Mile High Medicine Part 2 | Fit to Fly

Listen to episode #15 of NAVIGATE to learn if you’re ‘fit to fly’ and why that matters.

Mile High Medicine – Part 2:


Will McAleer

0:00:03 – 0:01:17

Welcome to NAVIGATE. My name is Will McAleer, and I’m the president of World Travel Protection, based in Canada. I’ll be your host for today for part two in our Mile High Medicine series. Now on the last episode, we covered medical emergency on planes and some of the things you can do on long haul flights to stay healthy. This episode focuses on the importance of a fit to fly program, and how that helps organisations to support their travellers, especially expats on assignment, perhaps to remote sites where medical assistance might not be readily available. Today, I’m joined by two experts in the field. First, we’ve got Dr. Joel Lockwood. He’s the Chief Medical Officer for the Americas for World travel protection. And in addition, Dr. Lockwood is active as a trauma lead at a major trauma center in Toronto, and has also served as a transport medicine physician at a government operated air ambulance service. Welcome Dr. Lockwood.

Dr Joel Lockwood

0:01:17 – 0:01:18

Thank you. Thanks for having me, Will.

Will McAleer

0:01:19 – 0:01:48

We’ve also got Graham Williamson, someone I’ve known in the in the business for a number of years who’s the CEO for Life Support Air Medical Services, EURAMI accredited worldwide provider of international air medical patient transportation. And additionally, commercial repatriation services are also provided by his firm. Welcome, Graham.

Graham Williamson

0:01:48 – 0:01:54

Thanks, Will. Great to be here and happy to lend some perspective to this very important topic today.

Will McAleer

0:01:54 – 0:02:07

Yeah, so so Mile High Medicine, and fit to fly specifically. Dr. Lockwood, when we when we talk about fit to fly, tell us what it means to you?

Dr Joel Lockwood

0:02:07 – 0:02:56

Well, you know, I think it means a few things, Will, and I think it kind of depends on who you are. Now for the lay public that may be going for a flight, they may be asked to fill out a form by their GP or doctor saying that they’re safe to fly on a commercial flight. And so I’d say that that’s one major thing that applies to the general population. But for us in our work, there’s also a few other kinds of populations that we look at. One is people that have had a medical emergency, and how they can safely travel and what that exactly means. And then the second is, I think, maybe how we should be thinking about it a bit more, I like to kind of term it as fitness to travel. Because while flying is one thing, you know, working abroad in a different setting, there may be some medical considerations that we want to pay attention to. So those are the kinds of ways I think that we can look at that topic.

Will McAleer

0:02:56 – 0:03:28

Hmm, so interesting. So what you’re saying is there’s a difference between individual and corporate definition. So that being the case, for really take a look at that corporate definition, or rather, the definition used when considering whether a patient, you know, following a medical emergency is fit to fly. So, so what do organisations and people need to consider, right when, when they’re when they’re going in there, they’re on an expat assignment before they get sick?

Dr Joel Lockwood

0:03:28 – 0:04:49

Yeah, I think that that’s a really good way to look at it, Will. I think we need to think of clients and businesses, individuals health, even before they go. And maybe the best way to bring it up is as a bit of an example for a hypothetical situation. So let’s say that the there’s a business that’s hired a young person to work in a mine in a very remote place, you know, obviously, it’s going to be hundreds of kilometres away from a hospital, and somewhere where they’ve never been before. And you know, obviously, it’s a strapping young person who’s strong and healthy otherwise. But unless things are investigated a bit more, you know, sometimes there can, there can be some problems. And let’s say maybe, again, this hypothetical situation that this person has a drinking problem that they may not have mentioned before, and they get travelling traveled to a mine that doesn’t have alcohol. So obviously, things may be fine on the flight there, you know, they may have had a few drinks while in the airport lounge. But upon arriving at a dry facility, they may experience signs of alcohol withdrawal. And so obviously, that’s a medical emergency and that that is going to put that person at risk. And certainly, the repatriation options at that point are going to be very limited. They may take some time, and they may be quite costly. So I think thinking of it holistically is a really good way to look at it because obviously that could be avoided. You know if it’s identified early, but identifying it late, leads to some obviously medical liability and also costs.

Will McAleer

0:04:49 – 0:05:16

So a little bit of preparation is is key there. I like that. So now let’s take the situation someone’s arrived at destination, they’ve they’ve, they’ve had a medical emergency, and they’re pretty sick. What are the types of considerations that that you look at as a physician to determine whether or not they are fit to fly?

