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Inflight medical emergency
Compilation made by Dr. Ramon Reyes, MD
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Grupo en TELEGRAM Sociedad Iberoamericana de Emergencias https://t.me/joinchat/GRsTvEHYjNLP8yc6gPXQ9Q
Emergencias médicas durante un vuelo comercial
It might seem like an odd thing to pack in a travel bag, but Rachel Zang, MD, never boards a flight without a supply of ondansetron. On a flight from the United Kingdom back to the United States, Zang stepped up to help a 2-year-old who was vomiting. To her surprise, the medical kit on board had no antiemetics.
“The standard [kits] do not require them,” says Zang, a fourth-year emergency medicine resident at the Hospital of the University of Pennsylvania in Philadelphia. “You have no ability to give a medication to stop vomiting.”
As a frequent traveler—she has been to 30 countries, including medical missions to Tanzania and Rwanda—Zang wanted to be better prepared when the next in-flight medical emergency crops up. She researched domestic and international laws and learned what those airline medical kits are supposed to contain and what they lack.
In fact, Zang amassed so much material that she shared it with her colleagues during a grand rounds on in-flight medicine. “Lots of people were interested,” she says. “[I]t’s something everyone’s a little uncomfortable with … so they want to know as much information as they can about it.”
With summer travel in full swing, Zang spent some on-the-ground time talking with JAMA about the ins and outs of responding to in-flight medical emergencies. The following is an edited version of that conversation.
JAMA:How often have you encountered medical emergencies on flights?
Dr Zang:In the last 4 years, I've had 2 medical emergencies that I responded to, and then my husband has had 2 as well. He’s also a physician.
JAMA:The common conditions that usually occur in flight are lightheadedness, loss of consciousness, nausea, vomiting, and cardiac or respiratory symptoms. Have these been the conditions that you, your husband, or other physicians you know have encountered during flights?
Dr Zang:Yes, definitely. My husband has responded to 2 syncopal episodes and many of my colleagues have responded to lightheadedness or vomiting. In the literature, the most common condition is syncope or near syncope. That accounts for about 37% of in-flight medical emergencies. The next most common is respiratory distress. That's about 12%, followed by vomiting and then chest pain.
JAMA:Are those conditions related to circumstances inside the plane, either cabin pressure or other factors?
Dr Zang:The airplane causes a lot of unique changes in the body that we're not really aware of. Being on a flight is the equivalent to being at 6000 to 8000 feet of altitude. At sea level, oxygen saturation in all of us healthy people is 99% to 100%, but when we go up into the air, most of us would be about 92% to 95%. So you can see how anyone who had underlying respiratory or cardiac issues, if their oxygen saturation drops lower, it's going to exacerbate angina or make their COPD [chronic obstructive pulmonary disease] or asthma worse. In turn, the very low humidity in the airplane has been shown to exacerbate asthma and COPD because of the increased dehydration and the increased mucosal dryness.
JAMA:Were the medical supplies on the plane adequate for the emergencies you dealt with?
Dr Zang:The emergencies that I handled were minor. One person had a headache and wanted Tylenol, which is in the medical kit. For the young child who was vomiting and very dehydrated, I had to mix my own oral rehydration solution, which is very easy. It's 6 teaspoons of sugar and half a teaspoon of salt in a liter of water. And you have syringes. So for very little kids, you can mix that up, and mom can give it to the child. Or you could use an IV [intravenous route] in a dehydrated child, which I think would be very challenging in the air.
JAMA:Are there standard supplies that airlines are required to keep on board, either by federal law or their company policies?
Dr Zang:In the United States, federal law mandates that all airlines have a first aid kit, an oxygen tank with enough oxygen for 2% of the passengers for the duration of the flight, and an AED [automated external defibrillator]. In the standard medical kit you get a stethoscope, blood pressure cuff, and gloves. You get an array of oral airways and bag valve masks and CPR [cardiopulmonary resuscitation] masks. You get a few needles, a few syringes, and a 500-cc bag of saline solution, and then you get a short list of medications: Tylenol and Benadryl in oral and IV form, aspirin, atropine, albuterol, and 1 A of D50 [50% dextrose]. You also have epinephrine in both IO [intraosseus] dose and anaphylactic dose, lidocaine, and nitroglycerin tablets.
JAMA:Despite the US minimum requirements, do any airlines go beyond the minimum?
Dr Zang:The only airlines I found that went beyond the minimum were international airlines. That's not to say US airlines don't; I just couldn't find any documentation. Some that go above and beyond are ANA [All Nippon Airways], a Japanese airline, and Lufthansa. Both of them have very extensive medical kits, and they have a program called Doctor on Board that allows you to designate yourself as a physician when you book your ticket so they don't have to page overhead. They provide some access to their medical supply kits and information when you sign up so you know what's on their plane. Turkish Airlines has a similar program.
JAMA:Would it be helpful to have a universal program like that for all airlines worldwide?
Dr Zang:Yes. We don't even have a national reporting database to figure out how often these in-flight medical emergencies happen. We think the numbers we have are grossly underestimated and it is well known in the airline industry that in-flight medical emergencies are expected to increase. People are flying more often and more elderly and people with preexisting medical conditions are flying. It's expected that by 2023, half of airline passengers will be over the age of 50. Doctors could be better equipped if there was a standard medical kit on every flight so you knew the medication and equipment you had access to.
JAMA:If you had a wish list of onboard improvements, what would they be?
Dr Zang:I would start small. Since 2001, when regulations for the emergency medical kit and the AED onboard went into effect, the FAA [Federal Aviation Administration] has not reexamined the medications in the kit. For example, lidocaine is still in the kit because it used to be recommended for cardiac arrest. It no longer is, but it's still in the kit, as opposed other medications. At the very least, it would be nice if the FAA would reevaluate what's in the mandated medical kit and add some basic things like Zofran for an antiemetic. On a broader scale, airlines are governed by so many different bodies, not just in the United States, but internationally.
So my wish would be that one person could create an international governing body of airlines and have it mandate medical equipment. The AED is necessary; a few more in the kit would be helpful. Now, if you want to put in an IV, you have 2 tries, and that's it. If you miss, you're done. Some more fluid in the kit would be helpful; 500 cc is not very much if you're dealing with a significantly dehydrated person on a long flight. Definitely, the medications need to be updated. If I had all of my dreams, pediatric and obstetric equipment would be included. There is no obstetric medication in any of the kits and there is no pediatric dosing or, aside from a CPR mask, anything pediatric related. There's not even a glucometer.
So my wish would be that one person could create an international governing body of airlines and have it mandate medical equipment. The AED is necessary; a few more in the kit would be helpful. Now, if you want to put in an IV, you have 2 tries, and that's it. If you miss, you're done. Some more fluid in the kit would be helpful; 500 cc is not very much if you're dealing with a significantly dehydrated person on a long flight. Definitely, the medications need to be updated. If I had all of my dreams, pediatric and obstetric equipment would be included. There is no obstetric medication in any of the kits and there is no pediatric dosing or, aside from a CPR mask, anything pediatric related. There's not even a glucometer.
JAMA:Do you think physicians sometimes are hesitant to come forward when there's a medical emergency on their flight?
Dr Zang:Yes, for a variety of reasons. You don't know why they're asking for a physician or if you're equipped to handle what they're asking for. Maybe you're really exhausted from a long trip. Maybe you had a beer with your dinner and you're not sure if you should step in. I think a lot of physicians aren't sure what their liability is if something goes wrong. So there's a whole host of reasons why physicians would feel uncomfortable.
JAMA:What are the potential legal liabilities?
