To the Editor: Grace and Penny present some fascinating “travellers tales” concerning travel insurance and medical evacuation.1 Although I recognise that there may have been difficulties with individual cases, the article probably paints an unnecessarily bleak picture of travel insurance and medical assistance companies. About a fifth of travel insurance claims involve the successful use of the emergency assistance service, which mostly does not involve aeromedical evacuation.2 Evacuation by a dedicated air ambulance is uncommon among travellers.2 Almost all travellers in need of medical and dental treatment source treatment locally, for which they are generally reimbursed. Aeromedical evacuation, where needed, is more likely by scheduled airlines with or without an escort.

The article may raise unrealistic expectations among travellers for aeromedical evacuation. Air ambulances do not operate and respond in the same way as ground ambulances. Time is required to assess and prioritise cases, select suitable aircraft, obtain flight plan clearance, check and equip aircraft, brief retrieval and receiving hospital personnel, and develop contingency plans. Aircraft may be required to refuel en route, as air ambulances tend to be based where they can be maintained and staffed adequately and safely — this may be far from the retrieval site.

It is useful to raise travellers’ awareness of the possible difficulties in accessing adequate medical facilities in many developing countries, especially where tourism is promoted, and create a sense of travellers’ responsibility for their own health, safety and welfare. The International Society of Travel Medicine has articulated this in a recently released policy statement.3 Readers should be wary of generalising from a small number of case studies from a “popular tropical island holiday destination”.1 It would be useful to collect data on medical retrievals and emergency assistance provided from various sources and consult all interested parties before attempting to establish guidelines for medical evacuation.

Grace and Penny do raise the important issue of the need for appropriate travel insurance for all travellers. This message needs to be conveyed by the travel industry and by travel health advisers. The article referred to a study of the travel health advice provided by general practitioners in New Zealand, but did not mention that only about half the GPs in that study routinely discussed travel insurance.4 A similar study in Australia indicated that less than 40% of GPs routinely give advice on travel insurance.5

To the Editor: As consultants in intensive care, experienced in transporting critically ill patients within Australia and internationally, we have also received complaints from clients about some travel insurance organisations.1

Poor service appears due partly to economic restrictions and partly to the paucity of experienced staff and specialised aircraft available.

Assistance companies implement travel insurance policies for underwriters, quoting 24-hour emergency call centres. Some companies economise by subcontracting (eg, episodic diversion of calls to another organisation). This can result in coordinators lacking an understanding of regional geography, population and medical services and omission of the early, vital input of senior medical advisers. Information relayed between several people can be lost or distorted. Failure to ask key questions can result in inappropriate clinical planning. Furthermore, time zone differences can result in calls being received late at night, further reducing availability of immediate expert opinion. Only a well-organised (and thus expensive) control centre with a critical care focus can manage all these variables.

Furthermore, it is difficult for a company to permanently employ current, high-grade healthcare staff in adequate numbers. Current critical care retrieval staff in Australia are confined to a few stand-alone aeromedical organisations or public hospitals which run aeromedical services for state governments and other organisations, using their regular anaesthesia, intensive care or emergency medicine staff. Reliable assistance companies tend to contract with these retrieval organisations or their off-duty staff.

In Australia, ambulance aircraft able to travel offshore, with adequate oxygen systems, stretcher attachments, electrical power, and so on, are uncommon and expensive to equip. Portable equipment to care for a critically ill patient represents a capital investment of over $100 000, and some services try to achieve results with inadequate tools or by borrowing.

ISAS (the International Society of Aeromedical Services, Australasian Chapter) promotes standards on staffing and equipment,2 including the Australian and New Zealand College of Anaesthetists/Australian College for Emergency Medicine standard for transporting the critically ill.3 Based on critical care practice, the standards are not legally binding, but one suspects they would be quoted in any litigation.

It behoves all travellers to scrutinise their travel insurance policies closely — many think of them only in terms of lost or stolen baggage. Following serious injury or illness, the policy may dictate what kind of care is offered.

To the Editor: As the medical director of Customer Care Medical Assistance, which manages the travel insurance policies of most travelling Australians, I wish to reassure readers that none of the experiences chronicled by Grace and Penny1 related to our company. I have previously described the activities of Customer Care in the Journal.2

I would welcome any enquiries from colleagues about the way our company functions.

I note that there was no declaration by Grace and Penny of their competing interests.