Dr Joel Lockwood

0:05:16 – 0:06:59

Yeah, there’s a number of considerations to think of, and I think that the way that I kind of categorise in my, in my mind is sort of a risk benefit for the patient. So obviously, depending on where the patient is currently and the resources they have available, it’s going to, it’s going to mean a lot. Now, if someone’s in a resource, high environment, you know, I think that obviously, flight is a risk, you know, because of a few reasons.

One of them is because of physiology. Obviously, people are in a confined area pressure with limited resources, things like gas laws change. So that’s one area of risk but I think even more importantly, it’s a it’s a, an area where there’s not a lot of help to get if you are on either a commercial flight or an air ambulance. So those things need to be, I think, calculated quite carefully.

The second is is you know, what, what kind of what’s a reasonable expectation to think of if the patient does fly, you know, how likely is something to go wrong. And I think that this is where there’s a lot of nuance, there’s some, there’s some guidelines that are driven by expert opinion on when people can fly, but it doesn’t really take in that risk. You know, an example of this is you know, let’s say someone has had a stroke. Now typically we try not to have people fly for about 10 to 14 days after a stroke, but if they’re in a very remote location, you know, I think that the risk of staying there is going to be higher than the risk of flying and I think that’s where it takes you know, a lot of nuance to really think of what is best for this patient at this at this point. You know, we know that things like after stroke care and rehab will reduce the the damage of the stroke can cause and I think sometimes looking at those rules like hard and fast and under no circumstances can we fly someone after a stroke doesn’t take into account the complexity of each individual or each client’s particular medical condition.

Will McAleer

0:07:00 – 0:07:23

Ah so a lot gets weighed in, not just a simple checkbox exercise, you’re looking at what’s actually happening what’s being presented. Very interesting. Now Graham on your side, I know you receive a lot of calls for help from medical assistance companies, what are some of the main reasons for needing a repatriation?

Graham Williamson

0:07:23 – 0:09:36


Yeah, so we break it down into into three categories. The first one is, you know, an evacuation or repatriation where as Joel described, the, the, the expatriate, the worker, the traveler has found themselves in a difficult situation in a in a remote area in a work camp, you know, in a far flung region where the employer has has brought them to and and in those cases, we typically take an evacuation approach where we’re transporting someone to a higher level of care.

Next circumstance is where we’re repatriating someone perhaps they have more of a chronic as opposed to an acute illness or injury, something that’s not likely to recover or in necessarily improve in the short term, maybe they’re looking at a few weeks to recover from a fracture or from a stroke and we’re going to bring them closer to home so that they have local support, they can be with friends, they can be with family and in an environment that’s more conducive to the care that they require.

And and then next is is making sure that they might have access to commercial airline resources or less less burdensome for the employer for the customer clients such as an air ambulance which was very cost intense so we have repatriation and fit to fly options on commercial flights. So from our perspective, it’s really about taking a look at the at the case on an individual basis.

So we receive these calls all the time, where we have a you know a step by step approach and looking at the case from the top down it – does the does the customer the patient needs immediate evacuation to a higher level of care whether we call it LLTO – life limb organ threatened case which is you know, in our in our world is a red call, everything stops and and we put our all of our resources into an immediate evacuation. Or we might go all the way down to saying you know, the customer might be fit to travel in a week or two from now and can take say a Lufthansa or United Airlines or a Qantas flight home. And and they don’t need immediate evacuation. So it runs the full continuum and full spectrum from from from now immediate, through to through to a more of a pre planned event.

Will McAleer

0:09:36 – 0:09:54

Wow. So it’s more than just getting them on a quick Learjet to get back into their home. You can take them to get better care if they can’t get it at destination or get them back home depending on the nature – I like those those options.

Graham Williamson

0:09:54 – 0:10:38

Yeah, precisely. And it’s about having a collaborative approach with the insurer and with the assistance company and with the physician medical directors. Both here on our side where we have our flight physicians, our chief medical officer and chief flight nurse review the cases in conjunction in collaboration with the with the medical underwriters or with the insurer or with the assistance company to discuss the the nature of the case the urgency of the case, the level of care at destination where the where the customer is right now where they’ve suffered their event, and the options available both for evacuation stay treat a little while longer you know perhaps things will get better or to decide if if a repatriation is necessary at that point.

