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19. Other Medical Disorders

Medicine has to be transported in the original packaging so that, if necessary, other people can identify which medicine the passenger takes.

In this section, we will discuss a variety of medical disorders and conditions which have not been described in earlier chapters and which can give rise to problems while flying.



Anaemia


Anaemia is a condition where the total haemoglobin content is reduced.

As haemoglobin is responsible for the blood’s oxygen transport, anaemia brings with it an increased risk of hypoxia of the vital organs during flying due to the reduced supply of oxygen within the pressurised cabin.

When evaluating whether a patient with anaemia is able to withstand a journey by air, one should carefully note whether the blood’s oxygen bearing capacity has been reduced by other causes, including poisoning such as carbon monoxide inhalation in association with tobacco smoking. Similarly, pulmonary stasis, emphysema, atelectasis, or pulmonary infarction can all reduce oxygenation of the blood.


Generally, air transportation should not be undertaken if the blood’s stable haemoglobin concentration is lower than the following limits:


Acute anaemia             6,0 mmoll/l                (approx. 10 gram/100 ml)

Chronic anaemia          4,5 - 5,0 mmol/l        (approx. 8 gram/100 ml)


Haemoglobin concentrations lower than those quoted above should, if at all possible, be corrected, perhaps by blood transfusion prior to transportation; if this is done, the haemoglobin concentration should be raised to a stable level 1 mmol/l above the recommended borderline values.

While considering whether the patient should receive a blood transfusion, one should consider the risk of blood-born infection by HIV, HBV, and HCV, among others, especially if the patient finds him- or herself in a place where there may be doubts as to whether transfusion blood is adequately screened.

Where transportation of a patient with a degree of anaemia in excess of the abovementioned borderline values is absolutely unavoidable, a continuous supply of oxygen should be administered during the journey.

Finally, the cause of the anaemia should be known, and any possible risk of deterioration in the condition of the patient during transportation should be eliminated.


Sickle-cell anaemia

The transportation of sickle-cell anaemia patients is particularly problematic. Sickle-cell anaemia is primarily seen in persons originating from Africa near the equator, though is also seen in Afro-Americans and Jamaicans. During the last couple of decades, sickle-cell anaemia has become more frequently observed in the Nordic countries due to immigration. The anaemia is of genetic origin and is caused by an abnormal haemoglobin molecule that is unstable in “stress situations”, such as infection, cold, dehydration, and reduced oxygen pressure, as occurs, for example, during flying. These stresses can lead to acute haemolysis with the formation of sickle-shaped erythrocytes, which collect in the capillaries, leading to multiple infarctions. The clinical picture, which is called “sickle-cell crisis”, is characterised by violent pains and damage to organs in the area of the infarctions.

Homozygotes have a characteristic chronic haemolytic anaemia. In homozygotes, the hypoxia normally induced by commercial flying can result in a sickle-cell crisis, especially if they have already been exposed to infection or other stressors.

Heterozygotes are usually healthy and not anaemic, but can, in special circumstances, also develop a sickle-cell crisis, triggered by the abovementioned “stress situations”.

In general, homozygotes with anaemia or a recently resolved sickle-cell crisis (within the previous week) should not fly. If they must fly, they should have received a blood transfusion before take-off and, if possible, have an oxygen supply during the journey.

The various airlines’ rules concerning homozygotes with sickle-cell anaemia vary from the requirement that one week should have passed since a resolved sickle-cell crisis, to the requirement for a complete blood transfusion before any flight and, sometimes, oxygen supply during the flight. Frequent short walks are recommended during long flights. Airlines impose no restrictions on heterozygotes.



Diabetes Mellitus


Non-insulin dependent Diabetes Mellitus (NIDDM) treated with tablets seldom gives rise to aeromedical problems. Therefore, this section deals only with recommendations for patients with insulin dependent Diabetes Mellitus (IDDM), and primary patients with type 1 diabetes.


Regulated IDDM

All patients with IDDM should take certain precautions when undertaking air travel. This, of course, is especially true when travelling long distances.

