The Anatomy of a Travel Recommendation: Who is and is not “Fit to Fly” Eugene Delaune, MD Jim Evans, MD

Objectives: Understand basic aerospace principles Understand how these principles effect the human body and some medical conditions Recognize patient who CAN fly despite illness Understand how medical coverage can be taken into account when issuing travel recommendations

Who is Sentinel MED? MDs /RNs who service medical needs of Europ Assistance (North America), individual hospitals, individuals and some travel insurances Specialize in managing medical cases where cost containment is a factor and timing of transport options consider financial consequence of this timing to our client. Getting patient home ASAP after emergent care over most of time. Different managing styles based on client desires/involvement/goals Team of medical escorts run by MD's and managed by RN's - not just an escort provider but manages the case Manage treating MDs - we can talk to them, they know we are monitoring case

Aerospace Physiology

Boyle’s Law

Boyle’s Law: Considerations? Commercial Airlines pressurized to the Equivalent of 6000'- 8000' Body Gases Expand times their sea level volume at this altitude Problem for conditions which result in trapped gas: – PTX, Eye surgery, brain surgery – NOT a problem for non-air containing swelling - e.g. cerebral edema, DVTs

Henry’s Law

The amount of gas dissolved in solution is directly proportional to the pressure of the gas OVER the solution

Oxygen desaturation at altitude Effects of Altitude on Oxygenation Altitude (feet) Atm pressure (mm Hg) PAO 2 (mm Hg) PaO 2 (mm Hg) PaCO 2 (mm Hg) Oxygen saturation (%) Sea level , , , , , , Relevant because, although same mix of gases, there is less pressure the higher you go, so less oxygen gets into blood at higher altitude - if sats 99% at sea level, will drop to low 90ssats

Transport Considerations Patient’s diagnosis, stability and unique stresses / isolation during travel must be considered when determining logistics of the following phases of travel: – Ground, Commercial, AA – Escort – WCHS – O2 – Destination – Timing – Special needs

Travel With Specific Medical Conditions: CARDIAC CAD – spectrum of disease Stents – concern with clotting CABG – postop concerns CHF – spectrum of disease, optimization of patient Pacemaker/defibrillator

PULMONARY Collapsed lung, with or without chest tube Pneumonia URI Pulmonary Embolus/DVT

NEURO Pneumocephalus – air resorbed Stroke – after acute phase resolved Seizures – controlled

Other ORTHO splints, hips, casts PSYCH positive control, willing to travel OPHTHO postops CAVEAT: – No 2 patients are the same – Age, motivation, comorbidites, body habitus, culture… all influence travel recommendation

Insurance Factors Only medically safe options are considered “Emergent”, “Medically Necessary”, “Secondary Coverage”, coverage limits Who is Paying Medical Expenses? Evacuation vs. Repatriation Examples: – Broken hip in Chile Delayed repat commercial if no medical coverage – if initial evac is necessary, we may recommend repat (even if not covered) to save on medical costs) Early repat to home country if coverage at home (age may be a factor for Medicare) – Stable cardiac pre-intervention May travel on own after intervention – Approved Test may just reveal need for further investigation – so early repat to hedge bet

The Anatomy of a Medical Transport

Special Considerations of Flight Expansion of gases (Boyles Law) Hypoxia (Henry’s Law) Dry air Time zones and medication timing No access to outside assistance Dietary requirements Privacy Issues

Transportation Options Air Ambulance Assisted Commercial Air Unassisted Commercial Air

Air Ambulance Providers will help with ground transportation and receiving beds Shop around for quality and cost May be more cost effective to go through broker For longer routes, range can be a factor Minimal space to manage patients Not comfortable

Commercial Airlines Logistical challenges Cost considerations Services available to assist discharge planners with this option Options/configurations: first class, business, stretchers

Is the Patient stable for transport? Will the condition worsen en route? – Same as inter-hospital transfers on ground Has the condition fully been evaluated to the extent of local capabilities? Are there any factors potentially effected by the hypoxic, low pressure environment of commercial aircraft? What are the needs of the patient during transport?

Mode of transport considerations for Mr. Smith Stretcher vs. AA vs. first 300lb patient PRN suctioning, scheduled nebs require special equipment – No alternating current available – Could be hypoxic at altitude – but only low-flow O2 commercial Cost considerations

Travel Arrangements Based on our equipment and staffing, cost considerations, decision to proceed with first class on commercial air Must fly on international aircraft with first class suites Aircraft configuration an issue

Escorts must be chosen prior to making reservations – MD required for possible intubation – Experienced RN for medications, airway/VS monitoring Flight reservations made United Airlines Medical Desk – Request for in-flight O2 – Clearance Arrangement of ground ambos Visas, hotels for escorts, accepting MD Travel Arrangements

SUMMARY Unique environment at altitude has major effect on travel recommendation These factors, together with non-altitude factors and access to immediate intervention must be considered when considering fitness to travel Insurance factors can be taken into account when considering options to move patient NO TWO PATIENTS ARE ALIKE. No algorithms available – a complex, multifactoral recommendation

Questions?