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Neurology (Expert Forum)
pending carotid surgery; can patient safely fly?
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pending carotid surgery; can patient safely fly?
by jamie, for marcus, Dec 30, 2000 12:00AM
I posted concerns regarding my 84 y/o mother on 12/27 and received very helpful answers. The situation has a new angle to it now and I would appreciate your advise, once again.
My mother's HMO will only authorize this surgery to be done here; they have refused coverage for the operation otherwise.
Their position is that this is elective surgery and my mother can fly home to have it done.
On Thursday, her blood pressure was found to be 170/82; (normally runs 140s/70s) heart rate was elevated 9 points from previous office visit. She was put on BP meds. Dr. is considering the rise to be anxiety. She was on 2.5 Ativan; this has been increased to .5 This is not anxiety due to this news; she thinks everything is okay and that the surgery will take place next Thursday. While this battle goes on with the HMO, they are keeping it from her. I believe I mentioned in my previous message that upon receiving the news from home of her condition, she was taken to the ER, where her BP flucuated wildly for hours; 205/55 and then down, and then up, etc; anxiety; she has no history of BP/cardiac problems.
This is my first question: is it medically contra-indicated for a patient with her condition (90% or greater stenosis, and now BP problems) to fly??
She wants this surgery done over there. Taking into consideration what she has endured here with the two physicians thus far involved, it is very understandable. She will need to find a new primary care doctor upon returning home, who will then need to refer her to a surgeon. I am greatly concerned about how the stress will affect her physical condition if and when she finds out surgery has been denied over there, etc.
Question 2: How important of a factor is stress (anxiety/agitation) in evaluating what is best for a patient like this? Should it be a factor for the HMO or not?
question 3: How considerable is the risk in delaying this surgery much longer?
Thanks very much for your help. If you have questions, you might find answers in my previous posting.
Bernadette
My mother's HMO will only authorize this surgery to be done here; they have refused coverage for the operation otherwise.
Their position is that this is elective surgery and my mother can fly home to have it done.
On Thursday, her blood pressure was found to be 170/82; (normally runs 140s/70s) heart rate was elevated 9 points from previous office visit. She was put on BP meds. Dr. is considering the rise to be anxiety. She was on 2.5 Ativan; this has been increased to .5 This is not anxiety due to this news; she thinks everything is okay and that the surgery will take place next Thursday. While this battle goes on with the HMO, they are keeping it from her. I believe I mentioned in my previous message that upon receiving the news from home of her condition, she was taken to the ER, where her BP flucuated wildly for hours; 205/55 and then down, and then up, etc; anxiety; she has no history of BP/cardiac problems.
This is my first question: is it medically contra-indicated for a patient with her condition (90% or greater stenosis, and now BP problems) to fly??
She wants this surgery done over there. Taking into consideration what she has endured here with the two physicians thus far involved, it is very understandable. She will need to find a new primary care doctor upon returning home, who will then need to refer her to a surgeon. I am greatly concerned about how the stress will affect her physical condition if and when she finds out surgery has been denied over there, etc.
Question 2: How important of a factor is stress (anxiety/agitation) in evaluating what is best for a patient like this? Should it be a factor for the HMO or not?
question 3: How considerable is the risk in delaying this surgery much longer?
Thanks very much for your help. If you have questions, you might find answers in my previous posting.
Bernadette
Doctor's Answer
by CCF Neuro[P] MD, RPS, Dec 31, 2000 12:00AM
Dear Bernadette:
I am sorry that your having so much trouble. The BP changes sound very anxiety related as the systolic pressure is increased out of proportion to the diasystolic pressure. I can't answer the question concerning the HMO. Each has their own rules and regulation. However, usually in emergencies they will allow surgery in out of the system hospitals and with other surgeons. I think that your mother is safe to fly, but the figures of stenosis are only with ultrasound and MRA and not angiography. I would get a release form okaying flying from the treating surgeon as a precaution. If he/she will not give a release, then the HMO has no alternative but to pay for the surgery where she is located. No one would do surgery within 6 weeks of her stroke event anyway, so a couple more days would not be too critical in her surgery. Why the need for a new primary physician? I would think there would be no problem in an immediate referral to a neurosurgeon. I am not sure what else to tell you.
