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VIP Traveler
30 VIP Traveler: Mission-Oriented Travel Medicine Roger A. Band, Edward Wasser, and Richard J. Tubb
KEY POINTS • VIP or dignitary travelers, by virtue of their role, title, stature, and/or mission, require special consideration with regard to medical security planning and medical support when they travel. • Operational planning for VIP travel medical support is a rigorous, time-consuming, detail-oriented process and focuses on proper training, equipment, and preparation. • The basic components of an operational plan include a medical threat assessment, medical threat countermeasures, resources and requirements, an “exit strategy,” and a communication plan. • This discipline incorporates skill sets of virtually all medical and surgical specialties and mandates a systematic approach to
premission planning, deployment, and after-mission assessment to ensure safe and successful outcomes. • Discretion and patient confidentiality are core principles of the physician-patient relationship. In dignitary and protective medicine, violations of this trust can have unique consequences, such as compromising mission security and personal safety. • With globalization, there is an ever increasing need for expertise in VIP medicine. Whether supporting life-saving foundation work, a head of state meeting, or global commerce, mission-oriented travel medicine can have a direct and extraordinary impact on many lives.
INTRODUCTION
MISSION-ORIENTED MEDICINE AND VIP TRAVEL MEDICINE
As the world becomes more accessible, physicians are increasingly called upon to prepare their patients for the demands of the global engagement. This was once the realm of the few, but is now a reality of modernity for many—and is the subject of this text. In this chapter, we will return to the “few,” a category of high profile patients whose very description as such illustrates both the reality and the paradox of healthcare delivery for a group of “patient-travelers” that the world most commonly, if at times uncomfortably, refers to as “VIPs” or “dignitary travelers”. By virtue of their roles, titles, stature, or mission, this cohort requires special consideration with regard to medical security planning or medical support when they travel. The principles described in detail here are critical and universally applicable. The authors combined experience includes decades of care for traditional heads of state, members of royal families, senior military officers, major league athletes, media celebrities, and ultra-high net worth individuals (UHNW).
THE MAN, THE MISSION, AND MEDICINE One characteristic that further distinguishes and even defines The Man (or “The Woman”) is “The Mission,” and the interface between the two. At times they can appear to be indistinguishable, the purpose for the one being the reason for the other. Failure of either has consequences that reach far beyond the person (or the patient), even to the world. This reality serves as an ever-present backdrop to VIP travel medicine not inherent to travel medicine for the masses. When “failure is not an option,” the physician must remain clear-eyed about how the health and healthcare of The Man potentially impacts the success of The Mission (and vice-versa) in what some have labeled “mission-oriented travel medicine,” the methodology discussed herein.
The prototype of mission-oriented travel medicine (including operational, expeditionary, dignitary, executive, protective, or performance medicine) might be that which supports the deployment of a military force into a foreign and hostile environment in pursuit of an objective (the mission) as defined by a commanding officer (the VIP). In pursuit of a shared objective, medicine joins other mission support elements (e.g., security, transportation, logistics, and communications) in developing a comprehensive operational plan. Within that “O-plan,” medicine serves not only as an end in and of itself, but also as a means to an end: to support and preserve the “fighting force” in order to secure the stated objective and accomplish the mission. Similarly, in many respects the physician supporting a VIP traveler also practices mission-oriented medicine. The VIP is the mission commander. He or she defines the mission objective. The objective drives planning, resources, and requirements. Contingency plans are developed in anticipation of potential obstacles to mission success. Additional non-medical support personnel may also be critical to the mission’s success, and may, therefore, be considered “proxies” for the VIP and as potential patients. If the prototype for mission-oriented medicine is that which supports a military deployment, the prototype for VIP travel medicine might be that which supports the President of the United States, for example, on a complex overseas diplomatic mission. From a planning perspective, such missions can sometimes resemble small-scale military deployments, employing the skills of hundreds of logistics, security, communications, administrative, transportation and diplomatic personnel, and their equipment. The President or “principal,” serves as the commander and defines the objective. His/her health, wellness, and performance are
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CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine Abstract
Keywords
With globalization, there is ever increasing need for expertise in missionoriented travel medicine (MOTM), which incorporates skill sets of virtually all medical and surgical specialties and mandates a systematic approach to premission planning, deployment, and after-mission assessment. Whether supporting life-saving foundation work, a head of state meeting or global commerce, MOTM can be extraordinarily impactful on many lives. Here we focus on the VIP or Dignitary traveler, who by virtue stature and/or mission, requires expertise and special consideration regarding medical security planning when they travel. The principles described in detail here are critical and universally applicable to dignitary travel. The authors combined experience includes decades of travel and experience caring for heads of state, members of royal families, senior military officers, and other luminaries.
Dignitary and protective medicine Discretion and confidentiality Medical security Operational security Travel medicine VIP
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BOX 30.1 Bushu-suru A Clinical Case Correlation in VIP Travel Medicine On January 1, 1992 President and Mrs. George H.W. Bush rang in the New Year in style from Sydney, Australia. It was the first leg of a 12-day, four-country, 26,000-mile mission to Australia, Singapore, South Korea, and Japan. It was also the first day of what their daughter, Doro, described as “the worst political year of their lives.”1 The trip was critical to the President’s re-election effort providing a media backdrop to counter an unflattering public perception of him, created by his opponent’s campaign. A week later, the President would make history in Japan, the last leg of the mission, by being the first President of the United States to vomit on a fellow head of state. As Newsweek reported,2 the 41st President had just “traveled through 16 time zones in 10 days and had just been creamed by the Emperor of Japan at tennis. As he stood in the receiving line before a state dinner in Tokyo…President Bush had to excuse himself to go into the bathroom and throw up. Most ordinary men would have called it a night and headed for bed. But Bush, ignoring the advice of his doctor, doggedly returned to his duties [believing to do otherwise would be discourteous to his hosts]. Still, the Secret Service was quietly warned that he might not make it through the meal. He didn’t.” The President and First Lady were seated with the Japanese Prime Minister in the center of a large u-shaped table in a room of 135 invited guests (all, themselves, VIPs). Part-way through dinner, the President became pale enough that his senior Secret Service agent became concerned and approached him at the head table. The President vomited, and fell to his host’s lap as the agent eased him to the floor. As the President’s daughter, Doro, describes it: “…Dad was unconscious for about three seconds before his doctors and nurses revived him. Paula Trivette, a very able Army nurse, literally vaulted over the table to get to Dad. Dr. Lee [Dr. Burt Lee, the President’s personal physician] opened his tie to get him some air, then he unzipped Dad’s trousers—which obviously caught Dad’s attention. ‘Burt. What the hell are you doing down there?’ Dad asked. Hearing this, Mom [The First Lady of the United States, Barbara Bush] turned to the crowd and said, ‘I think the President is going to be fine.’” (The President, for his part, as reported by Newsweek, “…quipped to his personal physician… ‘Roll me under the table until the dinner’s over,’ Burt.”) The President’s daughter notes that her mother’s comments “…helped to reassure everyone that the situation was not as serious as it might have appeared on TV.” Nevertheless, “…The images that [the] camera position caught of Dad fainting and being helped to his feet were soon beamed to the waiting world, and caused a global stir. What was left unreported was that almost half the press corps had also come down with the same flu. I was at the other end of that beam, in Bethesda, Maryland…out of habit, I turned on CNN. It was there
I saw over and over again, Dad fall over at the Japanese dinner.” Newsweek, after reviewing the video, reported that the “…site of Bush passing out and vomiting was truly frightening to those around him, especially to his normally stoic wife. Even the snippet that was publicly aired, showing the president prostrate and gray with nausea, shocked the American people.” The President’s daughter continues with what she describes as a “morbidly humorous postcript…Since the dinner that night was closed to the press, many of the working media members and camera people went to a Tokyo restaurant that night—all gathered in a single room. Clearly, there was a miscommunication as to what had happened to Dad, because a hostess entered the room and in that wonderfully formal and proper Japanese way kept saying, ‘Very sorry. Very sorry.’ When everyone quieted down, the hostess then dropped this bombshell: ‘Your President died tonight.’ After a moment of stunned silence, pandemonium broke out as everyone scrambled for the door—fearful that they were missing the story of the century.” Still in the early days of cable news and the 24-hour news cycle, bad could have easily grown disastrous very quickly, and nearly did. CNN’s Headline News anchorman, Don Harrison, based on a fraudulent tip by a caller to the network who had misrepresented himself as the President’s personal physician, began to report the “tragic news” of the President’s death. As the Los Angeles Times reports,3 “…Before Harrison could finish the sentence, an unidentified supervisor yelled ‘Stop!’ from off-camera. Harrison then corrected himself and read a different report merely stating that the President was ill.” Newsweek continued, “The image brought to mind the picture of [US President] Jimmy Carter, staggered by heat exhaustion as he stumbled along in a road race near Camp David in 1979. That grisly picture became a metaphor for a failed presidency; it haunted Carter right through his loss to [US President] Ronald Reagan in 1980. Democrats, naturally, were eager to make the videotape of Bush’s Tokyo collapse tell a similar story. ‘He’s almost a metaphor for a sick, wobbly economy looking for a Japanese pill to make him recover,’ said Mike McCurry [later Assistant to the President and Press Secretary for President Clinton, President Bush’s campaign opponent]….” Twenty-five years later, Newsweek reprised the story describing the impact of what, medically speaking, was of little consequence. USA Today later reported the incident as one of the “Top 25 memorable public meltdowns that had us talking or laughing or cringing over the past quarter century.”4 The Encyclopedia of Political Communication noted that “The incident caused a wave of late night television jokes and ridicule in the international community, even coining Bushu-suru which literally means ‘to do the Bush thing.’”5
1
Koch D. My father, my president: a personal account of the life of George H.W. Bush. New York, NY: Warner Books; 2008. p. 380–5. McDaniel A. 25 years ago today, George H.W. Bush vomited on the prime minister of Japan. Newsweek, January 8, 2017, http://www .newsweek.com/25-years-ago-today-george-h-w-bush-vomited-prime-minister-japan-538581. 3 McDougal D. CNN averts hoax about Bush’s ‘death.’ Los Angeles Times, January 10, 1992, http://articles.latimes.com/1992-01-10/ entertainment/ca-1610_1_cnn-s-headline-news. 4 Keen J. They did what, said what? USA Today, May 7, 2007, https://usatoday30.usatoday.com/news/top25-meltdowns.htm. 5 Kaid L, Holz-Bacha C. Encyclopedia of political communication, vol. 1. Thousand Oaks, CA: SAGE, Inc; 2008. p. 72. 2
integral to the success of the mission, and vice-versa. Furthermore, the health, wellness, and performance of the support team can impact the principal and mission success as well. As proxies for the President, they too, are potential patients. As the historical case of Bushu-suru demonstrates, even a minor threat to the health of the President and his travel team, can have global visibility and far-reaching consequences (Box 30.1). The Man. The Mission. Medicine. (and The Media.) How much Bushu-sura, a relatively minor medical anecdote, clinically speaking, contributed to the public’s perception of the President, and the President’s
eventual defeat, will never be known. Moreover, while supporting Presidential diplomatic missions may be extreme examples of mission-oriented VIP travel medicine, the lessons learned illustrate its importance, and the key concepts of theses missions can inform the medical support of all VIP travelers, presidential or otherwise.
