Mitigating Risks for Medical Evacuations November 13, 2018 Dr. Ken McDonnell Medical Director & Vice President International SOS Government Services The information contained in this document is the property of International SOS and further dissemination is prohibited without the written permission of International SOS.

Proprietary and Confidential Business Travelers' Perspective According to a recent survey of US and UK business travelers: 38% said they never do any research on the countries they visit. 78% said they never carry an emergency phone number. 86% of travelers believe their firm has a legal obligation to support them while abroad. 50%+ would consider taking legal action in the event of an emergency being mishandled. (Business Travel Report) Proprietary and Confidential

Proprietary and Confidential The Reality Based on a study of health problems experienced by 100,000 individuals who traveled to a developing country for one month, the following could be expected to occur: 50,000 will develop some health problem 8,000 will see a doctor 5,000 will be confined to bed 1,100 will be incapacitated in their work 50 will be admitted to a hospital 30 will be evacuated 1 will die Steffen, R. et al.: "Health Problems After Travel to Developing Countries,” Journal of Infectious Disease (1987) 156, 84 Proprietary and Confidential

Proprietary and Confidential Hostile/High Medical Risk Areas LOW RISK HIGH RISK International Medical Cases 1 in 68 1 in 21 International Hospitalizations 1 in 824 1 in 137 International Medical Evacuations 1 in 6,325 1 in 268 Proprietary and Confidential

Proprietary and Confidential Global Health Trends: Evacuation and Repatriation Proprietary and Confidential

Proprietary and Confidential Air Ambulance Evacuation Data Analysis Top 10 Medical Categories of Cause for Evacuation 32.6 25 11.1 8.7 4.8 3.1 2.4 1.7 1.2 1 5 10 15 20 30 35 Trauma Circulatory system conditions Infectious diseases Digestive/abdominal system conditions Respiratory system conditions Systemic and other conditions Neoplasm Pregnancy and childbirth Nervous system conditions Genitourinary system conditions Mental health disorders Hematological conditions and immune disorders Dermatologic conditions Musculoskeletal system conditions Medical Condition PERCENT 24-Month Review: 2014/2015 Proprietary and Confidential

Proprietary and Confidential Pre-Deployment Medical Screening US CENTCOM Policy Modification 13 Targeted medical history, laboratory testing, physical examination, vaccinations, dental care Remove individuals who are at highest risk for medical complications Travel Risks Trauma Infectious Disease Public Health measures Prompt Medical Advice Cost-effective Patient Movement and Evacuation Options Steffen, R. et al.: "Health Problems After Travel to Developing Countries,” Journal of Infectious Disease (1987) 156, 84 Proprietary and Confidential

Prior to Departure Mobile friendly dynamic content, as seen from a general traveler's point of view Links to your own resources Comprehensive presentation of destination country

Aeromedical Evacuations

Proprietary and Confidential Commercial Airlines vs. Air Ambulance Considerations Cost Fuel Stops Privacy Impact on other passengers (risk of flight diversion) Medical resources (equipment and personnel) MEDIF Commercial Air Ambulance Proprietary and Confidential

Cutting flight time up to 50% compared to air ambulance Keflavik Goose Bay Frankfurt Richmond Larnaca Dubai 06.40 hrs flight time Caracas 09.30 hrs flight time Lufthansa LH 503 Lufthansa LH 629 Ambulance flight Sao Paulo 11.45 hrs flight time 23.00 hrs flight time

No room to medically intervene, if needed If you have a choice, try not to transport a sick patient in Economy Class No room to medically intervene, if needed

Stretcher Options on Commercial Carriers Varies by Airline

The Importance of Immediate Medical Advice From Physicians with Local Knowledge and Experience with Foreigners Quality of Case Outcome Duty of Care Employee Self-referral Exposure Medical Assistance Intervention based on what the employee thinks is wrong Intervention based on what a physician thinks is wrong

Discussion