The “rise” of medical tourism has been in the news quite a bit recently, and I’ve been wanting to blog about the topic anyway, plus I just got an email from a patient we transported back to the U.S. via air ambulance last year.  So, I figure, now’s the time.

To start, the term “medical tourism” broadly refers to travelling internationally for medical care.  Sometimes patients go outside of the United States for health care that is less expensive in other countries; sometimes they go for procedures that they can’t get here.

That was the case for Sarah, who we transported back to the U.S. from Costa Rica after she had alternative cancer treatment there.  At the time, Sarah’s health was not good enough to travel commercially, which is why she chose a worldwide air ambulance.  I was thrilled to read Sarah’s update that her cancer is now in remission and she’s even back to work part time.

Medical tourism itself can be a fairly controversial topic, and I really don’t want to get into that debate here, but I do want to share a few points that are important to bear in mind for anyone with a medical condition who’s thinking about travelling internationally, or for anyone who’s thinking about travelling outside the U.S. for a medical procedure.

Might you need a worldwide air ambulance?

Point 1: If you’re travelling internationally, think about what you’d do if you had a serious medical emergency.  Certainly if you’re travelling abroad to have a medical procedure done, it’s very important to consider what you’d do if the procedure went wrong.  What are the hospitals like?  Where/how were the doctors trained?  Do you speak the language?

If you’re not comfortable with the quality of emergency medical care, if you don’t speak the language, and/or if you would need long-term medical care, then you might need to come back to the U.S.

Point 2: If you’ve had a medical emergency or a medical procedure went wrong, how will you get back to the U.S.?  I’ve blogged quite a bit about when a person with a medical condition can fly on a commercial airline.  Certainly I would never recommend that a patient in distress fly alone on a commercial airplane; there is simply too much that could go wrong at 35,000 feet to not have expert medical help.

Now a commercial air medical escort is certainly an option, but it’s only for patients who are relatively stable.  For the vast majority of patients who have had a medical emergency, and all of those in acute medical distress, a worldwide air ambulance is the only way to get the patient back to the United States to an appropriate medical facility.  Because it’s the only transport option that is fast and has the full range of life-supporting equipment.

Point 3: Consider who will cover the cost of an air ambulance should you need it.  As I’ve written before, medical insurance sometimes covers international air ambulance transfers, as does travel insurance – but not always.  If you elected to travel abroad for medical care and something went wrong, my guess is that neither medical insurance nor travel insurance would cover an air ambulance to bring you back to the U.S. (though that of course depends on your particular policy, and the circumstances).

So again, I’m not giving any advice on whether a person should or shouldn’t go outside of the U.S. for medical care.  I’m simply offering some points on things to think about if you are considering “medical tourism.”

The November-December-January holidays are the most highly travelled times of the year.  If you’re travelling – whether by plane, train, or automobile – here are four tips to keep in mind if you have a medical condition.

Tip #1: Get travel insurance.  I’ve blogged before about the importance of some kind of insurance that would cover an air ambulance transfer for people with medical conditions (see Does Insurance Cover Air Ambulance Service? Part 1 – Travel Insurance).  The cost of a policy from Medjet Assist or a similar provider is likely well worth it should you have a medical emergency away from home.  Even for travelers without medical conditions, a travel insurance policy that would cover an air ambulance can be a very good idea (especially if you’re travelling overseas).

Tip #2: Move around.  Deep vein thrombosis, or DVT, is a clot that forms (usually in the legs), breaks off, moves through the bloodstream, and ends up blocking blood flow to the lungs (pulmonary embolism).  It is typically caused by prolonged periods of inactivity, most often when a person is sitting with his or her legs bent at the knee in the same position for an extended period of time – as on an airplane.

To reduce the risk of DVT, move around to whatever extent possible.  Changing sitting positions can help get the blood flowing and minimize the chances of a DVT.  For passengers who are mobile, that may mean short trips up and down the aisle.  Even for passengers who are not mobile, shifting positions and doing leg stretches and ankle rotations can reduce the chances of DVT.

See Traveler’s Deep Vein Thrombosis: How to Stay Safe for more ideas on minimizing the risk of DVT.

