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Flight Medicine

Aka: Flight Medicine, Air Travel Restriction, Contraindications to Air Travel, Inflight Emergency

I. See Also

  1. See DVT Prevention in Travelers

II. Background: Air Travel

  1. FAA requires cabin pressure <8000 feet (2438m)
    1. Most airplane cabins are pressurized to 6500 feet (+/- 1000 feet)
    2. 10% of airplane cabins are pressurized to 8000 feet
  2. Oxygen Saturation on airplane drops by 3-4%
    1. May exacerbate patients already hypoxic (e.g. severe COPD)

III. Precautions

  1. Do not remove drainage tubes immediately prior to air travel (risk of significantly increased pressure)

IV. Management: Emergency medical care in flight

  1. Epidemiology (based on Peterson study)
    1. One medical emergency for every 604 flights (11,920 emergencies in 7.2 Million flights)
    2. Only 7% of medical emergencies required flight diversion
      1. Only 25% of flight diversions required emergency department evaluation
      2. Only 8% of flight diversions required hospital admission
      3. Only 0.3% of flight diversions died
    3. Most common in-flight emergencies
      1. Syncope or Near Syncope (37%)
      2. Respiratory symptoms (12%)
      3. Nausea or Vomiting (10%)
    4. References
      1. Peterson (2013) N Engl J Med 368(22): 2073-33 [PubMed]
        1. http://www.nejm.org/doi/full/10.1056/NEJMoa1212052
  2. Emergency landing secondary to medical emergency is expensive
    1. Cost per incident: $500,000 to $1 Million dollars
  3. Medicolegal concerns
    1. Malpractice liability is based primarily on the laws of the airline's country of registry
    2. Some documentation of in flight care may be required
    3. Flight crew will ask that you verify credentials (i.e. medical license)
  4. Good Samaritan
    1. Aviation Medical Assistance Act (U.S.) offers broad protection extending beyond Good Samaritan
    2. Most other countries allow for Good Samaritan laws
    3. Good Samaritan protections require that no payment or reimbursement is made
    4. Good Samaritan protections assume that the flight crew asked for your medical assistance
  5. Airlines ground medicine control
    1. Ground-based Flight Medicine clinicians contracted by the airline
    2. Will direct some process decisions (e.g. emergency landing indications)
  6. Airplane medical equipment
    1. Type of available medical supplies varies between airlines and countries
    2. Oxygen supply may be limited

V. Contraindications: Cardiac conditions

  1. Acute Myocardial Infarction
    1. First 4 to 6 weeks after Myocardial Infarction
      1. No travel above 2,000 ft (610m)
    2. Subsequent (walk 328 ft or 100 m, climb 12 steps)
      1. Limit = 8,000 feet (2438m)
  2. Congestive Heart Failure
    1. No air travel for 2 weeks after decompensation
    2. Exception: Oxygen and <10,000 ft (3048m)
  3. Air travel is safe in stable cardiovascular disease
    1. Use below the knee Compression stockings
    2. Walk inside the cabin
    3. Avoid Alcohol and stay well hydrated
    4. Possick (2004) Ann Intern Med 141:148-54 [PubMed]

VI. Contraindications: Respiratory

  1. Chronic Obstructive Pulmonary Disease (COPD)
    1. No air travel if Vital Capacity <50% of predicted
  2. Pneumothorax
    1. No flight for 10 days after resolution
  3. Asthma
    1. No restriction if stable

VII. Contraindications: Pregnancy

  1. Physician must certify air travel after 36 weeks
  2. No surface travel above 15,000 feet (4572m)

VIII. Contraindications: Hematologic

  1. Anemia
    1. Oxygen needed if Hemoglobin <8.5 g/dl
  2. Hemoglobinopathies (Sickle Cell/Thalassemia)
    1. Avoid air travel if SS or SC variant
    2. No pressurized aircraft travel >22,000 ft (6705m)

IX. Contraindications: Thromboembolic disorders or patient over age 50 years

  1. See DVT Prevention in Travelers

X. Contraindications: Postsurgical

  1. Abdominal: No air travel for 7 days after laparoscopy
    1. Some recommendations for no travel for 10-14 days after other abdominal surgeries
  2. Colostomy or Ileostomy
    1. Use extra large bags
  3. Ophthalmologic surgery
    1. No travel above cabin pressure >5000 ft (1524m)

XI. Contraindications: Recent Scuba Diving

  1. No travel for 24 hours after decompression dive
  2. No travel for 12 hours after non-decompression dive

XII. References

  1. Lin and Delaney in Herbert (2015) EM:Rap 15(5): 7-8
  2. Leibman and Orman in Herbert (2014) EM:Rap 14(9): 8

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