including > media hype and reality > ten tips

Here in the United Kingdom, we have been bombarded of late through the media with scare stories on so-called "economy class syndrome", the potentially lethal risk to travellers on long haul flights from blood clots. Such a thrombosis - or DVT - can result, as we all now unhappily know, from the pooling of blood in the lower leg during long periods of immobility while travelling, exacerbated by the cramped conditions of limited legroom in aircraft.

Symptoms include, classically but not invariably, painful swelling in the lower leg. Statistics have not been forthcoming in the past but it is now believed that perhaps thousands die each year in the UK from the effects of DVT with an increasing and worrying number probably as a direct result of flying.

A few years ago, I featured briefly in the press as being at death's door, laid low in a Sydney hospital with such a thrombosis. At least one UK paper had me already a goner - not particularly helpful when I was trying to play down the seriousness of my plight for the sake of our children and friends.

It was all as a result of an accident during a concert tour of the Americas when I took a tumble on a slippery stage in Lima, Peru, tearing up the Anterior Cruciate Ligament (ACL) in one knee.

Foolish trooper that I was, I continued with the tour in both pain and wheelchair for another two weeks until I could get back to the UK for surgery.

Flying almost daily from concert to concert with one leg strapped up in a knee brace and struggling manfully on crutches, I checked in with four separate specialist doctors in Bolivia and Costa Rica as well as Philadelphia and Richmond, USA, to monitor the situation. Only one of these doctors gave any warning as to the dangers of travel in this condition, suggesting that I take an aspirin before the long flight back to the UK - but without really explaining why.

The UK surgeon who examined me prior to the knee surgery gave little hint as to the risks I might have already endured and offered only the same advice regarding the taking of aspirin before the horribly long flight to Australia due to take place a couple of weeks later when our concert touring schedule resumed.

I travelled out economy while my wife and the rest of the band flew business class. Mind you, I bought myself three economy seats so I could sit sideways with my bad leg horizontal and stretch out (almost) for a sleep.

After the first two Australian concerts I was in such pain throughout the knee and lower leg that I contacted the UK surgeon to express my fears and concern. I did not, however, exhibit the severe swelling associated with a DVT and was told categorically over the telephone that I did not have a blood clot.

But something didn't feel right with the leg - a deeper and more sinister feeling than just the dodgy knee - so, after a brief discussion with a worried hotel doctor, I took myself off to a Sydney hospital and insisted on an ultrasound scan to determine that, hopefully, no clot was present. Alas, the scan showed a huge and life-threatening clot stretching from just above the ankle to the upper thigh, just below the groin. Within two shakes of a Kangaroo's whatsit, I was in a different hospital and under the care of a doctor specialising in the treatment of such cases.

He explained that perhaps one in five people have a double vein system where, in the event of a clot, blood finds its way back up to the heart via alternative routes without displaying the degree of swelling normally associated with the condition. Indeed, he further amazed me with the tales of relatively large numbers of passengers arriving in the great Down Under with DVT and suggested strongly that, as the major destination in the Southern hemisphere for long-haul European flights, Australia possessed medical facilities which were, in his opinion, way ahead of other countries in diagnosis and treatment. My experience and ultimately my eventual recovery, more to the point, tend to endorse his humble view.

The dangers of the clot suddenly breaking up with pieces finding their way to my heart and lungs were solemnly explained and the realistic chances of survival in this event (not bloody good, mate!) were dutifully absorbed by this now strangely fatalistic patient.

In fact, late one night there was a bit of a scare when I became suddenly breathless with elevated pulse and was close to passing out. I found the strength to summon my wife by telephone from her hotel to say goodbye in person while they strapped on the oxygen mask, rosary beads and prayer mat. Now it may have been the hospital food (unlikely, for such fair tucker) or the sight of Damon Hill having a particularly bad race on my hospital room TV (possible): but if it was a bit of clot attempting to cut me off from the balmy Sydney night breeze drifting through the open window, I still prefer not to think about it too often.

Our good Aussie Doctor also expressed the view that the clot may have been there prior to my travel to Australia. The chances were, he thought, that the clot had begun to form even prior to surgery back in England due to all the previous travel and immobility of the limb. Why then, I wondered, had the surgeon not carried out a routine scan before the operation - or at worst - before my departure to Australia? "Good question," was the reply. "We do routine scans here on folks with knee and hip injuries, even young and fit athletes, and especially after carrying out operations on them."

Another surgeon, responsible for my physical rehabilitation and a specialist in sport injuries, was more scathing, claiming that the UK was horribly behind the times regarding surgical procedures for knee injuries as he had found when visiting the UK on lecture tours and hospital teaching demonstrations.

