatal mortality, eradicate border communicable diseases, and assure accessible medical services for marginalized citizens are criteria confirming that the project has achieved Goal 3. Goal 10: Reduce Inequalities The project’s aeromedical service has been provided indiscriminately to patients of all backgrounds to reduce inequalities in accessing medical treatments. The service is not limited to only patients of Somdejphrajaotaksin Maharaj Hospital but extended to those requesting a transport to more advanced hospitals with occasional fundraising for medical treatments to assist patients and relatives. Goal 16: Peace, Justice and Strong Institutions The collaboration among public sector institutions under the project has enabled aliens and refugees living scatteredly around the border in Tak to access medical care in emergency situations.

The project provides emergency patients in remote areas, regardless of races or whether they are medically insured, access to standard medical care, serving as a project model for other provinces. As the project's operations get publicized through the media, the public is more aware and contributes to the project in forms of the welfare assistance for underprivileged patients and relatives in addition to the hospitalization expenditure assistance. Moreover, this project, with its aeromedical service for emergency patients, is environmentally friendly, preventing deforestation for road construction in the mountainous areas belonging to the national park in which there are people residing.

The shortfall of public health service in Thailand is that hospitals in remote areas are lack of health personnel and are not fully equipped, making them unable to perform such complicated procedures as general surgery, cardiac surgery, and computer tomography, which are mostly required by emergency patients and timely access to such procedures is critical regarding mortality and disability rates. Through the project, emergency patients in remote areas are given equal opportunities as those in urban areas. This project has a positive impact through a multi-sectoral cooperation in bringing emergency patients to medical treatment under the limitations of having no aircraft designated for transporting patients, a limited number of staff with knowledge of aeromedical transportation, and a shortage of medical equipment. Despite these limitations, the crew has managed to run the project with risks minimized and practicality improved. Consequently, patients can access medical treatment more quickly. Additionally, there are fundraising through donations from the civil sector, procurement of backup tools, short-term training on basic knowledge on aeromedical care and transportation, and meetings to discuss and coordinate between the crew and local government agencies with the ultimate goal of providing patients with the safest and best possible services with limited resources.

The “Sky Doctor” project led by Somdejphrajaotaksin Maharaj Hospital places an emphasis on the context of human equality by providing comprehensive medical treatment based on the emergency severity index. Since the project’s crew does not discriminate against anyone, gender inequality is not of a concern. With teamwork, empathy, and coordination from all sectors, emergency patients are treated indiscriminately by the gender-impartial crew of the project.

The target groups or the groups benefiting the most from the “Sky Doctor” project are emergency patients residing on highlands and those from marginalized ethnic groups. Local health centers and community hospitals in such areas are largely understaffed and underequipped. Therefore, the aeromedical service is considerably useful since transporting critical patients by air can shorten the time required to access medical treatment and minimize the risk of mortality. The project’s crew considers the patients in remote areas deserving equal opportunities to access treatment from specialty physicians. While seeking treatment at Somdejphrajaotaksin Maharaj Hospital, the patients and their relatives are also provided additional care in terms of physical needs, that is, water, food, air, shelter and clothing, through the work of the hospital’s multidisciplinary crew since these patients are largely highland people, aliens, or stateless persons, many of whom do not have ID cards, before they can return home after recovery.

Having the 4th largest area in the country but being the 2nd least populated province in Thailand, Tak is a province by and large mountainous with a number of remote districts which are hardly accessible by road. A ground patient transport of critical patients which requires a considerable amount of time may inevitably result in a tragic loss of life or disability. National Institute for Emergency Medicine (NIEM) introduced a policy on aeromedical service in 2009 and such policy was implemented in forms of the “Sky Doctor” project in Tak in 2012. In 2015, emergency physicians at Somdejphrajaotaksin Maharaj Hospital came up with an operations manual for the “Sky Doctor” project in Tak with action plan and procedures for transporting patients by air from the site (primary mission) and referring patients to other health facilities (second mission). Since then, the project, led by Somdejphrajaotaksin Maharaj Hospital, has been running with experienced emergency physicians supervising the patient transport and coordination with the parties concerned. Each air patient transport mission is led and controlled by an emergency physician with sound knowledge of emergency medicine and aviation medicine with the following procedures: 5 1. Preflight procedures – mission plan, position plan, preflight assessment, aircraft conversion, enplaning and deplaning, and aeromedical airlift briefing 2. Inflight procedures – safety alertness, inflight feeding, aeromedical evacuation documentation, and unusual inflight occurrences 3. Postflight procedures – landing and deplaning preparation, patient transport to the destined health facility, appropriate storage of patient transport equipment, filing of a report to NIEM for statistics and health personnel remuneration, and preparing a case report for evaluation and improvements for the next service mission.

