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A commercial medical escort transport mission is defined as the transport of a patient whose condition warrants monitoring and minimal medical attention on a commercial aircraft.  Transfer may include multiple flights including airport layovers. 

Patients’ level of care should be individualised according to their clinical status, medical needs and HAD. 

The medical attendant must be certified to practice independently with ability to attend to the patient should they complicate.  All administration of medication and procedures should be well within their scope of practice.

Commercial Airline Medical Escort Standard Care

A stable patient requiring basic medical care for the duration of the transfer.  One medical attendant is appropriate.

Commercial Airline Medical Escort Advanced Care

• Stable patients who require nursing care on the transfer such as (but not limited to):
• O₂ supplementation
• Drainage bags – urinary catheter, surgical drains, NG tube bags
• Dressing changes of open wounds
• Medication administration / supervision of self-administration
• Dietary supervision
• Potential cardiac deterioration requiring emergency medical care
• Potential diabetic complications requiring emergency medical care
• Potential respiratory complications requiring emergency medical care.
• At least one medical attendant is permitted.

Commercial Airline Medical Escort Paediatrics

• Transfer of neonates by commercial medical escort is not recommended.
• Stable paediatric patients requiring nursing care such as (but not limited to):
• O₂ supplementation
• Drainage bags – urinary catheter, surgical drains, NG tube bags
• Dressing changes of open wounds
• Medication administration
• Potential cardiac deterioration requiring emergency medical care
• Potential respiratory complications requiring emergency medical care
• Medical personnel with additional qualifications in paediatric intensive care are recommended.

Commercial Medical Escort Stretcher Transport

• Stable patients with limited mobility.
• Patients who are unable to obtain or maintain an upright position for longer than 45 minutes.
• Patient examples are (but not limited to):
• Paralysis
• Neurological deficit post stroke
• Back injuries / recent surgery
• A urinary catheter is recommended.
• Bowel prep is recommended no closer than 24 hours prior to departure.
• Two medical escorts are recommended.

Advanced Life Support (ALS) or Registered Nurse

• Scope of practice for a Registered Nurse, Critical Care Attendant (Paramedic) or Respiratory Therapist 
• Stable patient 
• Medical care including (but not limited to):
• Basic airway management 
• Supplemental oxygen  
• Blood glucose control 
• Fluid drainage bags 
• Dressing changes  
• Administration of oral / intermuscular medication 
• Dietary supervision 

Medical Doctors as Escorts

• Medical doctor escorts are not required in most cases.
• Consider an AA should the patient require complex care.

CAMTS Medical Escort Accreditation Standards 7^th Edition (2023) Commission on Accreditation of Medica Transport Systems.  Available from https://www.camts.org/standards/

• At cruising altitude, the cabin is a hypobaric hypoxic environment. 
• Passengers will be breathing the equivalent of FiO₂ 0,15 at sea level. 
• Heart rate, respiratory rate and blood pressure will increase as a compensatory measure to hypobaric hypoxia. ⁽³⁾ 
• Increased heart rate with greater myocardial contraction results in an increased cardiac output, leading to higher O₂ demand.  O₂ demand may outstrip oxygen supply. ⁽³⁾ 
• A Hb < 4,34 mmol/L (7 g/dL), cardiac output may increase in response to lower O₂ carrying capacity.  A Hb 4,34 – 10 mmol/L (7 – 10g/dL) should be targeted and individualised according to patient pathology and cardiopulmonary reserve. ^(4,5,17) 
• Blood pressure may increase with acceleration and deceleration forces on take-off and landing respectively. ⁽³⁾ 
• Noise and vibration may increase systolic and diastolic blood pressure. ⁽³⁾ 
• Hypobaric hypoxia may increase the frequency of PVC’s.  Prolonged mild to moderate hypoxia may cause sustained PVCs with possible degradation into clinically significant ventricular arrythmias. ⁽⁶⁾ 
• The volume of intrathoracic free air post thoracic surgery increases at altitude.  Respiratory and cardiac function may be adversely affected by the greater volume. ⁽¹⁾ 
• The 50m Walk Test is a simple and validated test to demonstrate cardiopulmonary reserve ⁽¹⁾.  Should the patient not be able to complete the entire 50m without stopping, then they are not FTF independently.    
• Patients’ cardiopulmonary reserve may be adversely affected by HAD. 
• Rupture of arterial aneurysms at altitude has not been proven in the clinical setting.  In-flight aortic aneurysm rupture has not been reported in the literature. ⁽⁸⁾ 
• Hypobaric hypoxia may influence tissue oxygenation in peripheral vascular diseases. 

Generating a higher Minute Volume (MV) is the physiological response to hypobaric hypoxia. Creating a greater Tidal Volume (TV) contributes more than a higher Respiratory Rate (RR) in this compensation. ⁽⁴⁾

Cardiac compensation to hypoxia causes pulmonary vasoconstriction, blood flow is diverted to the apexes. ⁽⁴⁾ This generates a ventilation-perfusion (V/Q) mismatch.  Masses or diseases located in the apexes, will heighten the mismatch, causing early respiratory compromise. Other diseases affected by V/Q mismatch are Chronic Obstructive Pulmonary Disease (COPD), pulmonary embolism (PE), pulmonary fibrosis, cystic lung disease, pulmonary lobe resection. ⁽⁴⁾

Pulmonary vasoconstriction may cause clinically significant increases in pulmonary vascular pressure. ⁽¹⁾ 

Hospital-Associated-Deconditioning (HAD) will cause respiratory distress due to wasted respiratory musculature. ⁽⁴⁾

Patients with neuromuscular disease / chest wall disease will tire quickly with the higher respiratory workload.

An arterial blood gas measurement for chronic lung disease patients of PaO₂ < 67 mmHg on the ground, can be expected to drop to PaO₂ < 50 mmHg in-flight. ⁽⁴⁾

At cruising altitude, free air in the thoracic cavity increases approximately 30%. ⁽⁴⁾

Cabin humidity is approximately 10%. Dry air may lead to airway irritation, and regression of symptoms in particular diseases.

Respiratory conditions can negatively impact cardiac functioning, special consideration should be given to patients with cardiopulmonary diseases. ⁽¹⁾

Respiratory decompensation can be accelerated by multiple comorbidities.

The Hypoxic Challenge Test is the gold standard to predicting hypoxaemia in-flight, but this test is not widely available. ⁽¹⁾  The patient is exposed to FiO₂ 0.15 for 20 minutes.  At this point, an ABG is taken.  If the Pa O₂ > 50mmHg and SpO₂ > 85%, then the patient may not require supplemental O₂ at altitude. 

The 50m Walk-Test is a reliable and easy test to run.  The patient walks 50 m at a brisk pace, if the patient can complete the 50 m without stopping and has not desaturated SpO₂ < 85%, then they may not require supplemental O₂ at altitude. ^{(1, 2, 6)}.  Alternatively, the patient can climb 12 stairs.

The 6-Minute-Walk-Test is more accurate than the 50m Walk-Test to predict in-flight O₂ desaturations. ^(1,2) The patient may start the walk is SpO₂ > 95% at rest.  They attempt to walk for 6 minutes at their own pace, if the SpO₂ remains >84%, the patient may not require supplemental O₂ at altitude. ^{(1, 2)}

Resting SpO₂ at sea level does not reliably predict respiratory decompensation in the cabin environment in patients with respiratory disease/s. ^(1,3,6)

FEV1 does not reliably predict respiratory decompensation in the cabin environment in patients with respiratory disease/s. ^(1,6)

Predictive equations estimating the degree of desaturation in-flight are not reliable. ^(1,3)