Economy Class Syndrome How to avoid Economy Class Syndrome (ECS), blood clots formed during air travel. Various cases have been published whereby people, unaware of a blood clot having formed in their body during e.g. a long haul flight, died from that blood clot traveling to the lungs, brains, or heart. The time in which the blood clot travels, from where it was formed, can take hours, days, or even weeks. Medical journals say that during flight blood coagulability rises steadily and blood flow slows down, especially in the lower legs. Blood clots form, usually painlessly, but some cause pain and swelling. If a clot travels to the lung it can cause pain, fainting and death. A clot in the leg is called deep vein thrombosis (DVT). A clot in the lung is pulmonary embolism (PE). Clots also form in the arterial system and in the heart, leading to heart failure and stroke. Simple and effortless exercises prevent DVT and PE. You need to flex your leg muscles during flight. Advice for Passengers to Avoid Thrombosis Injury Coagulability rises steadily during air travel. The longer the flight, the greater the risk. Clots in the arterial system cause heart attack and stroke. If you are being treated for any heart condition, hardening of the arteries, diabetic arteriopathy, or similar conditions, taking aspirin may reduce your risk. Your doctor may also recommend injection (in the stomach fat) of a low molecular weight heparin. Clots in the venous system are more likely and easily preventable. Don't wear anything that could impede the circulation (like a knee brace). Frequent leg flexing is the best preventive for ECS. You need to activate the muscles enough to push the blood through the veins. Do it firmly and deliberately but not strenuously. If you are bothering your seatmates, you are doing it too vigorously. How often? It is recommended to flex your legs with 30 minute intervals, more frequently if you have any of the risk factors listed below. Extend your legs straight out in front of you and flex your ankles, pulling up and spreading your toes, then pushing down and curling the toes. If your shoes limit toe movement, just make the effort and don't worry, or remove the shoes. If there isn't room to extend your legs, start with your feet flat on the floor and push down and curl your toes while lifting your heels from the floor. Then, with your heels back on the floor, lift and spread your toes. Repeat this heel - toe cycle ten times. Exercise your thigh muscles by sitting with your feet flat on the floor and slide your feet forward a few inches, then slide them back and repeat. Avoid sleeping. A thirty minute nap would probably be OK, perhaps using an alarm watch to waken . You could sleep longer if there is enough room for you to lie with your legs up on the same level as your upper body. Flex thoroughly when you wake. Massaging the leg muscles (as some experts recommend) could be dangerous if a clot has formed, and a clot may have formed without your knowing about it. Crossing legs for more than a few minutes at a time is dangerous. Some experts recommend avoiding caffeine and alcohol. Others say this makes no difference. Drinking extra non-caffeine and non-alcoholic fluids is recommended. Risk Factors Statistics are showing that being young and athletic is the biggest risk factor for flight-induced DVT. The risk is compounded if you have one or more of the following: Personal or family history of DVT. Cancer, heart disease, diabetes, obesity. Recent injury or surgery, especially to the legs or lower torso. "Recent" means about six weeks, but if you still have any soreness, bruising, or other after-effects, you are still in danger. Women who are pregnant or taking extrogen as birth control or hormone replacement. Age past 60. (But remember, being young and fit is the biggest risk factor.) Precautions The more risk factors you have, the more frequently you need to flex. Compression stockings have proven very effective in several studies. A pre-flight self-administered shot of heparin is recommended if you can't stay awake to flex. Studies show that aspirin, often recommended, is not effective as an anti-DVT treatment. If you feel the symptoms listed below, see a doctor. A few days after reading this you will probably forget exactly what symptoms to watch for, so note them down. After 30 days you are probably safe, but you must still avoid surgery for three months. If surgery is unavoidable, seek advice from your doctor. Leg symptoms (Deep Vein Thrombosis, DVT) may appear during flight or in the next few days. Sudden swelling in one lower leg. (A little swelling in both legs is normal in flight.) Cramp or tenderness in one lower leg. Bruise or swelling behind knee. Chest symptoms (Pulmonary Embolism, PE) usually appear 2-4 days or more after the initial blood clot (which you may not have noticed). shortness of breath rapid breathing, panting cramp in your side, painful breathing chest pain accompanied by shoulder pain fever coughing up blood fainting (often the first sign, especially in older people) Tell the doctor that you have flown recently and that you suspect a blood clot. Misdiagnosis Most victims are stricken a few days after the flight. They have no idea what is wrong. Those who seek treatment are usually