Dr Zang:It depends on where you are. The US has the Aviation Medical Assistance Act of 1998 that says individuals shall not be liable for damages in federal or state court for any reason when they provide in-flight medical care unless they were grossly negligent or had willful misconduct. This covers physicians, nurses, nursing assistants, paramedics, and EMTs (emergency medical technicians). What that says is you will not be penalized if you attempt to help in good faith. The only reason that you could be liable is if you were grossly negligent because you were so fatigued you couldn't think straight, or you had taken medication because you were planning to sleep, or you were intoxicated because you drank a lot on the plane. The Act goes even further and says you can't be held liable if your recommendation is to divert the plane and they don't and something goes wrong. You can't be held liable if the equipment fails or if the patient collapses in front of you and you jump in to help even though nobody asked.
What’s less clear is when you're on international flights. For example, the United Kingdom does not have national law on this, and their airlines decide individually how they will cover physicians’ legal protections. British Airways, Virgin Atlantic, and other carriers provide indemnity for medical professionals, but unless you're looking up every flight, you might not know how you're covered. Then it becomes unclear what airspace you're in. If you’re on a French flight to the US in US airspace, are you covered under US law or French law? It can get complicated.
What’s less clear is when you're on international flights. For example, the United Kingdom does not have national law on this, and their airlines decide individually how they will cover physicians’ legal protections. British Airways, Virgin Atlantic, and other carriers provide indemnity for medical professionals, but unless you're looking up every flight, you might not know how you're covered. Then it becomes unclear what airspace you're in. If you’re on a French flight to the US in US airspace, are you covered under US law or French law? It can get complicated.
JAMA:Have you ever had to ask the pilot to divert the flight?
Dr Zang:I have never been in that situation. But diverting a flight is not as simple as it may seem because it involves a lot of other things besides the issue of that 1 patient. How far are you from the next possible airport and what is the emergency they're having? If somebody's going into labor, the next closest airport might not have medical capabilities to deal with obstetric issues. Ultimately, it's the pilot's decision.
JAMA:This issue was in the news recently after a lawsuit was filed in a case from 2016. A young woman died after a physician on the plane said she needed immediate care on the ground. An airline physician on the ground advised to continue on for 90 minutes and the pilot didn’t divert the flight. The woman died 3 days later; the cause reportedly was a pulmonary embolism. Is there anything else a physician could do in a circumstance like that?
Dr Zang:No. All you can do is speak with the ground doctor and the pilot and offer your recommendations. If the patient worsens or something changes, it's important to relay that to the ground doctor because it might change his or her decision. Statistically, the pilot will side with the doctor on the ground simply because they tend to have more experience in in-flight medical emergencies.
JAMA:During your grand grounds on in-flight medical emergencies, what were the most important things you felt your colleagues should know, especially those who had never encountered an in-flight emergency?
Dr Zang:The most important things for them to know were what equipment they can expect to have on board, the most common chief complaints, and what other resources they have. Flight attendants are all certified in CPR and AED use. Having access to a medical command doctor who deals with in-flight medical emergencies every day was something I didn’t know, and I think it's helpful to realize that you're not entirely alone up in the air.
I've received a lot of questions about credentials. The Aviation Medical Assistance Act of 1998 says that in good faith, the flight attendants believe the passenger offering assistance is a medical-qualified individual. So technically, you do not have to show credentials. But the FAA has come out with other regulatory letters, most recently in 2006, that said it’s preferable for flight attendants to check credentials of people holding themselves out as medical specialists. So I wouldn't be surprised or offended if somebody asks for credentials. I always fly with my medical credentials now.
I've received a lot of questions about credentials. The Aviation Medical Assistance Act of 1998 says that in good faith, the flight attendants believe the passenger offering assistance is a medical-qualified individual. So technically, you do not have to show credentials. But the FAA has come out with other regulatory letters, most recently in 2006, that said it’s preferable for flight attendants to check credentials of people holding themselves out as medical specialists. So I wouldn't be surprised or offended if somebody asks for credentials. I always fly with my medical credentials now.
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HOW LUFTHANSA CARES FOR PASSENGERS’ MEDICAL NEEDS
BY BEN GRANUCCI
Lets face it, nobody wants to need medical care while on board a plane. And yet, with a huge number of people traveling by air everyday, it’s inevitable that it will happen with some regularity. In fact if you travel by air regularly, you have probably heard the flight attendants ask over the PA if there is a “medical professional onboard.”
Any malady that can occur on the ground can happen in the air, and the altitude while on a commercial aircraft can even exacerbate certain medical conditions. That means that some people may be more likely to need medical assistance in the air than they do on the ground.
For German airline Lufthansa, there are about 3,000 passenger medical emergencies that occur on board each year. Of those, an average of 54 emergencies are serious enough that they require the flight to be diverted so that a patient can obtain urgent medical care. I recently had a chance to sit down with the airline and learn how they cope with these situations. Not only is the airline well prepared for any emergency that may arise in flight, they are also ready to treat those who need care before they board the aircraft.
Emergencies On Board
 A rendering of the inside of Lufthansa’s Patient Transport Compartment, the “flying ICU” – Image: Lufthansa
As mentioned above, Lufthansa averages 3,000 on-board medical emergencies of varying levels of severity each year. Just like any other airline, their flight attendants receive regular training on inflight first aid and emergency procedures. Crews are also trained to assist medical professionals when that need arises. However, this is where the similarities between Lufthansa and most other airlines ends.
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In-Flight Medical Emergency Support.
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On a Lufthansa flight, making a public call for any medical professionals on the plane is a last resort. The airline prefers to be far more discreet. After all, does the whole plane always need to know that somebody on board is having a problem? To accomplish this, Lufthansa launched the Doctors on Board program for physicians.
Doctors on Board allows Lufthansa to identify doctors long before an emergency occurs. By doing this, the cabin crews can personally and discreetly summon the doctor if their skills are needed during a flight. In order to find doctors who could potentially participate in this program, the airline scoured the data from its Miles and More frequent flier program. By doing this, Lufthansa was able to identify 15,000 doctors who regularly fly the airline. Of those, 10,000 opted to join the program.
 The “doctor kit” of medical supplies and drugs. One is stocked on every Lufthansa aircraft. Photo: Lufthansa
Doc Kit
The “doctor kit” of medical supplies and drugs. One is stocked on every Lufthansa aircraft. Photo: Lufthansa
Participation in the Doctors on Board program carries with it several benefits. The doctors are issued a handbook about aviation medicine, as well as receiving news and information via both the internet and postal mailings. They are insured by Lufthansa for any care that they provide during a flight. They are also rewarded with 5,000 Miles and More award miles and a discount code for €50 off of their next flight, plus they receive a special bag tag identifying their participation in the program. Finally, they are given the opportunity to participate in a course on aviation medicine and on-board emergency handling, for which they are paid an additional fee.
In the event that their services are needed inflight, Lufthansa stocks each aircraft with an extensive doctor’s kit. These kits are filled with high-quality medical equipment and a large selection of drugs and medications that may be needed in case of an emergency. These kits are separate from the first aid kits that the cabin crew has access to. And all of the costs of providing emergency medical care onboard are borne by the airline.
Transporting Ill Passengers
Stretcher
The installation of a stretcher over economy class seats
Of course, not every passenger who needs to travel by air is in perfect flying condition. There are a variety of medical situations in which a person may be able to fly with certain accommodations. Perhaps the most basic of these is the need for a little extra room. If one seat isn’t quite enough space for a person with a medical condition, Lufthansa can provide an empty seat next to them for a fee on all flights. Another option on long-haul flights is a full lie-flat seat in First or Business class, providing both space and comfort to the passenger.