1.Expenditure – each transport costs 3,300 USD at minimum excluding the patient assistance on hospitalization costs: by aids from NIEM and charity fund. 2.Occupational hazards – the medical crew is subject to risks enplaning an aircraft and flight stress: by adjusting the stretcher height to parallel with crew seats for seatbelt fastening and safety and expanding the crew to be able to rotate work shifts. Every crew member is insured. 3.Resources management – medical crew and equipment had to be shared between the hospital and the project: by setting a backup team and procuring a different set of medical equipment.

Tak is divided by a mountain range into eastern and western regions. In the west, there is the tallest dam in Thailand situated with people residing in the area above the dam, making a road transport impossible. NIEM has initiated the “Sky Doctor” project through its partnership with aviation divisions of Royal Thai Police and Army and Somdejphrajaotaksin Maharaj Hospital, turning helicopters, originally used for transporting merchandise for army affairs, into aircrafts suitable for aeromedical service. This innovation is a result of the project’s heeding emergency patients residing in remote areas under the context of having geographical and resource limitations.

Air patient transport dates back to WWI, used for transporting army patients before shifting to critical patients. Thai aeromedical service was initiated in 1943 for transporting the injured during wartime and the ill soldiers from the borders to Bangkok. Such service in the civil sector was started in Northern Thailand in 2009 in forms of the “Sky Doctor” project. The project was implemented in Tak in 2012, following examples of helicopter rescue from developed countries in addition to consulting with NIEM and Bangkok Hospital, the first Thai private hospital to start aeromedical service, to achieve an internationally recognized service standard.

With regards to transferring the initiative to deliver inclusive and equitable services for all in terms of air patient transport, the “Sky Doctor” team of Somdejphrajaotaksin Maharaj Hospital had an opportunity to deliver a presentation on a case study of air patient transport in the western region of Thailand in Advance Care Air Transport Conference in 2018 jointly organized by National Institute for Emergency Medicine (NIEM) and Police General Hospital between 22 – 24 August 2018. This presentation was to provide an example of Helicopter Emergency Medical Service: HEMS for emergency healthcare personnel in other areas in Thailand with the prospects of organizing aeromedical service teams. Additionally, in 2019, the “Sky Doctor” team of Somdejphrajaotaksin Maharaj Hospital received an award for Thailand Public Sector Excellence for public service from Office of the Public Sector Development Commission. To win this award, the team had to make a written report on the aeromedical service operations publicized for the public knowledge. The “Sky Doctor” team was also awarded an opportunity to do poster presentations on role-play learning for medical students on aeromedical service in International Association for Medical Education Conference between 24 – 28 August 2019 at Austria Convention Centre.

In addition to having transferred the initiative through publicizing the work of the project through award and conferences, there is also a potential for transferability in terms of collaboration with agencies in the public sector and aeromedical service training for medical students and health personnel. In the first regard, since Somdejphrajaotaksin Maharaj Hospital is not equipped with helicopters, they seek out collaboration with Royal Thai Police and Royal Thai Army. Such collaboration may extend to Ministry of Agriculture for transporting patients in forest areas and to private hospitals in Thailand with their own aeromedical teams in case helicopters of public sector divisions are not available for air patient transport. In the latter regard, since there are medical students trained at Somdejphrajaotaksin Maharaj Hospital, the “Sky Doctor” team aims to transfer the knowledge on aeromedical service, including enplaning, deplaning, and hospital referral, among medical students along with relevant health personnel every year in forms of role-playing training.

In terms of financial resources, the project receives funding on air patient transport from National Institute for Emergency Medicine, medical treatment at Somdejphrajaotaksin Maharaj Hospital from Ministry of Public Health, and welfare of patients and relatives from the hospital fund. About human resources, emergency physicians and nurses are sponsored to undergo trainings on Basic Aeromedical Evacuation and Advanced Care Air Transport. Regarding aeromedical service resources, the project is funded on equipment for air transport from the hospital budget, donations, and public sector agencies such as provincial divisions of Thai Red Cross Society and Ministry of Social Development and Human Security.