Tip #3: Stay hydrated.  Staying hydrated is another way to reduce the chances of deep vein thrombosis.  It’s also good practice for every traveler in general, helping to reduce jet lag.  Especially when travelling on a long flight, staying hydrated (with water, not alcohol or soda) is important.  In most airports passengers can purchase bottles of water at the gate-side of security – which is a good idea because it can sometimes take awhile for flight attendants to get water distributed to all passengers on the plane.

Tip #4: Ensure you have the proper documentation to bring your medical supplies and equipment on board.  Commercial airlines require passengers with medical conditions who need special supplies or equipment to have what’s called a medical fit-to-fly information form (MEDIF).  I wrote about the story of one of our commercial air medical escorts who nearly missed a flight to Bulgaria with his patient because the airline had re-routed the patient’s oxygen concentrator, which was listed on the MEDIF.

For travelers who need to carry liquid medications, syringes, oxygen tanks, or other medical supplies, having those supplies listed on the MEDIF – which must be submitted to and approved by the airline in advance of the flight – is absolutely critical.  Getting through security with those kinds of supplies also requires a MEDIF or other documentation that the supplies are medically necessary for the patient.

In the cases we’ve heard about where a patient was denied access to the flight, or even denied passage though security, it’s typically because of confusion about the proper documentation required to bring critical medical supplies past security and onto the airplane.  We’ve heard stories of people denied their liquid medications, oxygen concentrators, and other medical necessities because they didn’t have the proper documentation (and rules can vary by country, airline, even airport).

With these four tips, you’ll be well on your way to safe holiday travels this year.

Every so often a patient or patient’s family member will ask MedFlight911 Air Ambulance “How safe is an air ambulance?”  The answer is that all air ambulance operators are required to abide by the Federal Aviation Administration (FAA) safety regulations.

Now, I always tell patients to be aware that not all medical flight providers are truly air ambulances.  Some are what we call “angel flights” or “care flights” where an airplane owner volunteers his aircraft and a pilot volunteers her time to transport the patient.  Because those flights are not paid, operators are not required to abide by the same FAA regulations.

The FAA regulations that MedFlight911 Air Ambulance is required to abide by are known as Part 135.  They require adherence to regular maintenance and safety checks as well as pilot training time requirements.

I’ve written before about the difference between rotor-wing air ambulances and fixed-wing air ambulances.  Essentially, rotor-wing refers to helicopters and fixed-wing to airplanes.  Both are categorized as air ambulances by the FAA and governed by the same regulations.

After a number of rotor-wing air ambulance crashes last year, the FAA made regulations stricter for all air ambulances, including fixed-wing air ambulances (the only kind MedFlight911 Air Ambulance flies), which have always had a much better safety record than helicopter ambulances.

100% air ambulance safety record

So my basic answer to the “How safe is an air ambulance?” question is that operating an air ambulance requires us to meet the strictest FAA Part 135 standards.  Every operator must abide by them to maintain their FAA license.  But I also note that MedFlight911 Air Ambulance has a 100% safety record – no crashes, ever.  And, as they say, the proof is in the pudding.

Sometimes I also mention the certifications that all of the MedFlight911 Air Ambulance vendors maintain, including CAMTS, WYVERN, ARGUS, and EURAMI Platinum ratings as well.  Many of these certifications require more extensive pilot training than the FAA does.  And that’s important because how well the pilot knows the particular plane he or she is flying is important.

The age and maintenance record of the air ambulance matter too.  Is it a 1990 or 2000 Lear 35 or a 1960 model plane that has been stripped and rebuilt four times?  The newer a plane is, all else equal, the safer it is.

While no air ambulance service provider can give an absolute guarantee that no problems will ever arise, the result of the requirements that MedFlight911 Air Ambulance operators abide by is clear: a perfect safety record.

Our mission at MedFlight911 Air Ambulance is to get our patients from point A to point B as safely, quickly, and comfortably as possible.  For some patients, that means an air ambulance.  For others, it’s an air medical escort on a commercial flight.  For others it’s a commercial medical escort via motor coach.  But whatever the type of medical transportation, one thing is consistent: by the patient’s side every step of the way is at least one member of the MedFlight911 Air Ambulance medical personnel.