Oh quaint and archaic Blighty. She giveth and she almost taketh away.

After three weeks of blood-thinning drugs, elasticated compression hose (industrial grade support socks) and serious physiotherapy from some brutal antipodean task-masters more used to driving on the recovery of football players and track stars, regular scans revealed that the clot had reduced enough for me to risk the flight home.

Several months of daily Warfarin (Yes - the rat poison) treatment to keep the blood thin and increase clotting time meant a daily reminder of the potential perils of flying for a living. Several more scans later the clot was effectively gone and minimal damage was evident to veins and valves. I had been warned back in Australia however, that I might be susceptible to a further incident and advised to take certain precautions.

MEDIA HYPE AND REALITY

In recent weeks, many holiday travellers have been made aware of the risk through TV and the press and are confused and concerned as to how to minimise that risk. We are given to believe in the so-called "economy class syndrome" as if only the poor folks in the back of the plane need worry. Rubbish! In first class on Concord or in business class on a 747, you stand a small but real chance of suffering from a clot if you remain immobile for the duration of the journey and compound things by imbibing the full complement of freebie food and booze. Once the fellow in the seat in front reclines all the way for the overnight snooze, you will be as firmly trapped as if you were in the grip of 32 seat-pitch-inches of economy torture. "Immobility syndrome" might be a far better description.

"Embarassment syndrome" might also describe the plight of the window seat occupant or the poor schmuck-in-the-middle who, desperate for a mid-flight tiddle - especially given the copious quantities of water we are supposed to drink - can't quite bring himself to disturb the neighbouring and corpulent aisle-dweller, out for the count on sleeping pill and six lagers, headphones askew and drooling from one or other of his many chins. And, even if he makes it to freedom, our window-hugger is likely to encounter the "return to your seat" clear air turbulence message or the flight attendant with the aisle-blocking drinks trolley attempting to service the needs of four hundred passengers with a thirst for something stronger to mix with the water.

Some well-meaning wag proposed recently that the airlines should supply complementary in-flight support stockings for the passengers. Come on! The real thing is a heavy duty and not inexpensive item. It comes in various sizes and grades of elastic tension according to need. It must be tight fitting but not too tight. Some resemble the ladies' stocking of old: some are open-toed and reach to just below the knee but with a looser rim around the top to prevent garrotting the lower limb. To carry on board, say, four sizes (S, M, L, and XL), there would have to be in excess of a thousand pairs of such compression hose on a wide body jet to meet the needs of potential requests.

Far better that these items might soon become available for sale at the Chemist or gift shop in the terminal before departure.

Oh, wouldn't it be luvverly if there was an extra aisle in the larger jets so that no-one was more than one seat away from an escape route, whether for evacuation in the dubious event of landing on water or simply for the evacuation of one's own water. The airlines might be desperate for our business but they are not commercially suicidal. Perhaps things may go that way in a few years time but for now, we have to make the best of a far from ideal mode of travel.

Our fortunes aren't necessarily that much better travelling by road either. Incarcerated in the back of the family charabanc, you just have to be a little concerned at the prospect of granny making it in one piece to visit the in-laws in Cornwall. Especially after that hip-replacement operation and no DVT scan afterwards.

A rough back-of-the-envelope calculation suggests to me that, for around £20 per scan, an Ultrasound DVT scanning machine plus operator might be situated close to the arrivals hall in every airport servicing international flights. A passenger suffering from DVT-like symptoms could be scanned in a few minutes - a very few if no clot is present - and emergency cases detected and dealt with immediately, rather than the next day when it has so often proven to be too late.

The scan is completely painless and involves smearing the inside of the leg with a rather sexy jelly to aid contact with the hand-held probe which is moved smoothly up and down the inside leg. The image on the monitor tells the operator if the veins are clear and blood pumping or if there is some degree of blockage. The procedure is actually quite pleasant and trouserless gentlemen should beware that a stiffy may result.

Would it be possible to claim for such cost on our holiday travel insurance? I must read the small print. Still, we will have to wait for some real entrepreneurial initiative to see such machines waiting to greet the distressed arriving passenger. Sir Richard Branson, take note.

Studies in the field of travel-related DVT will take at least a year to bring about meaningful evaluation, we are told, and the airlines are being understandably cautious in responding to criticism and claims from sufferers. In the meantime, don't just literally sit back and think of England: I don't since I travel frequently in my profession - perhaps sixty or more flights a year, many of them long-haul.

TEN TIPS FOR THE TRAVELLER

So, what have I learned from my experience and what might we all do to make sense of the advice from the experts, however impractical it sometimes sounds?

