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

In acute anemia where bleeding has stopped and the patient is stable, air transport should generally not be performed if the blood hemoglobin concentration is lower than

                            5.3 mmol / l (about 8.5 grams / 100 ml)   

                        

One should wait until hemoglobin has crossed the border again.

If it is very important to transport a patient who has a lower hemoglobin than the above limit, this may be carried out with continuous oxygen during flight.

Patients with chronic anemia (such as with anemia) often tolerate the anemia well. They are usually allowed to travel by plane if they can handle normal physical activity (walk 50 m and walk up a staircase to the first floor without being breathless), even if hemoglobin is below 5.3 mmol / l.

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.

Kidney disorders

 

Kidney disorders do not usually cause major problems in relation with flight. However, infections and anaemia are of importance; thus, Hgb <4.5-5.0 usually contraindicates scheduled and charter flights. Patients undergoing dialysis must be optimally treated prior to air travel. Moreover, they must be ensured further treatment at the new destination - something the patient's usual dialysis centre, dialysis company or patient associations will often be instrumental in arranging.

 

 

Chronic renal failure not in need of dialysis

 

When planning especially longer flights for patients with advanced conservatively treated uraemia, a plan for minimum or maximum fluid intake and any restrictions on the diet's electrolyte content must be made. Especially for patients on the border of dialysis, it’s important to optimize their condition until the flight.

Accompaniment: The patient will usually be able to travel unaccompanied as a regular passenger on flights.

 

 

Chronic kidney failure requiring dialysis

 

Haemodialysis (HD)

If a patient undergoing chronic haemodialysis is to travel on vacation or other longer stays, it is important to ensure meticulous contact with the dialysis centre at the new residence. Before the journey, the new dialysis centre must have all relevant information about the patient's condition and current therapy of dialysis. The dialysis centre must also have information regarding the access route to dialysis:

- permanent - so-called arterial-venous fistula or shunt or

- temporarily - via a haemodialysis catheter inserted into a central vein.

Prior to the trip, there must be an appointment for dialysis in the new centre.

If a chronic haemodialysis patient is to travel longer by plane, he or she should undergo HD as close to flight departure as possible. The HD should be at least 1 hour longer than normal to ensure the patient is in optimal condition. The patient must not have anaemia that contraindicates flight.

Accompaniment: The patient will usually be able to travel unaccompanied as a regular passenger on flights.

 

Peritoneal dialyse (PD)

Many patients are treated with PD at home. The treatment is usually done by the patient himself or a family member. If the patient is going on a longer flight, it is important that all equipment for further treatment is ready at the point of arrival. This can be done, by appointment with a dialysis centre on site.

The patient must be well-dialled up to departure. For flights over 8 hours, there may be an indication of dialysis fluid change during the flight. The patient must therefore have the opportunity for space conditions that may allow this. Furthermore, it must be ensured that the airline accepts PD. Patients in PD usually have 200 ml of free air intraperitoneally. In flight, this air and intestinal air will expand due to the reduced cabin pressure. Therefore, to avoid abdominal pain in connection with the dialysis, a reduced amount of dialysis fluid is used, about 1.5 litres against normal 2.0 litres.

The patient must not have anaemia that contraindicates flight.

Accompaniment: If the patient is accustomed performing PD, the journey may go unaccompanied. If not, this should be accompanied by someone who is used to PD. The airline may require a companion. MEDIF must be made for the trip.

 

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.

Kidney Transplant

 

After kidney transplantation, the patient must fly when the cicatrix is healed, when the kidney function is of a size where dialysis is not necessary and where all external catheters are removed. Thus, they may well fly even if they have a JJ catheter located within the transplanted ureter. Flight as a normal passenger can normally take place approx. 3 weeks after successful kidney transplant.

 

 

 

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