What makes the initiative sustainable is the healthcare policy of Somdejphrajaotaksin Maharaj Hospital which assures every resident in Thailand of access to healthcare services from specialty physicians in case of emergency. Aeromedical service helps transporting critical patients in remote areas possible, reducing mortality and disability rates. The geographical limitations and refugee settlements along the border of Tak make the existence of this project led by Somdejphrajaotaksin Maharaj Hospital crucial. Despite the high costs of running the project in terms of financial aspect, the project is indispensable when taking the value of life of patients in remote areas into consideration.

Yes

The performance of the “Sky Doctor” project is formally evaluated by two external agencies, that is, National Institute for Emergency Medicine and Tak Provincial Public Health Office. The first agency evaluates the project at two stages: pre-mission evaluation, providing necessary trainings for the multidisciplinary aeromedical service team, and post-mission evaluation, reviewing a summary report prepared by the team’s head, an emergency physician, after each aeromedical service mission for the record. The latter agency also receives the same post-mission report in order to evaluate whether the project’s team needs help with any obstacles faced for smoother operations on the next mission.

The performance of the project is monitored and evaluated using quarterly set indicators such as the survival rate and the maximum time required from the service request moment to the patient airlift moment, while statistics on patients are also regularly kept. The results of the indicator-based evaluation and record keeping are used to improve the efficiency and reduce operations costs for sustainability. Since 2012, there have been 26 patients airlifted with the majority being child patients followed by OB/GYN patients and the 88.5% survival rate. The time required before a patient gets airlifted ranges between 20 minutes and 1.15 hours.

Based on the findings of the evaluation, the biggest challenge faced in the “Sky Doctor” project is the high costs of operations, for example, each mission costs 3,300 USD at minimum. To address this concerning matter, Somdejphrajaotaksin Maharaj Hospital has requested a financial support on fuel and personnel remuneration from National Institute for Emergency Medicine. Additionally, the hospital has set up a charity fund to provide a financial relief and welfare for underprivileged patients while admitted and their relatives. Most of these patients are people on highlands and ethnic citizens, yet the hospital sees that they are critical patients who need immediate care and humanitarian assistance as much as the emergency patients who are Thai nationals.

The operations of the “Sky Doctor” project is made possible through partnership with different agencies. First, Somdejphrajaotaksin Maharaj Hospital is the key player of the project in Tak since there are physicians of emergency specialty who have been trained on aeromedical care and can authorize medical treatments during the airlift mission together with an experienced multidisciplinary team and equipment, enabling the hospital to provide aeromedical assistance for patients in remote areas. Second, aviation units of Royal Thai Police and Royal Thai Army are another important player directly responsible for aircrafts. Third, primary health facilities help make aeromedical requests and treat emergency patients with primary, essential care. Fourth, destined hospitals which are in charge of patients till recovery after airlifted to. Finally, National Institute for Emergency Medicine which approves every mission and is reported to after each mission is completed since the agency sponsors fuel charge, medical supplies, and remuneration of aeromedical service personnel on the mission.

The “Sky Doctor” project requires integrated collaboration with concerning agencies to achieve a standardized aeromedical service which can be conveniently accessed. The command system and referral system are divided into two regions since there is a natural boundary, that is, a mountain range, separating Tak into the western and eastern sides. Somdejphrajaotaksin Maharaj Hospital is in charge of the west and Maesot Hospital takes care of the east in terms of emergency aeromedical service. There is a system on evaluation and accreditation of on-site emergency patient care for both regions to achieve the same standard of Thailand emergency medical service. The project partners with local administration organizations with workshops held annually to improve and standardize air transport of emergency patients with a network of emergency medical service stakeholders attending in order to deliver inclusive and equitable services for all regardless of races or ethnicities of emergency patients.

The “Sky Doctor” project’s initiative of delivering inclusive and equitable services for all is set to be improved through developing a standard manual for both emergency medical service and referral system for both western and eastern regions of Tak. Working with a multidisciplinary team to transport patients of critical conditions for prompt medical attention, each mission is monitored and supervised by a trained emergency physician in the field instead of consulting an emergency physician from National Institute for Emergency Medicine for better speed and efficiency in retrieving emergency patients. Besides, missions on the project are not limited to transporting patients to hospitals in Tak but to those of higher capacity in nearby provinces for immediate medical attention by specialty physicians.