Will McAleer

0:10:39 – 0:10:48

Wow. So so from a fit to fly perspective, maybe you can walk us through what’s involved in a commercial escort versus a private air ambulance evacuation.

Graham Williamson

0:10:48 – 0:12:57

Yeah, so it commercial escort and private air ambulance they’re – they interestingly, Will, they run from the two spectrums, the commercial looks, first and foremost at the stability of the patient to travel on a commercial airline. And exactly as you described, as I alluded to United, Lufthansa, Qantas, Emirates. These are these are when we collaborate with our assistance company partners to put the patient on a commercial flight. And we certainly absolutely do take some very sick people on commercial flights that we can appropriately manage. But that’s a conversation that has to occur with the airline as well because it is after all, their plane, their route, they want to make sure that that their passengers as a whole and the flight is looked after in addition to meeting the needs of their of the patients and the customer.

Then we have the air ambulance side, which is a dedicated aircraft as you describe the Learjet, it could be a Challenger or a Falcon really depends on where where the insured is and where they’re going and what the distances and ranges are. And and believe it or not, when we when we flip back and forth, sometimes between commercial or air ambulance, it’s it often focuses on logistics. We can cover longer distances with a commercial flight than we can with a Learjet. Conversely, we can cover there might be areas in the world and there, I shouldn’t say might, there are all sorts of spots over the world where employers have workforces. Joel mentioned the mine site. So for us to fly into a mine site, we wouldn’t be able to take a Qantas flight into the mine site, it just doesn’t exist. But we can take a King Air, or a Learjet or a Challenger jet into so it might not be a medical need that the customer has versus a logistical need. And that’s where options such as private charter, air ambulance come into play.

So again, what it really comes down to, Will, is a collaborative discussion between our medical team and your medical team to to decide on the best mode of transport, how quickly do you need it done? And what’s the what’s the most cost effective and beneficial route for the patient?

Will McAleer

0:12:57 – 0:13:11

So you must have, you must have said you get lots of calls from us, you must have been to some fairly far flung places. So what does that look like in terms of coordination and getting people out?

Graham Williamson

0:13:11 – 0:14:52

You know, it’s it’s always interesting, no day is ever the same. We we definitely have a variety of cases where we’ve had to approach it with creativity most especially over the last 18, 19, 20 months, where commercial options have been limited, but we’ve been able to use charter resources effectively. But really, you know, I say the middle of nowhere tongue in cheek, but it is the middle of nowhere. Our clients are engaging in resource development, mining, oil and gas exploration, defense, telecommunications, where we are finding people all over the world.

So really, it’s it’s, as we say, it’s when that email chimes and there’s an alert, you don’t know where you’re going until you read it and you finish wrapping your head around it and formulating a plan. And that’s the beauty is even though we have pre planned responses, so we work with our customers, such as World Travel Protection to pre-identify, pre-plan the resources knowing that there’s a group, there’s a group that’s going to be traveling to a certain remote area, we can provide that advice – we do provide that advice – and absolutely when the call comes in, we’ve pre-planned those events most of the time.

And of course, if it’s if the worker’s found themselves, the traveller’s found themselves in an area that was unexpected, and sometimes that could be they’re traveling to work, maybe they’re connecting through Dubai and they develop chest pain in Dubai. Perhaps they’re on their way to work in a job in India or in Pakistan and connecting through and we find them in places that might not have been planned for and we have to you know, we have to get our resources mobilised from that point.

Will McAleer

0:14:53 – 0:15:16

So, so planning interest thing thing that you brought up. So you get a request to go in and get a particular patient, it might be an easy to get to location, or it might be far-flung. What happens when you arrive there? And maybe it’s not quite the way that you were told it was? What do you do? How do you respond?

Graham Williamson

0:15:16 – 0:18:30

You know, that’s well, that’s the beauty of medicine in assistance is that until we actually put our hands on that patient, it’s a it is essentially a paper, email and telephone-based exercise. So the first and foremost is making sure that we do a comprehensive review and review all the information that’s been provided to us by our assistance company partners, such as yourself. The next step is making sure that our air medical crew and our medical team is involved in the discussions and reaching out to the treating physician and the treating medical team. Sometimes that’s possible. And sometimes it’s not possible. If it’s possible and we can have a dialogue with the care team that’s that’s that checks a major box for us, provides us the degree of comfort, knowing what we’re getting into.

