FIT TO FLY??FIT TO FLY??

The medical implications of this part of the

pilgrimage

How can we make the journey there and back as

safe as possible?

I WILL DISCUSS

• The international perspective on medical emergencies in flight

• The preparatory work pre travel

• How do we get accurate information?

• How do we assess the risks pre travel?

Examples

80 year old who forgot to use his nebuliser on return day. By 5.00 pm while plane was taking off he started to wheeze++.

Fortunately we were able to give him a nebuliser straight away.

80 year old who told us at the airport that she had called out a French doctor the night before to see her “dyspnoea”, now on diuretics. ? Recent MI ? Still in LVF.

Had to examine her at the airport and check all was well.

45 year old very anxious. IDDM, epilepsy and

spinal surgery.

• Forgot to take insulin pre flight ± anti-convulsants

• Fitted for most of the outward journey• Require transfer straight to hospital for

Airport • Had a letter from a Neurologist

explaining that Diazepam did not work and that she needed IV MIDAZOLAM to control her fits, which she showed us while in hospital

I am sure that you allhave other similar

stories!

BACKGROUND

Medical Emergencies inFlight course@ Gatwick Airport 2005

• Provides an overview of how to deal with • emergencies in flight.• How airlines record all events in flight.• What facilities they have.• What are the most common problems that occurand• The use of MEDLINK.

Have we ever been called upon to help?

WHAT DID WE LEARN?

A considerable amount of data is available re medical emergencies in flight.

A lot of the data is collated so that airlines can review what happens.

Some diversions are predictable.

It can be VERY difficult to prevent someone from flying, especially if they FAIL to declare they have a problem.

Two organisations monitor what happens;

JAROPSJoint Aviation Requirements

EASAEuropean Aviation Safety Agency

MEDLINKBased in Phoenix, USA

Calls can be made to MEDLINK in flight, usually by the Captain.

Advice is provided – can access up to 45 Specialists on an on-call rota straight away.

Translation service is provided.

Can be contacted pre-flight and prevent a passenger

being allowed to fly. These go to a Global Resource Centre.

MEDLINK advises re diversionsANDProvides indemnity for doctors who give advice.

All requests on board for medical advice require a form to be filled in.

This data should then be collated.

Virgin reviewed incidents in 2004;

50% vasovagal

The rest – vomitingscaldsnauseahead injury

Medical events 3,240

Emergencies 19

Death on board 1

Required 360 calls to MEDLINK

Diversions are expensive – 13 in total.

Can cost up to £50,000 and pose considerable safetyissues.

Cabin Crew Training

Initial courseVirgin 5 daysOthers 2 days

Virgin staff must pass final CPR exam Are trained in the use of First Aid Kits and

Defibrillators All staff have a one day update each year

Flight Crew

1 day initial training

½ day annual review

Have knowledge of emergency and safety equipment and what to do in case of pilot incapacitation

After an event the situation

is discussed and a few days

later there is a debrief.

British Airways

Top 6 conditions1. D & V2. Fainting 3. Asthma 4. Respiratory 5. Cardiac 6. Head injury

Remember

Ill people travel

People travelling become ill

Incidents in flight are poorly reported

Doctors can assist

The kit on board is useful

Ask yourself

1. Will it wait2. Am I skilled enough3. Do I have to act4. Where will I do it5. Review the medical kit6. Listen to the Cabin Crew7. Think carefully about diversion8. Keep the Captain informed

Remember on Virgin planes ONLY the cabin crew can operate the automated defibrillator

Respiratory Problems

Those with decreased O2 at sea level will have problems at altitude

Up to 18,000 feet O2 level is satisfactory Some people will develop symptoms of hypoxia at

10-11,000 feet Pulse oximeter not reliable if patient is anaemic Those who will definitely need O2

- Sickle cell anaemia - Pyrexial - Burns

- Hypothermia - Thyrotoxic (possibly)

Cardiac Patients

Airports are stressful Diastole decreased if tachycardic Decreased O2 Fear of flight Time zone changes Gastric distension DVT Rhythm problems may develop secondary

to decreased O2

Cardiac Patients

Give O2 supplements straight away to cardiac patients and those with chest pain

Remember DEFIB may affect the navigation system. The pilot is warned if it is used

? CCF – will be difficult to hear chest with engine noise

Rx 100% O2Sit upright Extra pillowsFurosemide 40 mgs

Older patients can become

acutely confused or even

psychotic due to decreased O2

on board.