OPERATIONALIZING VIP TRAVEL SUPPORT Operational planning for VIP travel medical support is a rigorous, time-consuming, detail-oriented process. Perhaps the first step in
CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine operational planning, one fundamental but not unique to military doctrine, is to “plan to plan” (Table 30.1). The basic components of an operational plan include a medical threat assessment, medical threat countermeasures, resources and requirements, an “exit strategy,” and a communication plan. Before developing the medical support plan, however, the physician must first have a solid understanding of the patient, the mission, its requirements, and available resources. While beyond the scope of this chapter, answers to the basic questions, “Who, what, when, where, how, and why?” will bring focus to that understanding and inform planning.
TABLE 30.1 Operationalizing VIP Travel
Support—The Plan’s Plan
• Identify the leader • Define the objective • Identify resources and requirements • Develop the plan • Address resource deficiencies and unmet requirements • Identify and address potential obstacles to mission success • Develop contingency plans • Communicate the plan to key stakeholders • Execute the plan • Adapt and reengage • Redeploy, recover, and learn for the future
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Medical Threat Assessment and Countermeasures The medical threat assessment (MTA; Table 30.2) is a comprehensive evaluation tool that provides a standardized mechanism for identifying and stratifying potential threats to the health and safety of the traveler. Only when the medical threats have been identified, contextualized, and stratified can recommended countermeasures follow. The document is an essential component of the medical operational plan and is tailored to the individual traveler and to the specific mission. It may represent only one annex among many other nonmedical operational support annexes to the larger mission plan, and serve several functions. It provides a flexible framework by which to aggregate information and can be used as a checklist to ensure that appropriate preventive measures are implemented during the planning phase of each trip and reduces the likelihood of missing critical details in the planning of the operational phases of a mission. The MTA is also a common language document that can be shared among mission partners to create an overall “common operating picture.” It should identify information intended for “situational awareness only” (aka “for information only”), as well as that which is actionable. Depending on the nature and complexity of the mission, planning window, and risk, a web-based, subscription-based, telephonic, and/or onsite survey of the actual destination may permit a better understanding of potential threats and risk mitigation strategies. A comprehensive assessment of destination medical resources is best conducted through face-to-face meetings with local hospital administrators, emergency medical service (EMS) personnel, nurses, and physicians. Prehospital,
TABLE 30.2 Medical Threat Assessment Medical Threat Assessment Behavioral Emergency contact numbers
Environmental risks
Evacuation
Food and water safety Infectious disease risk
Medical assets Preexisting medical conditions Trauma/violence
Examples • Plan/address travel-related fatigue, jet lag, alterations in sleep hygiene, diet, constipation; cultural considerations • Embassy or Government resources or contact • Hospitals • Evacuation services • Alternate transportation sources (helicopter, ferry, etc.) • Weather-related concerns (e.g., heat/cold exposure, rain, high/low humidity) • Altitude (see chapter 42) • Air quality • Envenomation and wildlife (see chapter 48) • Transport mode: local assets, team vehicles, air options • Locations of critical facilities: with specific capabilities and evacuation routes to regional referral hospitals • Transport times to local and regional hospitals • Terrain limitations (e.g., mountains, bodies of water) • Potability of local/hotel tap water, strategy for water purification (see chapter 5), alternative sources of trusted water and food • Vector-borne disease • Respiratory and other communicable disease (see chapter 59) • Blood-borne disease • Recommended and required travel and routine immunizations (see chapters 10–12) • Chemoprophylaxis requirements (e.g., malaria) (see chapter 15) • Local hospital quality, capabilities and access to pharmaceuticals (counterfeit prevalence), blood products, advanced care • Fitness for travel: Principal and team member baseline health and underlying medical conditions (diabetes, hypertension, coronary disease, etc.) • Motor vehicle safety • Civil disorder • Targeted violence (e.g., assault, assassination, kidnapping) • Mass casualty incidents (acts of terrorism)
From Band RA, Callaway DW, Connor BA, et al. Dignitary medicine: adapting prehospital, preventive, tactical and travel medicine to new populations. Am J Emerg Med 2012;30(7):1274–81.
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emergency, acute, interventional, and definitive care services (especially cardiac, stroke, and trauma care capabilities) should be evaluated as well as those specific to the traveling VIP, ancillary and diagnostic services, and medical evacuation options. It can be especially helpful to trace the physical pathway taken by a severely injured or seriously ill patient from the point of arrival to stabilization and treatment to eventual evacuation. These visits can also build lasting relationships abroad, which can provide real-time operational assistance and situational awareness of unanticipated or evolving threats, and may be determinative to the success of the mission at hand, or in the future. In the end, contingency hospitals should be designated based on their quality, relevant capabilities, proximity, accessibility, and security considerations.
Communicate: Translating the Medical Threat Assessment Into a Medical Travel Advisory Once the physician has identified, analyzed, contextualized, and stratified destination-specific health risks to the VIP traveler and mission, as well as recommended risk mitigation countermeasures, he or she should be prepared to communicate this analysis to the VIP and subsequently to any additional support or security staff or members of the traveling delegation. Web-based publications (e.g., Shoreland Travax) may inform the analysis, but ideally, the process should begin with a face-to-face conversation with the patient regarding risk and risk comfort. At a minimum, the following questions must be addressed: • Can the traveler safely participate in the mission (i.e., fitness for travel)? • How can traveler risks be minimized? • How can the probability of mission success be maximized? The conversation should be supplemented with a detailed but relevant document (a “Travel Advisory”) that will become part of the medical record. The advisory should inform the traveler of all relevant travel risks, proposed countermeasures (and risks inherent to those countermeasures, e.g., medication side effects), and action timelines. It should also identify medical contingency resources and points of contact for access to care before, during, and after travel, especially if the VIP will not be accompanied by medical support personnel. The advisory should be authored with an awareness not only of the intended audience (VIP, fellow travelers, support personnel), but also of any potential medical-legal ramifications (e.g., patient-physician relationship, explicit or implied). When possible the medical advisory should be published early enough in the planning window to permit stabilization of preexisting medical conditions (potentially impacting or impacted by travel or prescribed countermeasures); immunizations for vaccine preventable illnesses; chemoprophylaxis (e.g., malaria); “groundtesting” of medical countermeasures novel to the patient (e.g., jet lag management medications); and, in the case of fellow travelers/support personnel, consultation with their personal physicians. In addition to a comprehensive advisory, many VIP travelers will also appreciate a one-page fact-based “executive summary.” Electronic communication of the advisory not only permits timely “stand-off ” delivery of the information (sensitive to the traveler’s often-limited availability), but also provides time-stamped documentation of advice and “informed-consent.”
Support Requirements After having discussed the potential travel risks and proposed countermeasures with the patient, the physician should have an understanding of the risk comfort level of the informed VIP traveler. Ever mindful that patient perception may be as important as clinical reality, the patient-driven risk-benefit analysis may include: • Risk comfort—What is the level of risk with which the informed traveler is comfortable?
TABLE 30.3 Spheres of Travel and
Contingency Care
• Patient education • Travel-related preventive care • Patient advocacy and medical liaison • Ongoing primary care • Travel care • Comfort care • Acute care • Specialty care consultation • Emergency care • Intervention and stabilization • Medical evacuation • Definitive care • Centers of excellence • Recovery care
• Mission impact—What is the absolute and relative risk, and how does it potentially impact the mission? What is the potential risk of proposed countermeasures and planning options, and how could they impact the mission? • Independence—To what degree is the traveler willing to rely on external medical resources in the event of a medical contingency? • Patient-physician relationship—What is the comfort level of the traveler with the presence of any accompanying medical support personnel? • Privacy—Does access to care under the proposed options protect or potentially compromise patient privacy, discretion, and confidentiality? What is the impact of potential compromise? • Quality, access, convenience, and comfort—Is access to high-quality contingency or accompanied medical care easy, available, timely, and comfortable for the traveler at all times and in all places? • Security—Do proposed care options potentially compromise or protect information, communication, operational, personal, or mission security? • Is the VIP aware of the risks and the alternatives (e.g., telemedicine, medical travel kits) to an accompanying provider/healthcare team if he or she decides against medical escort? Medical requirements and resource solutions will be driven by risk stratification, mission impact, local resource availability, and the answers to the above questions. A risk-benefit/cost-benefit analysis of medical options must be undertaken at every relevant clinical level of required and contingent medical support (including quality, scope of care, clinical capabilities, availability of care, access to care) as noted in Table 30.3.
The Plan After talking with the traveler and completing the above exercise, the medical planner should now understand the medical “requirements” necessary to support the mission. Proposals for both the minimal and the optimal levels of medical support necessary for a safe and successful mission, as well as a contingency plan in the event circumstances exceed planned and available capabilities, should be built. The plan should be patient centered, mission oriented, contextualized, actionable, and impactful.
Nothing More, Nothing Less With an understanding of the desired independence from local, external medical resources, and the availability and quality of those resources, the medical planner must next address potential capabilities gaps. The key to medical contingency planning is to match resources
CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine to requirements; the right problem with the right solution: the right person, the right place, the right time…nothing more, nothing less.
Right Problem. Without an accurate understanding of the problem at hand, it becomes exponentially more difficult and merely a matter of chance to arrive at the correct solution. Failure to anticipate and prepare for the problem will handicap the best of intentions and practices. This entire textbook, as well as the processes discussed in this chapter, is designed to equip the physician to properly anticipate, identify, and address the “right” problem.