And, but sometimes communications are blacked out, communications are not available. There there are sometimes in certain areas, the hospital might be unwilling to have a conversation. Some hospitals might not want to talk to us on the phone, and so prying that information out can be very difficult. So we have a variety of, of resources that are available to us. And believe it or not, we get we get creative, we get our hands dirty, we will ask to speak to the patient on the phone. If we if we can’t speak to the medical team, we’ll call the patient and say how are you doing? How are you feeling? And if you can have a conversation with us on the telephone, that’s amazing. Because you’re you’re better than you’re better than we expected if we can chat with you. You might talk to a family member or a supervisor or a co-worker.

But you know, at the end of the day, we have to make a decision as a air ambulance and medical transport organisation, is this patient fit to fly? And our criteria is very simple. Do they need evacuation? If so yes, we fly. So my background is as a paramedic, I worked for a service very similar to the one that Joel has provided medical advice to where when the phone rings, the red phone goes, you fly or that’s it, that patient needs to reach a higher level of care so it doesn’t matter what’s wrong with you. You could you could be missing a limb or having or having a huge heart attack. But staying where you are is not an option. Staying where you are is a threat to your life and health. So we’re going to get you out no matter. We’ll stabilise you, we’ll do our best to stabilise you, but we’re going to evacuate you.

Whereas the second conversation is a repatriation where maybe they’re traveling on a commercial airline or even by air ambulance, we have a responsibility to make sure that the patient is fit to travel, if we’re doing it on an elective or cost containment basis. So so we’ll make sure before we leave, before we spend the customer’s money, we make that phone call. And again, we make that phone call 15 minutes before the plane leaves.

You know exactly case in point this morning, we are bringing someone from Florida, up to Montreal in Canada and everything was fine yesterday, patient was ready to go. It’s a totally normal routine hip fracture. But this morning, the customer had a bout of chest pain. So we have a responsibility to stop that aircraft from going because they’re in a great hospital in Florida, we just need to make sure it’s safe for the customer to travel. We’re satisfied that the customer’s safe and will take care of that chest pain issue once they get back up to Canada. Twenty minute delay to have a conversation doctor to doctor and we’re on our way.

Will McAleer

0:18:30 – 0:18:52

Great. And Joel from your side, what happens when you’re expecting a particular course of action? And maybe it’s not disagreement, but there’s there’s lack of clarity between you as Chief Medical Officer for an assistance company and the air ambulance provider on scene. How do you work through that?

Dr Joel Lockwood

0:18:52 – 0:20:00

So I think that you know, there’s there’s a number of kind of issues to go through there. The first thing is, I mean, I think that we have got a lot of great air ambulance providers. And we’re all kind of on board with the goal. And the goal is to make the right decision for the right patient. However, there’s sometimes can be conflict for a number of reasons. Sometimes it’s related to language issues, obviously, we have clients kind of all over the world. And communicating sometimes can be difficult, and we try to mitigate that as much as possible.

Sometimes it can be medical issues, but it’s usually not something that we kind of can’t take a step back and sort out. You know, we’ve worked with lots of different air ambulance providers. And occasionally if they see something that’s quite a bit different than what we see, I think we just need to take a step back and have a good discussion and really understand kind of where our partners are coming from and what their concern is. Sometimes, you know, I think that we can do our best to discuss with the physicians, the patient or the family, but really being there is something that’s very valuable. And I’d say that it’s really kind of quite rare that we can’t come to a kind of shared decision model using the same shared values about making the best decision for our clients and patients.

Will McAleer

0:20:00 – 0:20:11

So I’d imagine it’s it’s really a process of making sure that you’re also asking them the types of questions to make sure that the way that they get to their decision lines up with that best of patient care.

Dr Joel Lockwood

0:20:12 – 0:20:28

Yeah, I think a big part of it is kind of understanding, you know, where people are coming from when when there is a sudden kind of change in play or something comes kind of that’s, that’s much different than advertised. And generally speaking, I think we’re able to kind of work it out and figure out what’s best for the patient.

Will McAleer

0:20:29 – 0:20:48

I know we’re getting near the end of our time together here, but you know, when we think about mile high medicine, and and fit to fly, perhaps I’ll throw it to you first, Dr. Lockwood, any other closing thoughts about about how we look at whether a patient’s fit to fly or not?

