Nonurgent commercial air travel after nonhemorrhagic cerebrovascular accident.

Nonurgent commercial air travel in patients who have experienced a nonhemorrhagic cerebrovascular accident (CVA) may occur, particularly in the elderly traveling population. A recent CVA, particularly occurring during a person's travel, presents a significant challenge to the patient, companions, family, and health care team. Specific medical recommendation, based on accumulated scientific data and interpreted by medical experts, is needed so that travel health care professionals can appropriately guide the patient. Unfortunately, such recommendations are almost entirely lacking despite the relative frequency of CVA and air travel. This article reviews the existing recommendations with conclusions based on both these limited data and rationale conjecture.

Nonurgent commercial air travel after acute coronary syndrome: a review of 288 patient events.

OBJECTIVES: We studied a population of individuals who experienced an acute coronary syndrome (ACS) event while traveling abroad and required nonurgent commercial air travel to the home region. METHODS: This retrospective study gathered data from 288 patients enrolled in a travel-based medical assistance program. Interventions, complications, and travel home were assessed for trends. Descriptive and comparison statistical analyses were performed. RESULTS: Two hundred eighty-eight patients were identified and entered into the review. Of the patients in this study, 77.1% were male with an average age of 67.7 years. One hundred sixteen (40.3%) patients were diagnosed with unstable angina pectoris (USAP), whereas the remaining 172 (59.7%) patients experienced acute myocardial infarction (AMI). Regarding inpatient complications during the initial admission, 121 (42.0%) patients experienced 1 or more adverse event. The average number of days after an ACS event that a patient began to travel home was 10.5 days for the entire patient population (USAP patients = 8.8 days, AMI patients = 11.8 days). Two hundred twenty (76.4%) patients traveled with a medical escort, and 48 (16.7%) patients received supplemental oxygen during air travel. Four (1.4%) in-flight adverse events occurred in the following ACS diagnostic groups: 2 in the complicated AMI group, 1 in the uncomplicated USAP group, and 1 in the uncomplicated AMI group. No in-flight deaths occurred. Nine (3.1%) deaths were noted within 2 weeks after returning to the home region. The deaths after returning to the home region occurred in the following ACS diagnostic groups: 2 in the complicated USAP group, 1 in the uncomplicated USAP group, and 6 in the complicated AMI group. None of the patients who experienced in-flight events died after returning to their home region. CONCLUSIONS: Upon discharge, the vast majority of ACS patients who travel to their home region via commercial air do not experience adverse events in-flight; when such adverse events occur in-flight, these events do not result in a poor outcome. No in-flight deaths occurred; death occurred in a minority of patients after returning to their home region, particularly in the complicated USAP and AMI groups, who were planned readmissions to the hospital.

Air travel of patients with abdominal aortic aneurysm: urgent air medical evacuation and nonurgent commercial air repatriation.

Abdominal aortic aneurysm (AAA) presents across a spectrum of severity. Although some resources suggest a theoretic risk for rupture related to air travel, this claim remains unproven. In fact, there are little data from which to make evidence-based recommendations. Air medical evacuation of a patient with either an AAA at risk of imminent rupture or status post recent rupture can be performed, assuming that local surgical care is not available and that transfer is taking the patient to a higher level of medical intervention. Furthermore, medical opinion suggests that patients with asymptomatic and/or surgically corrected AAA can safely travel by commercial aircraft for nonurgent reasons, assuming that other issues including postoperative needs are appropriately addressed. In this discussion, answers to the following issues are sought: flight safety for urgent evacuation and nonurgent repatriation scenarios, waiting time to fly nonurgently after AAA diagnosis, and the need for medical accompaniment.

Commercial aircraft repatriation of patients with pneumothorax.

The transfer of patients with a pneumothorax via a commercial airline involves many medical, aeronautic, and regulatory considerations. In an attempt to further investigate these issues, we reviewed the medical records of 32 patient cases with a pneumothorax who were repatriated on commercial aircrafts. Sixteen patients were transferred with the thoracostomy tube in place and were escorted by medical personnel at an average of 5 days (interquartile range [IQR], 4-7 days) from diagnosis. Five patients without initial intercostal drainage (who either showed very limited air collection or underwent immediate surgical treatment) were all escorted by a physician at an average of 24 days (IQR, 18-25 days) of diagnosis. Eleven patients were transferred without medical escort aboard a commercial flight after removal of the chest tube at an average of 15 days (IQR, 9-17 days) of the diagnosis. This case review suggests that physicians recommend and follow markedly different management plans for the patient with a pneumothorax who is being transferred nonurgently by a commercial airliner. This differing practice management also is noted in the various existing specialty and industry guidelines, which are not evidence based; our review shows that poor agreement exists not only in these various guidelines but also among medical practitioners.

Commercial air travel after pneumothorax: a review of the literature.

