That Pleasure, Leisure Vacation Choice Abroad

"Can this [international travel] be done safely? The real answer is, 'look, in this era, there is going to be nothing that's without risk-- everything is going to be tied to some element of risk."
"People are going to have to make their own risk assessment to determine if this is worth it for them or their family, or not."
Dr.Isaac Bogoch, infectious disease scientist, Toronto

"So, unless you are going to screen every traveller immediately before each trip, then mass transit of any form comes with an inherent degree of risk."
Dr.Matthew Oughton, attending physician, division of infectious diseases, Jewish General Hospital, Montreal

"Even though I could screen completely negative and have a normal temperature today, I could be infectious and coughing and febrile tomorrow."
"If the symptom screening does pick up a couple of people, well, fine, that's helpful. But it might still miss 70 to 80 percent of people that might have COVID."
"If you're paying a lot of money for a transatlantic flight, there's a negative incentive for people to lie on those symptom screens, and get on the plane."
"But we know with this virus, even with good air exchanges, closed contacts and droplets are still a mode of transmission."
"We pose less of a threat to Europe. That doesn't mean Europe doesn't pose more of a threat to the average traveller."
Dr.Zain Chagla, associate professor of medicine in infectious disease, McMaster University, Hamilton

A family with members from North Carolina and Pennsylvania visits nearby Myrtle Beach, S.C. Domestic trips are expected to rise as people get comfortable with traveling again. (Jason Lee/The Sun News/AP)

To go, or not to go, that is the question. And the answer? Elusive at best. Troubling at the very worst, given the realities of today. The closed skies of today are verging on the opening skies of tomorrow. Travellers from selected countries are considered safe enough for the European Union to deem them welcome in European Union countries. The United States of America is not among those to be welcomed in those countries, not as long as COVID-19 infections continue to rage in various states.

Anthony Fauci, America's top infectious diseases expert has issued a forbidding warning that "if this does not turn around", cases in the United States could reach the dread figure of 100,000 daily. Canada, on the other hand, passes the criteria mounted for the 27-member EU bloc to represent a safe/er country to beckon as a visitor with its "stable or decreasing trend of new cases" over the past two weeks; citing as well the country's testing and contact tracing, and data reliability.

Those countries whose visitor status has been endorsed are to undergo review and update bi-weekly. And while EU member-states are now given an overall go-ahead to re-open their borders some may choose, like Denmark and Ireland, to forego the opportunity for the time being. Airlines everywhere are in deep financial straits. Now prepared to abandon social-distancing seating to resume using middle seats rather than have them vacant, may give some travellers pause for thought.

British Columbia's Health Minister did pause to issue this thoughtful statement: "What I'd like to hear from Transport Canada, from Health Canada is do they agree with this" move on the part of the badly beleaguered airlines, Air Canada and WestJet. Canadians are still being recommended by the federal government to avoid international non-essential travel. Any who enter or return to Canada are required to self-impose a 14-day quarantine. Failure to do so can result in a fine of up to $750,000, with a six-month imprisonment, or both.

A hotel in the Spanish island of Mallorca. (Jaime Reina/AP)

Thee is the reality that people expressing no or few symptoms are still capable of spreading COVID-19. Airlines have adopted some reassuring protective measures, such as pre-boarding temperature checks, health screening and masking requirements, but data appears to suggest that few people appear to take their flight with the first symptom of COVID-19 -- fever -- being present; in the commonplace actuality of pre-symptomatic transmission.

According to the U.S. Centers for Disease Control and Prevention, most viruses tend not to spread on flights as a result of the way air is circulated and filtered, which seems reassuring, but balanced against the probability or possibility of contracting the virus exposed to the presence of those shedding infectious droplets without being aware of having contracted COVID, decision-making represents a calculated and perhaps fraught decision to proceed.

And as Dr.Chagla points out, travel should be restricted to immediate or reasons related to urgency, setting aside visions of travel linked to pleasure, as a measure of pure self-preservation in risk-potential.

