Fit-to-fly or non-fit-to-fly?
T H I S I S T H E ( D I F F I C U L T ? ) Q U E S T I O N
I S T V Á N L U N C Z E R , B A L Á Z S K Á D Á R
Is he?
Physiological impacts
Change of pressure, temperature, humidity, tilt
Acceleration-deceleration
Sudden ascent-descent
Vibration, shake, turbulence
Jet-lag
Pre-assessment
Patient reports
Laboratory results
Imaging diagnostics
Consultation with the TD
Bedside visit
General condition
Age (?)
Agonizes, dying
Severe anaemia
Risk of bleeding
Circulatory & respiratory failure
Postoperative status (itself)
Arrhythmias
Intubated/ventilated
Inotropic support
Mobilization problems
Extreme obesity
body weight (capacity of stretcher)
body dimensions (size of A/C cabin, stretcher, width of A/C door)
Risk of bleeding
Circulation instability
Immobilization problems
Extreme obesity, other body size differences
Vacuum mattress (NB: cabin pressure)
Crutchfield, HALO, KTD, fixateur
Special devices, IABP, ECMO
Devices, competencies
• Quantity
• Quality (ranges)
ECMO?
Sea-level cabin pressure
pressurization is set to maintain a cabin pressure corresponding to sea-level pressure implications:
lower cruising altitude, different routing, higher consumption, more fuel stops possible indications:
Pneumocephalus
Pneumothorax
Intraocular gas
Abdominal distension
Decompression sickness
Gas gangrene
Hypoxic respiratory failure
Severe brain injury
ICP
Intracranial hypertension
Brainstem herniation
Is sea level the solution?
“I have never understood this. Many people say ‘yes, let’s do it sea level, just to be on the safe side’. But it puts the patient at greater risk. It means you can’t fly as high as you normally do. You can’t fly above the weather, there’s more vibration and turbulence, you burn more fuel, and on a long-distance flight you have at least one, sometimes two or three, fuel stops, and that’s where the danger starts: what’s really dangerous for the patient is the acceleration and deceleration during take-off and landing. I think it’s very stupid to say ‘let’s go sea level to be on the safe side’. You are definitely not on the safe side .”
(Dr. Thomas Buchsein, AirMed and Rescue, 2 April 2015)
In the thorax
Pleural effusion (htx, pyothorax, fluid)
Pneumothorax thoracostomy/tube?
Question
Penetrating trauma
Unstable chest
In the abdomen
Ileus
Failure of peristalsis
“Open abdomen”
Blood in the abdomen
Acute pancreatitis
Free intra-abdominal air
Vascular obstruction
Embolism (pulmonary, bowel, limb)
Acute myocardial infarction
Stroke
Ischaemia damages
Circulatory/respiratory failure
Cardiogen shock
Ineffective pump function
Septic shock
Arrhythmias
Severe asthma
Pulmonary edema
ARDS
Severe COPD
Blood gas analysis
If:
pO
2 is less than 60(?) Hgmm pCO
2 is more than 60(?) Hgmm
Hbg is less than 7-9(?) g/dl
Lactate?? BE??
FiO
2
correction:
FiO
2
(a)=FiO
2
(i)×P(GND)/P(cabin)
critical initial FiO
2 for 6000 ft cabin altitude:
(calculated with 1013 hPa GND and 800 hPa cabin pressure)
79%
Postoperative status
Thoracic/cardiac surgery
Expanded abdominal operations
Brain surgery, craniotomy/craniectomy
Stent implants
Contagious patient
Ebola
HIV
Special flu (H1N1, bird, etc..)
Incubator
Case report I.
45 yr female, transport from Porto to Dresden end stage gastric cancer multiple laparotomies
RR: 22/min, SpO2: 95%, HR:
140/min, BP: 90/60 Hgmm, febrile faeces present in drains, NG tube sea-level cabin pressure planned
(re-routing, consent from costbearer) uneventful transport
Case report II.
54 yr male, transport from Marrakech to Saint Etienne suffered a motorbike accident 2 days prior to transport diagnosed with broken nose, luxation of right elbow, fractures of pelvis & sacrum, damage to the urethra no PMH op. on right elbow, external fixation of pelvis
TD first disagrees with transport (compliance and language problems) vitals stable (GCS:15, NSR, 90/min, 135/80 Hgmm, SpO2: 95% @
RA, RR: 17/min) legs are spread (fixateur), feet 103 cm apart (LJ35 cargo door width:
91,5 cm), relatives state legs are immobile after extensive consultation and review of imaging, it turns out that immobilization of legs are caused by a large amount of scrotal edema after careful mobilization transport went down without problems
Decision making
Complex decision
What is the aim of the transport?
There is no fix „recipe”, every case is unique
Considerations:
medical (status of patient) ethical (terminally ill patient) legal (laws of multiple countries) logistical / organizational (double stretcher transport, distance, weather) financial
When in doubt consult the CMO!
(You are never alone!)
Many happy landings!
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