Corporate Travel Medicine—Priorities & Models - Panel Discussion, April 27, 2000

Michael Bagshaw, MD, Head of Medical Services, British Airways

DR. LIESE: Michael Bagshaw, who is the head of Medical Services of British Airways. He is actually responsible for delivery of occupational and aviation medicine to about 63,000 employees worldwide. He also maintains a professional pilot license and is regularly flying a corporate jet. And with that, I give the floor to Michael.

DR. BAGSHAW: Well, I should start off by saying good morning, but really it's good afternoon, and I'm now on my circadian low so forgive me.

What we've heard this morning has really been an interesting look at what is, in my view, one particular aspect of well-being. If you consider well-being to be a complex interaction between the physical, the physiological, and the emotional, we've just touched on just one aspect to start with. And it's quite interesting, picking up on what was said this morning, that of our 3,500 flight crew, a number of them are on their second, third, fourth marriages, which I think bears out the discussion this morning about the effect of travel on personal health.

The other thing that interested me was, in the responses on the trials that we discussed, there was little reference to the physical and the physiological aspects of well-being, and certainly on the other side of the Atlantic, I spend a great deal of my time defending cabin environment, cabin air quality, and denying the effect that this may or may not play in affecting the health of the traveler.

Another observation I'd like to make is that the airlines in general are very conscious of the stresses of travel, and this has been seen in the evolution of the airline product to look after the frequent flyers, to look after the Executive Club, and to make the whole travel experience a pleasant one so that our travelers get to the other end with minimum stress.

But I thought it would be helpful to just look at the physical side and get away from the psychological aspects for a moment and give you a quick revision in basic physics. When we're flying, we're in a potentially very hostile environment. As you know, at 18,000 feet the atmospheric pressure is half, and as you go higher, it's a smooth curve. So at 34,000 feet the atmospheric pressure is down to a quarter of what it was at sea level.

The cabin, of course, is pressurized to give an altitude effectively of up to 8,000 feet, but even at 8,000 feet, there is a reduction in pressure. And this will have an effect on you as an individual, but particularly if you're suffering from any pre-existing disease or medical condition.

The other aspect is the effect of Boyle's Law. No matter what you do, any gas trapped gas trapped in the body will expand as the pressure falls. So at 18,000 feet any trapped bubbles are twice the volume they were at sea level. But God meant us to fly because he gave us the hemoglobin molecule which has a great affinity for oxygen. The only thing it hangs onto even more, as you know is carbon monoxide. And the fall-off in blood saturation is only about 10 percent up to about 10,000 feet. So this allows us to function physiologically at the cabin altitude of up to 8,000 feet

What really happens, when you, as a traveler, are traveling on our airplane and you're taken ill? Now, if you read the press, you would believe that on every flight there is somebody taken ill. This slide shows that in the year ending March '97, British Airways carried nearly 34 million passengers, and we had only 3,000 in-flight medical incidents. That is one per 11,000 passengers or one per 33.8 million revenue passenger kilometers.

Now, I travel very frequently and touching wood rapidly, I've never been called in my 30 years to give medical assistance on board. So despite what you read in the paper, it's not that common to need medical help for a passenger. BA had ten deaths on board out of 33.5 million passengers, ; that's probably less than you'd expect in the general population. Some people, sadly, will reach the end of their life when they're on an aircraft. We had one birth on board. Now, you probably think that the commonest medical incident is heart disease. Again, this is what we tend to get from the media. In fact, most of our incidents are diarrhea and vomiting, following by cardiovascular things, which includes the faints. And if we look at our top six conditions, diarrhea is top of the list following by vomiting--those are only the diarrheas we know about, of course—vasovagal faint, head injury, asthma, and bruises and sprains. And, interestingly, the head injuries are often caused by things falling out of the overhead locker when the passengers open them. We had to divert an airplane last month when a lady had a fractured skull when a passenger opened the overhead locker and a laptop computer fell out, notwithstanding the netting that we have in place. So we take this very seriously as a safety issue.

But, notice, there's no heart attacks, there's no deep vein thrombosis, there's none of the things that you have perhaps been led to believe are the common items.

But if you are taken ill on a British Airways airplane, we've got lots of kits—most major airlines carry good equipment, but we like to think we're the best, (with apologies to Dr. Bergau from Lufthansa, who is sitting in the audience).

For the physicians in the audience, you're probably wondering why we have a stethoscope because the noise on an aeroplane makes it very difficult to hear heart and lung sounds. We didn't used to have a stethoscope, but we got so many complaints from physicians who assisted who said, "Where is the stethoscope?" Because the physicians in the audience will tell you that the stethoscope first is the badge of office and, secondly, is the thinking time.

[LAUGHTER]

So we now include a very expensive cardiological stethoscope, and it's interesting, when it's used, we never get it back because it's such a good one.

[LAUGHTER]

We train our crew to a very high standard. All our cabin crew are trained for five days in aviation medicine, intermediate first aid, intermediate life support, and we carry defibrillators on board which all the crew are trained to use. And we also subscribe to an air-to-ground telemedicine service, provided by MedAire, where the crew can speak directly to a physician in Phoenix, Arizona, who is experienced in delivering remote medical care, is experienced in aviation medicine, and has our kit on his or her desk and can say to the cabin crew member, "Second tray down, third on the left, give him one of those."

Because we believe that a doctor traveling is entitled to an undisturbed flight, we don't rely on the physicians traveling helping us out. We train our crew, and we subscribe to the MedLink service provided by MedAire. So we can contact Medlink via the satellite link, and we're developing data linking so that we can transmit ECGs (or EKGs) and other data to the physician to assist in the diagnostic process.

