Fit to fly

As summer approaches GPs will experience increasing requests for declarations that patients are “fit to fly”. Sessional GP and medicolegal consultant Dr Rachel Birch presents three case scenarios advising what you can do to support patients while minimising your risks.

Case 1 – Can I fly after surgery?

Mrs B came to see Dr A in the middle of a busy on-call surgery. She said she wouldn’t take up much of his time, but that she needed him to complete a form. She had undergone an elective laparoscopic cholecystectomy five days ago in the local private hospital. She had booked a flight to France for the following day as she wanted to visit her sister and recuperate there.

Since she had undergone recent surgery, the airline insisted that she produce a medical travel clearance form. She asked Dr A to complete the form there and then as she had lots to organise before her flight tomorrow.

Dr A explained to her that he didn’t feel he had the expertise to comment on her fitness to fly. Mrs B became quite distressed and started to cry. Dr A arranged to see Mrs B at the start of his afternoon surgery, as he felt that he couldn’t fully address this issue within a busy on call morning.

Dr A didn’t feel he had the competency or experience to be able to assess Mrs B’s fitness to fly and was reluctant to complete a form to state that she was “fit to fly”.

When Mrs B returned, Dr A took a full history of the date and type of surgery and how she had been in the postoperative period. He noted the absence of any symptoms of complications. He examined her abdomen and was satisfied that she appeared to be making a good recovery after her procedure.

He discussed with her whether or not she should actually be flying so soon after surgery, and whether or not she should ask for assistance at the airport with the walking distances involved. He advised her to discuss her recent surgery with her travel insurance company.

Dr A offered to write a factual letter for the airline, stating the date and type of surgery. However, she was adamant that she required a medical travel clearance form.

Dr A contacted her surgeon, Mr C, at the private hospital. He agreed to review the patient that evening and advise her on her travel arrangements.

Mr C was not happy with the patient travelling the following day. He advised her to wait a full ten days until after her abdominal surgery prior to flying. However he issued her with a medical travel clearance form for ten days post op and she changed her flight and travel plans accordingly.

Learning points

• The General Medical Council advises in paragraph 14 of Good Medical Practice that doctors “must recognise and work within the limits of your competence”.1 Dr A was correct not to provide a certificate for Mrs B when he felt this was outwith his expertise as a GP.
• It is appropriate to ask consultant surgeons for advice on travel after surgical procedures and they are likely to wish to be involved in such discussions.
• Patients should be advised to check with their travel insurance companies if there are any doubts about their fitness to travel.
• The Aviation Health Unit (AHU) of the Civil Aviation Authority (CAA) has a statutory responsibility to safeguard the health of persons on board aircraft. They have provided guidance for health professionals on fitness to fly.2 This is a useful resource for doctors.

Case 2 – A trip of a lifetime

Mrs H had insulin dependent diabetes mellitus and came to see Dr K in a routine diabetic clinic appointment. She was delighted as her husband had organised to take her to Australia for their ruby wedding anniversary. She had read that people with diabetes may require medical travel clearance from their doctors before being allowed to board an aircraft. She had downloaded information from the airline’s website to show Dr K and she asked him to provide her with a letter stating that she was “fit to fly”.

Dr K undertook a routine diabetic review with Mrs H. They discussed her medication regime, and she denied any hypoglycaemia symptoms. He looked at her recent blood results and conducted a physical examination. It appeared that her diabetic control was good and her condition was stable.

They discussed what she would need to carry with her on the flight. She would require needles, insulin, a blood sugar testing kit and medications for diabetic emergencies.

GPs should consider the wording of statements for airlines carefully, and where possible offer factual information about a patient’s condition, the stability of it and presence or absence of recent deterioration

Dr K arranged for her to see the diabetic specialist nurse at the local hospital to discuss the insulin regime she would require for the flight, and agreed to provide a typed letter outlining her diagnosis and the fact that her condition appeared to be stable with no recent deterioration. On this basis he felt able to state that there appeared to be “no reason why this patient should not be fit to travel”.

Dr K also planned to outline in the same letter the equipment and medication that Mrs H would be carrying in her hand luggage and the reason why she needed to carry it.

He advised Mrs H to contact the airline in advance to discuss the fact that she would be carrying equipment and medication and to discuss her dietary requirements for the flight.

