Who decides if you’re fit to fly? Inside the medical director’s role in emergency air transportation
By Dr. Paulina Villa, Medical Director at Medical Air Service
When patients or their families first enquire about medical air transportation, one question usually comes up immediately: how quickly can the aircraft depart?
In reality, the first question is very different.
Is the patient fit to fly?
The patient is clinically assessed prior to aircraft selection, assignment of the medical crew, and preparation of a flight plan. The answer to this question lies with the Medical Director, whose duties include emergency medicine, aviation, and the operational skills required for medical transportation.
Though the aircraft is the first thing people notice in air transportation, the medical decisions made before take-off determine the mission’s success.
Fit to fly means far more than being able to board an aircraft
“Fit to fly” is a phrase we all hear often in connection with airlines requiring medical clearance before flying.
In the case of medical aircraft transport, this term is much more complicated.
Being fit to fly means not just a patient’s readiness to travel. It implies a thorough assessment of the patient’s medical condition, his suitability for air transport, taking into account the physiological effects of flight, the expected time of travel, the medical care available during transport, and the risks of deterioration before arrival at the destination.
Importantly, being unfit to travel on a commercial airline does not necessarily mean a patient cannot fly. Medical aircraft are equipped very differently from scheduled passenger flights and can provide continuous monitoring, oxygen therapy, advanced medical equipment, and specialised medical staff throughout the journey. In many cases, this makes air transportation possible for patients who would otherwise be unable to travel safely.
On the other hand, the opposite is also possible – a seemingly stable patient is not yet ready for medical transport due to potential risks associated with air travel.
Fitness to fly is therefore not a certificate. It is an ongoing clinical judgement based on the patient’s current condition and the realities of the journey ahead.
Every patient requires an individual assessment
One of the most popular myths concerning medical transport is the notion that medical condition is the only determining factor of fitness to fly.
Actually, patients with the same condition may need completely different medical care.
The patient with pneumonia may need supplemental oxygen during air transport, whereas another patient with the same condition might need a few more days of treatment before being fit to fly.
After orthopedic surgery, a patient may be transported with certain precautions regarding positioning and pain management, whereas a patient with abdominal surgery will need additional time due to possible effects of cabin pressure changes on the progress of his recovery.
Patients who have experienced a stroke, heart attack, traumatic injury, respiratory illness, severe infection, psychiatric emergency, or other complex medical conditions each require their own detailed evaluation. Pregnancy, neonatal transport, and paediatric cases also involve their own specific considerations.
Not bound by any regulations, the Medical Director assesses the patient’s medical condition in its entirety – oxygen requirements, medications, mobility, recent surgery, laboratory data, imaging results, and the expected evolution of their condition over the next few hours or days.
No two assessments are exactly alike.
Clinical decisions cannot be made only on medical paperwork alone. Prior to approving medical transport, the Medical Director reviews medical reports and often speaks with the physicians treating the patient.
Hospital notes, laboratory results, imaging, medication lists, nursing observations, intensive care records, and specialist recommendations all help build a complete picture of the patient’s condition.
Sometimes, such assessment raises new questions:
- Has the patient’s neurological condition changed?
- Is the oxygen requirement growing or decreasing?
- Has the infection reacted to the treatment?
- Are any more surgical procedures going to be performed before discharge?
The purpose of these questions is to estimate how the patient’s condition may progress over the course of the journey.
As patients’ medical conditions change rapidly, such assessment is carried out even until departure. If the patient’s condition deteriorates, the transport plan may be altered or even cancelled.
Flying changes the medical equation
One of the things that makes medical transport different from traditional patient transfers is the aviation environment itself.
Even on pressurized aircraft, the cabin pressure is lower than in the normal environment, which decreases the oxygen content in the cabin. Healthy people do not notice this, but it can have a very significant effect on patients with respiratory or cardiovascular disease.
Flight time, vibration, cabin movements, altitude, availability of the nearest medical facilities, and the airport’s infrastructure are all part of the clinical assessment.
A patient who looks stable in a hospital room may face additional challenges in a flight.
Assessment of these aviation factors in combination with the patient’s condition is the key task of the Medical Director.
Choosing the right type of transport
One of the most important decisions for the Medical Director concerns not just a patient’s suitability to fly, but also the choice of transport method.
For some patients, transport with a medical escort on a scheduled commercial airliner may be an appropriate option. Other patients need a stretcher installation in a commercial airliner.
Some patients require a dedicated private air ambulance due to the need for continuous intensive care, advanced monitoring, mechanical ventilation, or complex medication management.
In some cases, transport by ground ambulance may be the safest solution.
And occasionally, the correct decision is that the patient should not travel at all until additional medical treatment has been completed.
The goal is always the same: selecting the transport solution that best matches the patient’s medical needs, not automatically choosing the most complex or expensive option.
Building the medical mission
Once the decision about medical transport is made, planning begins.
The Medical Director chooses the composition of the medical crew, which may include various specialists – flight nurses, emergency physicians, intensive care physicians, neonatologists, and others, depending on the patient’s condition.
Also, the Medical Director selects the medical equipment required during the flight.
- Does the patient need additional oxygen during the flight?
- Is mechanical ventilation required?
- Is it necessary to prepare infusion pumps?
- Should cardiac monitoring be performed during the entire flight?
- Do we need to have any specific medications on board for the entire journey?
All these questions influence not only the medical crew but also the selection of the aircraft. The size of the cabin, electrical power capacity, oxygen system, stretcher configuration, flight range, and airport accessibility and ground ambulance services are part of the integrated medical plan.
Everything is done to provide the conditions the patient needs.
Sometimes the safest decision is to wait
Of course, everybody is eager to start the transport as soon as possible, especially if the patient is hospitalized abroad.
But sometimes one of the Medical Director’s most important tasks is to assess the patient’s need for additional medical treatment to ensure his safety during transport.
The patient with unstable blood pressure, uncontrolled bleeding, worsening of infection, respiratory distress, or complications after surgery is likely to benefit from additional treatment before transport.
It is not the lack of action, but the safest medical decision.
Explaining it to patients and their families may be very difficult due to relatives’ emotional state, but in most cases, allowing sufficient time to stabilize the condition will enable a safer journey and better outcomes.
Medicine and logistics working together
Medical air transport is a unique field that combines aviation and healthcare.
Close cooperation among the Medical Director, flight coordinator, pilots, hospitals, ambulance providers, insurers, and international medical assistance companies ensures that all aspects of the patient’s journey are considered.
Medical decisions influence the organization of transport, and vice versa: operational realities can shape some medical decisions.
Weather, airport operating hours, customs procedures, availability of the destination hospital, ambulance access, among others, can influence the planning of the transport mission.
Thus, the success of medical transport depends on close cooperation among professionals from different areas, who all aim to achieve one goal.
The most important decision happens prior to take off
When talking about medical air transport, people usually imagine aircraft, advanced medical equipment, and flight crews.
All of this is important indeed.
But prior to take off, every successful transport starts with assessing the patient’s condition, his suitability for the journey, and the support needed on board.
This decision is made by the Medical Director, who combines medical, aviation, and operational skills to prioritize patient safety.
For the patient and his relatives, this work remains unseen. For professionals engaged in medical transport, this is the basis of every successful flight.
About Medical Air Service
Medical Air Service provides worldwide medical evacuation, medical repatriation, and medical escort services, transporting patients who cannot be treated where they are and transferring them to the required destinations on board fast medical jets or with medical escorts on commercial flights.