Air ambulances transport patients in emergency medical situations. They are able to reach areas a traditional ambulance cannot reach quickly and easily. Air ambulances are also used to quickly transport critically ill patients to hospitals.

Air ambulances contain the same equipment used on standard ambulances, including CPR equipment, heart rate monitors and respirators.

The standard crew for an air ambulance varies. However, emergency medical technicians or paramedics are often used. Some air ambulances will also include a flight nurse or physician. An experienced pilot is also required for air ambulance flights.

The largest company is Air Methods Corp. This company operates a fleet of more than 340 helicopters and fixed-wing aircraft in 42 states and is headquartered in Englewood, Colorado. Also there are companies with International presence who do worldwide air medical transportations. They operate out of countries like India like Vibha Lifesavers - Hi Flying aviation who provide the same professional services as air ambulance companies in the developed western countries but are economical due to lower operating costs as their operations and offices are based in Asia. They are the preferred service providers for non insurance patients, insurance companies who are looking for cost containment and air ambulance companies wanting to outsource their evacuations for faster, prompt and economical services.

Air ambulances must be accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS). This accrediting body ensures air ambulances meet national public safety standards. The process examines the air ambulance operations, including management, flight operations and medical protocols.
Alternatively, ISO accreditions are a norm in the Eastern countries like India, Thailand and other countries in Asia.

In the event of a serious emergency that requires more (and more immediate) assistance than can be provided by a traditional ambulance, you may elect to call an air ambulance. These business-class aircraft are outfitted with everything necessary to safely and quickly transport even intensive-care patients from one location to another with minimum stress and danger. However, before you call for an air ambulance, which is usually a private service, make sure you understand the monetary ramifications of doing so--particularly if you are not in an emergency situation.

Air ambulances can access areas that traditional ambulances cannot. They are also much faster when it comes to transporting patients, which can be crucial if a patient needs specialty treatment from a hospital that is not in the immediate vicinity. Air ambulances have trained medical staff on board who communicate directly with a patient's personal physician(s) to ensure the maximum health and safety of the passenger. However, all of this private expertise comes with a fee, and the base cost of the ambulance can jump dramatically with each additional team member.

Air ambulances are intended to serve two purposes: emergency transport and speedy transport. If you or a loved one are in a serious accident--particularly if that accident occurs away from a roadway--you may be taken to the hospital by air ambulance, rather than risking traveling over the ground on a stretcher to reach a motorized ambulance or other medical vehicle. However, air ambulances are also popular when intensive-care patients who may not be particularly stable must be moved, as this method requires them to spend the least amount of time out of the ICU.

Private air ambulances fly everywhere. Most air-ambulance services will go just about anyplace but Antarctica. They will also usually take almost any method of payment, since they understand that this type of transportation is generally not something that is easy to plan for ahead of time. Air ambulances typically have room for a fair amount of additional medical equipment, but equipment that is not part of the service will usually cost extra.

Many people think that air ambulances are simply a faster method of transportation in an emergency. However, air ambulances also provide "bedside-to-bedside" services for invalids and highly customized care for people who are in critical condition yet must make a trip for any reason. Many private air-ambulance services can provide all the comforts of a private jet or airplane cabin, along with trained medical personnel to make sure the trip goes smoothly for all parties.

Always work with your doctor whenever possible if you are in poor health and considering making a trip. While an air ambulance may seem like the perfect way to deal with your unstable condition while still allowing you to travel, nothing can replace the care you get from a doctor who knows you and is familiar with your condition. Never arrange any type of medical transport without keeping all of your attending physicians in the loop, as well

  BRITISH AIRWAYS HEALTH SERVICES

YOUR PATIENT AND AIR TRAVEL

A GUIDE TO PHYSICIANS

Contents

Introduction

Pre-flight Assessment and Medical Clearance

Assessment Criteria

Considerations of Physical Disability or Immobility

Oxygen

Stretchers

Conditions requiring Special Precautions or Planning

Summary of Contra-Indications

Other Precautions

Conclusion

Additional Information - Contact Details

Page 1 of 1

 

Introduction

Commercial air travel is a comfortable, speedy and safe means of transport and is now

accepted as a part of everyday life for many people in the developed world.