What's been very interesting is, since we've established this linked with MedAire, our diversion rate is halved. Before we subscribed to MedLink, we were diverting an aeroplane about 70 or 80 times a year to offload a sick passenger, and that rate has now dropped to about 40 times a year. As well as the cost saving to the airline, much more important is the lack of disruption to the other 399 people on board. We will do all we can for the sick passenger, but we also have an equal responsibility to the remaining passengers on the aircraft.

This is a picture of the MedAire team waiting to take our call, and this is just to remind me of my military flying days. I'll just have a moment of nostalgia, excuse me. That's me.

[LAUGHTER.]

Another thing that has gotten a lot of interest recently is cosmic radiation. We're just in a period of intense sunspot activity, and there's been a lot of questions: Is this a danger to us flying?

The Concorde flies up to 60,000 feet and gets a higher dose of radiation than a subsonic airplane. So for the last 25 years, we've been monitoring cosmic radiation exposure on the Concorde.

We also monitor cosmic radiation exposure on our long-haul aircraft. The International Commission on Radiological Protection recommended dose limit for a worker, is 20 milliSieverts per annum?

If you take the radiological protection practice of taking three-tenths of the occupational exposure as being the limit for deciding whether a worker is a controlled worker or not, that works out at six milliSieverts per annum?.

Our work shows that the average Concorde flight crew are getting about four milliSieverts per year. Theoretically, they can go up to six, although we've got no crew members who do reach six. Long-haul crew flying 747s on very long range—over the Poles, over the Northern latitudes— get on average between four to five, with a maximum of five milliSieverts, and short-haul crew operating in Europe are getting about three milliSieverts per annum.

So what we're finding is that cosmic radiation exposure is well below the International Commission on Radiological Protection standard, and our epidemiological studies show that our long-haul crew on average live about five years longer than a matched population. And after the discussion this morning, I won't start talking about matched populations, but we've done intensive epidemiology, and we're part of the pan-European study which is looking at morbidity and mortality in crew.

Now, you as corporate people, of course, say, well, never mind the crew. They have flight time limitations. What about us as the frequent flyer?

As a frequent flyer, the International Commission on Radiological Protection has indeed decreed that you as a frequent flyer are flying as part of your occupation. Therefore, the 20 milliSievert limit applies to you. One milliSievert is the public limit for non-occupational exposure, and you have to fly 200 transatlantic trips to exceed this level. To exceed the 20 milliSieverts in a year you would never be home with your spouse. So we can reassure you on that. And these figures and these trials have been validated by the independent National Radiological Protection Board in the U.K., and we've also worked with the NCRP here in Washington.

So I can reassure you that it's not a problem, and there is no epidemiological evidence of cancers that could be related to exposure to radiation. In fact, the number of leukemias in our flight crew is much lower than we expected. The only cancer in excess is malignant melanoma, which could have something to do with the fact that they spend a lot of time by the swimming pool.

I would just like briefly to touch on the question of cabin air. I know I'm about to get a time card waved at me. But cabin air quality and the cabin conditioning system does raise concern..

This proves I'm a pilot because it's an engineering slide. But what it shows is how the cabin air is distributed around the airplane. There is no truth in the rumor that the cabin air moves from front to back. In fact, when you look at the distribution, the distribution is radial. It comes down from the racks overhead, goes down the side, and goes down into the cargo compartment.

There's a slight positive pressure in the flight deck. In the event of fumes or fire, we don't want the fumes and fire moving forward. But he positive difference between flight deck and the cabin is only enough to prevent the smoke or fumes moving into the flight deck..

Now, we re circulate air. Why? The main reason is that we can maintain acceptable cabin temperatures, we can improve the humidity, and we can reduce the drafts. Because if you have a through-flow of air at all times, the drafts will be very uncomfortable.

We're often asked, well, doesn't this affect the fresh air feeling? The number of changes, complete cabin air change, is 10 to 15 per hour compared with five in a hospital room and about 1.5 in this room. And I'm a member of the ASHRAE Cabin Air Quality Committee, and, as you know, ASHRAE sets the standards for buildings. Even with the re circulation we change the air more frequently than in a conditioned building.

I'm often asked about the oxygen. Don't we deplete the oxygen? No, we don't. This slide shows that the oxygen consumed is 0.015 cubic feet per minute per passenger, whereas the conditioning system makes available 4.20 cubic feet per minute per passenger.

And, finally, the carbon dioxide, which is said to cause stuffiness. In the lungs you have 50,000 parts per million by volume. The NIOSH physiological limit is 30,000 parts and the occupational limit is 5,000. The ASHRAE standard is 2,500 parts per million by volume. And you can see from the slide that aircraft even with 50 percent recirculation are well below those limits in the amount of CO2 that's allowable.

Finally, the recirculated air is filtered. You can hear I've got a cold. It has nothing to do with flying. I had the cold before I got on the British Airway flight. If you look at the efficiency of the filters, they meet the MIL Standard of 99.97 percent filters out removing single viruses, bacteria, and tobacco smoke particulates. Even the 94 percent efficiency standard, which is the lowest standard, is filtering out most of the bacteria and most of the viruses, and modern aircraft all have 99.99 percent. There's been independent work done which shows that the cabin air is of a higher bacteriological quality than the air in this room or the air out on the city street, and the filter efficiencies are almost 100 percent.

So the evidence is that the filtered recirculated air is microbe-equivalent to fresh air which has not been contaminated.

So the point of me raising these things is actually to put to bed some of the misconceptions and to reassure you that with all your stresses of travel, you needn't be worried about the cabin air quality, about the oxygen or the CO2, and if you are unfortunate enough to suffer an in-flight incident, if you're traveling on my airline in particular, you will have the benefit of highly trained crew and equipment and the telemedicine link to a physician on the ground.

Thank you very much.

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