Right Person. One of the greatest threats that the provider may face when caring for a VIP traveler is the threat of his or her own desire to please the VIP or validate the medical team’s value in the face of other support personnel—that is, saying “yes” when the more appropriate answer is “no” or “I don’t know.” When confronted with one’s own limitations or externally imposed limitations, every problem may begin to look like one that the provider “should” be able to address at that time, in that place. A steady focus on the patient’s best interests may mean that the right person’s greatest strengths include: • Knowing one’s own limitations, that is, when help is needed (“Am I the right person to address this problem?”) • Knowing where to get help • Not being too proud to ask for assistance Right person: expeditionary medical staffing. It has been said that the right time to fire somebody is before you hire them. Returning to our example of the VIP Travel Medicine prototype, the recruitment and selection of a new member of the White House Medical Unit was designed to do exactly that, that is, avoid hiring the “wrong person.” This principle should also be kept in mind for the staffing of any other VIP medical support team. But, even at the White House, despite candidates having been rigorously prescreened and preselected by the most-senior levels of the military services, despite an arduous internal selection and security clearance process, and despite a comprehensive training program, it was the exceptional candidate who not only survived but actually thrived in the zero-error atmosphere of the White House. This reiterates that there are many characteristics (intellectual, social, emotional intelligence, situational awareness and planning, etc.) requisite for success in this role and those like it. More often than not, the characteristics that best predicted excellence over time were not the “tangibles” of academic pedigree, clinical credentials, military or academic rank, training, or accomplishments. It suffices to say that clinical excellence was a “given”—necessary but not sufficient. Instead, the difficultto-quantify “intangibles” that characterized the man or woman with “The Right Stuff ” were revealed in the individual’s attitude, demeanor, and motivation; their willingness and ability to anticipate the needs of others; to be a “team-player,” readily subordinating their own best interests to those of their patients and the mission—to manage their own ego; to be the right person. Your patients deserve nothing less. Staffing options: right training. To our knowledge there are no formal training programs in VIP travel medicine (at the time of this writing). Much of the body of knowledge is built on the experience of White House, State Department, military, and other physicians who have traveled extensively with dignitaries, including current and former heads of state, members of royal families, professional sports, and entertainment celebrities, senior military officers, diplomats, and ultrahigh net worth individuals. That experience has demonstrated that the patient and the mission are best served by a physician with a diverse knowledge base and technical skill set who maintains proficiency across multidisciplinary core competencies. The physician must possess a working knowledge of both primary care medicine and acute care/emergency medicine. Sound diagnostic and decision-making skills (often in the face of
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uncertainty, competing priorities, and incomplete information), the ability and desire to work as part of a team, the confidence to make unpopular medical recommendations in the face of authority, and the ability to think “outside the box” and function comfortably in medically austere environments without the benefit of advanced diagnostics, are all essential attributes. The VIP travel physician must maintain competency in practical procedural skills. It may also be helpful to have a working knowledge of relevant communications equipment, evacuation platforms, and casualty movement techniques. These individuals will posess a broad working knowledge of the most likely medical situations, as well as the ability to intervene and stabilize the acute, urgent, or emergent situation. Moreover, they are likely to be comfortable practicing in an environment with few support staff, little ancillary or logistical support, and in an environment where more advanced specialty care might be inappropriate or potentially deleterious to the patient’s best interests. Those supporting VIP travel care should also consider additional training, certification, and practice in areas such as advanced cardiac and trauma care, advanced airway management, prehospital care, travel medicine, operational medicine (flight, dive, wilderness, tactical), basic dental care procedures, and chemical, biologic, radiologic (CBR) training. All supporting practitioners should maintain sufficient clinical currency to inspire and deserve confidence…both in perception and reality. Lastly, the planner must be mindful of any existing medical-legal and cultural considerations in providing medical support while traveling in the given location. Licensing, credentialing, and medical liability must be considered, as must the ability to liaison with the local health care system/personnel especially when traveling abroad. Staffing options: right team. If the VIP travel medicine provider is fortunate enough to serve alongside other medical professionals as part of a medical support team, he or she must possess an understanding not only of his own limitations, but also an appreciation of the complementary skill sets that the other team members (medical and nonmedical) bring to the mission, including the nurses & physician assistants (PAs) and/or medics in the White House Medical Unit, and other VIP protective details. Much of the success of the White House Medical Unit could be attributed to the early recognition that nurses or midlevel providers brought a skill set, training, relationship, and approach to medicine and, more importantly, to their patient that physicians did not, would not, or could not provide. It suffices to say that a high-functioning integrated clinical team best serves patient and mission, and gives proof to the adage of “the whole being greater than the sum of its parts.” It also provides the greatest opportunity to, appropriately, remain independent of external medical resources until absolutely necessary. Team makeup will ultimately be determined by the VIP, on the advice of his or her physician and additional relevant nonmedical mission team members (e.g., security). Considerations informing that decision are largely those already addressed: risk, risk comfort, and the desired degree of independence. With decreasing probability of reliance on organic host resources in a medical contingency, potential staffing solutions for the VIP traveler may include those noted in Table 30.4.
Right Equipment. As with virtually all of the travel support planning process, trip resourcing is driven by patient needs and preferences, the mission, actual risks and actionable countermeasures, staffing, and other available resources. One of the most commonly encountered challenges is balancing anticipated medical needs with mission priorities, with the logistical constraints inherent to travel. While the focus of this discussion will be equipping a solo provider, the spectrum of equipping options from least to most comprehensive might include those in Table 30.5.
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TABLE 30.4 VIP Travel Medicine Staffing
Options
• Patient education, self-care, and medical logistic support with reach-back (telephone, email, telemedicine) to “medical control” • Nonmedical (e.g., personal aid or security) traveling support with reach-back to medical control • Basic medical (EMT, paramedic, RN) support with reach-back to medical control • Midlevel (PA-C, NP) provider with reach-back to medical control • “Operational physician” provider (no preexisting relationship) with reach-back to physician of record • Physician of record (i.e., preexisting patient-physician relationship) • Physician of record with medical support team • Prestaged • En route • Additional ancillary medical professionals (e.g., physical therapy)
TABLE 30.5 VIP Travel Medicine
Equipment Options
• Self-aid kit to be carried by traveler • Expanded “self-aid” kit to be carried and administered by nonmedical team members • Augmented aid kit for use under advice of remote medical control (telephone, email, telemedicine) • Accompanying lone physician or physician extender kits oriented toward continuing care (for preexisting conditions), acute care (addressing “most likely” scenarios), and interventional care (addressing scenarios for which treatment delay may result in significant adverse impact) • Expanded diagnostic and interventional care kits carried by a physician and nurse team—complementary capabilities with intentional minimal duplication • Comprehensive, potentially definitive, care (comprehensive care kits prestaged on transport platform and/or at destination meeting or residential sites) • Mission-designed treatment platform (e.g., on aircraft, water vessel, tactical ambulance)
A comprehensive analysis of equipping each and every possible permutation would not only be beyond the scope of this chapter, but unwise. The supporting provider must be prepared to handle an array of medical contingencies within the limitations of travel space, weight, budget, and, most importantly, sound medical practice. Specific types and quantity of supplies will be guided largely by the dignitary’s medical history; the intended destination(s) and attendent risk; anticipated duration of travel; the number and health of any accompanying proxies (guests or support personnel); the quality, availability, and sophistication of local medical facilities and resources; and mode of transportation. Equipment must be compact enough to be easily carried, be readily accessible, and must not invite unneccessary attention. Storage space (aka “the cube”) can be “minimized to maximize” by means of prioritized packing, modular kit design, and maximal utilization of dual-use equipment. Prioritized packing requires knowledge, forethought, experience and empathy. Each stakeholder on the travel team may have a different view of priorities, and each of those views may change with the particular demands of any given moment—or even the meaning of the moment. The medical provider must anticipate both the imminent and future
needs of the travelers that they support—even before the travelers themselves are aware of, or react to, the need. With that in mind, priorities in packing can be grouped by stakeholder priorities: Primary Patient Priorities—These priorities are based on knowledge of the primary patient’s medical history and personal preferences. They may address ongoing or continuing care needs as well as reasonably anticipated acute and comfort care needs specific to the individual (e.g., backup supplies of chronic and travel-related prescription medications, corrective lenses, preferred sleep aids, most recent electrocardiogram [EKG]). Also of note, “mission impact” must be considered in the provider’s decision to intervene or prescribe medications for these patients earlier, prophylactically, or where otherwise not often utilized (e.g., travelers’ diarrhea prophylaxis, “sleeping pills,” “wakefulness-promoting agents”). Proxy-Patient Priorities—Thoughtful preparation for the most likely needs to arise in day-to-day life “on the road” or that would otherwise distract, discomfort, or introduce needless delay, and the ability to discreetly address those needs in real time for all team members (even if only as a stop gap until a more appropriate time and place for a more throrough evaluation and treatment), go far in inspiring confidence, enhancing performance, and increasing the likelihood of mission success. Examples include: over-the-counter (OTC) or prescription remedies for upper respiratory or genitourinary infections, analgesics, bandages, surgical glue, and even “tweezers.” Traveling Physician Priorities—These represent urgent, emergent, or evolving conditions that, although unlikely, require immediate diagnosis and rapid field intervention to achieve greatest impact without incurring even greater risks; to prevent imminent or ultimate clinical deterioration, harm, or death; or to evacuate the patient to an environment better suited to address clinical unknowns and potential complications. Epidemiology and impact will guide packing priorities (e.g., automated electronic defibrillator [AED], airway adjuncts, hemostatic dressings, tourniquets, cervical collars, needles for chest decompression, chest seals, aspirin, nitrates, epinephrine). Packing can also be prioritized by considerations: high frequency; high acuity; or even “high meaning”—all with high impact. Regardless of the method used, one can see that “prioritized packing” readily lends itself to a modular medical kit design (e.g., emergency care, acute care, and personal care), each of which can contain submodules (e.g., airway, breathing, circulation). Modules permit rapid, easy, and discreet access to items needed—and only the items needed—at that specific moment. Modular design enhances provider familiarty and confidence in a “medical moment” that may already be stressful, and instills confidence in the patient and the unavoidable onlooker. It reinforces an intuitive, mission-oriented way of thinking that permits further customization during and between missions and allows for easy inventory and repacking at the end of the day and at the end of the trip. Lastly, the modular, mission-oriented approach reinforces (and perhaps even “enforces”) behaviors to counter the tendency to overpack, as discussed below. For prolonged or remote missions, redundant, bulky, or more comprehensive supplies may be prestaged on the transport platform (e.g., car, ship, airplane) or destination meeting/residential sites for utilization as/when/where appropriate. It is imperative that the medical team coordinates with security and transportation teams to ensure access to prestaged gear in the event of an emergency. This in turn allows the medical team the agility to travel only with a lightweight, consolidated medical kit. Common pitfalls. Given the nature of physician personalities, and the unknowns of most missions, “overpacking” with the intent of understandable desire to address every possible contingency no matter how unlikely is exceedingly common, especially among physicians who
CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine are new to VIP medical support or who are new to the particular patient or team. Overpacking can make it difficult to access the items necessary to treat the most common—or worse, the most urgent—scenario, especially under duress. Overpacking also makes it much more difficult to maintain the familiarity with the inventory that is necessary for a rapid, confident response. Moreover, the perceived lack of discretion, mission understanding, or sense of proportion by an asset whose mission is not often readily understood by the VIP or mission partners, can lead to isolation by either or both. The very fear of failure that drives such physician decision making virtually ensures it. At times, the most difficult decision is not what medical resources to carry, but what not to carry. Furthermore, carrying equipment that permits or encourages practice beyond the scope and ability of the provider/team, or the environment, or the ability to manage second- and third-order consequences invites medical, legal, and reputational harm. The very presence of such resources can place an undue temptation on the provider to employ those resources even when medically inappropriate (e.g., beyond the provider’s skill comfort level) or invite criticism as to why the provider had the resources available but chose not to utilize them. When equipping a medical team, material resources should be appropriate for professional qualifications, training, currency, and comfort. Except for a small nucleus of planned, intentionally redundant capabilities, equipment carried as part of a team should be complementary thereby serving as a “force multiplier” enhancing and expanding the scope of care, and decreasing dependency on exogenous medical resources. Most physicians have little difficulty identifying resources requisite for an emergency. It should, however, also be clearly understood that seemingly trivial but commonplace medical issues can have significant impact or meaning for the patient or other members of the traveling party. These common medical problems are frequently overlooked while planning for less common life-threatening emergencies. To do so is a serious oversight, from which it is sometimes difficult to recover. The use of a standardized predeployment checklist of medications and medical supplies can ensure adequate preparation for these common but less dramatic medical issues. Faithfulness in these “small things” is precisely what builds the relationship, trust, confidence, and perceived mission relevance necessary to be the present and proximate solution for the medically “big things.” One final summary note bears repeating when considering the “right equipment.” As already noted, the presence of trip medical personnel is often not understood by the VIP and mission support teammates—that is, until the VIP and teammates discover that they need medical assistance. Supplies, medications, and equipment should be sufficient, and sufficiently available, to confirm value-added support when and where called upon, but not so robust as to invite unwanted attention, criticism, or “value-subtracted” support. The provider must be self-confident enough to understand both his or her place and value while navigating a potential no-man’s land of irrelevance, too-little-too-late, and too-much-trouble-to-bother attitudes.