MedFlight911 air medical transport personnel qualifications

All MedFlight911 air medical personnel are highly experienced and extensively trained in their respective specialties. Physicians are board-certified in emergency medicine. Critical care flight nurses, paramedics and respiratory therapists are licensed and carry specialized certifications above the normal requirements.

Before working for MedFlight911, all registered nurses and paramedics are required to have at least the following core certifications:

• Advanced Cardiac Life Support (ACLS)
• Basic Life Support (BLS)
• Neonatal Resuscitation (NRP)
• Pediatric Advanced Life Support (PALS)
• Pre-hospital Trauma Life Support (PHTLS)

Many air ambulance service providers don’t require their medical personnel to have training beyond those core certifications.  But at MedFlight911 we also require advanced transport certification for all of our registered nurses and paramedics.  Those certifications include:

• Advanced Trauma Life Support (ATLS)
• Critical Care Emergency Medical Technician Paramedic (CCEMTP)
• Certified Critical Care Registered (CCRN)
• Certified Emergency Nurse (CEN)
• Certified Flight Paramedic (FP-C)
• Certified Flight Registered Nurse (CFRN)
• Transport Nurse Advance Trauma Course (TNATC)

Of course, we all know that certifications are one thing, and experience quite another.  So in addition to the core and advanced certifications we require our air ambulance personnel to hold, we also require rigorous air medical transport training.  Orientation alone includes:

• Advanced and alternative airway management
• Altitude physiology/flight stressors
• Anatomy, physiology and assessment for adult, pediatric & neonatal patients
• Burn emergencies
• Cardiac emergencies & advanced cardiac critical care
• Environmental emergencies
• Equipment education including hemodynamic monitoring, pacemakers, AICD, central lines, IABP, pulmonary artery & arterial catheters, ventricular assist devices and ECMO
• High risk obstetric emergencies
• Mechanical ventilation and respiratory physiology for adult, pediatric and neonatal patients
• Metabolic endocrine emergencies
• Multi-trauma
• Neonatal emergencies
• Oxygen therapy in medical transport environment
• Pediatric medical emergencies
• Pediatric trauma
• Pharmacology
• Respiratory emergencies
• Stress recognition & management
• Survival training
• Toxicology

And once on the MedFlight911 Air Ambulance team, all medical personnel are required to do 100 hours of continuing education every year.  That continuing education includes:

• Hazardous materials recognition & response
• Infection control
• Stress recognition & management
• Survival training
• Critical care for adult, pediatric and neonatal patients
• Emergency/trauma care
• Invasive procedure labs including a minimum of 5 intubations per year
• Labor and delivery

Clearly, at MedFlight911 Air Ambulance we set high standards for our air medical transport personnel.  Why?  It goes back to our core mission: to get our patients from point A to point B as safely, quickly, and comfortably as possible.  That requires the best of the best medical flight crew.

Issues surrounding caregiving are important to us at MedFlight911 Air Ambulance in part because many of the patients who use our air ambulance service require some form of convalescent care or end-of-life care.  Last week we wrote about Alzheimer’s disease and the warning signs of the disease.  Today I’d like to focus on an underutilized resource for end-of-life care: hospice.

Hospice care is defined as specialized medical care for people with terminal illnesses.  It focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis.  The ultimate goal of hospice is to improve the quality of life for both the patient and his or her family.

According to the National Hospice and Palliative Care Organization, an estimated 1.56 million patients received hospice care services in 2010.  Yet hospice is often underused or is involved too late in the process.  Indeed, many families say they wish they called earlier.

What will hospice do?

Utilizing a team approach, hospice provides expert medical care, pain management, and emotional and spiritual support specifically tailored to the patient’s needs and wishes.  Support is often provided to the patient’s family in the form of respite care, support groups, and end-of-life planning.  In addition, hospices provide services to the family for 13 months after the patient’s death.

Once the patient’s doctor makes a referral, a hospice professional will evaluate the patient and determine if he or she qualifies for services.  The general rule is that to qualify for services an individual must have a life expectancy of 6 months or less.  However, people with degenerative illnesses – like multiple sclerosis and Alzheimer’s disease – often qualify for services much earlier.

