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Airlines need to highlight chemo drug flight spill risks

Our airlines need to use some very plain words about cytotoxic drug spills in passenger cabins

Ben Sandilands — Editor of Plane Talking

Ben Sandilands

Editor of Plane Talking

General layout of a vascular access device

This article is about communicating an air safety risk, it is NOT medical advice.

Crowding isn’t just apparent in air travel, but in matters of public health. The asset, whether it is a seat in a jet, or a bed in a ward, is constantly under pressure to be ‘more efficiently utilised’ or occupied.

In the air, that can mean being in much closer contact with your by chance travelling companions, or the fixed seating around you, which may no longer be as likely to be unoccupied as it may have been in recent years.

In a hospital, even in private rather than public ward care, there is a cost driven focus on such procedures as ERAS, early release after surgery, or periodic home or self administered periods of on-going treatment.

For this now mildly disabled reporter, who is recovering from a slowly healing back fracture, and receiving management through chemotherapy for the consequences of stage four cancers, these matters have converged in a way that makes a safety risk to flight obvious, yet it is one that none of our four main brands of air travel currently deal with in simple, unambiguous, and direct language.

THE ISSUE is passengers not being explicitly warned against flying or even using crowded trains, trams and buses, while receiving slow release cytotoxic chemotherapy drugs via vascular access devices such as subcutaneous ports, often branded Power Ports, or the likes of Hickman’s Catheters.

These devices are usually fed off reservoirs contained in bottles worn as bum bags and through a thin plastic tube that lead up to the skin covered bump over the catheter assembly housing in a large vein just above your heart.

The slow release infusion process begins typically on day one of a regular chemo regimen in hospital, then continues at home for much of the 40 hours or so set aside for the process, which ends on the third day again under strict medical supervision to disengage, flush, and lock the access port.

It is in that middle day when a user of a such a port might feel perfectly entitled to do a day return flight to another city. There is nothing in big, unambiguous lettering on any of the main airline sites that says they shouldn’t.

Yet the oncology wards and specialists quite correctly issue users with spill kits and very explicit instructions as to how to protect themselves and those around them by putting on provided protective light plastic gloves and cover-alls, similar in intent to those heavier duty copies that are so meticulously used by chemo nursing staff.

In those kits chemo patients are told to immediately head for a hospital emergency department and show their see-me-without-delay cards. Needle pop outs or other disconnection events are potentially life threatening. The sudden infusion of slow release cytotoxic drugs can kill. Jets can’t suddenly divert to a landing at an ED department. Breathing the volatile traces in a hot confined space like an airline cabin is a severe risk to the health of those within it. Aircraft cabins circulate the air efficiently, in cases like this, arguably much too efficiently. There are no good scenarios concerning cytotoxic drug spills at altitude.

A review of the web page advice to intending passengers on Jetstar, Qantas, Tigerair and Virgin, and confirmed by discussions with them, makes it clear that they are all abundantly aware of their obligations to make passenger safety the number one priority. (It isn’t optional, it is in regulatory terms, the number one priority.)

Jetstar stood out as best at being direct, although it makes no reference to this specific set of risks, and nor did any other site, except the very legalistic and detailed Qantas pages, which on repeated readings, only mentioned chemotherapy directly once a passenger with powers of endurance gets to a sub section of a Part B questionnaire.

As the written guidance to Plane Talking said: While all medical clearance forms are assessed individually, patients undergoing active chemotherapy treatment would generally fall outside the category of passengers cleared to fly.

But the Qantas guidance assumes that passengers even consider, or know about, a need to have a clearance form.

Where does a Qantas passenger, or any passenger, get asked to consider whether or not they need a medical clearance to fly subject to certain circumstances linked to their cancer treatment?

No one is being asked up front, on web sites at least, are you being treated for cancer, or receiving passive medications using an implanted device? It is far too late to do this at a terminal kiosk, or an identity check.

Although dangling a visible plastic line from an object worn on a hip to somewhere on your upper body might get noticed by security, where that medical emergency card might come in handy. Then again, in some parts of the world, you might get tackled to the ground, which would quite likely bring on an immediate cytotoxic crisis.

Nor can a user just switch off the device, except by following the very specific spill or blockage management instructions. Chemotherapy users are at elevated risk of general infections, and crowded places are a health risk to them at the very outset. If an access point pops out for any reason the sharp end just can’t be shoved back in without creating the near certainty of a massive infection, if not a potentially lethal overdose of a poison that is intended to kill or more correctly shrink or stay the progress of a cancerous lesion or tumour.

The medical risks and manifest rewards of effective chemotherapy are matters on which professional advice is critical. This post is about the need for airlines to be far more direct in preventing people who are on the day of intended travel using vascular access devices actively delivering cytotoxic drugs as part of their chemo regimens from putting themselves and others at risk in aircraft.