Right Place, Right Time. Because the VIP and supporting colleagues do not necessarily understand intuitively the value added of medical support personnel, if the VIP has asked for onsite medical support (as opposed to remote medical support by phone, email, or telemedicine), it is important to help him or her understand the impact of the provider’s physical proximity on managing care, expectations, and responsiveness to those expectations either acutely or in an emergency. Locations where those expectations might reasonably enter into play include while in transit (e.g., vehicle/motorcade, plane, yacht); in residence (e.g., hotel, private residence, or nearby); and in situ (e.g., during mission events, meetings). Other support team members (e.g., security) may also have
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requirements in this regard. If medical support personnel are expected to be immediately available, onsite, in real time, at all times and in all places (aka “velcroed” [as in Velcro]), then it is important to remain as discreet as possible—“available but invisible” but also “just in time.” If not “velcroing” the principal, the VIP and the support team must also know how to contact the provider, be aware of the expected delay in response, and provide transportation and access to the VIP. Rested and ready to respond. Just as with mission colleagues who carry weapons (i.e., security personnel) the medical support for the traveling VIP must also be rested and ready to respond when “the balloon goes up.” The nature of the mission, the expectations of the VIP, and the availability of resources (e.g., financial, logistics, transportation, lodging) will dictate the level of staffing necessary to ensure responsiveness and readiness—and adequate to defend real-time decision making to potential after-the-fact inquiries. Right environment. The risk of too much—training, qualifications, capabilities, equipment, medication, personnel—can sometimes exceed the risk of too little. In such a situation, the adage, “Just because you can, doesn’t mean that you should,” might apply. Not every travel environment can or should be able to support every intervention of which the provider may be capable in his or her own emergency department, cath lab, etc. Not every environment will be conducive to rapid sequence intubation and advanced airway management when other options will suffice (e.g., back seat of an armored limousine fleeing “shots fired”). Tissue plasminogen activator (tPA) may not be in the patient’s best interests at 35,000 feet with a one-person medical “team.” The environment must support not only the appropriate skill set but also the potential complications of that skill, treatment regimen, or medication.
KNOWING WHERE TO GET HELP: HOST COUNTRY SOLUTIONS By its very name, the purpose of medical contingency planning is to plan for the unplanned—the “what-ifs.” Contingency planners and other team members must have a thorough working knowledge of all available resources once mission-owned medical capabilities can no longer act in the best interests of the patient or the mission. Whether the decision to elevate care is triggered remotely, en route, or onsite, the answer to “What’s next?” should already be known. From departure to return, from “wheels up to wheels down,” the provider who supports the travel mission of the VIP must have a plan for elevating medical capabilities whenever and wherever necessary, for every medical need along the contingency care spectrum (Table 30.6). At a minimum, those answers should already be contained in the contingency plan and will include the data points outlined in Table 30.7.
TABLE 30.6 Contingency Care Spectrum • Preventive travel care • Continuing care (primary care) • Pharmaceutical support • Ancillary and diagnostic support • Specialty care • Urgent care • Emergency care and stabilization • Definitive care • Centers of excellence (including trauma centers, chest pain centers, stroke centers) • Medical evacuation
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TABLE 30.7 Next-Level Medical
Contingency Resource Data Points • Resource/facility identification (name) • Location • Proximity (“time to target”/time en route) • Relevant capabilities and deficiencies • Quality of care • Accessibility • Modality (private vehicle, ambulance, rotary wing aircraft, fixed wing aircraft) • Entry control point or point of access • Availability • Operating hours • Financial considerations • Communication—point of contact (e.g., phone number) • Name and location of contingency resource “next level of care”or western-style care
WHAT NEXT? EVACUATION PLANNING When it is no longer in the patient’s best interests to remain “on mission,” in country, medical evacuation is indicated. The decision that needs to be made may be difficult but is also quite straightforward: Are the risks of staying greater than the risks of going? Optimally, the information necessary to facilitate rapid, real-time decision making should already be in hand as part of the contingency planning process. Additionally, good practice and attention to detail dictate that the information and plan should be reconfirmed immediately upon arrival, well ahead of any contingency need. As already noted in Table 30.7, it is imperative to know the destination of the nearest, most appropriate medical care and the relevant resources available there (as well as relevant deficiencies). Additional critical information includes location (address and GPS grid coordinates); availability, proximity, adequacy of airports and helicopter landing zones (LZ); distances and travel times to these facilities; and relevant points of contact at these locations. Likewise, an “exit strategy” (i.e., medical evacuation options) should already have been part of the contingency plan. The plan should identify and integrate optimal transport and evacuation routes to the care destination from every point on the itinerary. The VIP medical provider should consider real-world factors that may impact evacuation time, such as security assessments, road conditions, limitations of locally acquired vehicles, weather, and any potential barriers to transportation, such as roadblocks and checkpoints. Choosing the most appropriate evacuation mode may require information such as the routine flight schedules, roundtrip time by air (if an air ambulance must be summoned), size and capabilities of the aircraft, and realistic ground transportation options. Risks inherent to the mode of transport itself along with in-transit care capabilities and limitations must be factored into the risk-benefit analysis. Depending on the mission, it may be reasonable to rely on local EMS resources for transport.1,2 However, in other situations this may not be possible or safe (e.g., delays in waiting for EMS arrival to a remote or otherwise inaccessible location, the lack of discretion when a patient is transported by EMS, quality concerns, or security considerations, etc.) Depending on the setting, extraction by medevac helicopter may be a
consideration. Rotary wing evacuation is complex and requires at least a scene security assessment, a feasibility determination for establishing a safe LZ, and knowledge of the receiving facility’s ability to accommodate the designated aircraft onsite or nearby. In the end, military doctrine teaches, “No plan survives first contact with the enemy.” Even with extensive planning, the physician must be prepared to manage the patient for a prolonged period.1,2
OPERATIONAL SECURITY: DON’T BECOME A LIABILITY Discretion and patient confidentiality are core principles of the physicianpatient relationship. In VIP travel medicine, violations of this trust can have unique consequences, such as compromising mission security and personal safety. Mission-specific details such as travel plans and routes, overnight locations, transportation methods, schedules, and off-therecord stops can be exploited by adversaries. Therefore all trip-related information should be considered privileged and should only be distributed in consultation with the protective services detachment. The VIP travel team often will operate in environments with significant information gaps and multivariate threats.
Economics of VIP Travel Medicine Support The costs associated with a VIP travel medicine support team can be significant. However, the costs associated with a failed mission, or compromised VIP are likely many times greater. Medical equipment, salary, and travel expenses of a medical provider who can function and make decisions in a resource-limited setting must be weighed against an illness that prevents a crucial meeting, results in lost work productivity, creates a politically sensitive situation, and/or requires emergency evacuation, all of which may be exponentially more costly.
CONCLUSION In this chapter we have examined the “special healthcare needs” of a group of travelers most known to the world as VIPs. While medically mere mortals, their mission, position, and impact on society may significantly affect their healthcare. As with the general practice of medicine, the practitioner of “mission-oriented medicine” is, therefore, well advised to assess the patient’s preferences and priorities (the “mission”), and threats to those priorities, that is, a medical threat assessment. Resulting threat countermeasures, resources and requirements will inform development of medical contingency plans, and a medical advisory that is then communicated to the patient-traveler. The VIP traveler may also be accompanied by nonmedical support personnel who may be impacted by, or become beneficiaries of, mission medical support. In the end, whether a VIP or “just another P,” the underlying medical “mission objective” is always the same: to understand our patients as people, “meet them where they are,” and truly care for them.
REFERENCES 1. Band RA, Callaway DW, Connor BA, et al. Dignitary medicine: adapting prehospital, preventive, tactical and travel medicine to new populations. Am J Emerg Med 2012;30(7):1274–81. 2. Christopher F. Medical support to military operations on urban terrain. In: Schwartz RBMJ, Swienton RE, editors. Tactical emergency medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. p. 44–9.