In most cases, hospice care is provided in the patient’s home – allowing the patient to remain in a comfortable, non-institutional environment until the end of life.  Hospice services can also be provided in hospice centers, hospitals, long term care facilities, or assisted living facilities.  Hospice care is covered by Medicare, Medicaid and most private health care plans, making the service free to many patients.

Typically, a family member will serve as the primary caregiver with regular visits from hospice staff, who are on call 24 hours a day.  An interdisciplinary team involving a physician; nurses; home health aides; social workers; bereavement counselors; spiritual advisors; and speech, physical, and occupational therapists will create a care plan that meets each patient’s individual care needs.  Symptom control and pain management are generally the primary focus of the care plan.

End-of-life care can be difficult to discuss; but it is best for loved ones and family members to discuss and share their wishes.  Early discussions help avoid uncomfortable situations later.  More information about hospice services, including how to find and choose a local hospice, can be found at the National Hospice and Palliative Care Organization website or by calling 1-800-658-8898.

In last week’s post, “Pan Am Episode 8: Would That Ever Really Happen?” I promised that I would blog this week on when bad weather forces an airplane to divert, or limits landing options when there’s a medical emergency on board.  Well, it’s just about wintertime, and you know what that means (for everyone outside of Arizona, that is): airport delays.

Earlier this month I came across the story of a JetBlue flight on which passengers were stranded on the tarmac for more than seven hours.  One passenger, a man who is paralyzed from the waist down, was held on the airplane for nearly nine hours.  (Read about the story here and here.)

There’s good reason for the Passenger Bill of Rights, which is a set of passenger protections issued by the U.S. Department of Transportation in 2009 that “prohibit U.S. airlines operating domestic flights from permitting an aircraft to remain on the tarmac for more than three hours, with exceptions for safety, security and air traffic control related-reasons.”

One good reason is that after many hours sitting on the tarmac, food and water often runs out, and lavatories clog up.  Tempers often flare.  On the recent JetBlue flight, the pilot pleaded for police officers to board the plane to calm passenger tensions.

But there’s also a really critical safety issue here, too.  I’ve blogged before about deep vein thrombosis (DVT), which is a clot that forms in the legs, breaks off, moves through the bloodstream, and ends up blocking blood flow to the lungs (pulmonary embolism).  It’s most often caused by periods of extended inactivity (like sitting on a plane for nine hours).

DVT is a danger for anyone, though certain people are more at risk than others: those who have had a DVT before; people who have certain heart diseases, cancer, or a blood clotting disorder; pregnant women; smokers; people who are obese; women on birth control; and older patients.  People who have recently had major surgery or trauma are also at a higher risk for DVT, as are paraplegics like the JetBlue passenger I mentioned (see Traveler’s Deep Vein Thrombosis: How to Stay Safe).

The Department of Transportation’s Aviation Consumer Protection division is investigating the delay on the JetBlue flight.  If the government determines any airline violated the tarmac delay rule, that carrier could be fined as much as $27,500 per passenger.  Hopefully that would be enough of a sting to keep the airline from letting something like this happen again.

But if you find yourself sitting on the tarmac for nine hours — or on a transatlantic flight that can easily exceed that length — it’s important to get up and move around.  For passengers who are immobile, leg massage, stretches, and ankle rotations can help keep the blood flowing.  Staying hydrated is also important — though that’s hard to do, of course, when trapped in an airplane with no functioning lavatories.

I’ve written lots about the importance of being prepared.  And that holds here, too.  Passengers with medical conditions need to prepare far in advance of the flight to ensure that they can bring their medical supplies on board.  Though you hope it never happens, once you board that plane, you really are at the mercy of the pilot and crew.  Passenger Bill of Rights or no, you never know when a three-hour flight will turn into nine.

Okay, so who’s a fan of Pan Am?  Teressa watches it sometimes, and – you know, I just might be around.  Anyway, after catching the last episode, titled A Hurricane, Heart Attack, and Haitian Situation I thought, “I’ve got to blog about this!”  So here’s the question I know everyone was thinking: could that ever really happen?

The answer is: maybe, yes, and probably not – in that order.