As a result of the thinner air that comes from a cabin altitude of roughly 8,000 feet, some passengers with reduced lung function need supplemental oxygen while onboard. Lufthansa has specialized Wenoll System oxygen supplies available for use on all flights. These devices provide up to 15 hours worth of supplemental oxygen for passengers in need.
For those passengers that must remain lying down for the entire flight, there is the option of stretcher transportation. On each Lufthansa aircraft, a section of seats at the rear of the Economy cabin can be folded forward, providing space for a specialized stretcher to be installed. These stretchers cover several rows and require the width of two economy seats. Due to emergency egress requirements, the stretcher must be positioned along the side of the aircraft. For patient privacy, a curtain is installed around the stretcher.
Assistance Centre In Flight Medical Emergency Support
A caretaker travels with each stretcher patient. On aircraft where the Economy cabin has rows of two seats along the side of the plane, that caretaker would sit across the aisle from the patient being transported. For aircraft that have three seats between the aisle and the window, including all narrow-body aircraft, the attendant would sit in one of the aisle seats next to the stretcher.
Lufthansa can accommodate requests for stretcher space with 24 hours of advance notice. These requests are made through the airline’s Medical Operations Center. This dedicated team is responsible for all of the necessary arrangements that are needed in order to transport a patient. In addition to managing the operational logistics, this team also ensures that the patient is medically cleared for travel. Because of the limitations in treating a patient being transported in this manner, they must be in a relatively stable condition in order to fly. After all, diverting a flight is expensive and can be a major inconvenience to the other passengers.
The Flying ICU
 The installation of a stretcher over economy class seats
Air Ambulance vs Lufthansa
How a Lufthansa flight can move patients faster than a traditional air ambulance
Sometimes, however, waiting for a patient to stabilize before transporting them just isn’t an option. In certain cases, the best option for a patient’s recovery is to evacuate them to a country where better medical care is available. Typically, that evacuation takes place on a small air ambulance jet that has been specially equipped for this mission. However there are a few significant drawbacks to this method. First, it is incredibly expensive. Costs for a long-haul air ambulance flight can easily exceed €100,000 ($125,000). And the flights can be extremely long. The relatively short range of the jets that are used mean that they need to make multiple fuel stops en route, which has the potential to significantly increase the distance that needs to be flown. This, in turn, increases the flight time significantly.
However, Lufthansa has another option available for some of these patients. The airline has developed the Patient Transport Compartment, a “flying ICU” of sorts, that allows unstable patients to be transported in a method that is both faster and more economical than an air ambulance jet. This compartment is suitable for the transport of just about any critical care patient. The only notable exception are those patients who are being treated for communicable diseases, including the recent Ebola outbreak in Africa. The compartment was designed by Lufthansa’s medical department, and is built and sold by Lufthansa Technik.
The Patient Transport Compartment is a fully-enclosed hospital room in the sky that can be installed center section of seats on some of the airline’s A330, A340, and 747-400 aircraft. A version that can be used Lufthansa’s 747-8i and A380 fleets is coming this winter. The compartment is installed as needed. Several rows of economy class seats in the center section at the rear of the plane are removed. Next, walls are installed along with several modules of medical equipment. In addition to the patient’s bed, the compartment also has seats for a doctor and a paramedic. As an added feature, family members of the patient can travel on the same aircraft, something which is not possible on a conventional air ambulance.
Each aircraft that is capable of having this compartment installed must be specially modified in advance of the compartment being loaded. As a result of the added installation costs and the weight that must be carried whether a patient is being transported or not, only a few of each compatible fleet type are given the modifications. One of the modifications that must be made is the installation of a dedicated outflow line. This is a regulatory requirement that exists because of the use of large quantities of bottled oxygen and other gases. Another necessary modification, required on the A380s that will be able to be fitted with the Patient Transport Compartment, is reinforcement of the floor in the rear of the aircraft.
 How a Lufthansa flight can move patients faster than a traditional air ambulance
PTC on 744
The Patient Transportation Compartment installed in a Lufthansa 747-400
The core of the Patient Transport Compartment is the bed module. It is equipped with several large bottles of oxygen, as well as the most essential pieces of equipment for monitoring and treating patients. Other medical equipment is installed elsewhere in the compartment. This gear includes telemetry monitors, ventilators, injection and infusion pumps, a defibrillator, blood gas analysis equipment, and a suction machine.
The Patient Transport Compartment reduces the cost of transporting a critical patient to between €32,000 ($40,600) and €68,000 ($86,400). This is pretty much an all-inclusive price that includes more than just the costs of transporting the patient and the installation and removal of the compartment. All medical equipment and supplies that are needed are provided by Lufthansa. The airline also sends a paramedic who has been trained in the use of the compartment to assist in the patient’s care. The cost even includes business-class transportation of the patient’s doctor to the patient, so that they may accompany the patient back to Germany while providing care. The doctor’s services to the patient are just about the only thing that isn’t included in the price. And Lufthansa allows one relative to accompany the patient at no additional charge.
While Lufthansa is the only airline currently flying the Patient Transport Compartment, that doesn’t mean that they are the only customers of the equipment. Lufthansa Technik has found customers for the core module in the Luftwaffe and United States Air Force. And the Patient Transport Compartment is a popular option for the private jets of Middle Eastern sheiks. The airline is currently exploring offering the Patient Transport Compartment onboard other Lufthansa Group carriers such as Swiss Airlines and Brussels Airlines, as new fleet types such as the A350 are introduced.
Lufthansa’s patient transportation services are something that is relatively unique, especially among European airlines. It enables the airline to respond as necessary whether an emergency effects one patient or many. In fact, the largest use of the airline’s patient transportation service was following the Asian tsunami in 2004. As for the most common use of the Patient Transport Compartment, Lufthansa told me that it was carrying German citizens injured in motorcycle crashes in Bangkok back to Germany for treatment.
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| How airlines deal with in-flight medical emergencies |
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| The Patient Transportation Compartment installed in a Lufthansa 747-400 |
1 in every 604 flights involves medical situation, study says
You may have heard this announcement before:
"Ladies and gentlemen, a passenger requires medical attention. If there is a physician or medical personnel on board, please identify yourself to a flight attendant."
One in every 604 flights involves a reported medical emergency, according to a 2013 study published in the New England Journal of Medicine. Researchers at the University of Pittsburgh Medical Center calculated that translates into 44,000 in-flight medical emergencies worldwide every year.
The actual number may be much higher, because no mandatory reporting system exists and minor issues are very likely underreported.
The most common problems, according to the data collected, were fainting or feeling dizzy and lightheaded (37%), respiratory symptoms (12%) and nausea or vomiting (10%).
But how are these emergencies handled, especially when they're more complicated or life-threatening
Ground support
In-flight medical emergencies unfold in the skies above us every day, so many large airline companies spend a lot of time and money training their flight crews on what to do when presented with these types of extraordinary situations.
"The flight attendants are trained as new hires very extensively, and then every year they have recurrent training that includes emergency response," said Barbara Martin, general manager for Air, Crew and Passenger Health Services at Delta Air Lines.
"They are using a medical assistance form to get the key, most important data on signs, symptoms and vital signs," said Martin, who is an occupational nurse by training.
"The pilots and dispatchers on the ground ... are also trained in what the key elements of information are that need to be transmitted to STAT-MD if there's a consult," Martin said. "It's really a team effort."
You've probably never heard of STAT-MD, but the medical professionals at this low-profile University of Pittsburgh Medical Center medical communications center provide ground-based support services for a number of large commercial airlines based in North America.
"We basically provide in-flight consultations for in-flight emergencies, and we also provide fitness-to-fly screening for the airlines for (passengers) on the ground in case there's a question on their ability to go up into the air," said Dr. TJ Doyle, STAT-MD's medical director.
