Medical Education Unit

Blok Kesehatan Matra dan Manajemen Bencana

Kasus Tutorial Matra Udara TA 2018-2019

In April 2003, VNN, 59 years old and currently a senior pilot with a commercial airline with over
12,000 hours of flying to his credit developed a mild swelling over his left ankle, four hours into his ten
hour long haul trans-continental flight, while flying as second commander. Over the next 6 hours the
swelling gradually increased from the ankles to involve the entire left leg, accompanied by a nagging
pain. He had last flown the same sector four days back. On arrival he reported to the airline physician
and was referred to a hospital. On admission, all routine blood and biochemical parameters including
LFT were within normal limits. Ultrasound Doppler examination of the left lower limb showed extensive
deep vein thrombosis extending from the left femoral vein down to the proximal calf veins. Left iliac vein
and IVC were patent. All coaguloapthy tests were normal, including Factor II, VIIa and VIIc levels,
Fibrinogen levels, Innohep Xa Anticardiolipin (lgG, lgA, and lgM) antibodies, serum homocystenine
levels, genetic tests for Factor V Leiden, Prothrombin mutation and serum homocysteine levels were
normal. He got the medication

Three weeks later, a colour Doppler showed a large organized chronic thrombus in the left
femoral, popliteal and proximal posterior tibial vein, with minimal recanalization in the femoral vein.
There was no incompetence of the sapheno-femoral junction or evidence of incompetent perforators.
Currently he is able to carry out his daily activities and wears a compression stocking. He continues to
have edema over his left ankle and lower third of the leg. He is currently on tab Warfarin 4 mg OD, to
maintain INR between 2-2.5. Preflight, he had no complaints and had signed in as fit for the flight. His
last aircrew medical examination was done on 24 Dec 2002, including a Stress ECG, Holter ECG and 24
hour ambulatory BP monitoring, for elevated BP readings. As these results were within normal limits, he
was cleared for a full flying category. He had stopped smoking 4 years back and takes alcohol
occasionally. He has no relevant family or past history or past history of any contributory cause for this
symptom.
Medical Education Unit
Blok Kesehatan Matra dan Manajemen Bencana
Kasus Tutorial Matra Udara TA 2018-2019

TUTOR GUIDE
Learning Objective
1. Mahasiswa mampu menyusun analisis tugas dokter terkait dengan kondisi matra udara.
2. Mahasiswa mampu menjelaskan hukum-hukum fisika dasar yang berperan dalam
perubahan fisiologi tubuh terkait kondisi matra udara.
a. Hukum Boyle, Hukum Henry
3. Mahasiswa mampu menjelaskan dasar-dasar penerbangan pesawat (aerodinamika).
4. Mahasiswa dapat menjelaskan tentang aerofisisologi:
a. Lapisan atmosfer
b. Klasifikasi lapisan atmosfer berdasarkan faal tubuh
c. Pengaruh percepaan/akselerasi terhadap faal tubuh
d. Gaya G (G force; Gx, Gy dan Gz()
5. Mahasiswa mampu menjelaskan tentang kabin bertekanan (pressurized cabin)
a. Hukum fisika yang bekerja dalam kabin bertekanan
b. Fungsi kabin bertekanan
c. Prinsip kerja kabin bertekanan
6. Mahasiswa mampu menjelaskan tentang gangguan kesehatan yang terkait dengan
kondisi matra udara:
a. Deep Vein Thrombosis (DVT) : definisi, faktor risiko, etiologi, epidemiologi,
gejala klinis, pmeriksaan fisik, pemeriksaan penunjang, dan penatalaksanaan
b. Penyakit dekompresi, : definisi, faktor risiko, etiologi, epidemiologi, gejala
klinis, pmeriksaan fisik, pemeriksaan penunjang, dan penatalaksanaan
c. Barotrauma, : definisi, faktor risiko, etiologi, epidemiologi, gejala klinis,
pmeriksaan fisik, pemeriksaan penunjang, dan penatalaksanaan
d. Hipoksia. : definisi, faktor risiko, etiologi, epidemiologi, gejala klinis,
pmeriksaan fisik, pemeriksaan penunjang, dan penatalaksanaan
e. Jetlag: definisi, faktor risiko, etiologi, epidemiologi, gejala klinis, pmeriksaan
fisik, pemeriksaan penunjang, dan penatalaksanaan
Medical Education Unit
Blok Kesehatan Matra dan Manajemen Bencana
Kasus Tutorial Matra Udara TA 2018-2019

Guiding question:
1. Bagaimana tugas pokok seorang dokter di maskapai penerbangan?
a. Melakukan identifikasi risiko gangguan kesehatan yang mungkin terjadi pada kru kokpit,
kru kabin, penumpang dan ground handling
b. Memberikan penyuluhan untuk pencegahan timbulnya gangguan kesehatan terkait kondisi
matra
c. Memberikan penatalaksanaan yang sesuai bial terjadi gangguan kesehatan
d. Mengadakan kerja sama dengan pihak manajemen mengenai penanganan karyawan dan
penumpang bila mengalami gangguan kesehatan terkait kondisi matra udara
e. Merencanakan dan melakukan koordinasi untuk evakuasi pasien (penumpang dan
karyawan)

2. Apa masalah yang ada di kasus tersebut?

a. Bengkak di kaki
b. Riwayat merokok
c. Penerbangan dengan sektor yang sama
d. Hasil pemeriksaan penunjang