• The diabetes should be well regulated before the journey. If needed, a check-up at a physician or an

   outpatient clinic should be done before departure.

• The patient should always carry his or hers diabetes identification card in English. Among other

   things, this will avoid medicine and injection equipment causing problems when going through

   security at the airport.

• Bring enough medication for the entire vacation.

• Diabetic meals should be reserved through the airline. However, as a precaution a small amount of

   diabetic fare together with glucose tablets should be brought along in hand luggage in case of flight

   delays, etc.

• All insulin needed for the journey and the sojourn together with injection equipment should be

   carried in hand luggage. If possible, divide the insulin between the patient and a travelling

   companion. Insulin cannot withstand the intense cold that can occur within the aircraft’s cargo

   compartment, and should therefore not be packed into suitcases. Though insulin is best kept in a

   refrigerator, it can be kept for a month at room temperature. If the insulin is at risk of becoming

   exposed to high temperatures during the journey, it is advisable to carry it in a small thermos flask

   until it can once again be stored in a refrigerator. A small cooler box may also be used, but the

   insulin must not rest upon the freezer pack.

• Bring a blood sugar apparatus and test paper in hand luggage. Blood sugar apparatus test paper must

   not be exposed to cold.

• When travelling through many time zones, it may be difficult to ensure proper insulin dosage and

   proper mealtimes. Before starting the journey, a plan for the administration of insulin and meals

   must be worked out, and blood sugar must be regularly checked during the journey.

• Elderly patients with IDDM, who find it difficult to keep a check on insulin and meal intake

   themselves, as well as keeping to timetables themselves, should, when travelling longer distances,

   travel with an escort who is able to help in the administration of such.

• If the diabetic patient is travelling with an escort, glucagon should be brought on the journey if the

   escort is able to administer it in the case of hypoglycaemia.

• Remember to carry at least 2-3 days’ supply of any other important relevant medication in hand

   luggage, in case checked-in luggage is mislaid during the flight.

• The best guarantee for a diabetic patient to make a long and complication-free journey is for the

   patient to be familiar with his or her disorder and be accustomed to self-regulation and self-

   treatment of the diabetes.


Poorly controlled type 1 diabetes

In cases of unavoidable or prolonged transportation of patients with precariously balanced blood sugar levels, an accompanying physician will often be necessary in order to monitor and treat the patient.


Diabetic coma

After true diabetic coma, most airlines will not accept patients until the patient’s condition is stable and at least five full days after the event.



Renal and urinary tract disorders


Kidney stone / ureteric stone

Kidney stone attacks can be very painful and if you have just had a seizure you should not fly. The patient should be examined with urinary ultrasound or CT scan. In the case of uncomplicated ureteric stone (no blocked urine flow or infection) the patient can fly by air as fast as he/she has been painless for 72 hours. This does no matter if there are still stones in the ureter.

If a patient still has symptoms and need to be flown to treatment – caused by lack of examination and treatment facilities at the side of injury – the patient should be accompanied by a physician.


Urinary tract obstruction

Where there is an obstruction of the urinary tract, including ureter calculi and bleeding with the risk of bladder tamponade, the condition should be fully diagnosed and, where possible, treated or relieved before air transportation.


Uraemia

When planning the transportation of a uremic patient, the following should be taken into account: the need for minimum or maximum fluid intake, any limitations on food’s electrolyte content, possible arterial hypertension, and the degree of anaemia.


Dialysis

Under normal circumstances, a person in chronic dialysis treatment does not require an escort when travelling by air. Haemodialysis patients must have received optimal treatment before transport. Dialysis should be planned for immediately before departure, and it should be ensured that the patient is expected and treatment is available on arrival at the agreed destination. Any dialysis catheters or circulatory access points should be secured.

Many patients undergo treatment by chronic ambulatory peritoneal dialysis (CAPD).

Such treatment may be carried out during long air journeys with the patient sitting in a seat where there is plenty of room and whose backrest can be inclined – normally in business class. It may be necessary to reduce inlet dialysis fluid amounts, mostly because such patients will always have small quantities of free air (up to 100ml) in the peritoneum.


 





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