It is affordable and accessible to all sectors of the population and it is easily forgotten that the

individual is travelling in an unfamiliar and physiologically unusual environment.

For the fit, healthy and mobile individual there is no problem but for the passenger with

certain pre-existing conditions or developing an acute medical problem in flight, the cabin

environment may exacerbate the condition.

In-flight medical problems can result from the exacerbation of a pre-existing medical condition

or can be an acute event occurring in a previously fit individual.  Although the main problems

relate to hypoxia and expansion of trapped gases, the stress and physical challenge to

passengers of the complex airport environment should not be overlooked (e.g. carrying

baggage, walking long distances and dealing with unexpected delays).

Cabin Crew receive training in advanced first aid and basic life support and in the use of the

emergency medical equipment, including automated external defibrillators which are carried

on board all British Airways aircraft.  In the future, British Airways intends to install air-to-

ground cardiac monitors to assist with diagnosis.  In serious cases assistance will be requested

from the airline’s medical advisers via the air-to-ground link or a medical professional who

may be travelling as a passenger.

In a medical emergency, other (non-medical) factors need to be taken into account when

considering whether a diversion is appropriate, including:

•

suitable convenient airport

•

appropriate medical facilities

•

terminal facilities for the number of passengers

•

sufficient hotel accommodation for passengers and crew

Most airlines provide services for those passengers requiring extra help but these can be made

available only if the airline is advised of the need for special assistance by the passenger or

his/her medical practitioner prior to the flight.  Most airlines also have a medical adviser to

assess the fitness for travel of those with medical needs.  The information needed for provision

of appropriate assistance depends upon an understanding of the practicalities of air travel as

well as an understanding of the basic physics of the flight environment and its effect on human

physiology.

The operational effect of the use of equipment such as wheelchairs, ambulances and stretchers

must be taken into account and the possibility of aircraft delays or diversion to another airport

must be considered.  It may be necessary to change aircraft and transit between terminals

during the course of a long journey and land-side medical facilities will not be available to a

transiting passenger.  At London’s Heathrow Airport, for example, transfer traffic accounts for

more than 40% of all passengers.


Deterioration on holiday or on a business trip of a previously stable condition such as asthma,

diabetes or epilepsy or accidental trauma frequently gives rise to a request for medical

clearance for the return journey.  A stretcher may be required, together with medical support

and this can incur considerable cost.  Hence the importance of adequate travel insurance which

includes the provision of a specialist repatriation company.

Aside from the considerations specific to flying, thought should, of course, also be given to

immunisation and anti-malarial prophylaxis where appropriate, adverse effects of the

destination climate, inadequate health resources and the potential impact of lost or stolen

medication.

Pre-flight Assessment and Medical Clearance

The ideal traveller is one who is fully vaccinated, insured, taking appropriate protection

measures, aware of potential risks, prepared for the demands of the journey (both on the

ground and in the air) and fully conversant with their destination.  (For example, Mexico City

with its high pollution levels and an altitude above 9,500 feet should not be contemplated by

those with respiratory impairment.)

Objective

The objectives of medical clearance are to provide safe, healthy travel, high levels of customer

satisfaction and to prevent delays and diversions to the flight as a result of a deterioration in

the passenger’s well-being.  It depends, however upon self-declaration by the passenger and

upon the attending physician having an awareness of the flight environment and how this

might affect the patient’s condition.

Mechanism

Early notification to the airline is essential to ensure communication to operational areas for

pre-board and baggage assistance, provision of buggies or wheelchairs for distances, special

diets and seating.

The Aerospace Medical Association has published guidelines on fitness for travel and the

International Air Transport Association (IATA) publishes a recommended Medical

Information Form (MEDIF) for use by member airlines.  This is available from the airlines

directly or from travel agents.

Part 1 of the MEDIF is completed by the agent and/or passenger and Part 2 by the passenger’s

medical representative.  It should then be passed to the airline at the time of booking to ensure

timely medical clearance.  It isessential

that the form is fully completed as delays can result if

information is omitted.

The need for Medical Clearance

Medical clearance is required when:

•

fitness to travel is in doubt

as a result of recent illness, hospitalisation, injury, surgery or

instability of an acute or chronic medical condition

•

special services are required

e.g. oxygen, stretcher or authority to carry or use

accompanying medical equipment.

passengers are contemplating overseas diagnostic or hospital treatment in specialist

hospitals.  There is still the need to conform to airline requirements for medical clearance.