Doyle said they did about 10,000 consults last year, so they're fielding about one or two calls an hour.
"The captain is always in charge," said Doyle. "We make a recommendation based on our expertise, and our experience. We've been doing this for a while and we do it quite often. So we'll make a recommendation to the captain on what we think can occur."
In the most extreme cases, that might mean recommending diverting the flight. This occurred in 7.3% of the cases reported in the 2013 study.
Far more often, the issue is something much simpler: a diabetic whose sugar has plummeted, so he or she needs a sip of orange juice. Or perhaps someone is feeling lightheaded and may just need to be administered oxygen.
Managing medical emergencies at 30,000 feet
When the problem is more serious
"If it can happen on the ground, it's going to happen in the air, as well, so we need to be able to respond to that appropriately," said Delta flight attendant trainer Justin Eberle. "Passenger safety is always our number one priority."
All flight attendants working routes in the United States must be trained in CPR and how to use a defibrillator.
"The flight attendants have access to what we call a medical accessory kit," said Martin. "That's got basic equipment in it for taking blood pressure, thermometers, personal protective equipment. If there's a medical volunteer on board, then they're given access to our emergency medical kit, and that kit has resuscitation equipment, IV equipment, medications."
Many airlines require consultation with a ground-based physician, such as STAT-MD, before the emergency medical kit is used. There is one other prominent medical communications center in the United States called MedAire, based in Phoenix, Arizona, but those calls may not always be answered by a medical doctor.
Kits vary widely in quality. The FAA requires contents such as saline solution, aspirin, antihistamines, epinephrine and nitroglycerine tablets. Some airlines choose to supplement the basic provisions, but supplies and medications are expensive, they take up weight and they have to be replaced when they expire.
It goes without saying, too, that some protocols and procedures are more challenging in the air. A simple stethoscope, for example, is rendered relatively useless in flight because of all the ambient noise.
'Is there a doctor on the plane?'
More useful, often, than the equipment is the expertise of a fellow passenger. Physician passengers provided medical assistance in 48.1% of reported in-flight medical emergencies, according to the 2013 study. Nurses assisted in 20.1% of the cases.
Martin says the number is even higher.
"Over the years, we've seen at least an 80% presence of a physician or RN volunteer," said Martin. "In fact, the most recent year we compiled data on, 2014, we have 90% volunteer by physician or nurse during a medical event."
But what about liability?
"Although U.S. health care providers traveling on registered U.S. airlines have no legal obligation to assist in the event of a medical emergency, ethical obligations may prevail," according to a 2015 study, also published in the New England Journal of Medicine.
"In addition, many other countries, such as Australia and in Europe do impose a legal obligation to assist," according to researchers at the Georgetown University School of Medicine.
To encourage medical professionals to assist, Congress passed the Aviation Medical Assistance Act in 1998, which protects providers who respond to in-flight medical emergencies from liability and thus encourages medical professionals to assist.
"This law applies to claims arising from domestic flights and most claims arising from international flights involving U.S. carriers or residents," the authors of the 2015 study wrote. "The AMAA does allow for liability of providers if the patient can establish that the provider was 'grossly negligent' or intentionally caused the alleged harm ... An example of such disregard would be an intoxicated physician treating a patient."
Worst-case scenario
Among in-flight medical emergencies, cardiac arrest is very rare, accounting for only 0.3% of such emergencies, yet it is responsible for 86% of in-flight deaths, according to the 2013 study.
When possible, protocol recommends the deceased passenger should be left in place or placed out of the direct view of other passengers (possibly in the lavatory).
Flight attendants are also advised to relocate nearby customers to alternate seats when possible. A blanket can be used to cover the customer as needed. The flight deck crew is also instructed to inform the airline's operations center to make appropriate arrangements once the aircraft is on the ground.
As with any in-flight emergency, the situation is evaluated on a case-by-case basis and flight attendants are advised to use their best judgment.
Air rage is a real thing, but the biggest problem is much simpler
Psychiatric issues constitute 3.5% of in-flight medical emergencies, according to the 2015 study.
"Potential stressors include a lengthy check-in process, enhanced security measures, delayed flights, cramped cabins and alcohol consumption," the researchers wrote. "Acutely agitated passengers pose considerable safety concerns."
The most common problem in flight, though, is actually dehydration. And there's a reason you feel dehydrated when you travel.
"Passenger aircraft cabins are pressurized by air pumped through the engines, which results in a relatively arid environment," according to Georgetown University researchers. "As such, many passengers are somewhat dehydrated."
The simplest, but most significant piece of advice: Stay hydrated. That means drinking of plenty of water and avoiding alcohol when you fly.
And if you take any medications, pack them in your carry-on. They won't do you any good in the cargo hold.
In-Flight Medical Emergencies Posted by Carla Rothaus • September 4th, 2015 When a medical emergency occurs during a commercial flight, health care providers should be prepared to respond. A new review article offers guidance on how to respond to the more common emergencies and on roles and liabilities in offering medical assistance aboard an airplane.
Estimating the frequency of in-flight medical events is challenging because no mandatory reporting system exists. A study of a ground-based communications center that provides medical consultative service to airlines estimated that medical emergencies occur in 1 of every 604 flights. This is likely to be an underestimate, however, because uncomplicated issues are probably underreported.
Clinical Pearls
• Is cardiac arrest one of the more common in-flight emergencies?
Among in-flight medical emergencies, cardiac arrest is quite rare, accounting for only 0.3% of such emergencies, yet it is responsible for 86% of in-flight events resulting in death. Syncope and presyncope are relatively common medical events; in one study, these conditions accounted for 37.4% of all aircraft medical emergencies. Seizures and postictal states account for 5.8% of aircraft emergencies, and complications from diabetes account for 1.6%. Psychiatric issues constitute 3.5% of in-flight medical emergencies. Suspected strokes account for approximately 2% of in-flight medical emergencies.
• What resources are available for managing an in-flight medical emergency?
The Federal Aviation Administration (FAA) mandates that United States-based airlines carry first-aid kits that are stocked with basic supplies such as bandages and splints. At least one kit must contain the additional items listed in Table 1 (see below). At least one automated external defibrillator (AED) must be available. These supplies are not comprehensive (e.g., there are no pediatric or obstetrical supplies). Because health professionals are not aboard every flight, most airlines contract with ground-based medical consultation services. The clinicians at these centers can provide treatment recommendations. On-board volunteer providers can also consult these services during an emergency. The FAA also mandates that flight attendants receive training every other year in cardiopulmonary resuscitation and the use of AEDs.
Morning Report Questions
Q: What option may be considered, in addition to supplemental oxygen, to improve oxygenation in patients who develop respiratory compromise during a commercial flight?
A: Supplemental oxygen should be provided if the clinician suspects respiratory compromise, and the clinician might request a descent to a lower altitude to improve oxygenation. Because of Dalton’s law and because commercial airliners are usually pressurized to the equivalent altitude of 6000 to 8000 ft, passengers typically have a partial pressure of arterial oxygen of 60 mm Hg (at sea level, it is normally 75 to 100 mm Hg). A descent in altitude may permit higher pressures of oxygen, though at a risk of the use of more fuel, because fuel consumption is greater at lower altitudes.
Q: Do physicians have a legal obligation to provide assistance for an in-flight medical emergency, and what legal protections are in place for doing so?
