iPMI Magazine Speaks With Dr. Gert Muurling, Medical Director, Air Alliance

On air ambulance flights, patients are transported with many different complicated medical conditions and injuries, and it is crucial for the safety of the patient and crews that the aircraft is kept meticulously clean. In this iPMI Magazine exclusive interview Christopher Knight, CEO, iPMI Magazine asks Air Alliance Medical Director and Hygiene Specialist, Dr. Gert Muurling, what the potential hazards are and how the hygiene and infection control on board are ensured.

Which infections are most prevalent on air ambulance flights?

In general, the most common infections are urinary tract infections caused by bladder catheters and pneumonia.

All airways, catheters and access points are potential pathways for bacteria to enter the body. If care on board is not performed correctly, a life-threatening sepsis could potentially occur.

Many of our patients are intensive care patients who have already spent one or two weeks in a hospital abroad. This group of patients have multiple accesses and catheters, and they all receive antibiotics, which are unfortunately often given on a large scale. This means that a germ count or a sensitivity / resistance test has not been performed. All antibiotics weaken the immune system and can lead to secondary infections and this is how the proliferation of multi-resistant bacteria is promoted.

During our missions we see many different intensive care units worldwide and through this experience we can see that we are immediately battling with infection prevention. We regularly see units where no hand disinfection gel is provided and so everyone who enters or works in that unit is a potential infection risk.

How are hygiene and infection protection on board ensured?

There are two important pillars: training and preparation. The more the staff know about the different pathogens, the more effectively they can protect themselves, the crew and the patient. By “effective”, I do not mean that you should dress like Dustin Hoffman in "Outbreak"! Most bacteria and viruses do not "jump" directly from the patient to the medical team and vice versa and therefore, for many infections, wearing gloves while working with the patient is fully sufficient. No pathogens will penetrate intact skin. The most important thing before and after touching a patient is the correct disinfection of one's own hands.

Colonization of the nasopharyngeal space may lead to droplet transmission during coughing and sneezing. In these cases, however, a normal surgical mask is sufficient for the patient to reduce the risk as much as possible. This should be done especially when loading and unloading, as it can endanger other non-trained people. If the patient does not tolerate it, then the persons working on him/ her must wear a mask (possibly with improved protection and exhalation valve). Droplets rarely fly further than one to two meters. Distance means safety!

I am very careful with pathogens that are transmitted via the air. We talk about tuberculosis bacteria, measles viruses and chickenpox viruses. All three have potentially serious consequences for us or the staff on the ground ambulance and the receiving hospital.

After each patient transfer, the used equipment and the patient room in the cabin are generously disinfected by wiping. Depending on the germ or a reasonable suspicion, the hydrogen fogging machine ("sanitizer") is also used immediately after the flight.

What happens during missions in "Remote Areas"?

As we regularly fly patients from "remote areas" who have not been sufficiently tested for pathogens, there are two things to consider; one is the detection of inflammatory symptoms by clinical examination. The second is to know the current infection status in the country where the patient is. The WHO has excellent maps on its website showing the corresponding percentage of the various common multidrug-resistant bacteria. So prior to dispatch we can already assess which germs the patient might probably "bring along".

Are there any special considerations for patients with hemorrhagic fevers?

That is a difficult question. Generally, the hemorrhagic fevers (Ebola, Lassa) are transmitted by droplets or direct contact. Distance is safety! At a few meters distance, nothing happens, you do not get infected. But on air ambulance flights, you cannot maintain this distance, especially as you are likely to have a highly unstable patient.

There are several infection control chambers (isolators) on the market with special ventilation and filters, but this also requires regular training of the staff and exercises. If you fly just one or two missions of this kind a year, such a system is more of a risk than a help.

Regions with Ebola outbreaks do not have a high medical standard. The risk of virus transmission in a hospital where Ebola patients are treated is very high however the areas of where the Ebola virus is prevalent are well identified. Therefore if we have a patient within the same country, but with a confirmed non-Ebola diagnosis and not within the Ebola high risk zone, we can transport these patients safely. Preparation is the key. However, the important question in Africa is always: where was the patient and where did he get sick? So you can then perform a repatriation that is safe for all concerned.

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