Sincerely,
CCF Neuro MD
I am sorry that your having so much trouble. The BP changes sound very anxiety related as the systolic pressure is increased out of proportion to the diasystolic pressure. I can't answer the question concerning the HMO. Each has their own rules and regulation. However, usually in emergencies they will allow surgery in out of the system hospitals and with other surgeons. I think that your mother is safe to fly, but the figures of stenosis are only with ultrasound and MRA and not angiography. I would get a release form okaying flying from the treating surgeon as a precaution. If he/she will not give a release, then the HMO has no alternative but to pay for the surgery where she is located. No one would do surgery within 6 weeks of her stroke event anyway, so a couple more days would not be too critical in her surgery. Why the need for a new primary physician? I would think there would be no problem in an immediate referral to a neurosurgeon. I am not sure what else to tell you.
Sincerely,
CCF Neuro MD
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With all that being said, I am of the opinion that my mom needs to stay with this doc in order to get an immeidate referral for surgery, should the HMO deny her present situation. She can change primary care docs later; he will not be involved in her surgical care. The nightmare of starting all over with a primary care doc at this time is not appealing to me. I am thinking that when the situation is explained as to why we need an immediate appointment, "we are not taking new patients" with be all I will hear from every doctor's office i call.
I am understanding your answer regarding "figures of stenosis" to mean that she can most likely fly with a 90% stenosis, if that figure was confirmed with angiography. This is leading me to believe that if the actual figure of stenosis is higher than 90%, flying would not be advisable. What is the cut off point for % of stenosis and safety in flying?? If there is such a figure, and there's a possibility she might be there, we may have an avenue to go down.
When angiography is used to determine % of stenosis, it is my understanding that the % is more often found to be less than what US and MRA have shown, rather than more. So if this testing is employed, it may very well give a green light for a flight home. But if it's found to be more than 90%, she may need to stay there. It appears that this question is coming down to angiography and without it, no one can say she's safe to fly. Is my understanding of the situation accurate?
Thank you once again for your time. I'm sorry to be such a pest, but without doctors here to speak with, I'm needing to turn to other sources. Thank you for your understanding.
Correct, I would just use the current HMO primary physician to get a referral to a neurosurgeon. No, I would not get an angiogram at this point, just a letter that the diagnosing physican of the stenosis okays her to fly. Get two opinions from two different neurosurgeons if possible and be sure to get a history of their past surgeries (from the hospital or nurses at the hospital). Get the surgery done and then worry about a new primary care physician. And no, the US and MRA can either be underestimated or overestimated by the person reading the studies, especially if they are not very good at reading the studies. The trend of the better neuroradiologists is to over call the MRA and ultrasound, but we have seen it the other way as well. The cabin of the airplane will be pressurized and therefore not too much of a problem.
CCF Neuro MD
She ended up paying for everything herself. When my Dad passed away 5 years ago, she ended up selling their home. She bought a small mobile home and wisely invested the remainder of the money from the sale; is an avid coupon clipper and buys everything she can on sale! I haven't asked yet "how much??"; I'm just thankful that she's okay!!
She'll be returning here the end of January; now the search for new Drs. begins!! And a couple of well thought out letters will be written regarding the behavior of the two who are now history.
Mistakes are an inherent part of medicine and I accept that, but what these two guys did seems inexcusable to me.
Thank you ever so much for all of your guidance and patience in reading my wordy messages! The Cleveland Clinic provides a great service through this outlet. Many people benefit from your advise and support. And hopefully, you all benefit in some way from this experience, also!
Bernadette