Dr Joel Lockwood

0:20:48 – 0:21:54

So let’s say that, you know, the fit to fly kind of paradigm is it’s, it’s a lot more kind of complex, I think, than people realise, because there’s a lot of other factors that need to be taken into account, when deciding who to transport, you know, under what sort of circumstances to transport and using what teams to transport them.

Obviously, air ambulances now are very close to flying hospitals. And sometimes sending a team like that, that can be the number one intervention. If they’re in a very low resource setting, you know, they can start to get better when a medical team arrives. Other times, you know, it’s it’s really about making sure that they’re safe to be on, you know, a commercial flight, and that the risk of them decompensating from either a known or unknown medical condition is incredibly low, and that that transport can happen safely.

So I think my kind of closing would be that, you know, I want clients and patients to know that really, there’s kind of a lot that goes on behind the scenes. Sometimes it’s medical, sometimes like Graham was saying, it’s logistical. Sometimes it’s even based on things like language, but there’s no matter what, there’s always kind of a large team kind of looking out for your best interest when you choose to travel.

Will McAleer

0:21:55 – 0:22:00

Good points to – good points to consider indeed. Graham, closing thoughts?

Graham Williamson

0:22:00 – 0:24:35

Yeah, absolutely, Will. So first and foremost, I think it’s ensuring that customers and and consumers of the assistance services have plans in place, that they there is great communication between the, between the employer, between the travel company and the assistance company. Most especially working with an experienced assistance company.

An assistance company that truly has a global reach and has a global network is very important. Those assistance companies will have the experience in operating in remote areas, have the experience in dealing with mine sites with with faraway places that we might not yet have heard of until an emergency occurs.

And then working with an experienced provider. It’s, you know, it’s we are in a global environment now. We are in an environment where workforces are spread around the world, specialised expertise, and the employers have, you know, a responsibility to take care of those folks. And that starts again, with making plans, working with an experienced assistance company who’s going to work with an experienced air ambulance company. So that is pre-planning fit to fly before the emergency occurs.

And if those three items are in place, then it actually goes relatively smoothly and quickly where you’ve got, you know, an employer can have great conversations with their assistance company. And as Joel said, very rarely, if ever, does an assistance company and an air ambulance company come into any sort of disagreement on fit to fly because this is our bread and butter. This is the this is what we do every day, 365 days a year. So just allows things to go really smoothly when someone needs an evacuation or repatriation, it can happen in hours.

I can not tell you know how many times we encounter events with customers and clients that don’t, don’t plan these things don’t think these things through, they just go ahead and insure somebody. And, and then you know, and then it hits the fan and they don’t have any idea what they’re doing. This is what we have to do. It saves lives, it saves limbs, and it saves you guys time and your customers money.

What I can tell you is that when we deal with corporate clients, and we deal with group benefit plans and stuff, where there’s a, you know, it’s just different than dealing with someone who’s purchased $25 insurance and on their on their MasterCard. Those are nightmares to deal with, right? Policy limits and this and that. When I when I phone you and say I got to spend $220,000, to fly to the middle of nowhere, I actually really mean we got to spend $220,000, and we have to do it within 24 hours. And so just having that flow is and that willingness to jump is important.

Will McAleer

0:24:36 – 0:25:10

Very well put Graham Williamson, CEO for Life Support Aeromedical Services. Thank you for the time. And I’d also like to thank Frank Harrison, our regional security director for doing all of the great work behind the scenes to make this happen. Dr. Joel Lockwood, Chief Medical Officer for World Travel Protection. I know I’ve learned a few things and hopefully our listeners have learned in the second part of the Mile High Medicine – a NAVIGATE podcast.

In the second episode of this series on medical support in the air, guest host Will McAleer, President of World Travel Protection (WTP) – Canada, delves into the term ‘fit to fly’ and what it means for travellers, airlines and medical repatriations.

Will is joined by Dr Joel Lockwood, Chief Medical Officer – Americas for WTP, and Graham Williamson, CEO for LIFESUPPORT Air Medical Services. As medical and operational experts, they share a behind-the-scenes look at all the coordination involved in a successful evacuation.

Listen to this episode to learn the most common reasons for needing a repatriation, what happens when evacuation specialists arrive on scene to find the situation isn’t what they were expecting, and why having a plan ‘save lives, limbs, time and money’.

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