3. Apa saja hukum fisika yang bekerja pada penerbangan?

a. Hukum Boyle
b. Hukum Henry
c. Hukum Charles
d. Hukum Dalton

4. Jelaskan mengenai kabin bertekanan

Cabin air pressure

Although aircraft cabins are pressurized, cabin air pressure at cruising altitude is
lower than air pressure at sea level. At typical cruising altitudes in the range 11 000–
12 200 m (36 000–40 000 feet), air pressure in the cabin is equivalent to the outside
air pressure at 1800–2400 m (6000–8000 feet) above sea level. As a consequence,
less oxygen is taken up by the blood (hypoxia) and gases within the body expand.
The effects of reduced cabin air pressure are usually well tolerated by healthy
passengers.
Oxygen and hypoxia
Cabin air contains ample oxygen for healthy passengers and crew. However,
because cabin air pressure is relatively low, the amount of oxygen carried in the
blood is reduced compared with that at sea level. Passengers with certain medical
conditions, particularly heart and lung diseases and blood disorders such as anaemia
(in particular sickle-cell anaemia), may not tolerate this reduced oxygen level
(hypoxia) very well. Some of these passengers are able to travel safely if
arrangements are made with the airline for the provision of an additional oxygen
supply during flight. However, because regulations and practices differ from country
Medical Education Unit
Blok Kesehatan Matra dan Manajemen Bencana
Kasus Tutorial Matra Udara TA 2018-2019

to country and between airlines, it is strongly recommended that these travellers,

especially those wishing to carry their own oxygen, contact the airline early in their
travel plans. An additional charge is often levied on passengers who require
supplemental oxygen to be provided by the airline.

Gas expansion
As the aircraft climbs in altitude after take-off, the decreasing cabin air pressure
causes gases to expand. Similarly, as the aircraft descends in altitude before landing,
the increasing pressure in the cabin causes gases to contract. These changes may
have effects where air is trapped in the body.
Passengers often experience a “popping” sensation in the ears caused by air escaping
from the middle ear and the sinuses during the aircraft’s climb. This is not usually
considered a problem. As the aircraft descends in altitude prior to landing, air must
flow back into the middle ear and sinuses in order to equalize pressure. If this does
not happen, the ears or sinuses may feel as if they are blocked and pain can result.
Swallowing, chewing or yawning (“clearing the ears”) will usually relieve any
discomfort. As soon as it is recognized that the problem will not resolve itself using
these methods, a short forceful expiration against a pinched nose and closed mouth
(Valsalva manoeuvre) should be tried and will usually help. For infants, feeding or
giving a pacifier (dummy) to stimulate swallowing may reduce the symptoms.
Individuals with ear, nose and sinus infections should avoid flying because pain and
injury may result from the inability to equalize pressure differences. If travel cannot
be avoided, the use of decongestant nasal drops shortly before the flight and again
before descent may be helpful.
As the aircraft climbs, expansion of gas in the abdomen can cause discomfort,
although this is usually mild. Some forms of surgery (e.g. abdominal surgery) and
other medical treatments or tests (e.g. treatment for a detached retina) may introduce
air or other gases into a body cavity. Travellers who have recently undergone such
procedures should ask a travel medicine physician or their treating physician how
long they should wait before undertaking air travel.

https://www.who.int/ith/mode_of_travel/cab/en/

5. Apa saja masalah kesehatan yang mungkin timbul terkait kondisi matra udara?
a. DVT
b. Jetlag
c. Motion sickness
d. Penyakit Dekompresi
e. Trapped gas
f. Hypoxia
g. Spatial disorientation
h. Acceleration (G Force)
Medical Education Unit
Blok Kesehatan Matra dan Manajemen Bencana
Kasus Tutorial Matra Udara TA 2018-2019

Alur pikir

Pria, 59 tahun, penerbang sipil dgn total jam kerja

12.000 Pemeriksaan lab:
- Darah rutin : dalam batas normal
- Saat bertugas dalam penerbangan yang - Kimia darah : dalam batas normal
lamanya 10 jam, timbul keluhan bengkak di - Fungsi liver : dalam batas normal
pergelangan kaki kiri sesudah terbang selama - Tes koagulopathi Factor II, VIIa and VIIc levels,
4 jam. Pasien bertugas sebagai Second Fibrinogen levels, Innohep Xa Anticardiolipin (lgG,
Commander (SIC). lgA, & lgM) antibodi, kadar homocystenine serum,
tes genetic Factor V Leiden, mutasi Prothrombin &
- Sesudah 6 jam penerbangan, bengkak
serum homocysteine : dalam bats normal
menyebar ke seluruh tungkai disertai nyeri
- Doppler : trombosis vena dalam yang luas dari Vena
menetap. Femoralis Sinistra sampai ke Vena Calf Proksimalis
- 4 hari yang lalu, pasien tugas terbang dengan
sektor yang sama
- Berhenti merokok 4 tahun yang lalu
- Tidak minum alkohol
- Tidak ada riwayat keluarga dengan keluhan
serupa
- Saat mendarat, pasien lapor ke klinik
kemudian dirujuk ke RS

DVT

- Molecular weight
heparin (LMWH)
- Anticoagulants
(Warfarin 4 mg OD)

3 minggu kemudian, Doppler: thrombus kronis luas di

femoralis sinistra, popliteal dan proksimal vena tibialis
posterior, recanalisasi di vena femoralis. Tidak ada
inkompetensi di sapheno-femoral junction atau kejadian
perfora incompeten. Saat ini pasien dapat mengerjakan
tugas harian dan mengenakan stoking kompresi. Masih
ada bengkak di atas pergelangan kaki kiri dan sepertiga
distal tungkai. Pasien masih minum obat tab Warfarin 4
mg OD, untuk mempertahankan INR 2-2.5.