Perhaps 30 people were involved in helping the patient get to the right  hospital safely

Living in Cambodia with no health cover? You’re risking a $10,000 flight home.

The call can come at any time, during rushed breakfast, in the shower or middle of the night: “Doctor, there’s a patient you need to see, can you come now?” 

I go into the clinic and find John, a 54-year-old Australian with a badly broken leg lying in the bed. He is in pain and his wife is relieved to see me arrive.  They are already pretty sure the leg is broken and are anxious about what to do next.  

First things first, so we make sure his vital signs are stable, that he doesn’t have any other injuries, and then get him some serious pain relief.  The team works well, with the nurses and pharmacist working together to dispense and administer effective pain relief.  The lab technician analyses his blood sample to make sure he hasn’t lost too much blood into his broken femur, and readies the X-ray machine.

This is just the start of the long and complex process that leads a seriously unwell or injured patient safely to the right level of treatment.

Medical evacuation is expensive and can cost as much as $10,000 for a commercial aircraft evacuation, and more than twice as much for an air ambulance.  

Most expatriates living here recognise medical facilities are limited,  and some serious health problems require urgent evacuation to a country with more specialised services, usually Bangkok or Singapore.  

A good health insurance or evacuation policy is a wise investment.  

Meanwhile, our patient feels better, but knows his Cambodian holiday is over.  As his treating doctor, I have written a full medical report detailing his condition.  The leg is broken in several places and will need complex surgery and aftercare, and I have recommended that he be evacuated for specialist orthopaedic  assessment and treatment.  

He needs morphine injections to keep him comfortable, and he should have a medically trained escort to go with him to make sure he can manage the flight.  Fractured femurs can bleed large volumes into the leg, so the escort will also need to keep an eye on his pulse, blood pressure and breathing and be ready to resuscitate him if necessary.  

The operations team has swung into action assessing John’s insurance coverage, and the patient has already called his insurer.

The insurance call centre staff initiate their procedures, and inform their own doctors about the case.  It takes some time,  but the insurance doctor calls me to find out how the patient is doing and to get some details.  The insurance organisation activates its assistance company to arrange the evacuation as quickly as possible.  

The assistance company has many different people who get involved at this point.  Logistics staff check flight availability and begin the process of getting approval from the airline for the patient to fly.  Plane tickets must be booked, and a hospital found with a free bed and a specialist willing to receive and treat the patient.

Local and receiving airport staff must be informed and all the details of a ground transfer arranged.  The patient will need a wheelchair to get him to the door of the plane, and then assistance to get him to his seat.  The airline  and the captain of the flight, who has final say on whether anyone is allowed on the plane, must be comfortable that the patient is not an infection risk to other passengers and is well enough that he will not have any crisis mid air that might cause a problem or an expensive diversion of the flight.  

The extensive working relationship that the assistance company has with the airline  and with the airports stands them in good stead when asking for help.  

An escort must also be found who can accompany the patient on the flight.  This person, usually a nurse, doctor or paramedic trained in aviation medicine,  must stop whatever other work he or she was engaged in and begin to prepare for the evacuation.  The escort must make an assessment of the case and discuss the risk assessment that has been made by the treating doctor.  

The escort must also think through risk scenarios and prepare for the worst of these.  

Once the plane has taken off, the escort will have access to only the medical equipment that is brought in the medical in-flight bag.  This must be packed and all the drugs and equipment checked.  Nursing, pharmacy and maintenance staff all play a role in making sure this bag is safely and specifically equipped for each evacuation, although ultimate responsibility is with the escort.  

The patient has been found a bed, an orthopaedic specialist, a flight, an experienced nurse escort and all the transfers have been booked.   Accommodation has been sourced for his wife and a seat booked on the same flight for her. The airline is happy for him to travel, and I am happy as his treating doctor that he is fit to fly.  

It is touch and go with the timing, but the insurance approval comes through just in time for him to get to the airport. It’s rush hour, but the drivers know the fastest way to the airport and make it in time.  Airport staff meet them with a wheelchair,  and the group is whisked through check-in and customs by internal airport staff.  

Permissions have been arranged in advance so there are no questions about fitness to fly.  

This isn’t a real patient scenario, but it is very close to what does really happen with an evacuation. Perhaps 30 people were involved in helping the patient get to the right hospital safely, and we haven’t even got to the receiving airport ground staff: ambulance crew and hospital staff.  

The connections and communications between these people is what make it all flow.

Anyone who has been through a medical evacuation knows that it can be incredibly difficult and stressful.  Having the right help at the right time can not only save lives and limbs, but can reduce a crisis to a stressful but safe level.

Dr Laura Watson is the deputy chief medical officer of international SOS Cambodia.