A: Liability is generally determined under the law of the country in which the aircraft is registered, but the law of the country in which the incident occurs or in which the parties are citizens could arguably apply. Although U.S. health care providers traveling on registered U.S. airlines have no legal obligation to assist in the event of a medical emergency, ethical obligations may prevail. In addition, many other countries, such as Australia and many in Europe, do impose a legal obligation to assist. In 1998, Congress passed the Aviation Medical Assistance Act (AMAA), which protects providers who respond to in-flight medical emergencies from liability and thus encourages medical professionals to assist in emergencies. This law applies to claims arising from domestic flights and most claims arising from international flights involving U.S. carriers or residents. The AMAA does allow for liability of providers if the patient can establish that the provider was “grossly negligent” or intentionally caused the alleged harm. With respect to “gross negligence,” providers are liable only if they exhibit flagrant disregard for the patient’s health and safety.
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| In-Flight Medical Emergencies Posted by Carla Rothaus • September 4th, 2015 |
Be Prepared for In-Flight Medical Emergencies
ACEP News
August 2010
August 2010
By Amit Chandra, M.D., and Shauna Conry, M.D.
In-Flight Advice For Volunteer Docs
1. Introduce yourself to the cabin crew and state your qualifications.
2. Ask the patient for his or her permission before performing a thorough history and physical exam.
3. Use an interpreter if necessary.
4. If the patient's condition is critical, request diversion to the nearest appropriate airport.
5. Cooperate with a medical response center and coordinate with airport medical staff.
5. Cooperate with a medical response center and coordinate with airport medical staff.
6. Keep a written medical record of your patient encounter.
7. Perform only treatments you are qualified to administer.
Source: N. Engl. J. Med. 2002;346:1067-73
An overhead speaker rings several times and is followed by a brief burst of static.
"Ladies and gentlemen, if there is a medical doctor on board, please notify the nearest flight attendant. Once again, if there is a medical doctor on board, please notify the nearest flight attendant."
On a recent US Airways flight from Phoenix to Philadelphia, this announcement was followed by tragedy with the death of a 73-year-old passenger. The plane made an emergency landing in Pittsburgh, where paramedics were waiting to provide emergency care. The man was pronounced dead at the scene, and a subsequent medical examiner's report attributed the death to a cardiac condition.
Unique Aspects of In-Flight Emergencies
An emergency physician is ideally suited to volunteer to assist during an in-flight medical emergency. Emergency medicine provides a breadth of training across all age groups and organ systems. Our ability to improvise and focus on the diagnosis and immediate care of sick patients sets us apart as a specialty.
Providing medical assistance at 36,000 feet is nevertheless a daunting proposition. Lower air pressure (cabin pressure is maintained at 5,000 to 8,000 feet), cramped quarters, and the roar of engine noise make an overcrowded county ED seem an ideal working environment by comparison.
Providing medical assistance at 36,000 feet is nevertheless a daunting proposition. Lower air pressure (cabin pressure is maintained at 5,000 to 8,000 feet), cramped quarters, and the roar of engine noise make an overcrowded county ED seem an ideal working environment by comparison.
Common In-Flight Emergencies
The actual incidence of medical emergencies during commercial air travel is unknown. In a report using data from British Airways published in the BMJ in 2000, Nigel Dowdall estimated 1 in-flight emergency per 11,000 passengers. MedAire, a medical assistance company that provides remote assistance to several commercial airlines in the United States, responds to an average of 17,000 calls per year.
Common emergencies include chest pain, syncope, asthma exacerbations, and GI complaints. Air travel in the cheap seats has often been described as "economy class syndrome," a sort of midair version of Virchow's triad: dehydration, immobilization, and predisposing factors increasing the risk of deep vein thrombosis.
What's Available on a Flight?
FAA regulations require all U.S. commercial airlines weighing 7,500 pounds or more and serviced by at least one flight attendant to carry a defibrillator and an enhanced emergency medical kit. Flight attendants must be certified in CPR, including the use of an AED, every 2 years. Pilots must also be trained in the use of the AED.
An emergency physician responding to an in-flight emergency is unlikely to have an ACLS cart packed in his or her carry-on luggage. The standard emergency medical kit, which is based on recommendations by the Aerospace Medical Association's (AsMA) air transport medicine committee, includes a stethoscope, syringes and IV catheters in a range of sizes, and commonly used medications (see box).
While most domestic airlines carry this kit, there are no international regulations requiring the complete kit to be available.
What Are Your Options?
There are no federal regulations or guidelines on the management of an in-flight medical emergency. A growing number of airlines now utilize the services of remote emergency response centers. MedAire, for example, offers 24-hour consultation via call centers staffed by emergency physicians. If medically trained passengers volunteer their assistance, they are required to work with cabin crew and the response center's physician. If there is no call made to a call center, the volunteer physician must work with cabin crew and can suggest treatment or diversion options.
Medical-Legal Liability
Federal legislation contained in the Air Carrier Access Act of 1998 has provided limited protection and guidance for physicians and other medical professionals who volunteer their services during flight. Volunteers must be "medically qualified," render care in good faith, and receive no monetary compensation to be protected under this Act.
The legislation states that "an individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct."
There are no documented cases of a physician being sued for providing assistance during an in-flight emergency. A review article published in 2002 by Grendau and DeJohn in the New England Journal of Medicine offers several suggestions for physicians who volunteer to help during an in-flight emergency (see box).
Other Resources
Several organizations currently work in the field of aviation medicine, including AsMA, the International Air Transport Association (IATA), and the International Civil Aviation Organization (ICAO). Many members of these organizations have advocated in recent years for a registry of in-flight medical emergencies to assist with research, training, and quality improvement.
Dr. Claude Thibeault, medical adviser for the IATA and member of the Air Transport Medicine committee of the AsMA, said, "If we had a good repository of data, that would help when we stock the medical kits. [The kits] are based on opinions, not data."
Dr. Claude Thibeault, medical adviser for the IATA and member of the Air Transport Medicine committee of the AsMA, said, "If we had a good repository of data, that would help when we stock the medical kits. [The kits] are based on opinions, not data."
No matter how well stocked the kits are, in-flight medical emergencies are inevitable given the size of the commercial airline industry. According to Dr. Thibeault, "People don't realize that an aircraft is a taxi; it is not meant to transport sick people. But because it transports so many people, it is bound to transport a sick person once in while."
He also said an equal measure of the debate on this issue should focus on prevention, and "emphasis should be placed on the physician's responsibility to tell patients whether or not they should travel."
For now, emergency physicians who are frequent fliers can familiarize themselves with in-flight medical resources. And when it comes to responding to a medical emergency during commercial air travel, expect the unexpected.
DR. CHANDRA is a faculty member and a practicing emergency physician at New York Hospital Queens. DR. CONRY is a first-year emergency medicine resident at New York Hospital Queens.
The Emergency Medical Kit
Medications
Epinephrine 1:1,000
Antihistamine, injectable (inj.)
Dextrose 50%, inj. 50 mL (or equivalent)
Nitroglycerin tablets or spray
Major analgesic, inj. or oral
Sedative anticonvulsant, inj.
Antiemetic, inj.
Bronchial dilator inhaler
Atropine, inj.
Corticosteroid, inj.
Diuretic, inj.
Medication for postpartum bleeding
Normal saline
Acetylsalicylic acid for oral use
Oral beta-blocker
Epinephrine 1:10,000
List of medications: generic name plus trade name if indicated on the item
Antihistamine, injectable (inj.)
Dextrose 50%, inj. 50 mL (or equivalent)
Nitroglycerin tablets or spray
Major analgesic, inj. or oral
Sedative anticonvulsant, inj.
Antiemetic, inj.
Bronchial dilator inhaler
Atropine, inj.
Corticosteroid, inj.
Diuretic, inj.