Because of the physiological stresses of commercial air travel, the presence of a pneumothorax has long been felt to be an absolute contraindication to flight. Additionally, most medical societies recommend that patients wait at least 2 weeks after radiographic resolution of the pneumothorax before they attempt to travel in a nonurgent fashion via commercial air transport. This review sought to survey the current body of literature on this topic to determine if a medical consensus exists; furthermore, this review considered the scientific support, if any, supporting these recommendations. In this review, we found a paucity of data on the issue and noted only a handful of prospective and retrospective studies; thus, true evidence-based recommendations are difficult to develop at this time. We have made recommendations, when possible, addressing the nonurgent commercial air travel for the patient with a recent pneumothorax. However, more scientific research is necessary in order to reach an evidence-based conclusion on pneumothoraces and flying.

K-plan for patient repatriation after mass casualty events abroad.

In addition to requests for individual aeromedical evacuation (AE), medical assistance companies also may respond to mass casualty incidents abroad. The purpose of this report was to evaluate the effectiveness of our primary casualty plan, based on experience involving a January 2010 bus crash in southern Egypt. The main evaluative criterion was time elapsed from the initial call until the return of victims to their home country. Three critically injured patients underwent an initial AE to Cairo for advanced trauma care. After stabilization, they arrived back in their home country 42 hours after the initial call. The remaining group of patients arrived 27 hours later, or a total of 69 hours after the first call. These findings suggest that the "K-Plan" standardized operating process may be effective for rapid and appropriate repatriation of numerous victims. Some specific issues, such as efficiently locating a large-capacity charter aircraft, require further improvement.

Air medical repatriation: compassionate and palliative care consideration during transport.

As the world's population ages, the number of elderly and very elderly international travelers continues to increases. Many of these travelers are afflicted with multiple, often severe, medical conditions; in fact, a significant portion of these elderly travelers are considered end stage with respect to their disease state. While traveling, they are exposed to travel hazards and deterioration of their already compromised health. Once acute illness or injury occurs, medically appropriate, compassionate repatriation of these elderly patients is associated with a range of complex challenges. In this series, we present 4 cases that demonstrate these challenges.

Evaluation of a specific score for air medical evacuation triage.

Age, local resources, and locations have been identified as independent factors indicating the need for immediate air medical evacuation. This preliminary case-control study aimed to evaluate the relevance of a score from 0 to 6 based on these criteria and to identify thresholds. The 3-step scale we obtained may help in prioritizing repatriation requests.

Multidrug-resistant bacteria among patients treated in foreign hospitals: management considerations during medical repatriation.

BACKGROUND: The repatriation of patients from foreign hospitals can foster the emergence and spread of multidrug-resistant bacteria (MRB). We aimed to evaluate the incidence of MRB in patients treated in foreign hospitals and repatriated by international inter-hospital air transport in order to better manage these patients and adjust our procedures. METHODS: The records from all consecutive aeromedical evacuations and overseas repatriations carried out by Mondial Assistance France between December 2010 and November 2011 were reviewed for this study. Only inter-hospital transfers with inpatient destination of an acute care unit were considered. Patients were allocated to one of two groups: those identified as MRB carriers at their arrival in France and those who were not identified as such (either negative for MRB or not tested). Data were compared between the two groups. RESULTS: Analysis was performed on 223 patients: 16 patients (7%) were identified as MRB carriers. Compared with confirmed non-MRB patients, MRB carriers came more frequently from a high-risk unit (88% vs 59%, p = 0.05) and had a longer foreign hospital stay [13 (3-20) vs 8 (6-14) d, p = 0.01]. CONCLUSIONS: The occurrence of MRB among patients repatriated from foreign hospitals is noted in a significant minority of such individuals transferred back to their home country. The typical MRB patient was admitted to a high-risk unit in a foreign hospital prior to repatriation with longer foreign hospital admissions. The prospective identification of these patients prior to transport is difficult. While these factors are associated with MRB presence, their absence does not rule out highly resistant bacterial colonization. A systematic review of this important medical issue is warranted with the development of guidelines.

Decision criteria of immediate aeromedical evacuation.

BACKGROUND: The decision whether to immediately evacuate an international traveler who has become ill is a challenge for physicians of aeromedical evacuation companies. The aim of this study is to characterize international aeromedical evacuations in order to identify predictive factors that indicate urgent evacuation. METHODS: The records from all consecutive aeromedical evacuations and overseas repatriations carried out by Mondial Assistance France between August 2006 and July 2007 were reviewed for this study. Patients were allocated to one of two groups: those requiring immediate aeromedical evacuation by air-ambulance and those whose condition allowed subsequent, nonurgent repatriation. Data were compared between the two groups. RESULTS: Overseas repatriations numbering 402 were executed: 35 immediate aeromedical evacuations with air-ambulance and 367 nonurgent repatriations. Age < or =15 years [odds ratio (OR), 7.0; 95% CI, 1.6-30.6], whether there was a high standard structure in the country (OR, 0.28; 95% CI, 0.09-0.85), and location in sub-Saharan Africa (OR, 12.6; 95% CI, 2.3-71.4) were independent factors indicating the need for immediate aeromedical evacuation. CONCLUSIONS: Patient age, availability of local resources, and locations are the criteria associated with the need for immediate aeromedical evacuation. Creation of a specific standardized scoring system based on these criteria could be of great value to help physicians of aeromedical evacuation companies in initial management of cases.