Assessment

Physiological Considerations

Basic principles of physics, physiology and pathology should be used in determining the

passenger’s fitness to fly.

Modern commercial airliners fly with a cabin altitude of between 4000 and 8000 feet when at

cruising altitude, which means a reduction in ambient pressure of the order of 20% compared

with sea level and a consequent reduction in blood oxygen saturation of about 10%.

Consideration must be given therefore to the effects of the relative hypoxia encountered.

Any trapped gas will expand in volume by up to 30% at the normal aircraft cabin cruise

altitude, potentially leading, for example to pain and perforation of the ear drum if the

Eustachian tubes are blocked by infection or to stretching of suture lines following recent

abdominal surgery.

The cabin air is relatively dry which can lead to a sensation of dryness in the mouth and

extremities, though studies have shown that it does not lead to central dehydration and

plasma osmolality is unchanged.

The potential for the development of traveller’s thrombosis, particularly on long haul routes,

should be borne in mind.  Many airlines (including British Airways) promote lower limb

exercise in the in-flight magazine and encourage mobility within the cabin.  However, those

passengers known to be vulnerable to DVT (for example with clotting disorders, recent

surgery or trauma and those with certain types of malignancy) should undergo appropriate

medical evaluation, and consideration given to the use of compression stockings, aspirin or

anti-coagulants.

In addition to the effect of the condition upon the sick passenger, account must be taken of the

effect or potential effect on other passengers or crew members.  It is important to recognise

that the filters for re-circulating cabin air remove bacteria and most viruses, so that any risk of

transmission of infection in the cabin is remote and usually confined to those passengers

seated near to the infected passenger.  However, it is an International Health Regulation that

an individual should not fly during the infectious stage of a contagious disease.

Practical Considerations

The best time to establish the fitness of the prospective passenger for a commercial airline

flight is in the weeks prior to the intended departure.

The pre-flight evaluation should focus on the passenger’s medical condition with special

consideration given to possible infectivity, the dosage and timing of any medication and the

need for special assistance requests.

The physician can achieve much by simply reminding passengers to hand carry life-line

medication and by endorsing the need for valid travel insurance which includes adequate

health cover.



Criteria

Examples of conditions requiring particular evaluation include cardiovascular disease, deep

vein thrombosis, upper and lower respiratory tract disease (e.g. sinusitis, asthma, chronic

obstructive airways disease, emphysema), recent surgery, cerebro-vascular disease, unstable

psychiatric illness, diabetes and infectious diseases.

Assessment is often relatively simple.  For example, a knowledge of the passenger’s exercise

tolerance can be a useful indication of fitness to fly.  If someone is unable to walk a distance

greater than 50 metres without developing dyspnoea, there is a risk that they will be unable to

tolerate the relative hypoxia of the pressurised cabin.  More specific information can be gained,

if necessary, from a knowledge of the passenger’s blood gas levels and oxygen saturation.

Operational airline crew are familiar with the risk of otic barotrauma from flying with an

upper respiratory tract infection, hay fever or sinusitis but passengers may need to be

reminded of this potential hazard.  It is also considered unwise to travel by air with otitis

media unless appropriate antibiotics have been administered for at least 36 hours and the

patency of the Eustachian tubes assessed by a health professional.

It is advisable to carry written confirmation of non-infectivity, for example when jaundiced.

Similar documentation is wise if carrying medication to satisfy customs at ports of entry.

One other important point is to avoid prescribing a medication for in-flight use unless the

would-be traveller has used it before, is familiar with its primary effects and has no undue side

effects.

Waivers and disclaimers are inappropriate and are not recommended practice.

Medical Criteria for Fitness to Fly

There are a number of contraindications to flying that are absolute, many more of which are

relative.  The following guidelines are in use in

British Airways

, which are, in turn, based on

those issued by IATA (the International Air Transport Association).  It is impossible to give

definitive advice for every condition and the information provided is for guidance only and

may be varied for reasons such as complications or multiple pathology.

Medical escorts may be required if there is a high level of dependency or if there is a

significant risk of deterioration.  In all cases, passengers must be reminded to carry into the

cabin with them any medication that might be required in flight.