First, the hurricane.  I’m not sure a commercial airplane would intentionally fly through a hurricane.  But there’s no doubt that bad weather does force airplanes to divert – or limit landing options in a time of onboard crisis.  Maybe more often than not (stay tuned, in fact, for next week’s blog on that very topic).

Next, the heart attack.  In the episode, an elderly gentleman named Mr. Henry Belson (yes, they called people “Mr.” in those days!) – who had for forty years saved “lots of mason jars filled with spare change” – has a heart attack on board. There’s no doctor on the plane, and no medical supplies that will make any difference.  So the pilot decides to divert to Port-Au-Prince, Haiti (because, of course, all of the nearby U.S. airports are being pummeled by the hurricane).

There’s no doctor waiting at the airport (in fact, the airport is closed), so our two protagonists Ted and Colette commandeer a Haitian military jeep to go off into the jungle in search of a doctor for poor Mr. Henry Belson.  They find one, but he won’t help except to offer a few nitroglycerin pills.  Returning back to the airplane with the pills, Ted and Colette are too late.

So what’s the lesson here?  First off, this kind of thing does happen.  Perhaps more often than any of us would like to consider.  Think about it this way: According to the CDC, an American has a “coronary event” every 25 seconds.  About one American every minute will die from a coronary event.

As I’ve written before, that doesn’t mean you don’t fly – even if you’re elderly and/or at higher risk for a heart attack.  It does mean you should consider taking extra precautions, perhaps even having a medically-trained commercial air medical escort fly with you (see Can’t I Just Take My Sick/Injured Loved One on a Plane Myself?).

When MedFlight911 Air Ambulance arranges commercial air medical transports for our clients, the patient is accompanied by a critical care nurse, a critical care paramedic, or a physician – a medical professional who has the expertise and the equipment to handle a medical emergency should one arise.

Finally, the Haitian situation.  A commercial airplane would not divert to a politically unstable foreign country because of a medical emergency on board.  As I’ve said before, it is always the pilot’s – and only the pilot’s – call to divert in the event of a medical emergency, but I’m sure the pilot’s rulebook says, “No diverting to unstable foreign country where the runway is torn up and the airport is closed!”

In fact, I’ve recounted stories in which the pilot, for a range of reasons, decided not to divert the plane at all (see Emergency On Board: Woman Sits Next to Her Deceased Boyfriend for Nine Hours and also this story).

Okay, so obviously Pan Am is a TV show – and we all know they only ever very loosely resemble reality.  But the episode afforded me a good opportunity to talk about some of the considerations passengers – especially elderly passengers and/or those with medical problems – should make before booking that commercial flight.

Teressa and I attended the Stepping Stones of Hope 8th Annual Gala last Saturday, and it was such a beautiful testament to the power of the work that the organization does.  (Learn more about Stepping Stones of Hope on their website here and in my Save the Date! blog here).

A friend of ours who attended the event with us sent me a lovely note about how much it touched her.  She’s given me permission to share it with you here, which I wanted to do because grief touches all of us at some point in our lives, and Stepping Stones of Hope is about learning to deal with that grief and move on.

Stepping Stones of Hope is like MedFlight911 Air Ambulance in the sense that it’s the kind of organization whose services you hope you never need.  But for families dealing with the death of a loved one – as much as they wish they weren’t – Stepping Stones gives them hope that tomorrow will be a better, brighter day.

Dear Dee and Teressa,

Thank you so much, again, for inviting Alex and me to the Stepping Stones of Hope Annual Gala last Saturday.  It was a beautiful celebration of life, love, and memories — and a far more emotional experience that we had envisioned for the evening!

My best friend of many years lost her younger brother in 2007 in a car crash.  Two years later, she lost her first daughter.  Finding a way to grieve those losses without coming completely unraveled was all but impossible for her.  She definitely felt alone — like no one around her understood or could even begin to understand the profound grief she felt.  How I wish I had known then about Stepping Stones of Hope.  My friend doesn’t live in Arizona, but I would have flown her here to attend one of their camps.

Listening through the evening to the stories of Stepping Stones of Hope participants who now volunteer their time and talents with the organization, I was sure glad I had brought my Kleenex (and glad too that the lights were dimmed!).  I kept thinking about how it would be if I lost my husband, or one of my young kids.  I feel sure that I would be one of the parents that Dr. Ellen Kelman talked about, crying in the closet all day.