Medication for postpartum bleeding
Normal saline
Acetylsalicylic acid for oral use
Oral beta-blocker
Epinephrine 1:10,000
List of medications: generic name plus trade name if indicated on the item
Equipment
Stethoscope
Sphygmomanometer
Airways, oropharyngeal
Syringes
Needles
IV catheters
Antiseptic wipes
Gloves
Sharps disposal box
Urinary catheter
Intravenous fluid system
Venous tourniquet
Sponge gauze
Tape adhesive
Surgical mask
Flashlight and batteries
Thermometer (nonmercury)
Emergency tracheal catheter
Umbilical cord clamp
Basic life support cards
Advanced life support cards
Sphygmomanometer
Airways, oropharyngeal
Syringes
Needles
IV catheters
Antiseptic wipes
Gloves
Sharps disposal box
Urinary catheter
Intravenous fluid system
Venous tourniquet
Sponge gauze
Tape adhesive
Surgical mask
Flashlight and batteries
Thermometer (nonmercury)
Emergency tracheal catheter
Umbilical cord clamp
Basic life support cards
Advanced life support cards
Source: Aerospace Medical Association
More: In-flight Medical Emergencies |
Be Prepared for In-Flight Medical Emergencies |
The Art of EMS
by Steve Whitehead
8 tips for responding to in-flight emergencies Now that I have half a dozen or so of these experiences under my belt, here’s what to expect when responding to a medical assistance call on a flight
Now that I have half a dozen or so of these experiences under my belt, here’s what to expect when responding to a medical assistance call on a flight
Original from www.ems1.com
Last night I went to a Tai Kwon Do black belt testing to watch a friend who was testing for a fourth-dan master belt. It was a pretty impressive affair, capped off by watching my friend break a tall stack of bricks, and break his hand in the process. He then proceeded to walk around the forum shaking hands with everyone using his bloody, broken hand.
I was invited to attend because of a friendship, but it was also made clear by several of the instructors that it would be nice if I could come, you know … "just in case."
This sort of thing happens to all of us from time to time.
As cliché as it sounds, very few of us really take off the uniform when our work day is over. Being an EMT or a paramedic is a 24/7 job.
Our neighbors know that we work in emergency services. Our friends and family look to us for advice and medical guidance.
Happy to help
I’m not complaining. I wouldn’t want it any other way.
In fact, I get a little perturbed when friends or family describe a significant injury or illness that they didn’t tell me about because, "Well, we just didn’t want to bother you."
And don’t even get me started on the time when my father, visiting from out of state, drove himself to the hospital with chest pain because he didn’t want to wake me up.
I think most of us make peace with the fact that we are always on call to some extent. In fact, the majority of us prefer it. I don’t know if it’s like this in other professions. I’ve been in emergency service for my entire working career.
I’m not sure if construction workers or accountants get called to ply their trade outside of their work environment, or if tax preparers ever get the urgent knocks on their door from neighbors who are about to miss a filling deadline.
I don’t know if people who work in sales get calls from friends asking for advice on how to best word their Ebay furniture description or if dental hygienists get asked about the best toothbrush.
I do know that I’ve never heard any of them called for while flying on an airplane.
I have, on several occasions, heard urgent requests for medical assistance while flying. I’ve even responded to these requests when the call went unanswered.
The first time I stood up and offered my help to the flight crew, I had no idea what to expect. Now that I have half a dozen or so of these experiences under my belt, I thought I might pass on a few tips for responding to in-flight emergencies.
1. Don’t depend on the flight crew for medical assistance
They are trained in basic CPR and AED operations. They also receive some basic medical training as part of their annual required emergency training.
They will be more than happy to take direction and bring you things that you need, but they are not clinicians. They are typically very happy to receive your assistance but, for the most part, they will leave the emergency to you.
2. You won’t be the only one
United Airlines reports that three out of four requests for assistance are answered by a qualified medical professional, so it’s likely you won’t be the only one who responds to the call for assistance.
Talk with the other medical providers and decide who would like to take the lead and who would like to assist. Don’t assume that you are the most qualified person to take care of the patient.
Having said that, don’t automatically differ to the highest level of training. A family practice physician or a pediatric nurse may be more comfortable assisting than leading the patient evaluation.
3. Have your ID handy
The plane will likely have a fairly extensive medical kit, but don’t expect to get your hands on it without proper identification. The crew will accept your help, but they can only turn the kit over to someone who has a valid medical identification.
If you don’t have the proper ID, they may not even tell you that the kit exists.
4. Know what you have to work with
Inside the kit you’ll find a blood pressure cuff and a stethoscope, as well as IV supplies, first round cardiac arrest medications and several commonly used emergency medications.
You may also find intubation supplies and basic trauma dressings. Don’t forget you have an AED available as well. Call for it sooner rather than later if you think you might need it.
They also should have supplemental oxygen for one person for the duration of the flight, but if you are using high flow rates you may want to assess the supply. Flight attendants can also apply oxygen but will probably prefer to let you do it.
5. Know your limits
Regardless of what medical equipment is made available to you, you are still obligated to stay within the limits of your scope of practice, your training and your local protocols. Make good clinical decisions and don’t get too far out in the weeds when you’re operating off-duty and outside of your response area.
6. Clear some space
You can ask to move passengers around if you and the patient need more room. Unless the flight is filled, the crew should be able to accommodate you.
You’ll have to decide if you’d prefer to assist the patient and return to your seat to check on them periodically, or if you’d like to remain with them for the duration of the flight.
7. Phone for help if necessary
It’s a good idea to keep your local ER phone numbers in your cell phone. Most planes have several options to make a phone call from inside the plane.
If you’re assisting with a medical emergency, your local doctors back home should be more than happy to help you out with some advice and direction.
8. Advise an emergency landing
If you deem the emergency significant enough to divert to an alternate location, you’ll need to speak with the captain about your options. Remember that you are only there to advise and recommend. It isn’t your aircraft and it isn’t your emergency.
Depending on your location and a myriad of other factors, landing the plane at an alternate location might not be possible even for the most critical of medical emergencies. Act in the patient’s best interest, but understand that diverting to an alternate airport isn’t as easy as steering an ambulance toward a different hospital.
Sometimes, answering the call for assistance on a day off, especially in the middle of a busy travel day at 30,000 feet above ground can be an inconvenience, but most of us wouldn’t want it any other way.
Hopefully, the next time you hear a request for assistance on an airplane, you’ll feel a bit more comfortable about offering your help.
About the author
Steve Whitehead, NREMT-P, is a firefighter/paramedic with the South Metro Fire Rescue Authority in Colo. and the creator of blog The EMT Spot. He is a primary instructor for South Metro's EMT program and a lifelong student of emergency medicine. Reach him through his blog at steve@theemtspot.com or at Steve.Whitehead@EMS1.com.
Related: http://www.ems1.com/pediatric-care/articles/2016286-Doctor-treats-toddler-in-cardiac-arrest-on-plane/
"Some times the Onboard Health professional must think and make inventor to save a life"
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| Table 1 Study characteristic and incidence of in-flight medical emergencies Go to the Table 1 link |
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| Table 2 In-flight emergencies by diagnosis Go to the Table 2 link |
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| Table 3 In-flight emergencies by diagnosis Go to the Table 3 link |
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| Table 3 cont In-flight emergencies by diagnosis Go to the Table 3 link |
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| Table 4 In-flight emergencies by diagnosis Go to the Table 4 link |
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| Table5 In-flight emergencies by diagnosis Go to the Table 5 link |
Is there a doctor on board? In-flight medical emergencies
Release date: June 1, 2017
ABSTRACT
Although not legally required to render assistance in the event of a medical emergency aboard an airplane, physicians have an ethical obligation to do so and should be prepared.