Passengers are distanced on this flight from Vancouver to Calgary, but that is unlikely to last as more people start flying again. (Jonathan Hayward/The Canadian Press/AP)

Inflight Medical Emergencies Best Practice

"Every health-care professional is likely to hear this call at some point when flying, but for most of us, treating patients on a plane is a completely unfamiliar scenario."
"When you're in a moment of crisis, you don't really want to be learning about what you have [available on board a plane] to help you."
"We want more physicians and health-care professionals to read this [Canadian Medical Association Journal (CMAJ)] article and gain some comfort in their ability to approach a medical problem on an aircraft."
Dr. Alun Ackery, emergency physician, St.Michael's Hospital, Toronto

"Each airline's kit [first aid medical kit] is going to look different, and the contents aren't always going to be familiar, which adds another layer of complexity to an already stressful situation."
Dr. David Kodama, emergency medicine president, University of Toronto

"[Physicians are encouraged under the organization's code of ethics to provide] whatever assistance they can to any person with an urgent need for medical care."
"But there's no law or regulation except in Quebec that requires a physician to do this. And it's very different if you're in Canada versus, say, over Russian airspace or sub-Saharan African airspace or American airspace what your liability may or may not be."
"You have to make a judgement whether to participate and then sometimes make life and death decisions in a very less than optimal environment, with or without the necessary equipment."
"And you can't sort of stop to say which airspace are we in?"
Dr. Jeff Blackmer, vice-president of professionalism, Canadian Medical Association

Number one cause of medical emergencies on commercial flights is lightheadedness/loss of consciousness, a new report states.    Photo: Nicolas Russell

World wide, an estimated 2.75 billion passengers fly yearly on commercial airlines. Figures for 2015 confirm that there were about 133 million flyers in Canada, representing a 27 percent increase over passenger flight numbers for 2009. Increasing numbers of passengers explains in part a recognized rising incidence of in-flight medical emergencies, with estimates ranging from one per every 604 flights, to one per 7,700 passengers.

Of in-flight medical emergencies, the top five incident causes are listed as light-headedness/loss of consciousness; respiratory symptoms; nausea or vomiting; cardiac distress; and seizures. Given the number of such incidences and their growing occurrences in lock-step with increased passenger air traffic, it is unclear what a doctor's ethical and legal obligation is to come forward when a call goes out for flight medical aid. Some instances of Canadian doctors facing lawsuits after attempts to give aid to sick passengers on flights have occurred.

The Canadian Medical Protective Association provides legal defence and liability protection to doctors but it stops short of of blanket coverage in such cases; even so such protection as is available is determined on a case-by-case basis. Brought into consideration as another element in a somewhat complex issue is which country's airspace the events occur within.

Dr. Blackmer has had his own experience in responding to appeals for medical assistance for a fellow passenger, and acknowledges that doctors struggle with the issue of their ethical responsibilities weighted against the potential of legal backlash.

The issue of urgent medical situations calling on medical personnel who just happen to share flights with other passengers who become ill has been a vexing one for the profession. Efforts to treat someone suddenly becoming ill in poorly illuminated and cramped aircraft confinement represents a daunting proposition, all the more so when a physician has no prior knowledge what inflight medical equipment will be available to him or her.

Dr. Ackery, along with Dr. Kodama undertook to produce in collaboration with Air Canada and WestJet -- both of which carry comprehensive first aid kits -- a compendium of best-case-scenario reactions, recommendations whose purpose it is to guide doctors in both their decision-making and subsequent actions undertaken to come to the aid of distressed passengers. Their recommendations were published in the latest issue of the CMAJ.

The cramped quarters of an airplane can be a stressful environment for a doctor onboard who responds to a medical emergency   CMAJNews

A standard of best-practise response, and a standardized medical kit to be carried by airlines, containing various medications, saline, blood-pressure cuff, stethoscope and allied basic medical equipment. Bearing in mind also that the airplane interior alters the responses of certain equipment in that diagnostic results become more difficult to assess. When, for example, a patient's normal oxygen saturation is lower at altitude than on the ground. Aircraft sound may also interfere with accurate blood pressure reading; use of the cuff and stethoscope become more complicated.

Add to that the fact when physicians travel they are no different in their behaviour than any other airline passenger; they kick back, relax and think of matters other than  medical response. If a doctor on board a flight indulges in a few alcoholic drinks, has been suddenly jostled awake in the middle of the night, the result may be impaired judgement. Under which influence it is entirely conceivable their emergency reaction could produce more harm than help.

"So you can't have a black-and-white statement that says doctors have an absolute ethical obligation ... It's much more nuanced and complicated than that", explained Dr. Blackmer.

New recommendations intended to help doctors feel more comfortable providing emergency medical aid on flights have been published in the Canadian Medical Journal.  (Todd Korol / REUTERS file photo)