Don’t hide the message behind a wall of waffle. Tell the customers DON’T DO IT.

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11 comments

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11 thoughts on “Airlines need to highlight chemo drug flight spill risks

  1. Tom the first and best

    Hopefully there does not need to be a death (or deaths) or serious injury on a plane for this to get fixed, although I suspect it might.

    If this happened at altitude, would the cabin need to be de-pressurised to maximise fume removal?

  2. comet

    There is very little documentation worldwide about this. And there don’t appear to be any incidents involving chemotherapy spills in aircraft.

    Long ago, when I suffered a broken arm, I was refused travel by various airlines (hello Singapore) when I wanted to get home. They list all sorts of other conditions that can’t fly. They don’t mention chemotherapy.

    1. Dan Dair

      It’s a very ‘niche’ point that Ben is making,

      but in the context of not being able to fly with your arm in plaster,
      it seems like a much more threatening problem, albeit an extremely unlikely one, than a broken arm would present.?

      Maybe the rules on plaster-casts & so on, were written before the advent of body-scanning & have never been revised.?

      1. ggm

        Dan, the ban on casts is not security-related, its patient health. My wife flew with a cast in Europe and then home after a break in Amsterdam (pun intentional) and was told the DVT issue is why there is a partial-ban case by case on flying with a cast. We had warfarin needles, and both showed them and used them getting home. The spanish docters were absolutely amazed we’d been boarded in AMS without any warning or discussion of the risks. Thats when we got the jabs issued and strict instructions to check things on arrival for the long-leg (sorry, another one) home

        Ben makes a very significant point here, that a bunch of ‘not on a plane’ rules are really badly understood. How many times have you been raced through the ‘any of these items’ list without a sense of engagement? Given the effect Hg has on aluminium, I am constantly amazed we haven’t had a serious incident. Uncle-Joes family heirloom barometer.

        A colleague from international standards meetings said when he flew post radiation therapy, he was given a two seat clearance from other PAX. Perhaps an over reaction but those radium needles do create a measurable effect outside the body. Ben’s cycotoxic example is huge one. One spill? that carpet is now a severe, longterm biohazard. We’re frequently told that tray-cleaning is at best haphazard.

        1. Sue B

          I’m honestly surprised they even let someone on the plane following radiation therapy. Was he allowed to go to the toilet? Those holding tanks would also be radioactive following any toilet use. I work in a lab and we were once sent a bottle of urine that was labelled as radioactive. We had to keep it in a lead-lined safe for a week until it decayed enough to be safe to handle (luckily these medical isotopes have a very short half-life).

          1. ggm

            I doubt he flew during the mandated witholding period the hospital sets, some of that you’re in a lead-lined chamber being poked with a stick (warning: stick poking may not happen in all cases). Do you think the medics and the airlines caucus on what is a common threat risk?

            I’m about to have minor surgery for a BCC. It only just occurred to me I might actually not want to be on a plane. the obvious google search says “it depends”. So this “yea, pax can’t be dumb enough to present” thing? well I could be!

        2. PaulM

          Ggm, the scenario you describe is not a biohazard. It is a chemical spill, but I agree it will be potentially a long term hazard. A biohazard can usually be addressed by disinfection (although the use of hospital grade bleach in an aluminium airframe isn’t advisable).
          As for the haphazard tray cleaning, it is the cleaning staff who are most likely to be exposed to the cytotoxic risk, although an inflight spill would also expose the flight attendants (not tomention any well-intentioned fellow passenger who tries to assist). However, to use an unavoidable pun, a spill on the floor of the cabin may well be, metyaphorically, swept under the carpet and linger a long time.

      2. Mark Pawlak

        I thought the plaster cast restriction was about the potential for limb swelling and the serious consequences of developing a compartment syndrome. Bi-valving the cast then wrapping in a bandage is usually sufficient to mitigate this risk.

        1. Jackson Harding

          You are quite correct. But bivalving is associated with the possibility of the fracture moving and the risk of potential malunion. The airlines really don’t want to be held liable for that so they prefer people in casts stay away.

  3. Roger Clifton

    I am surprised to hear the air in the cabin is recycled over and over. The cabin provides so little volume per passenger, that it would seem to be straightforward to provide a steady replacement flow of air through the overhead nozzles provided. Admittedly, the freshly compressed air is quite hot (that’s how it got up there), so must be cooled before distribution, but that doesn’t seem to be a demanding requirement.

    The air from the nozzle is often too cold, so passengers prefer to shut it down and re-breathe their neighbours’ breathed air. Health would be served by setting the thermostat at 25° C.

    1. Jackson Harding

      The temperature is set low for good reason. The colder it is the more pax are likely to sleep. A sleeping pax doesn’t need constant attention from cabin staff, particularly on long haul flights.