The special features of trips to Lourdes are:

1. We take SICK PEOPLE

2. We use CHARTER AIRLINES

3. It is a SHORT FLIGHT, but the UNEXPECTED ALWAYS SEEMS TO HAPPEN

I WILL TRY TO DEAL WITH SOME OF THESE QUESTIONS:

• Do some patients need oxygen?If so, which ones?

• How do we assess for the journey back, as patients may have deteriorated or had surgery?

• The role of the insurance company?

THE PREPARATORY WORK

1. Do the forms we use give the detailed information we need?

2. Have we enough people to visit those who seem at risk before we accept them?

3. Is the information we are given by GPs or hospital doctors accurate enough?

4. What happens if a patient deteriorates after doctor has given us the information. Are we informed?

THE OUTWARD FLIGHT

• Some patients dislike flying and are very anxious

• Some forget their medications and don’t take them on the day of travel

• Some don’t realise they will not be able to walk the long corridors in Airports

• Access to the plane is very difficult for some and the aisles are narrow

• Some require special seating, which they cannot have on a plane

• Fortunately disembarkation at Lourdes is a lot easier

DURING THE FLIGHT

• On a Jumbo it may be possible to have the sick all together with doctors and nurses nearby

• The unpredicted can always happen ? MI ? CVA

• A new problem may have arisen before the day of travel and the patient may have failed or been unable to see GP

• With early flights some patients omit their medication, e.g. insulin or nebulisers, with adverse effects

THE RETURN FLIGHT

• 6 days of different food, odd hours and some C2H50H may take their toll on all of us

• Usual medications may have been left at home

• Afraid to take diuretics pre travel• Wish to get home, even though quite ill

are they safe to fly?• Have had an acute problem the night

before travel, but may or may not have sought medical advice

• Delays make the whole problem worse

THE THORNY ISSUE

• Who needs O2?• Who needs to be assessed?• Severe COAD or asthma• Pulmonary fibrosis • Cystic fibrosis • H/O air travel intolerance• Pulmonary TB• Those discharged up to 4/52 ago from hospital

with a respiratory illness• Recent pneumothorax • Risk of or previous VTE• Pre-existing need for O2 or ventilator support

At 8000 ft pO2 decreases to 15.1% O2

In healthy adults pO2 decreases to 85-91%Altitude exposure may worsen hypoxia

Normal response to decreased pO2 is:

Moderate hyperventilation and a tachycardia and in some agitation

HOW TO ASSESS A PATIENT PRE-TRAVEL

• History & examination• Spirometry • pO2, blood gases if CO2 retention is

suspected• 50 metre walk test• For those who have pO2 of 92-95% and

additional risk factors, HYPOXIC RISK CHALLENGE should be doneThis is available at cost to patient in some Departments of Respiratory Medicine

HYPOXIC CHALLENGE

pO2 >7.5 Don’t need O2pO2 6.6-7.4 A walk test may be

neededpO2 <6.6 Need in-flight O2 2l/min

• O2 must be ordered well in advance • There will be a charge levied, this varies from

one airline to another (can be up to £400 per patient)

• Will usually be delivered via nasal prongs only• Have to try and ensure that it will be placed near

to the patients who require it!

WHAT CAN WE DO?

1. Full assessment pre flight. This takes time. Ensure we have all the information in advance re nebs, CPAP, O2, hoist etc

2. Ensure hotel sick know they can see one of our doctors

3. Be sure we are made aware of problems on the day of the return flight, so we can assess the patients before they get to the airport

4. Risk assess those who have deteriorated acutely pre travel

We need to understand the rules re insurance cover for flights,

especially for those who have had surgery

BA website provides useful information re most conditions

E.g. Travel allowed

Major chest or after 10 daysabdominal surgery

Laparoscopic surgery after 4 daysor appendicectomy

Cardiac surgery after 10 days, but preferably 4-6

weeks

TO CONCLUDE

It is not always possible to plan for all emergencies pre flight or during flight

However, we must fully assess those who

are more likely to develop problems inadvance as best as we can