KEY POINTS • VIP or dignitary travelers, by virtue of their role, title, stature, and/or mission, require special consideration with regard to medical security planning and medical support when they travel. • Operational planning for VIP travel medical support is a rigorous, time-consuming, detail-oriented process and focuses on proper training, equipment, and preparation. • The basic components of an operational plan include a medical threat assessment, medical threat countermeasures, resources and requirements, an “exit strategy,” and a communication plan. • This discipline incorporates skill sets of virtually all medical and surgical specialties and mandates a systematic approach to
premission planning, deployment, and after-mission assessment to ensure safe and successful outcomes. • Discretion and patient confidentiality are core principles of the physician-patient relationship. In dignitary and protective medicine, violations of this trust can have unique consequences, such as compromising mission security and personal safety. • With globalization, there is an ever increasing need for expertise in VIP medicine. Whether supporting life-saving foundation work, a head of state meeting, or global commerce, mission-oriented travel medicine can have a direct and extraordinary impact on many lives.
INTRODUCTION
MISSION-ORIENTED MEDICINE AND VIP TRAVEL MEDICINE
As the world becomes more accessible, physicians are increasingly called upon to prepare their patients for the demands of the global engagement. This was once the realm of the few, but is now a reality of modernity for many—and is the subject of this text. In this chapter, we will return to the “few,” a category of high profile patients whose very description as such illustrates both the reality and the paradox of healthcare delivery for a group of “patient-travelers” that the world most commonly, if at times uncomfortably, refers to as “VIPs” or “dignitary travelers”. By virtue of their roles, titles, stature, or mission, this cohort requires special consideration with regard to medical security planning or medical support when they travel. The principles described in detail here are critical and universally applicable. The authors combined experience includes decades of care for traditional heads of state, members of royal families, senior military officers, major league athletes, media celebrities, and ultra-high net worth individuals (UHNW).
THE MAN, THE MISSION, AND MEDICINE One characteristic that further distinguishes and even defines The Man (or “The Woman”) is “The Mission,” and the interface between the two. At times they can appear to be indistinguishable, the purpose for the one being the reason for the other. Failure of either has consequences that reach far beyond the person (or the patient), even to the world. This reality serves as an ever-present backdrop to VIP travel medicine not inherent to travel medicine for the masses. When “failure is not an option,” the physician must remain clear-eyed about how the health and healthcare of The Man potentially impacts the success of The Mission (and vice-versa) in what some have labeled “mission-oriented travel medicine,” the methodology discussed herein.
The prototype of mission-oriented travel medicine (including operational, expeditionary, dignitary, executive, protective, or performance medicine) might be that which supports the deployment of a military force into a foreign and hostile environment in pursuit of an objective (the mission) as defined by a commanding officer (the VIP). In pursuit of a shared objective, medicine joins other mission support elements (e.g., security, transportation, logistics, and communications) in developing a comprehensive operational plan. Within that “O-plan,” medicine serves not only as an end in and of itself, but also as a means to an end: to support and preserve the “fighting force” in order to secure the stated objective and accomplish the mission. Similarly, in many respects the physician supporting a VIP traveler also practices mission-oriented medicine. The VIP is the mission commander. He or she defines the mission objective. The objective drives planning, resources, and requirements. Contingency plans are developed in anticipation of potential obstacles to mission success. Additional non-medical support personnel may also be critical to the mission’s success, and may, therefore, be considered “proxies” for the VIP and as potential patients. If the prototype for mission-oriented medicine is that which supports a military deployment, the prototype for VIP travel medicine might be that which supports the President of the United States, for example, on a complex overseas diplomatic mission. From a planning perspective, such missions can sometimes resemble small-scale military deployments, employing the skills of hundreds of logistics, security, communications, administrative, transportation and diplomatic personnel, and their equipment. The President or “principal,” serves as the commander and defines the objective. His/her health, wellness, and performance are
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CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine Abstract
Keywords
With globalization, there is ever increasing need for expertise in missionoriented travel medicine (MOTM), which incorporates skill sets of virtually all medical and surgical specialties and mandates a systematic approach to premission planning, deployment, and after-mission assessment. Whether supporting life-saving foundation work, a head of state meeting or global commerce, MOTM can be extraordinarily impactful on many lives. Here we focus on the VIP or Dignitary traveler, who by virtue stature and/or mission, requires expertise and special consideration regarding medical security planning when they travel. The principles described in detail here are critical and universally applicable to dignitary travel. The authors combined experience includes decades of travel and experience caring for heads of state, members of royal families, senior military officers, and other luminaries.
Dignitary and protective medicine Discretion and confidentiality Medical security Operational security Travel medicine VIP
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BOX 30.1 Bushu-suru A Clinical Case Correlation in VIP Travel Medicine On January 1, 1992 President and Mrs. George H.W. Bush rang in the New Year in style from Sydney, Australia. It was the first leg of a 12-day, four-country, 26,000-mile mission to Australia, Singapore, South Korea, and Japan. It was also the first day of what their daughter, Doro, described as “the worst political year of their lives.”1 The trip was critical to the President’s re-election effort providing a media backdrop to counter an unflattering public perception of him, created by his opponent’s campaign. A week later, the President would make history in Japan, the last leg of the mission, by being the first President of the United States to vomit on a fellow head of state. As Newsweek reported,2 the 41st President had just “traveled through 16 time zones in 10 days and had just been creamed by the Emperor of Japan at tennis. As he stood in the receiving line before a state dinner in Tokyo…President Bush had to excuse himself to go into the bathroom and throw up. Most ordinary men would have called it a night and headed for bed. But Bush, ignoring the advice of his doctor, doggedly returned to his duties [believing to do otherwise would be discourteous to his hosts]. Still, the Secret Service was quietly warned that he might not make it through the meal. He didn’t.” The President and First Lady were seated with the Japanese Prime Minister in the center of a large u-shaped table in a room of 135 invited guests (all, themselves, VIPs). Part-way through dinner, the President became pale enough that his senior Secret Service agent became concerned and approached him at the head table. The President vomited, and fell to his host’s lap as the agent eased him to the floor. As the President’s daughter, Doro, describes it: “…Dad was unconscious for about three seconds before his doctors and nurses revived him. Paula Trivette, a very able Army nurse, literally vaulted over the table to get to Dad. Dr. Lee [Dr. Burt Lee, the President’s personal physician] opened his tie to get him some air, then he unzipped Dad’s trousers—which obviously caught Dad’s attention. ‘Burt. What the hell are you doing down there?’ Dad asked. Hearing this, Mom [The First Lady of the United States, Barbara Bush] turned to the crowd and said, ‘I think the President is going to be fine.’” (The President, for his part, as reported by Newsweek, “…quipped to his personal physician… ‘Roll me under the table until the dinner’s over,’ Burt.”) The President’s daughter notes that her mother’s comments “…helped to reassure everyone that the situation was not as serious as it might have appeared on TV.” Nevertheless, “…The images that [the] camera position caught of Dad fainting and being helped to his feet were soon beamed to the waiting world, and caused a global stir. What was left unreported was that almost half the press corps had also come down with the same flu. I was at the other end of that beam, in Bethesda, Maryland…out of habit, I turned on CNN. It was there
I saw over and over again, Dad fall over at the Japanese dinner.” Newsweek, after reviewing the video, reported that the “…site of Bush passing out and vomiting was truly frightening to those around him, especially to his normally stoic wife. Even the snippet that was publicly aired, showing the president prostrate and gray with nausea, shocked the American people.” The President’s daughter continues with what she describes as a “morbidly humorous postcript…Since the dinner that night was closed to the press, many of the working media members and camera people went to a Tokyo restaurant that night—all gathered in a single room. Clearly, there was a miscommunication as to what had happened to Dad, because a hostess entered the room and in that wonderfully formal and proper Japanese way kept saying, ‘Very sorry. Very sorry.’ When everyone quieted down, the hostess then dropped this bombshell: ‘Your President died tonight.’ After a moment of stunned silence, pandemonium broke out as everyone scrambled for the door—fearful that they were missing the story of the century.” Still in the early days of cable news and the 24-hour news cycle, bad could have easily grown disastrous very quickly, and nearly did. CNN’s Headline News anchorman, Don Harrison, based on a fraudulent tip by a caller to the network who had misrepresented himself as the President’s personal physician, began to report the “tragic news” of the President’s death. As the Los Angeles Times reports,3 “…Before Harrison could finish the sentence, an unidentified supervisor yelled ‘Stop!’ from off-camera. Harrison then corrected himself and read a different report merely stating that the President was ill.” Newsweek continued, “The image brought to mind the picture of [US President] Jimmy Carter, staggered by heat exhaustion as he stumbled along in a road race near Camp David in 1979. That grisly picture became a metaphor for a failed presidency; it haunted Carter right through his loss to [US President] Ronald Reagan in 1980. Democrats, naturally, were eager to make the videotape of Bush’s Tokyo collapse tell a similar story. ‘He’s almost a metaphor for a sick, wobbly economy looking for a Japanese pill to make him recover,’ said Mike McCurry [later Assistant to the President and Press Secretary for President Clinton, President Bush’s campaign opponent]….” Twenty-five years later, Newsweek reprised the story describing the impact of what, medically speaking, was of little consequence. USA Today later reported the incident as one of the “Top 25 memorable public meltdowns that had us talking or laughing or cringing over the past quarter century.”4 The Encyclopedia of Political Communication noted that “The incident caused a wave of late night television jokes and ridicule in the international community, even coining Bushu-suru which literally means ‘to do the Bush thing.’”5
1
Koch D. My father, my president: a personal account of the life of George H.W. Bush. New York, NY: Warner Books; 2008. p. 380–5. McDaniel A. 25 years ago today, George H.W. Bush vomited on the prime minister of Japan. Newsweek, January 8, 2017, http://www .newsweek.com/25-years-ago-today-george-h-w-bush-vomited-prime-minister-japan-538581. 3 McDougal D. CNN averts hoax about Bush’s ‘death.’ Los Angeles Times, January 10, 1992, http://articles.latimes.com/1992-01-10/ entertainment/ca-1610_1_cnn-s-headline-news. 4 Keen J. They did what, said what? USA Today, May 7, 2007, https://usatoday30.usatoday.com/news/top25-meltdowns.htm. 5 Kaid L, Holz-Bacha C. Encyclopedia of political communication, vol. 1. Thousand Oaks, CA: SAGE, Inc; 2008. p. 72. 2
integral to the success of the mission, and vice-versa. Furthermore, the health, wellness, and performance of the support team can impact the principal and mission success as well. As proxies for the President, they too, are potential patients. As the historical case of Bushu-suru demonstrates, even a minor threat to the health of the President and his travel team, can have global visibility and far-reaching consequences (Box 30.1). The Man. The Mission. Medicine. (and The Media.) How much Bushu-sura, a relatively minor medical anecdote, clinically speaking, contributed to the public’s perception of the President, and the President’s
eventual defeat, will never be known. Moreover, while supporting Presidential diplomatic missions may be extreme examples of mission-oriented VIP travel medicine, the lessons learned illustrate its importance, and the key concepts of theses missions can inform the medical support of all VIP travelers, presidential or otherwise.