Learning points

• Airlines may ask patients to provide letters or medical certificates confirming that a person’s medical condition is currently stable and the patient is “fit to fly”.
• GPs should consider the wording of statements for airlines carefully, and where possible offer factual information about a patient’s condition, the stability of it and presence or absence of recent deterioration.
• If asked to comment on fitness to fly, avoid stating a patient is “fit to fly” as the latter could be perceived as a guarantee of a patient’s fitness.
• Try to word statements carefully, using phrases such as “this patient’s condition appears to be stable” or “I know of no reason why this patient shouldn’t be fit to fly”.
• The British Diabetic Association offers advice on diabetes and travel. It is advised that for flights over eight hours a specialist doctor or nurse should be consulted regarding an insulin regime.3 Passengers should be able to administer their own medication without difficulty. It is important that they are aware of problems caused by time zone changes and follow the specialist advice.

Case 3 – Last holiday before the baby comes along

Dr B received a form in her pigeon hole regarding Mrs F, a new patient to the practice who was 30 weeks pregnant. She had never met this patient before. In fact, her only medical record entry was when she became pregnant. She saw Dr B’s partner and was referred to the midwife.

The form was for medical confirmation of fitness to fly. It asked the doctor or midwife completing the form to state that the pregnancy was uncomplicated, providing the estimated delivery date and confirming that the patient was “fit to fly”.

The following day, Mrs F had a telephone consultation with Dr B. She told her that she had booked a long weekend in Prague with her husband, as they felt it was important to have a holiday before the baby arrived. She would be 32 weeks pregnant at the time of the trip.

Dr B took a history from Mrs F. It appeared she was fit and well and had had no problems during her pregnancy at all. This was her first pregnancy and she had been seeing the midwife regularly.

Dr B discussed her concern about signing a form to state that Mrs F was “fit to fly” without seeing her. Mrs F fully appreciated her dilemma

Dr B felt that before she could complete the form, she would like to see Mrs F for a face-to-face appointment and review her maternity notes. Mrs F was not keen to do this, as she was still working full-time and had already taken time off work to see the midwife the following day.

After a discussion, they decided that it would be most appropriate for the midwife to complete the form for Mrs F, as she had been regularly seeing her throughout her pregnancy.

The following week Dr B received a message from Mrs F to let her know that her midwife had completed the form and she was off to Prague.

Learning points

• The General Medical Council states in paragraph 71 of Good Medical Practice that “you must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading… you must take reasonable steps to check the information is correct.”
• Dr B was correct to wish to review Mrs F in person and review her maternity record to ensure that the information was correct.
• Most airlines ask for a medical confirmation of fitness to fly once a pregnancy has reached 28 weeks’ gestation. They ask for this to be completed by either a doctor or a midwife. In the above situation it was appropriate for the midwife to complete the form, as Dr B had never met Mrs F.
  Airlines have rules about how late in a pregnancy a patient may travel and it is important that patients check the rules with the individual airlines. The Royal College of Obstetricians and Gynaecologists have published guidance for patients considering flying during their pregnancy.4

Summary

Air travel is so accessible and it is increasingly common for people to go abroad for holidays. Patients may not always consider that air travel is risky and consider that it is a routine matter for a GP to sign a fitness to fly statement.

Doctors may wish to consider discussing with the patient whether air travel could adversely affect a pre-existing medical condition. The guidance outlined by the Aviation Health Unit of the CAA is a useful resource as it outlines factors to consider including the effect of decreased air pressure in the cabin, immobility, timings of medication, the mental and physical effect of navigating through airports and the need for health insurance.

Doctors may wish to contact individual airlines’ medical advisors or the Aviation Health Unit at the CAA if they have specific queries.

Fitness to fly can be an emotive area. Patients may have special reasons for wanting to travel and doctors may feel pressure to complete forms and declarations of fitness to fly. However, it is important that GPs act in their patients’ best interests and only make statements that are truthful and honest and not misleading.

Rather than signing a statement of “fitness to fly” doctors may wish to consider providing a factual letter outlining the recent course and stability, or not, of the patient’s medical condition. The final decision as to whether a patient may fly rests with the airlines and information provided from the GP will assist them in this decision.

References

1. GMC, Good Medical Practice (2013)
2. Aviation Health Unit of Civil Aviation Authority, Guidance for Health Professionals: information on assessing fitness to fly
3. British Diabetic Association
4. Royal College of Obstetricians and Gynaecologists, Air travel and pregnancy: information for you