1. 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?

2. 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?

3. 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.

4. 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.

5. 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

6. I am sure that you all have other similar stories!

7. BACKGROUND Medical Emergencies in Flight 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 occur and The use of MEDLINK. Have we ever been called upon to help?

8. 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.

9. Two organisations monitor what happens; JAROPS Joint Aviation Requirements EASA European Aviation Safety Agency MEDLINK Based in Phoenix, USA

10. 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 diversions AND Provides indemnity for doctors who give advice.

11.  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 –vomiting scalds nausea head injury

12. Medical events3,240 Emergencies19 Death on board1 Required 360 calls to MEDLINK

13. Diversions are expensive – 13 in total. Can cost up to £50,000 and pose considerable safety issues.

14. Cabin Crew Training  Initial course Virgin 5 days Others 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

15. 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

16. After an event the situation is discussed and a few days later there is a debrief.

17. British Airways Top 6 conditions 1.D & V 2.Fainting 3.Asthma 4.Respiratory 5.Cardiac 6.Head injury

18. Remember  Ill people travel  People travelling become ill  Incidents in flight are poorly reported  Doctors can assist  The kit on board is useful

19. Ask yourself 1.Will it wait 2.Am I skilled enough 3.Do I have to act 4.Where will I do it 5.Review the medical kit 6.Listen to the Cabin Crew 7.Think carefully about diversion 8.Keep the Captain informed Remember on Virgin planes ONLY the cabin crew can operate the automated defibrillator

20. 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)

21. 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

22. 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 Rx100% O2 Sit upright Extra pillows Furosemide 40 mgs

23. Older patients can become acutely confused or even psychotic due to decreased O2 on board.

24. 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

25. 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?

26. 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?

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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 done This is available at cost to patient in some Departments of Respiratory Medicine

33. HYPOXIC CHALLENGE pO2 >7.5Don’t need O2 pO2 6.6-7.4A walk test may be needed pO2 <6.6Need 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!

34. 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

35. 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

36. E.g.Travel allowed Major chest or after 10 days abdominal surgery Laparoscopic surgeryafter 4 days or appendicectomy Cardiac surgeryafter 10 days, but preferably 4-6 weeks

37. 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 in advance as best as we can