OPERATIONALIZING VIP TRAVEL SUPPORT Operational planning for VIP travel medical support is a rigorous, time-consuming, detail-oriented process. Perhaps the first step in
CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine operational planning, one fundamental but not unique to military doctrine, is to “plan to plan” (Table 30.1). The basic components of an operational plan include a medical threat assessment, medical threat countermeasures, resources and requirements, an “exit strategy,” and a communication plan. Before developing the medical support plan, however, the physician must first have a solid understanding of the patient, the mission, its requirements, and available resources. While beyond the scope of this chapter, answers to the basic questions, “Who, what, when, where, how, and why?” will bring focus to that understanding and inform planning.
TABLE 30.1 Operationalizing VIP Travel
Support—The Plan’s Plan
• Identify the leader • Define the objective • Identify resources and requirements • Develop the plan • Address resource deficiencies and unmet requirements • Identify and address potential obstacles to mission success • Develop contingency plans • Communicate the plan to key stakeholders • Execute the plan • Adapt and reengage • Redeploy, recover, and learn for the future
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Medical Threat Assessment and Countermeasures The medical threat assessment (MTA; Table 30.2) is a comprehensive evaluation tool that provides a standardized mechanism for identifying and stratifying potential threats to the health and safety of the traveler. Only when the medical threats have been identified, contextualized, and stratified can recommended countermeasures follow. The document is an essential component of the medical operational plan and is tailored to the individual traveler and to the specific mission. It may represent only one annex among many other nonmedical operational support annexes to the larger mission plan, and serve several functions. It provides a flexible framework by which to aggregate information and can be used as a checklist to ensure that appropriate preventive measures are implemented during the planning phase of each trip and reduces the likelihood of missing critical details in the planning of the operational phases of a mission. The MTA is also a common language document that can be shared among mission partners to create an overall “common operating picture.” It should identify information intended for “situational awareness only” (aka “for information only”), as well as that which is actionable. Depending on the nature and complexity of the mission, planning window, and risk, a web-based, subscription-based, telephonic, and/or onsite survey of the actual destination may permit a better understanding of potential threats and risk mitigation strategies. A comprehensive assessment of destination medical resources is best conducted through face-to-face meetings with local hospital administrators, emergency medical service (EMS) personnel, nurses, and physicians. Prehospital,
TABLE 30.2 Medical Threat Assessment Medical Threat Assessment Behavioral Emergency contact numbers
Environmental risks
Evacuation
Food and water safety Infectious disease risk
Medical assets Preexisting medical conditions Trauma/violence
Examples • Plan/address travel-related fatigue, jet lag, alterations in sleep hygiene, diet, constipation; cultural considerations • Embassy or Government resources or contact • Hospitals • Evacuation services • Alternate transportation sources (helicopter, ferry, etc.) • Weather-related concerns (e.g., heat/cold exposure, rain, high/low humidity) • Altitude (see chapter 42) • Air quality • Envenomation and wildlife (see chapter 48) • Transport mode: local assets, team vehicles, air options • Locations of critical facilities: with specific capabilities and evacuation routes to regional referral hospitals • Transport times to local and regional hospitals • Terrain limitations (e.g., mountains, bodies of water) • Potability of local/hotel tap water, strategy for water purification (see chapter 5), alternative sources of trusted water and food • Vector-borne disease • Respiratory and other communicable disease (see chapter 59) • Blood-borne disease • Recommended and required travel and routine immunizations (see chapters 10–12) • Chemoprophylaxis requirements (e.g., malaria) (see chapter 15) • Local hospital quality, capabilities and access to pharmaceuticals (counterfeit prevalence), blood products, advanced care • Fitness for travel: Principal and team member baseline health and underlying medical conditions (diabetes, hypertension, coronary disease, etc.) • Motor vehicle safety • Civil disorder • Targeted violence (e.g., assault, assassination, kidnapping) • Mass casualty incidents (acts of terrorism)
From Band RA, Callaway DW, Connor BA, et al. Dignitary medicine: adapting prehospital, preventive, tactical and travel medicine to new populations. Am J Emerg Med 2012;30(7):1274–81.
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emergency, acute, interventional, and definitive care services (especially cardiac, stroke, and trauma care capabilities) should be evaluated as well as those specific to the traveling VIP, ancillary and diagnostic services, and medical evacuation options. It can be especially helpful to trace the physical pathway taken by a severely injured or seriously ill patient from the point of arrival to stabilization and treatment to eventual evacuation. These visits can also build lasting relationships abroad, which can provide real-time operational assistance and situational awareness of unanticipated or evolving threats, and may be determinative to the success of the mission at hand, or in the future. In the end, contingency hospitals should be designated based on their quality, relevant capabilities, proximity, accessibility, and security considerations.
Communicate: Translating the Medical Threat Assessment Into a Medical Travel Advisory Once the physician has identified, analyzed, contextualized, and stratified destination-specific health risks to the VIP traveler and mission, as well as recommended risk mitigation countermeasures, he or she should be prepared to communicate this analysis to the VIP and subsequently to any additional support or security staff or members of the traveling delegation. Web-based publications (e.g., Shoreland Travax) may inform the analysis, but ideally, the process should begin with a face-to-face conversation with the patient regarding risk and risk comfort. At a minimum, the following questions must be addressed: • Can the traveler safely participate in the mission (i.e., fitness for travel)? • How can traveler risks be minimized? • How can the probability of mission success be maximized? The conversation should be supplemented with a detailed but relevant document (a “Travel Advisory”) that will become part of the medical record. The advisory should inform the traveler of all relevant travel risks, proposed countermeasures (and risks inherent to those countermeasures, e.g., medication side effects), and action timelines. It should also identify medical contingency resources and points of contact for access to care before, during, and after travel, especially if the VIP will not be accompanied by medical support personnel. The advisory should be authored with an awareness not only of the intended audience (VIP, fellow travelers, support personnel), but also of any potential medical-legal ramifications (e.g., patient-physician relationship, explicit or implied). When possible the medical advisory should be published early enough in the planning window to permit stabilization of preexisting medical conditions (potentially impacting or impacted by travel or prescribed countermeasures); immunizations for vaccine preventable illnesses; chemoprophylaxis (e.g., malaria); “groundtesting” of medical countermeasures novel to the patient (e.g., jet lag management medications); and, in the case of fellow travelers/support personnel, consultation with their personal physicians. In addition to a comprehensive advisory, many VIP travelers will also appreciate a one-page fact-based “executive summary.” Electronic communication of the advisory not only permits timely “stand-off ” delivery of the information (sensitive to the traveler’s often-limited availability), but also provides time-stamped documentation of advice and “informed-consent.”
Support Requirements After having discussed the potential travel risks and proposed countermeasures with the patient, the physician should have an understanding of the risk comfort level of the informed VIP traveler. Ever mindful that patient perception may be as important as clinical reality, the patient-driven risk-benefit analysis may include: • Risk comfort—What is the level of risk with which the informed traveler is comfortable?
TABLE 30.3 Spheres of Travel and
Contingency Care
• Patient education • Travel-related preventive care • Patient advocacy and medical liaison • Ongoing primary care • Travel care • Comfort care • Acute care • Specialty care consultation • Emergency care • Intervention and stabilization • Medical evacuation • Definitive care • Centers of excellence • Recovery care
• Mission impact—What is the absolute and relative risk, and how does it potentially impact the mission? What is the potential risk of proposed countermeasures and planning options, and how could they impact the mission? • Independence—To what degree is the traveler willing to rely on external medical resources in the event of a medical contingency? • Patient-physician relationship—What is the comfort level of the traveler with the presence of any accompanying medical support personnel? • Privacy—Does access to care under the proposed options protect or potentially compromise patient privacy, discretion, and confidentiality? What is the impact of potential compromise? • Quality, access, convenience, and comfort—Is access to high-quality contingency or accompanied medical care easy, available, timely, and comfortable for the traveler at all times and in all places? • Security—Do proposed care options potentially compromise or protect information, communication, operational, personal, or mission security? • Is the VIP aware of the risks and the alternatives (e.g., telemedicine, medical travel kits) to an accompanying provider/healthcare team if he or she decides against medical escort? Medical requirements and resource solutions will be driven by risk stratification, mission impact, local resource availability, and the answers to the above questions. A risk-benefit/cost-benefit analysis of medical options must be undertaken at every relevant clinical level of required and contingent medical support (including quality, scope of care, clinical capabilities, availability of care, access to care) as noted in Table 30.3.
The Plan After talking with the traveler and completing the above exercise, the medical planner should now understand the medical “requirements” necessary to support the mission. Proposals for both the minimal and the optimal levels of medical support necessary for a safe and successful mission, as well as a contingency plan in the event circumstances exceed planned and available capabilities, should be built. The plan should be patient centered, mission oriented, contextualized, actionable, and impactful.
Nothing More, Nothing Less With an understanding of the desired independence from local, external medical resources, and the availability and quality of those resources, the medical planner must next address potential capabilities gaps. The key to medical contingency planning is to match resources
CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine to requirements; the right problem with the right solution: the right person, the right place, the right time…nothing more, nothing less.
Right Problem. Without an accurate understanding of the problem at hand, it becomes exponentially more difficult and merely a matter of chance to arrive at the correct solution. Failure to anticipate and prepare for the problem will handicap the best of intentions and practices. This entire textbook, as well as the processes discussed in this chapter, is designed to equip the physician to properly anticipate, identify, and address the “right” problem.
