Abstract
BACKGROUND: Air transport for medically complex patients presents unique challenges, particularly without specific guidelines for conditions such as pneumomediastinum or medical devices like peripherally inserted central catheters (PICC lines). Although organizations such as the Aerospace Medical Association (AsMA) and the International Air Transport Association (IATA) provide general recommendations for medical air travel, these guidelines often lack the precision required to address such complex clinical scenarios. Consequently, healthcare teams frequently face difficult decisions under constraints of time and resources, navigating the interplay of patient safety, autonomy, and logistical considerations. CASE PRESENTATION: This case involves a 30-year-old American woman with type 2 diabetes, obesity, and a recent history of pancreaticoduodenectomy, who was hospitalized in Japan with cellulitis and incidentally diagnosed with pneumomediastinum. She was treated with intravenous antibiotics and central venous nutrition administered via a PICC line. However, she requested an early discharge to return to the United States for family and financial reasons. Her travel insurer declined coverage, citing potential risks associated with pneumomediastinum. Ultimately, the patient discharged herself against medical advice; the PICC line was removed, and she transitioned to oral antibiotics for her journey home. CONCLUSION: This case highlights the complexities of patient preferences, medical risks, and insurance limitations when evaluating air travel safety. The absence of specific guidelines for conditions such as pneumomediastinum and the use of medical devices highlights the need for condition-specific protocols. Effective communication and customized documentation, including modifications to the "Against Medical Advice" form proved essential in addressing both patient autonomy and the responsibilities of healthcare providers.