Some Medical Conditions Requiring Pre-Flight Medical Evaluation:

Cardio-Vascular Disease

Examples include recent

myocardial infarction, coronary artery bypass grafting , angina

pectoris

and

congestive cardiac failure

.


Most cardiac patients on medication can tolerate cabin air if stable, with the use of

supplementary oxygen in some cases.

Following an uncomplicated

myocardial infarction

, passengers should not fly for at least 7

days.

Angina

, if stable with infrequent attacks, is not usually a problem.

Coronary artery bypass grafting

and other

chest surgery

should pose no risk providing the

passenger has made a normal uncomplicated recovery.  Air travel can be contemplated, if

necessary, at 10 days post surgery, thus allowing time for the air introduced into the chest to

be reabsorbed.  The situation following the relatively new procedure of

angioplasty

(with or

without stent) is less clear because of the risk of early re-occlusion.  In most cases travel can be

contemplated within 3 to 5 days but individual assessment is required.

Respiratory Disease

Passengers with

asthma

and

chronic lung disease

(including

chronic obstructive pulmonary

disease

(COPD)

and

pulmonary fibrosis

) are usually able to travel safely if the condition is

stable and there has been no recent deterioration.

One method for use by the physician when making an assessment is to check whether the

passenger

can walk 50 metres on the flat or up one flight of stairs

without becoming severely

dyspnoeic.  If the answer is “yes” then the passenger is likely to be fit to fly; if “no” most of the

passengers may be transported safely and without incident providing that supplemental

oxygen is available during the flight as standby or for continuous use.  Individuals who are

markedly breathless at rest should be advised not to fly.

For borderline cases or when oxygen is required on the ground (and the trip is essential),

measurements of oxygen saturation and/or blood gas analysis can be useful.  Although the

of oxygen remains constant at around 21% whatever the altitude, the

percentage

partial

pressure

of oxygen in the cabin at the highest cruising altitude can be considered to be

equivalent

to an oxygen concentration of approximately 17% at sea level.  Some respiratory

physicians therefore, have assessed oxygen saturation levels on patients whilst breathing 16-

17% oxygen as a definitive test of fitness to fly.  More information on the provision of in-flight

oxygen can be found below.

There is no specific risk to passengers with

asthma

in the aircraft cabin, the most significant

problem encountered is when medication is inadvertently packed in the hold.  For travellers to

areas of the world where health care provision may not be readily available, it may be prudent

for all but the mildest asthmatics to be advised to take a course of steroids with them for use in

an emergency.

Pneumonia

should be resolved, with no residual infection and satisfactory exercise tolerance

as above.  If the passenger also has existing pathology (such as

COPD

) it is often prudent to

delay travel for a few weeks if possible.

Under conditions of reduced pressure, gas trapped in the body cavities will expand and this

must be considered following a

pneumothorax

.  Generally, it should be safe to travel by air

two weeks after successful drainage.



Blood Disorders

For passengers with

anaemia

special consideration should be given to anyone with a

haemoglobin below 7.5gm/dl as it reduces the tolerance to hypoxia.  If there is any doubt

oxygen should be considered.

Those with

chronic renal failure

and other

conditions predisposing to anaemia

, usually

tolerate a lower haemoglobin level at cabin cruising altitude than someone with a recent

haemorrhage.

Those with

sickle cell anaemia

should travel with supplemental oxygen and should defer

travel for 10 days following a sickling crisis.

Sickle cell trait

has not been associated with problems at normal cruising altitude.

Central Nervous System Disorders

Following a

stroke

or

cerebrovascular accident,

passengers can usually travel after 3 days if

stable or recovering, though formal medical clearance should be sought if travel is required

within 10 days.  For those with

cerebral artery insufficiency,

hypoxia may lead to problems

and supplementary oxygen may be advisable.

Travel should be delayed for 24 hours after a

grand mal seizure

.

The passenger with stable

epilepsy

may be more prone to seizures during a long flight; mild hypoxia and hyper-

ventilation are known precipitating factors, in addition to the aggravation of fatigue, anxiety

and irregular medication.  Whilst it would not be appropriate to change medication

immediately prior to a trip, consideration should be given to providing extra anti-convulsant

medication.  If nothing else, the passenger with

epilepsy

must ensure that they have sufficient

medication in their hand baggage for the duration of the flight and also for any unexpected

delays.