KEY POINTS
- The exact incidence of medical emergencies aboard airplanes is unknown, but they occurred in 1 in 604 flights in 1 study, which is likely an underestimate.
- The relatively low air pressure in the cabin can contribute to the development of acute medical issues.
- In the United States, the Federal Aviation Administration mandates that airlines carry a limited set of medical resources.
- The Aviation Medical Assistance Act protects responding providers against liability except in cases of “gross negligence.”
- You the physician can recommend that the flight be diverted to the closest airport, but only the captain can make the actual decision.
It could happen. You are on a plane, perhaps on your way to a medical conference or a well-deserved vacation, when the flight attendant asks you to help a passenger experiencing an in-flight medical emergency. What is your role in this situation?
FLIGHT ATTENDANTS USED TO BE NURSES
Before World War II, nearly all American flight attendants were nurses, who could address most medical issues that arose during flights.1 Airlines eliminated this preferential hiring practice to support the war effort. Traveling healthcare providers thereafter often volunteered to assist when in-flight medical issues arose, but aircraft carried minimal medical equipment and volunteers’ liability was uncertain.
In 1998, Congress passed the Aviation Medical Assistance Act (AMAA), which provides liability protection for on-board healthcare providers who render medical assistance. It also required the Federal Aviation Administration (FAA) to improve its standards for in-flight medical equipment.2,3
HOW OFTEN DO EMERGENCIES ARISE?
How often medical events occur during flight is difficult to estimate because airlines are not mandated to report such issues.4 Based on data from a ground-based communications center that provides medical consultation service to airlines, medical events occur in approximately 1 in every 604 flights.5This is likely an underestimate, as many medical events may be handled on board without involving a ground-based consultation center.
The most common emergencies are syncope or presyncope, representing 37.4% of consultations, followed by respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%).5 Very few in-flight medical emergencies progress to death; the reported mortality rate is 0.3%.5
CABIN PRESSURES ARE RELATIVELY LOW
The cabins of commercial airliners are pressurized, but the pressure is still lower than on the ground. The cabin pressure in flight is equivalent to that at an altitude of 6,000 to 8,000 feet,6,7 ie, about 23 or 24 mm Hg, compared with about 30 mm Hg at sea level. At this pressure, passengers have a partial pressure of arterial oxygen (Pao2) of 60 mm Hg (normal at sea level is > 80).8
This reduced oxygen pressure is typically not clinically meaningful in healthy people. However, people with underlying pulmonary or cardiac illness may be starting further to the left on the oxygen dissociation curve before gaining altitude, putting them at risk for acute exacerbations of underlying medical conditions. Many patients who rely on supplemental oxygen, such as those with chronic obstructive pulmonary disease, are advised to increase their oxygen support during flight.9
Boyle’s law says that the volume of a gas is inversely proportional to its pressure. As the pressure drops in the cabin after takeoff, air trapped in an enclosed space—eg, in some patient’s bodies—can increase in volume up to 30%,10which can have medical ramifications. Clinically significant pneumothorax during flight has been reported.11–13 Partially because of these volumetric changes, patients who have undergone abdominal surgery are advised to avoid flying for at least 2 weeks after their procedure.10,14 Patients who have had recent ocular or intracranial surgery may also be at risk of in-flight complications.15
IN-FLIGHT MEDICAL RESOURCES
The limited medical supplies available on aircraft often challenge healthcare providers who offer to respond to in-flight medical events. However, several important medical resources are available.
Medical kits and defibrillators
FAA regulations require airlines based in the United States to carry basic first aid supplies such as bandages and splints.3Airlines are also required to carry a medical kit containing the items listed in Table 1.
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| Contents of on-board emergency medical kits mandated by US Federal Aviation Administration |
The FAA-mandated kit does not cover every circumstance that may arise. Although in-flight pediatric events occasionally occur,16 many of the available medications are inappropriate for young children. The FAA does not require sedative or antipsychotic agents, which could be useful for passengers who have acute psychiatric episodes. Obstetric supplies are absent. On international carriers, the contents of medical kits are highly variable,17 as are the names used for some medications.
The FAA requires at least 1 automated external defibrillator (AED) to be available on each commercial aircraft.3 The timely use of AEDs greatly improves survivability after out-of-hospital cardiac arrest.18,19 One study involving a major US airline found a 40% survival rate to hospital discharge in patients who received in-flight defibrillation.20 Without this intervention, very few of the patients would have been expected to survive. In addition to being clinically effective, placing AEDs aboard commercial aircraft is a cost-effective public health intervention.21
Consultation services
Most major airlines can contact ground-based medical consultation services during flight.10 These centers are staffed with healthcare providers who can provide flight crews with advice on how to handle medical events in real time. Healthcare providers can likewise discuss specific medical issues with these services if they respond to an in-flight medical event. Ground-based call centers can also communicate with prehospital providers should a flight need to be diverted.
Other on-board providers
Some medical events require the involvement of more than one medical provider. Other physicians, nurses, and prehospital providers are often also on board.22 Responding physicians can also request the assistance of these other healthcare providers. Flight attendants in the United States are required to be trained in cardiopulmonary resuscitation (CPR).23
Flight diversion
Critically ill patients or those with time-sensitive medical emergencies may require the aircraft to divert from its intended destination. As may be expected, medical emergencies suspected to involve the cardiovascular, neurologic, or respiratory system have been shown to most likely result in aircraft diversion.5,24 Approximately 7% of in-flight medical events in which a ground-based medical consultation service is contacted result in diversion.5
While an on-board responding physician can make a recommendation to divert based on the patient’s acute medical status, only the captain can make the ultimate decision.4 On-board healthcare providers should clearly state that a patient might benefit from an unscheduled landing if that is truly their assessment. In addition to communicating their clinical concerns with the flight crew, the responding physician may also be able to discuss the situation with the airline’s ground-based consultation service. On-board physicians can make important contributions to the assessment of illness severity and triage decisions.
MEDICOLEGAL ISSUES
No legal duty to assist
US healthcare providers are not legally required to respond to on-board medical emergencies on US-based airlines. Canada and the United Kingdom also do not require providers to render assistance. But the General Medical Council (the regulatory body for UK doctors) states that doctors have an ethical duty to respond in the event of a medical emergency, including one on board an aircraft. Other countries, notably Australia and some in the European Union, require healthcare professionals to respond to on-board medical emergencies.10
Regardless of potential legal duties to assist, healthcare providers are arguably ethically obliged to render assistance if they can.
Aviation Medical Assistance Act
The extent of an American healthcare provider’s liability risk for assisting in a medical emergency on a plane registered in the United States is limited by statute. The 1998 AMAA provides liability protection for on-board medical providers who are asked to assist during an in-flight medical emergency. This statute covers all US-certified air carriers on domestic flights and would likely be held to apply to US aircraft in foreign airspace because of the general rule that the law of the country where the air carrier is registered applies to in-flight events.
Under the AMAA, providers asked to assist with in-flight medical emergencies are not liable for malpractice as long as their actions are not “grossly” negligent or intended to cause the patient harm.25 This is distinguishable from a standard malpractice liability scenario, in which the plaintiff only needs to show ordinary negligence. In a traditional healthcare setting, a provider has to act within the “standard of care” when assessing and treating a patient. If the provider deviates from the standard of care, such as by making an error in judgment or diagnosis, the provider is legally negligent. Under traditional malpractice law, even if a provider is minimally negligent, he or she is liable for any damages resulting from that negligence. Under a gross negligence standard, providers are protected from liability unless they demonstrate flagrant disregard for the patient’s health and safety.