Right Person. One of the greatest threats that the provider may face when caring for a VIP traveler is the threat of his or her own desire to please the VIP or validate the medical team’s value in the face of other support personnel—that is, saying “yes” when the more appropriate answer is “no” or “I don’t know.” When confronted with one’s own limitations or externally imposed limitations, every problem may begin to look like one that the provider “should” be able to address at that time, in that place. A steady focus on the patient’s best interests may mean that the right person’s greatest strengths include: • Knowing one’s own limitations, that is, when help is needed (“Am I the right person to address this problem?”) • Knowing where to get help • Not being too proud to ask for assistance Right person: expeditionary medical staffing. It has been said that the right time to fire somebody is before you hire them. Returning to our example of the VIP Travel Medicine prototype, the recruitment and selection of a new member of the White House Medical Unit was designed to do exactly that, that is, avoid hiring the “wrong person.” This principle should also be kept in mind for the staffing of any other VIP medical support team. But, even at the White House, despite candidates having been rigorously prescreened and preselected by the most-senior levels of the military services, despite an arduous internal selection and security clearance process, and despite a comprehensive training program, it was the exceptional candidate who not only survived but actually thrived in the zero-error atmosphere of the White House. This reiterates that there are many characteristics (intellectual, social, emotional intelligence, situational awareness and planning, etc.) requisite for success in this role and those like it. More often than not, the characteristics that best predicted excellence over time were not the “tangibles” of academic pedigree, clinical credentials, military or academic rank, training, or accomplishments. It suffices to say that clinical excellence was a “given”—necessary but not sufficient. Instead, the difficultto-quantify “intangibles” that characterized the man or woman with “The Right Stuff ” were revealed in the individual’s attitude, demeanor, and motivation; their willingness and ability to anticipate the needs of others; to be a “team-player,” readily subordinating their own best interests to those of their patients and the mission—to manage their own ego; to be the right person. Your patients deserve nothing less. Staffing options: right training. To our knowledge there are no formal training programs in VIP travel medicine (at the time of this writing). Much of the body of knowledge is built on the experience of White House, State Department, military, and other physicians who have traveled extensively with dignitaries, including current and former heads of state, members of royal families, professional sports, and entertainment celebrities, senior military officers, diplomats, and ultrahigh net worth individuals. That experience has demonstrated that the patient and the mission are best served by a physician with a diverse knowledge base and technical skill set who maintains proficiency across multidisciplinary core competencies. The physician must possess a working knowledge of both primary care medicine and acute care/emergency medicine. Sound diagnostic and decision-making skills (often in the face of
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uncertainty, competing priorities, and incomplete information), the ability and desire to work as part of a team, the confidence to make unpopular medical recommendations in the face of authority, and the ability to think “outside the box” and function comfortably in medically austere environments without the benefit of advanced diagnostics, are all essential attributes. The VIP travel physician must maintain competency in practical procedural skills. It may also be helpful to have a working knowledge of relevant communications equipment, evacuation platforms, and casualty movement techniques. These individuals will posess a broad working knowledge of the most likely medical situations, as well as the ability to intervene and stabilize the acute, urgent, or emergent situation. Moreover, they are likely to be comfortable practicing in an environment with few support staff, little ancillary or logistical support, and in an environment where more advanced specialty care might be inappropriate or potentially deleterious to the patient’s best interests. Those supporting VIP travel care should also consider additional training, certification, and practice in areas such as advanced cardiac and trauma care, advanced airway management, prehospital care, travel medicine, operational medicine (flight, dive, wilderness, tactical), basic dental care procedures, and chemical, biologic, radiologic (CBR) training. All supporting practitioners should maintain sufficient clinical currency to inspire and deserve confidence…both in perception and reality. Lastly, the planner must be mindful of any existing medical-legal and cultural considerations in providing medical support while traveling in the given location. Licensing, credentialing, and medical liability must be considered, as must the ability to liaison with the local health care system/personnel especially when traveling abroad. Staffing options: right team. If the VIP travel medicine provider is fortunate enough to serve alongside other medical professionals as part of a medical support team, he or she must possess an understanding not only of his own limitations, but also an appreciation of the complementary skill sets that the other team members (medical and nonmedical) bring to the mission, including the nurses & physician assistants (PAs) and/or medics in the White House Medical Unit, and other VIP protective details. Much of the success of the White House Medical Unit could be attributed to the early recognition that nurses or midlevel providers brought a skill set, training, relationship, and approach to medicine and, more importantly, to their patient that physicians did not, would not, or could not provide. It suffices to say that a high-functioning integrated clinical team best serves patient and mission, and gives proof to the adage of “the whole being greater than the sum of its parts.” It also provides the greatest opportunity to, appropriately, remain independent of external medical resources until absolutely necessary. Team makeup will ultimately be determined by the VIP, on the advice of his or her physician and additional relevant nonmedical mission team members (e.g., security). Considerations informing that decision are largely those already addressed: risk, risk comfort, and the desired degree of independence. With decreasing probability of reliance on organic host resources in a medical contingency, potential staffing solutions for the VIP traveler may include those noted in Table 30.4.
Right Equipment. As with virtually all of the travel support planning process, trip resourcing is driven by patient needs and preferences, the mission, actual risks and actionable countermeasures, staffing, and other available resources. One of the most commonly encountered challenges is balancing anticipated medical needs with mission priorities, with the logistical constraints inherent to travel. While the focus of this discussion will be equipping a solo provider, the spectrum of equipping options from least to most comprehensive might include those in Table 30.5.
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TABLE 30.4 VIP Travel Medicine Staffing
Options
• Patient education, self-care, and medical logistic support with reach-back (telephone, email, telemedicine) to “medical control” • Nonmedical (e.g., personal aid or security) traveling support with reach-back to medical control • Basic medical (EMT, paramedic, RN) support with reach-back to medical control • Midlevel (PA-C, NP) provider with reach-back to medical control • “Operational physician” provider (no preexisting relationship) with reach-back to physician of record • Physician of record (i.e., preexisting patient-physician relationship) • Physician of record with medical support team • Prestaged • En route • Additional ancillary medical professionals (e.g., physical therapy)
TABLE 30.5 VIP Travel Medicine
Equipment Options
• Self-aid kit to be carried by traveler • Expanded “self-aid” kit to be carried and administered by nonmedical team members • Augmented aid kit for use under advice of remote medical control (telephone, email, telemedicine) • Accompanying lone physician or physician extender kits oriented toward continuing care (for preexisting conditions), acute care (addressing “most likely” scenarios), and interventional care (addressing scenarios for which treatment delay may result in significant adverse impact) • Expanded diagnostic and interventional care kits carried by a physician and nurse team—complementary capabilities with intentional minimal duplication • Comprehensive, potentially definitive, care (comprehensive care kits prestaged on transport platform and/or at destination meeting or residential sites) • Mission-designed treatment platform (e.g., on aircraft, water vessel, tactical ambulance)
A comprehensive analysis of equipping each and every possible permutation would not only be beyond the scope of this chapter, but unwise. The supporting provider must be prepared to handle an array of medical contingencies within the limitations of travel space, weight, budget, and, most importantly, sound medical practice. Specific types and quantity of supplies will be guided largely by the dignitary’s medical history; the intended destination(s) and attendent risk; anticipated duration of travel; the number and health of any accompanying proxies (guests or support personnel); the quality, availability, and sophistication of local medical facilities and resources; and mode of transportation. Equipment must be compact enough to be easily carried, be readily accessible, and must not invite unneccessary attention. Storage space (aka “the cube”) can be “minimized to maximize” by means of prioritized packing, modular kit design, and maximal utilization of dual-use equipment. Prioritized packing requires knowledge, forethought, experience and empathy. Each stakeholder on the travel team may have a different view of priorities, and each of those views may change with the particular demands of any given moment—or even the meaning of the moment. The medical provider must anticipate both the imminent and future
needs of the travelers that they support—even before the travelers themselves are aware of, or react to, the need. With that in mind, priorities in packing can be grouped by stakeholder priorities: Primary Patient Priorities—These priorities are based on knowledge of the primary patient’s medical history and personal preferences. They may address ongoing or continuing care needs as well as reasonably anticipated acute and comfort care needs specific to the individual (e.g., backup supplies of chronic and travel-related prescription medications, corrective lenses, preferred sleep aids, most recent electrocardiogram [EKG]). Also of note, “mission impact” must be considered in the provider’s decision to intervene or prescribe medications for these patients earlier, prophylactically, or where otherwise not often utilized (e.g., travelers’ diarrhea prophylaxis, “sleeping pills,” “wakefulness-promoting agents”). Proxy-Patient Priorities—Thoughtful preparation for the most likely needs to arise in day-to-day life “on the road” or that would otherwise distract, discomfort, or introduce needless delay, and the ability to discreetly address those needs in real time for all team members (even if only as a stop gap until a more appropriate time and place for a more throrough evaluation and treatment), go far in inspiring confidence, enhancing performance, and increasing the likelihood of mission success. Examples include: over-the-counter (OTC) or prescription remedies for upper respiratory or genitourinary infections, analgesics, bandages, surgical glue, and even “tweezers.” Traveling Physician Priorities—These represent urgent, emergent, or evolving conditions that, although unlikely, require immediate diagnosis and rapid field intervention to achieve greatest impact without incurring even greater risks; to prevent imminent or ultimate clinical deterioration, harm, or death; or to evacuate the patient to an environment better suited to address clinical unknowns and potential complications. Epidemiology and impact will guide packing priorities (e.g., automated electronic defibrillator [AED], airway adjuncts, hemostatic dressings, tourniquets, cervical collars, needles for chest decompression, chest seals, aspirin, nitrates, epinephrine). Packing can also be prioritized by considerations: high frequency; high acuity; or even “high meaning”—all with high impact. Regardless of the method used, one can see that “prioritized packing” readily lends itself to a modular medical kit design (e.g., emergency care, acute care, and personal care), each of which can contain submodules (e.g., airway, breathing, circulation). Modules permit rapid, easy, and discreet access to items needed—and only the items needed—at that specific moment. Modular design enhances provider familiarty and confidence in a “medical moment” that may already be stressful, and instills confidence in the patient and the unavoidable onlooker. It reinforces an intuitive, mission-oriented way of thinking that permits further customization during and between missions and allows for easy inventory and repacking at the end of the day and at the end of the trip. Lastly, the modular, mission-oriented approach reinforces (and perhaps even “enforces”) behaviors to counter the tendency to overpack, as discussed below. For prolonged or remote missions, redundant, bulky, or more comprehensive supplies may be prestaged on the transport platform (e.g., car, ship, airplane) or destination meeting/residential sites for utilization as/when/where appropriate. It is imperative that the medical team coordinates with security and transportation teams to ensure access to prestaged gear in the event of an emergency. This in turn allows the medical team the agility to travel only with a lightweight, consolidated medical kit. Common pitfalls. Given the nature of physician personalities, and the unknowns of most missions, “overpacking” with the intent of understandable desire to address every possible contingency no matter how unlikely is exceedingly common, especially among physicians who
CHAPTER 30 VIP Traveler: Mission-Oriented Travel Medicine are new to VIP medical support or who are new to the particular patient or team. Overpacking can make it difficult to access the items necessary to treat the most common—or worse, the most urgent—scenario, especially under duress. Overpacking also makes it much more difficult to maintain the familiarity with the inventory that is necessary for a rapid, confident response. Moreover, the perceived lack of discretion, mission understanding, or sense of proportion by an asset whose mission is not often readily understood by the VIP or mission partners, can lead to isolation by either or both. The very fear of failure that drives such physician decision making virtually ensures it. At times, the most difficult decision is not what medical resources to carry, but what not to carry. Furthermore, carrying equipment that permits or encourages practice beyond the scope and ability of the provider/team, or the environment, or the ability to manage second- and third-order consequences invites medical, legal, and reputational harm. The very presence of such resources can place an undue temptation on the provider to employ those resources even when medically inappropriate (e.g., beyond the provider’s skill comfort level) or invite criticism as to why the provider had the resources available but chose not to utilize them. When equipping a medical team, material resources should be appropriate for professional qualifications, training, currency, and comfort. Except for a small nucleus of planned, intentionally redundant capabilities, equipment carried as part of a team should be complementary thereby serving as a “force multiplier” enhancing and expanding the scope of care, and decreasing dependency on exogenous medical resources. Most physicians have little difficulty identifying resources requisite for an emergency. It should, however, also be clearly understood that seemingly trivial but commonplace medical issues can have significant impact or meaning for the patient or other members of the traveling party. These common medical problems are frequently overlooked while planning for less common life-threatening emergencies. To do so is a serious oversight, from which it is sometimes difficult to recover. The use of a standardized predeployment checklist of medications and medical supplies can ensure adequate preparation for these common but less dramatic medical issues. Faithfulness in these “small things” is precisely what builds the relationship, trust, confidence, and perceived mission relevance necessary to be the present and proximate solution for the medically “big things.” One final summary note bears repeating when considering the “right equipment.” As already noted, the presence of trip medical personnel is often not understood by the VIP and mission support teammates—that is, until the VIP and teammates discover that they need medical assistance. Supplies, medications, and equipment should be sufficient, and sufficiently available, to confirm value-added support when and where called upon, but not so robust as to invite unwanted attention, criticism, or “value-subtracted” support. The provider must be self-confident enough to understand both his or her place and value while navigating a potential no-man’s land of irrelevance, too-little-too-late, and too-much-trouble-to-bother attitudes.