I know I can’t imagine what spouses, parents, brothers, sisters, grandparents, grandchildren who have lost close loved ones too early feel.  But even beginning to imagine how they might feel, I see how absolutely invaluable an organization like Stepping Stones for Hope is.  So, thank you for introducing us to Stepping Stones and its founder Dr. Finch — and for the support you provide at their Camp Paz and beyond.

Warmest regards,

Molly

Issues surrounding caregiving are important to us at MedFlight911 in part because many of the patients who use our air ambulance service require some form of convalescent care or end-of-life care.  And, this is a critically important health concern that we should all be aware of: Alzheimer’s disease is the 6th leading cause of death in the United States and the 5th leading cause of death for those aged 65 and older.

Earlier this week we wrote about what Alzheimer’s disease is and five warning signs of the disease.  Today I’d like to focus on the other five symptoms of the disease and outline the resources offered by the Alzheimer’s Association.

Alzheimer’s disease is the most common form of dementia – which is a general term for the loss of memory, intellectual and reasoning abilities.  People with Alzheimer’s disease often joke that they “can’t remember.”  But that underscores a common misunderstanding of the disease.  In reality, Alzheimer’s does not only affect memory; it affects the brain as a whole.  If your brain can be visualized as a house, Alzheimer’s disease slowly closes off rooms.

More Alzheimer’s Warning Signs

New problems with words in speaking or writing – People with Alzheimer’s disease may have trouble following or joining a conversation.  They may struggle with vocabulary, often talking “around a word” – for example, calling the television “the radio with pictures.”  Over time, the ability to read and write also declines.

What’s a typical age-related change?  It is normal to sometimes have difficulty finding the right word.

Misplacing things and losing the ability to retrace steps – People with Alzheimer’s disease may put things in unusual places.  They may lose things and be unable to go back over their steps to find them again.  They may accuse others of stealing.

What’s a typical age-related change?  It is common to misplace the car keys occasionally.

Decreased or poor judgment – People with Alzheimer’s may use poor judgment when dealing with money.  They may gift large amounts to telemarketers or charities thinking they are paying bills.  They may also pay for the same service multiple times.  We’ve heard stories of people with Alzheimer’s disease cancelling life insurance policies due to confusion.

What’s a typical age-related change?  It is normal to make a poor financial decision once in a while.  It is not normal to pay the same company three times to remove one tree in your yard.

Withdrawal from work or social activities – Individuals with Alzheimer’s disease often experience a lack of motivation to join activities formerly enjoyed.  They may stop going to social activities or sporting events.

What’s a typical age-related change? It is normal to sometimes feel tired of work, family or social obligations.

Changes in mood and personality – Changes in personality and mood can be the most challenging and upsetting symptom for caregivers.  People with Alzheimer’s disease can be confused, agitated, depressed or fearful.  They often accuse their loved ones of theft or infidelity.  Language changes, including an increase in profanity, are common.  Sleeping habits change – individuals either sleep significantly more or far less.

What a typical age-related change?  It is normal to have a specific routine and to become irritated about change.

Alzheimer’s disease affects every individual differently.  Not everyone will experience all of these symptoms, or experience them in the same way.  If you see any of these warning signs in yourself or a loved one, please contact the Alzheimer’s Association.  They offer education, resources and caregiver support in every state in the U.S.  Specific services at the state level include:

• Information and referral
• Care consultation
• Support groups for caregivers and individuals with dementia
• Safety services
• Free educational programs

To find your local office, click here or call 1-800-272-3900.

Last month we blogged about the story of Kim Alvarez, a patient whose family we have been privileged to get to know since we flew Kim in an air ambulance to a brain injury rehab facility in Marin County, California this past July.  (Read our Sophie’s Mommy blog post here.)

Kim’s sister Sarah has planned a fundraiser to help cover some of Kim’s expenses (she is still at a rehab facility).  The event is coming up!  It’s on November 26th at the Ventura Theater from 6 PM-10PM. There will be dinner, a comedian, and an auction.  Purchase tickets on Kim’s website (even if you can’t attend the event, you can join MedFlight911 and others in making a donation).