Deep Vein Thrombosis (DVT)

Those with a

DVT

of the leg can travel once the condition is stabilised on an appropriate anti-

coagulation regime with resolution of the clot.

Prolonged immobility is a known risk factor for

thrombo-embolic disease

and all passengers

should keep mobile whilst in flight.  It is recommended that they stand in their seat area and

stretch their arms and legs every couple of hours, walk around the cabin whenever they can

and follow an in seat exercise programme. Such as that contained in the British Airways in

flight magazine, High Life.

Passengers with intrinsic risk factors, such as a history of

DVT

or

pulmonary embolism

,

post

thrombotic syndrome

,

chronic venous insufficiency

,

malignancy

,

coagulopathy

,

heart disease

or

pregnancy

, should, in addition, seek medical advice and take appropriate precautions.

Prophylaxis with low molecular weight heparin or aspirin may be appropriate.

ENT Disorders



Otitis media

,

sinusitis

and any other condition leading to

blockage of the Eustachian tube

may lead to problems because of gas expansion.  Pain, perforation of the tympanic membrane

and sinus barotrauma can result and flying should be delayed until the condition has resolved.

Passengers can fly 10-14 days after

tonsillectomy

or

middle ear surgery

.  If the jaw has been

wired for any reason, a passenger may only travel if there is an escort equipped with wire

cutters or a self quick release mechanism is fitted.

Fractured Limbs

Following application of a

plaster cast

, British Airways restricts flying for 24 hours for flights

under 2 hours and 48 hours for longer flights.  However, these restrictions do not apply if the

cast has  been bi-valved which helps to avoid harmful swelling, particularly on long flights.

Full length

,

above the knee plasters

or those who require

leg elevation

are required to

purchase appropriate seating (First, Club World or extra seats in World or Euro Traveller) in

order to obtain the necessary leg room.  Fractures of the

hip

or

femur

will almost certainly

require a stretcher.  Safety regulations preclude the use of Emergency Exit rows for any

passenger with a medical condition.

Gastro-Intestinal Disease

Passengers who have had

abdominal surgery

in which hollow viscus has been sutured are at

risk of perforation or haemorrhage as a result of gas expansion at altitude. Air travel should be

discouraged for 10 days following any

abdominal surgical procedure

.  In addition stretching

gastric or intestinal mucosa may result in haemorrhage from

ulcer

sites although travel may be

permitted if there is clear endoscopic evidence of healing.

Travellers with

colostomies

are not at increased risk during air travel although intestinal

distension may increase faecal output.  The use of a large

colostomy

bag is recommended.

More frequent changes may be necessary for smaller bags and extra supplies should be carried

in the cabin hand baggage.

Passengers may experience abdominal discomfort because of gas expansion in flight but this is

not of significant medical concern.

Infectious Diseases

In common with other public transport systems, an airline cannot accept passengers with

infectious conditions until the risk to other passengers has passed.

Diabetes Mellitus

As long as they can administer their own medication passengers with

diabetes

mellitus

can

usually travel without difficulty and medical clearance is not required.  It is important that

they are aware of problems caused by time zone changes.  It is recommended to remain on one

time system during the flight and only attempt to readjust to local time on arrival at their

destination.

For flights over 8 hours a specialist doctor or nurse should advise regarding an insulin regime.



Diabetics also need to be reminded that insulin does not generally require refrigeration.  The

British Diabetic Association

recommend carriage of insulin in the hand baggage and not in the

aircraft hold where it is possible that the insulin may be frozen and so become inactivated.

Needles should be disposed of safely and never in seat pockets or toilets.  Further information

on diabetes and travel is available on the British Diabetic Association website at

www.diabetes.org.uk.

Special diets can be requested at the time of making a reservation.  It is often sensible to

specify what the dietary requirements are rather than just asking for a “diabetic meal”.

Ophthalmological Procedures

Procedures for

retinal detachment

can involve the intra-ocular injection of gas in order to

temporarily increase intra-ocular pressure.  This gas bubble needs to be fully absorbed prior to

any flight.  This takes approximately 2 weeks if sulpha hexafluoride is used and 6 weeks with

the use of perfluoropropane.