misdiagnosed at first, aggravating the injury and increasing the risk of death. This is a double tragedy. First, passengers could easily avoid this if they knew the simple exercises that prevent it. Second, victims could easily avoid misdiagnosis if they knew how. Arterial clots are less easily avoided, but a little information can be lifesaving. More often than not, flight-induced DVT is initially undiagnosed or misdiagnosed, aggravating the injury and increasing the risk of death. Here are two simple ways to avoid misdiagnosis. If you have leg symptoms and the doctor says you have only a muscle sprain (or anything else other than DVT), insist on an ultrasound scan of the leg. Without it, your chances of a correct diagnosis are only 50/50. If you have chest symptoms and you are being told you have a chest infection, anxiety attack, cold, or anything else other than PE, ask for a blood oxygen measurement. A small device (no needle) placed on your fingertip measures blood oxygen. If the reading is below 80, you need a lung scan to check for PE (unless there is some other reason for low blood oxygen, such as emphysema.) Turbulence? The usual advice is "Sit tight, enjoy the flight, and keep the seatbelt fastened to avoid turbulence injury". But serious turbulence injuries average only five per year, according to the records. There are thousands of times more thrombosis victims each year than all the turbulence and crash victims in all of aviation history. Half of the people hospitalized with DVT each year are caused by air travel. PE victims often die, and victims of stroke and heart failure add to the toll, which probably exceeds cancer deaths. For people in their 20's and 30's this is one of the leading causes of death. Never in history could so many injuries and deaths be avoided so easily. Security? Should this take a back seat to security? More lives are ruined or ended every single day by ECS than the number of people on board all four of the hijacked airliners. If air travel thrombosis were caused by terrorists putting something in the food, no expense would be spared to stop them. But since this is simply caused by airline industry indifference to human life, the injuries and deaths continue. Common misconceptions: If I am in good shape, it won't happen to me. Athletic people are at much greater risk than other passengers. No one is safe from this. More than half the victims have no risk factor other than air travel. On the airhealth.org site you will see remarks from victims who were young, fit, and active: avid bicyclists, runners, a scuba diver. I'll just upgrade and avoid the cramped seats. At cabin altitude, blood coagulability rises steadily and the altitude is the same in the front of the plane as in the rear. The ratio of victims is the same in all sections of the aircraft, including the flight deck. The term economy class syndrome (ECS) is a misnomer. A more accurate term is air travel thrombosis. You just need to stretch if you feel a cramp. You probably won't feel a cramp, and if you do, it's too late. Researchers find that 94% of blood clots are silent, symptomless. Symptomless blood clots were found in 10% of air travelers and are not harmless. They can progress to fatal pulmonary embolism without warning. If I get a clot, drugs will dissolve it. The usual heparin/warfarin treatment doesn't dissolve the clot. It just reduces the risk of more clots. The original clot has to be broken down in a natural process called lysing, which can take months. Warfarin is a blood thinning drug and rat poison. If you are a person who tries to avoid toxic substances, you will not enjoy being forced to take rat poison. The treatment usually continues for three to six months; some have to take it for life. Pilots acclimate. They don't need to worry. Pilots are at risk, too, and the first sign often is fainting. The most common causes of sudden pilot incapacitation are cardiac arrest, arrhythmia, and fainting. (All of which are often caused by a blood clot in the lung). With DVT, pilots, like other victims, often struggle with symptoms for days or weeks, not knowing what is wrong. During that time they are at risk of sudden collapse, a danger to themselves and their passengers. Pilots are also at risk of sudden collapse due to arterial clots causing heart failure or stroke. Stroke, PTSD, Pulmonary Hypertension More reasons to take this seriously: About 35% of adults have a "right/left shunt," a small hole in the heart allowing venous blood to pass into arterial circulation without passing through the lungs and allowing clots to travel to the brain, causing stroke. About 10% of the victims contacting us are stroke victims. A common after-effect of ECS is post-traumatic stress disorder, PTSD, with symptoms such as depression and anxiety. Victims find their lives ruined, unable to enjoy the things that previously gave meaning to their lives. PE can lead to pulmonary hypertension, a serious lung condition which is often fatal. Airhealth.org Much information on ECS can be found on the website Airhealth.org, a non-profit organization dedicated to ending the suffering and deaths caused by flight-induced blood clots. They also have a leaflet that you can download and print.

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