Well, the jury might be out on the question of aspirin but I have no hesitation in advising anyone with no adverse reaction to that humble little pill to religiously use it for cramped journeys of more than, say, three or four hours duration. But you don't need a whole standard 300mg tablet: a modest child's aspirin of 75mg will do just fine. If you can't find that dosage, then half or even quarter of a regular pill will do. Don't leave it until you are airborne to swallow: take the small dose the night before travelling, just before leaving home and again during the journey. If you have any doubts about using aspirin, consult your doctor.

You can buy or order compression hose from any decent pharmacy. I would recommend class 2 knee-length hose with open toes. Suggested manufacturers include Scholl and Duomed. It's important to know your size so the pharmacist can supply the correct item. Before you go shopping, measure round your ankle, the widest part of the calf and around the knee. If you want the full-length version, measure round the widest part of the thigh as well. It's best to measure as soon as you get up in the morning before your legs swell slightly as a result of sitting or standing for any length of time.

Put on your fabulous and exotic new accessories in the airport loo or in the departure lounge. Trying to heave them on in the confines of your economy seat may prove difficult and remember, they have to be on properly: no wrinkling or crooked seams, chaps. You can put your regular socks back on top of the eerily flesh-coloured compression hose if you feel just a teensy-weensy bit too Nora Batty.

Although these stockings may look impossibly small, they should be a relatively tight fit. If you haven't had time to take your measurements, medium should be about right for the average slightly built male or healthy full figured female. Small would be fine for petite folks. Large and extra large for the big and bigger, beefier types. Compression hose cost in the range of £15 - £20 and can be bought singly as well as in pairs.

Drink plenty of water during the flight. Lay off the alcohol although a glass of wine won't hurt so long as you drink plenty of water too. Remember, alcohol will add to the dehydration problems of aircraft travel.

Eat lightly and think twice about popping a sleeping pill, especially if you are a deep sleeper. Wear loose clothing for comfort and to minimise constriction around the thighs and knees. Try not to sit with crossed legs for too long and, if you are short or your feet don't reach flat to the ground, put a rolled-up coat or pillow below your feet, raising the legs to prevent pressure from the seat edge to the area under the knee.

Don't, for heaven's sake, feel embarrassed to ask your neighbour to move so you can stretch your legs or visit the toilet. Just try to lever yourself up using the arm rests rather than to swing like some demented monkey on the seat back in front of you where I, or another potential subscriber to air-rage, might be trying to enjoy a little beauty sleep.

I invariably request an aisle seat, as do all of our band members and crew. Now, obviously we can't all manage that on a full flight but if you are travelling alone, check in early and go for it. Family groups don't worry so much about climbing over each other to get to the aisle and are usually happy enough in rows of three or four.

I still can't help but feel that a 1 x 3 x 3 x 2 configuration of seating giving three aisles would greatly aid our wide body long haul jet travel. No one would have to negotiate more than one seated person to access the aisle. The resultant extra aisle would reduce economy seating availability by ten per cent but I for one would rather pay a little more for the flexibility of seating, especially when travelling alone.

Exercise every hour - or even more often - by flexing the feet while seated. Keeping the heel on the floor, raise and lower the rest of the foot, rather like operating a foot pump. Do this for a couple of minutes at a time. Try to get up and move about the cabin at least three times on an eight hour flight. Choose your moment when the drinks and food trolleys are not active and the seat belt sign is not on.

Raising the knees alternately up to waist height is a good little exercise while standing in the aisle or a quiet corner near the loos or galley. Raising and lowering the heel up behind you with bent knee helps uncoil stiff and sore legs. Bobbing up and down from flat heel to tip-toe helps too. All these simple routines will work well to stimulate circulation.

If you can, travel with only such hand luggage as will fit unselfishly in the overhead lockers. Leave that precious legroom under the seat in front to stretch your legs. Remember, you paid for that luxurious two cubic feet, or so, of vital space: don't waste it by stuffing it full of all the things you forgot to pack last night and jammed into the Tesco's carrier bags at the last minute.

If you are in what may be determined as the high risk categories - overweight, recently injured or operated on, professional athlete (odd, I know), suffering from any circulatory problems or having a family history of thrombosis - do please consult your doctor before travel. It's a fair bet your local GP is brushing up right now on the subject given all the recent publicity.

And if you ever find yourself sitting next to me on an eleven hour hop to LA, please, please don't hesitate to ask me to let you past my hard-won aisle seat on your way to exercise those little leggies.

Hell, I might even join you.

Ian Anderson.
February 2001