For other

intra-ocular procedures

and

penetrating

eye injuries, one week should elapse before

flying.  There is no specific restriction on flying after

cataract surgery

and

corneal laser surgery

.

Pregnancy

Whilst

pregnancy

is not a “medical condition”, flying whilst

pregnant

is a frequently raised

topic.  Normally pregnancy is a happy event for all concerned but delivery in flight it is not

without risks to the mother and baby.  For this reason British Airways, along with many

airlines, refuses to carry women in the latter stages of pregnancy, typically after 36 weeks for

single pregnancies, 32 weeks for multiple.

A certificate is normally required to be carried after 28 weeks confirming the estimated date of

delivery, that there are no complications and, in the view of the doctor or midwife, the

passenger is fit to fly.

Passengers should be reminded that health travel insurance in the latter stages of pregnancy

can be difficult to obtain.

Psychiatric Disorders

Because of the safety implications,

psychiatric disorders

need to be stable and controlled.

Generally any acute severe condition (such as an

acute psychosis

) would need to have an

appropriately trained medical escort (RMN) plus suitable sedation which can be administered

by the escort.  Medical clearance must be sought well in advance of intended travel.

For passengers with other disorders, such as

anxiety

or

depressive

neurosis

, the airport

environment and the flight itself may have a significant impact.  Small doses of anxiolytics

may

be helpful in passengers who are familiar with their effects and side effects.  However, great

care must be taken to avoid over sedation (which could be misinterpreted by cabin crew as

serious illness) and mixing with alcohol which can lead to unpredictable behaviour.

A variety of courses is available to help those with a

fear of flying

and passengers will usually

find cabin and flight crew extremely supportive if they are aware of the problem.



Terminal Illness

Not infrequently airlines are asked to carry passengers with terminal illness with only a matter

of days or weeks to live, usually in circumstances where the passenger has expressed a desire

to die in their native country.  Whilst recognising the need to deal sympathetically with such

requests, the airline medical department will need to evaluate very carefully the risk of in-

flight death or unexpected deterioration.  While a proportion of such passengers can be

accommodated with special arrangements such as a stretcher with a  qualified escort, the

treating physician needs to be mindful of how distressing it can be to relatives (and indeed

airline cabin crew) should the passenger die in flight and the subsequent burden of regulatory

requirements at the destination.

Summary of Contra-Indications

It should be noted that a passenger with a medical condition will be assessed as an individual

and any complications or additional medical problems may extend the period for which they

are unable to fly.

•

Anaemia -

with haemoglobin less than 7.5g/dL

•

Cardiac Failure

- uncontrolled

•

Cerebral Infarction

- within the last 3 days

•

Contagious

or

Communicable

diseases

•

DVT

- acute

•

Fractures

- unstable/untreated

•

Haemorrhage

- recent gastro-intestinal

•

Jaw

- fractured with fixed wiring

•

Myocardial Infarction

- within last 7 days

•

Operations

- depending on the nature of the surgery, within 5 to 10 days.

•

Otitis Media

- with loss of Eustachian tube function

•

Pneumothorax

- suspected or confirmed

•

Pregnancy

beyond the 36

week of gestation

t h

•

Psychiatric Disorders

and those

whose behaviour is unpredictable, aggressive

or may

disrupt

the flight or endanger other passengers

•

Respiratory Disease

- with marked breathlessness at rest

•

Sickling crisis

- recent

•

Sinusitis

- severe

•

Any Conditions

which may be

exacerbated

by the flight environment

•

Unstable Conditions

with a risk of deterioration prejudicial to the passenger or the flight

Oxygen

In addition to the main ventilation system, all commercial aircraft carry an emergency oxygen

supply for use in the event of failure of the pressurisation system or during emergencies such

as fire or smoke in the cabin.  The passenger supply is delivered via drop down masks from

Page 10 of 10

 

chemical generators or emergency reservoir and the crew supply is from oxygen bottles

strategically located within the cabin.

Sufficient first aid oxygen bottles are carried to allow the delivery of oxygen to a passenger in

case of a medical emergency in flight.

Specific arrangements for a premeditated supply of oxygen for a passenger needs pre-

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