Right Place, Right Time. Because the VIP and supporting colleagues do not necessarily understand intuitively the value added of medical support personnel, if the VIP has asked for onsite medical support (as opposed to remote medical support by phone, email, or telemedicine), it is important to help him or her understand the impact of the provider’s physical proximity on managing care, expectations, and responsiveness to those expectations either acutely or in an emergency. Locations where those expectations might reasonably enter into play include while in transit (e.g., vehicle/motorcade, plane, yacht); in residence (e.g., hotel, private residence, or nearby); and in situ (e.g., during mission events, meetings). Other support team members (e.g., security) may also have
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requirements in this regard. If medical support personnel are expected to be immediately available, onsite, in real time, at all times and in all places (aka “velcroed” [as in Velcro]), then it is important to remain as discreet as possible—“available but invisible” but also “just in time.” If not “velcroing” the principal, the VIP and the support team must also know how to contact the provider, be aware of the expected delay in response, and provide transportation and access to the VIP. Rested and ready to respond. Just as with mission colleagues who carry weapons (i.e., security personnel) the medical support for the traveling VIP must also be rested and ready to respond when “the balloon goes up.” The nature of the mission, the expectations of the VIP, and the availability of resources (e.g., financial, logistics, transportation, lodging) will dictate the level of staffing necessary to ensure responsiveness and readiness—and adequate to defend real-time decision making to potential after-the-fact inquiries. Right environment. The risk of too much—training, qualifications, capabilities, equipment, medication, personnel—can sometimes exceed the risk of too little. In such a situation, the adage, “Just because you can, doesn’t mean that you should,” might apply. Not every travel environment can or should be able to support every intervention of which the provider may be capable in his or her own emergency department, cath lab, etc. Not every environment will be conducive to rapid sequence intubation and advanced airway management when other options will suffice (e.g., back seat of an armored limousine fleeing “shots fired”). Tissue plasminogen activator (tPA) may not be in the patient’s best interests at 35,000 feet with a one-person medical “team.” The environment must support not only the appropriate skill set but also the potential complications of that skill, treatment regimen, or medication.
KNOWING WHERE TO GET HELP: HOST COUNTRY SOLUTIONS By its very name, the purpose of medical contingency planning is to plan for the unplanned—the “what-ifs.” Contingency planners and other team members must have a thorough working knowledge of all available resources once mission-owned medical capabilities can no longer act in the best interests of the patient or the mission. Whether the decision to elevate care is triggered remotely, en route, or onsite, the answer to “What’s next?” should already be known. From departure to return, from “wheels up to wheels down,” the provider who supports the travel mission of the VIP must have a plan for elevating medical capabilities whenever and wherever necessary, for every medical need along the contingency care spectrum (Table 30.6). At a minimum, those answers should already be contained in the contingency plan and will include the data points outlined in Table 30.7.
TABLE 30.6 Contingency Care Spectrum • Preventive travel care • Continuing care (primary care) • Pharmaceutical support • Ancillary and diagnostic support • Specialty care • Urgent care • Emergency care and stabilization • Definitive care • Centers of excellence (including trauma centers, chest pain centers, stroke centers) • Medical evacuation
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TABLE 30.7 Next-Level Medical
Contingency Resource Data Points • Resource/facility identification (name) • Location • Proximity (“time to target”/time en route) • Relevant capabilities and deficiencies • Quality of care • Accessibility • Modality (private vehicle, ambulance, rotary wing aircraft, fixed wing aircraft) • Entry control point or point of access • Availability • Operating hours • Financial considerations • Communication—point of contact (e.g., phone number) • Name and location of contingency resource “next level of care”or western-style care
WHAT NEXT? EVACUATION PLANNING When it is no longer in the patient’s best interests to remain “on mission,” in country, medical evacuation is indicated. The decision that needs to be made may be difficult but is also quite straightforward: Are the risks of staying greater than the risks of going? Optimally, the information necessary to facilitate rapid, real-time decision making should already be in hand as part of the contingency planning process. Additionally, good practice and attention to detail dictate that the information and plan should be reconfirmed immediately upon arrival, well ahead of any contingency need. As already noted in Table 30.7, it is imperative to know the destination of the nearest, most appropriate medical care and the relevant resources available there (as well as relevant deficiencies). Additional critical information includes location (address and GPS grid coordinates); availability, proximity, adequacy of airports and helicopter landing zones (LZ); distances and travel times to these facilities; and relevant points of contact at these locations. Likewise, an “exit strategy” (i.e., medical evacuation options) should already have been part of the contingency plan. The plan should identify and integrate optimal transport and evacuation routes to the care destination from every point on the itinerary. The VIP medical provider should consider real-world factors that may impact evacuation time, such as security assessments, road conditions, limitations of locally acquired vehicles, weather, and any potential barriers to transportation, such as roadblocks and checkpoints. Choosing the most appropriate evacuation mode may require information such as the routine flight schedules, roundtrip time by air (if an air ambulance must be summoned), size and capabilities of the aircraft, and realistic ground transportation options. Risks inherent to the mode of transport itself along with in-transit care capabilities and limitations must be factored into the risk-benefit analysis. Depending on the mission, it may be reasonable to rely on local EMS resources for transport.1,2 However, in other situations this may not be possible or safe (e.g., delays in waiting for EMS arrival to a remote or otherwise inaccessible location, the lack of discretion when a patient is transported by EMS, quality concerns, or security considerations, etc.) Depending on the setting, extraction by medevac helicopter may be a
consideration. Rotary wing evacuation is complex and requires at least a scene security assessment, a feasibility determination for establishing a safe LZ, and knowledge of the receiving facility’s ability to accommodate the designated aircraft onsite or nearby. In the end, military doctrine teaches, “No plan survives first contact with the enemy.” Even with extensive planning, the physician must be prepared to manage the patient for a prolonged period.1,2
OPERATIONAL SECURITY: DON’T BECOME A LIABILITY Discretion and patient confidentiality are core principles of the physicianpatient relationship. In VIP travel medicine, violations of this trust can have unique consequences, such as compromising mission security and personal safety. Mission-specific details such as travel plans and routes, overnight locations, transportation methods, schedules, and off-therecord stops can be exploited by adversaries. Therefore all trip-related information should be considered privileged and should only be distributed in consultation with the protective services detachment. The VIP travel team often will operate in environments with significant information gaps and multivariate threats.
Economics of VIP Travel Medicine Support The costs associated with a VIP travel medicine support team can be significant. However, the costs associated with a failed mission, or compromised VIP are likely many times greater. Medical equipment, salary, and travel expenses of a medical provider who can function and make decisions in a resource-limited setting must be weighed against an illness that prevents a crucial meeting, results in lost work productivity, creates a politically sensitive situation, and/or requires emergency evacuation, all of which may be exponentially more costly.
CONCLUSION In this chapter we have examined the “special healthcare needs” of a group of travelers most known to the world as VIPs. While medically mere mortals, their mission, position, and impact on society may significantly affect their healthcare. As with the general practice of medicine, the practitioner of “mission-oriented medicine” is, therefore, well advised to assess the patient’s preferences and priorities (the “mission”), and threats to those priorities, that is, a medical threat assessment. Resulting threat countermeasures, resources and requirements will inform development of medical contingency plans, and a medical advisory that is then communicated to the patient-traveler. The VIP traveler may also be accompanied by nonmedical support personnel who may be impacted by, or become beneficiaries of, mission medical support. In the end, whether a VIP or “just another P,” the underlying medical “mission objective” is always the same: to understand our patients as people, “meet them where they are,” and truly care for them.
REFERENCES 1. Band RA, Callaway DW, Connor BA, et al. Dignitary medicine: adapting prehospital, preventive, tactical and travel medicine to new populations. Am J Emerg Med 2012;30(7):1274–81. 2. Christopher F. Medical support to military operations on urban terrain. In: Schwartz RBMJ, Swienton RE, editors. Tactical emergency medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. p. 44–9.