Nursing at 30,000 Feet: Flight Nursing in the United Kingdom

Peggy Dryden, RN, MSN, MBA

Disclosures

December 31, 2002

Introduction

In this interview, Ray Skarratt, BA, RGN (registered general nurse), RMN (registered mental nurse), RNT (registered nurse teacher), a flight nurse from the United Kingdom, describes the autonomous role that nurses have in repatriating citizens from foreign countries back into the United Kingdom (Figure 1).

Ray Skarratt.

Question: Could you describe your position and how you came to be doing this unusual type of work?

Response: I am a freelance flight nurse, which means that I am self-employed and am available for a number of repatriation companies to call. A flight nurse is responsible for the care of a patient being transported by air, usually from one country to another or sometimes within the United Kingdom. The usual form of transport is a fixed wing aircraft but may be by sea ferry or train. I have been involved in nursing since 1959, having qualified first in psychiatric nursing and then in general nursing, training at Highcroft Psychiatric Hospital and the Queen Elizabeth School of Nursing, both of which are in Birmingham, England.

I worked in an accident and emergency department before becoming a clinical teacher. I then received my nurse teacher's diploma. I remained in nurse teaching while being a flight nurse in my spare time. There were only a few companies who undertook the repatriation of the sick and injured. One of the key players in this work was the St. John Ambulance Association (Figure 2). As I was already a member of the St. John Ambulance Brigade, it was only a short step to start this work. When I started in the early 1980s, it was "voluntary," which meant that we only received expenses (no salary). Because of the nature of the organization, many well-respected medical consultants in flight nursing were also members. Working with these medical consultants provided the on-the-job training, as well as participation in more formal conferences.

St. John Ambulance Association logo.

Eventually, as the work expanded, the Royal College of Nursing set up a course to train the increasing number of in-flight nurses coming on the scene. This involved learning about the atmosphere and the changes that occur at altitude. The physics of the various gas laws are important, as is knowledge of how altitude affects physiology and medicine.

As you can imagine, the study of oxygen outside and inside the body occupies a large part of the course. Also covered in the course is extensive information on the aircraft cabin environment, such as pressurization, cabin atmosphere, and the limitations imposed by lack of space. Practical work takes place on both small and large aircraft. This practical experience involves loading and unloading patients as well as the logistics of stowing and using medical and nursing equipment. Aircraft safety is studied with the cooperation of commercial airlines. In the late 1980s to the early 1990s, I was involved in organizing and teaching courses for in-flight nurses in Birmingham.

In the United Kingdom, flight nurses work autonomously for the most part. Some nurses may work full-time for a repatriation company, but most work on a more casual, part-time and/or freelance basis for perhaps more than one company. Sometimes, the clinical conditions dictate a physician and nurse work together, but usually nurses work alone. This means that a flight nurse has to be confident in what he or she is doing and be prepared to take total responsibility for any action taken.

Question: How are patients "assigned" to you? What types of cases do you take -- what cases would you refuse and why?

Response: When a patient becomes ill while in another country, their first point of contact most likely will be their insurance company, perhaps via the representative of the holiday or tour company. When a repatriation company becomes involved, the company's initial function is to gather the medical and nursing information about the patient. When this is done and it has been decided that a nurse is required, the repatriation company will contact myself or another appropriate in-flight nurse.

I escort psychiatric patients and most patients with general health problems. These problems include general medicine concerns such as cerebrovascular accidents, myocardial infarctions, and respiratory disorders. I also accompany patients who have had accidents and have sustained bony injuries. There are, however, many patients I would not accompany. These include children, maternity patients with additional complications, and patients requiring intensive care such as artificial ventilation. The reason for my refusing these patients is that for some, such as children and maternity, I am not qualified, and for others I do not feel that I am suitably experienced or competent.

Because the true nature of the patient's condition cannot be determined until they have been seen and assessed, it sometimes may be necessary to refuse to transport a patient because they are not fit to fly. All of the agencies for which I work are at least 100 miles away from my home, so I need to have my own equipment, which includes such things as a scoop stretcher and a mattress (designed to prevent pressure problems) together with equipment such as an electronic sphygmomanometer and pulse oximeter for assessing and monitoring the patient. It is also necessary to carry general nursing equipment such as bedpans, urinals, and feeding utensils. Drugs necessary for the patient are usually dispensed by the host hospital. Drugs necessary for an emergency need to be carried by the nurse. Because space is at a premium on the flights, most of the equipment is disposable or miniaturized.

Question: Could you describe a rewarding experience that you have had? Also, could you describe a challenging and/or harrowing experience?

Response: Patients and their accompanying relatives are very varied. Because most patients are in foreign countries with all the attendant culture and language difficulties, the in-flight nurse or physician is often seen as "a knight in shining armor." Tears of relief are not uncommon as we walk through the door and the patient discovers that we speak English. Each repatriation event is a story in itself. Sometimes the repatriation is seen as a rescue from unsuitable medical or cultural conditions. This particularly applies to the psychiatric patient.

One story that comes to mind concerns a patient who had arrived from abroad. As sometimes happens because of different location, different language, and different customs, this young man had "lost it." He had become disorientated, agitated, and was quite violent. He managed to kick out the windows of the ambulance that was transporting him to the hospital and, on arrival, required heavy doses of medication to calm him down. He was repatriated using the Cessna aircraft shown in the picture (Figure 3). When we arrived at the hospital, he was extremely confused and frightened. When he realized that we were English and we were taking him home, he became more cooperative. By the time we returned, he was considerably improved. He was admitted to a psychiatric hospital in England for a short while. I learned 12 months later that he had had no recurrence of his psychotic episode.

Cessna Conquest Air Ambulance, waiting on the tarmac for departure.

Other times, my work involves simply bringing a patient home after they have recovered from the acute phase of their illness. A sense of humor is essential in a flight nurse, so most of us have amusing stories to tell. One time, I was returning with a patient from the Costa del Sol in the South of Spain. This patient had had a myocardial infarction some 10 days before. The consultant cardiologist who was with me was collecting the medical report, and I was collecting the drugs for the journey. The patient, meanwhile, was being taken down in the lift and loaded in the ambulance. The physician and I walked down the stairs and out through the door to see the ambulance with the patient roaring off down the road toward the airport. We had to hail a taxi and "keystone cops" style ordered him to "follow that ambulance." We did manage to arrive at the airport just behind the ambulance and retrieve our patient.

Question: In conclusion, do you have any suggestions for those readers interested in a position like yours? Can you provide any recommendations to the readers about whom they should contact for more information about this type of work?

Response: I can only speak with any authority about the British scene. Nurses who are interested in in-flight work need to be able to work independently, as there is very little support during the repatriation itself. The responsibility for the safe transfer of the patient is entirely in the hands of the escorts -- physician or nurse. It is also essential that a specialized course be undertaken as I have described above. In the United Kingdom, these courses are taught at the University of the South Bank in London. The In-Flight Nurses Association has a forum on the Web site of the Royal College of Nursing (Figure 4).

The Royal College of Nursing In-Flight Nurses Association logo.

Thank you, Ray, for telling your story. Readers interested in contacting Ray Skarratt, flight nurse, may email him at: rayskarratt@ntlworld.com.

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