An international airlift of a newborn baby from Georgia to Japan

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International air transport over long distances requires considerable effort. It is even more difficult when the patient is a newborn and has a congenital disease. We hereby report a case of international air transport of a newborn from Tbilisi, Georgia to Osaka, Japan. The patient was rushed to Osaka University Hospital after being diagnosed with Double Outlet Right Ventricle (DORV), requiring surgery. This unique experience raised four issues: 1) language issues for referral and counselling; 2) the medical equipment and health professionals necessary to accompany the transport for adequate care; 3) international flight scheduling; and 4) administrative procedures such as birth certificate, passport and health insurance. In this report, we describe how the patient was successfully transported, received treatment, and returned home.

Introduction

International emergency newborn airlift may occur when an unexpected preterm birth has occurred or undiagnosed birth defects are discovered in an infant when advanced neonatal care is not available in an isolated location. There are a significant number of case reports of neonatal transport by air, but international transport of newborns over long distances using medically equipped aircraft is extremely rare. This is largely because most of these infants receive advanced neonatal care locally, and if this care is not available, they may not survive until the transport team reaches them. Other possible barriers to long-distance air travel include reluctance to accept medical personnel and the perceived overall burden on families. A previous case report highlighted the clinical and planning difficulties of long-distance neonatal transport from China to Italy [1]. In addition to medical conditions, social criteria such as departure/receiving countries, nationality of patients and their families, and health insurance coverage can turn into factors that can affect the medical care patients receive. . Therefore, it is very important to accumulate knowledge and experience about the main outcomes of cases with different medical and social history. Therefore, we hereby report a case of international air transport of a newborn from Tbilisi, Georgia to Osaka, Japan.

Presentation of the case

A dizygous male child was born in Tbilisi, Georgia at 36 weeks gestational age by emergency cesarean section due to maternal hypertensive disorder during pregnancy. Her mother is Japanese while her father is American. This is a delivery given by a Georgian surrogate mother. He was small for gestational age with a birth weight of just 1200g. He suffered from tachypnea and the heart murmur was heard. The infant was diagnosed with a double outlet right ventricle (DORV), but the parents were told that no surgeon in Georgia could perform heart surgery on an infant with his body weight. Therefore, the parents contacted the Cardiovascular Surgery Department of Osaka University Graduate School of Medicine. The Georgia doctors were unable to communicate in English and their referral letter was written in Georgian. Therefore, the surgeon at Osaka University Hospital had to obtain medical information mainly from parents through email and web conferencing services. The parents requested the transfer through a private international transfer agency (Pediatric Air Ambulance, Munich, Germany).

A pediatric cardiologist and a nurse from the transfer company left Munich for Tbilisi, then transferred the patient and his family to Osaka using an airplane. The plane departed Tbilisi International Airport (TBS) and arrived at Kansai International Airport (KIX) at dawn, with brief stops for fuel in Tibet and Ulaanbaatar. Although the planning was discussed via the internet, due to complications in routing the transfer with the authorities of the People’s Republic of China and the Russian Federation, we were not informed of the arrival date until three days before arrival. At the time of departure from Georgia, the medical team had not provided treatment such as oxygen, mechanical ventilation or injection of diuretics. A peripherally inserted central venous catheter (PICC) was placed and an infusion was made en route. The aircraft was equipped with the Baby Pod II® incubator (Advanced Healthcare Technology Ltd., Suffolk, UK); a mechanical ventilation device (Hamilton T1®, Hamilton Medical, Bonaduz, CH); a blood gas analysis device (Alere EPOC®, Siemens Healthineers, Erlangen, DE); a monitor equipped with an electrocardiogram (ECG), a defibrillator, a pacemaker; saturation of peripheral oxygen (SpO2), non-invasive blood pressure (NIBP) and invasive blood pressure (IBP) sensors (Corpuls C3®, Corpuls, Bayern, DE); and syringe pumps (Perfusor®, B. Braun Medical Inc., Melsungen, DE). These allowed the medical team to ensure the best follow-up and the best care during transport (Figure 1).

The patient arrived at Osaka University Hospital on postnatal day (PND) 20 via commercial ambulance from the airport. Previously diagnosed DORV was confirmed by echocardiography. Chest X-ray showed increased pulmonary blood flow and diuretics were instituted. Physical examination revealed increased head circumference and hepatomegaly. CT scans of the head and abdomen revealed no ventriculomegaly, no brain tumors, and no space-occupying lesions in the liver. He had a normal karyotype (46, XY). The blood test was significant for elevated brain natriuretic peptide (553.9 pg/dL). Parenteral nutrition with amino acids and lipids was given from PND 22 to PND 30. At PND 31, pulmonary artery banding (PAB) was performed. After confirming no abnormalities in the brain by MRI on PND 77, the patient was discharged home on PND 81. Meanwhile, the patient’s mother applied for residency and public health insurance in Osaka, in Japan, which allowed the patient to stay in Japan during his medical examination. expenses were covered as a dependent of his mother.

Discussion

In this case, there were difficulties and problems generally encountered in any international air transport as well as in international neonatal transport. The barriers highlighted in this case can be grouped into four categories: 1) language issues for referral and counselling; 2) the medical equipment and health professionals necessary to accompany the transport for adequate care; 3) international flight scheduling; and 4) administrative procedures such as applying for a birth certificate, passport and health insurance.

First, language issues hampered communication between medical teams. The information provided by the former doctor was in Georgian. Although Japan has introduced medical interpreters as a nation to deal with patients with limited Japanese proficiency [2]according to the Georgian Embassy in Japan, as of March 2021, official language assistance in Georgian can only be provided by the Embassy and no commercial professional services are currently available.

Second, a newborn who needs to be transported overseas may face unique health situations. Potential risk of air travel may have decreased oxygen partial pressure as this infant had congenital heart disease [3]. However, this effect could have been negated because he had high blood flow to the pulmonary arteries. Another risk could be apnea of ​​prematurity [4], which can be managed by the medical team on board. Additionally, although modern neonatal transfer by aircraft is known to be relatively safe [5]the unstable environment of the aircraft, such as high altitudes and vibrations, could have a negative impact on the health of the newborn [6]. Therefore, a medically equipped aircraft and medical professionals are needed on board, which can make the transfer fee quite expensive for the family. [7].

Third, there was a difficulty in routing management. Our file encountered complications with the routing of the transfer to the authorities of the People’s Republic of China and the Russian Federation. Accordingly, the schedule was set on a Friday and the patient arrived before dawn the following Monday.

Fourth, social problems may arise in the care of newborns arriving from abroad. Since newborns need to get a birth certificate and a passport at the same time, this complicated documentation arrangement may prevent the patient from being able to leave the foreign country smoothly. When newborns born overseas are to return to Japan, a passport will only be issued after obtaining a civil status certificate. This can be overridden in an emergency, but registration of a birth certificate is still required at the embassy to obtain a single-use emergency travel document. In this case, the nationality of the patient’s father allowed the patient to obtain US citizenship, so obtaining a US passport for international departure was quite easy. In addition, for foreign patients, the problem of expensive medical expenses arises in Japan. [8]. In this case, the patient was able to obtain public medical insurance by becoming the dependent of the mother, who had a residence in Japan.

conclusion

In summary, international transfers of newborns can encounter many medical, linguistic, financial and legal difficulties. Medical institutions should be aware of these possibilities and provide adequate preparations by arranging resources to deal with international situations such as language assistance which may not be provided by medical interpreting companies and financial support for transportation newborns.

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