Postflight issues
A provider who undertakes care should continue to provide care until it is no longer necessary, either because the patient recovers or the responsibility has been transferred to another provider. At the point of transfer, the healthcare provider’s relationship with the patient terminates.
The provider should document the encounter, typically using airline-specific documentation. The responding physician needs to be mindful of the patient’s privacy, refraining from discussing the event with others without the patient’s authorization.26
SUGGESTED RESPONSE
Healthcare providers who wish to respond to in-flight medical emergencies must first determine if they are sufficiently capable of providing care. During a flight, providers do not expect to be on duty and so may have consumed alcoholic beverages to an extent that would potentially render them unsuitable to respond. When it is appropriate to become involved in a medical emergency during flight, the healthcare provider should state his or her qualifications to the passenger and to flight personnel.
If circumstances allow, the volunteer provider should obtain the patient’s consent for evaluation and treatment.10Additionally, with the multilingual nature of commercial air travel, especially on international flights, the provider may need to enlist a translator’s assistance.
Providers may find it preferable to treat passengers in their seats.27 Given the confined space in an aircraft, keeping ill passengers out of the aisle allows others to move about the cabin. If it becomes necessary to move the patient, a location should be sought that minimally interferes with other passengers’ needs.
If a passenger has critical medical needs, in-flight medical volunteers can recommend flight diversion, which should also be discussed with ground-based medical staff. However, as emphasized earlier, the captain makes the ultimate decision to divert, taking into account other operational factors that affect the safety of the aircraft and its occupants. In-flight medical care providers should perform only the treatments they are qualified to provide and should operate within their scope of training.
After the aircraft lands, if the passenger must be transported to a hospital, providers should supply prehospital personnel with a requisite transfer-of-care communication. In-flight medical providers who have performed a significant medical intervention might find it appropriate to accompany the patient to the hospital.
SPECIFIC CONDITIONS
The list of possible acute medical issues that occur aboard aircraft is extensive. Here are a few of them.
Trauma
Passengers may experience injuries during flight, for example during periods of heavy air turbulence. Responding physicians should assess for potential life-threatening injuries, keeping in mind that some passengers may be at higher risk. For example, if a passenger on anticoagulation experiences a blunt head injury, this would raise suspicion for possible intracranial hemorrhage, and frequent reassessment of neurologic status may be necessary. If an extremity fracture is suspected, the physician should splint the affected limb. Analgesia may be provided from the medical kit, if appropriate.
Gastrointestinal issues
Acute gastrointestinal issues such as nausea and vomiting are often reported to ground-based medical consultation services.5 Responding on-board providers must consider if the passenger is simply experiencing gastrointestinal upset from a benign condition such as gastroenteritis or has a more serious condition. For some patients, vomiting may be a symptom of a myocardial infarction.28 Bilious emesis with abdominal distention may be associated with small-bowel obstruction. While antiemetics are not included in the FAA-mandated medical kit, providers can initiate intravenous fluid therapy for passengers who show signs of hypovolemia.
Cardiac arrest
Although cardiac arrest during flight is rare,5 medical providers should nonetheless be prepared to handle it. Upon recognition of cardiac arrest, the provider should immediately begin cardiopulmonary resuscitation and use the on-board AED to defibrillate a potentially shockable rhythm. Flight attendants are trained in cardiopulmonary resuscitation and therefore may assist with resuscitation efforts. If the patient is resuscitated, the responding physician should recommend diversion of the flight.
Anaphylaxis
In the event of a severe life-threatening allergic reaction, the FAA-mandated emergency medical kit contains both diphenhydramine and epinephrine. For an adult experiencing anaphylaxis, a responding on-board physician can administer diphenhydramine 50 mg and epinephrine 0.3 mg (using the 1:1000 formulation), both intramuscularly. For patients with bronchospasm, a metered-dose inhaler of albuterol can be given. As anaphylaxis is an acute and potentially lethal condition, diversion of the aircraft would also be appropriate.29
Myocardial infarction
When acute myocardial infarction is suspected, it is appropriate for the provider to give aspirin, with important exceptions for patients who are experiencing an acute hemorrhage or who have an aspirin allergy.30 Supplemental oxygen should likewise be provided if the responding physician suspects compromised oxygenation. As acute myocardial infarction is also a time-sensitive condition, the clinician who suspects this diagnosis should recommend diversion of the aircraft.
Acute psychiatric issues
While approximately 2.4% of on-board medical events are attributed to psychiatric issues,5 there are few tools at the clinician’s disposal in the FAA-mandated emergency medical kit. Antipsychotics and sedatives are not included. The responding physician may need to attempt verbal de-escalation of aggressive behavior. If the safety of the flight is compromised, the application of improvised physical restraints may be appropriate.
Altered mental status
The differential diagnosis for altered mental status is extensive. The on-board physician should try to identify reversible and potentially lethal conditions and determine the potential need for aircraft diversion.
If possible, a blood sugar level should be measured (although the FAA-mandated kit does not contain a glucometer). It may be appropriate to empirically give intravenous dextrose to patients strongly suspected of having hypoglycemia.
If respiratory or cerebrovascular compromise is suspected, supplemental oxygen should be provided.
Unless a reversible cause of altered mental status is identified and treated successfully, it will likely be appropriate to recommend diversion of the aircraft.
Acknowledgment: The authors acknowledge Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine University of Maryland School of Medicine, for her contributions as copy editor of a previous version of this manuscript.
References
Doctor Channels MacGyver to Help Asthmatic Toddler Aboard Transatlantic Flight
Improvised nebulizer during In-flight Medical Emergencies
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| Improvised nebulizer during In-flight Medical Emergencies |
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| Improvised nebulizer during In-flight Medical Emergencies |
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In-flight emergencies Dr. Ramon REYES DIAZ, MD AA American Airlines
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| In-flight emergencies Dr. Ramon REYES DIAZ, MD Iberia Airlines |
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American Airlines
December 10, 2015
Dear Dr. Ramon Reyes Diaz:
Please accept our company's formal "Thank You" for the assistance you provided aboard your recent flight. We are all grateful that you were on board and freely offered your medical expertise when it was needed most. Without a doubt, you greatly improved a difficult situation.
As a tangible expression of our appreciation for volunteering your time and experience, we have added 50,000 miles to your AAdvantage® account. This mileage adjustment should appear in your account in a few days. You can view your account viahttp://www.aa.com/aadvantage. These miles can also be used to claim AAdvantage® awards.
I realize your offer of assistance was not motivated by any potential reward. Nevertheless, we wanted you to know how much your efforts were appreciated -- and that we look forward to serving you again soon. It will be our privilege to welcome you aboard American when your plans call for travel by air.
Sincerely,
Dr. Jeral Ahtone, MD.
Director, Medical and
Occupational Health Services
AA Ref#1-5004788459
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| Dr. Ramon A. Reyes Diaz, MD How airlines deal with in-flight medical emergencies 1 in every 604 flights involves medical situation, study says. In-flight Medical Emergencies "Be Prepared" |
"Hoy 08 Diciembre 2015, después de tantas emergencias manejadas en vuelos comerciales, he te nido una que me ha impactado. 86 años parada cardíaca súbita, vuelo Dallas-Miami (aterrizaje de emergencias en New Orleans). Luego de nuestro esfuerzo y de las chicas de sobrecargo de American Airlines y una enfermera de EUA, pudimos recuperar la paciente y entregarla a los médicos del aeropuerto de Lousiana con TA 130/80 Oxymetria 97% FC: 86 totalmente consciente y orientada en tiempo y espacio. Gracias RCP-AHA, Gracias AED, Gracias TEAM Work, Gracias. Salir del Avion con alausos de más de 300 personas y que el capitan te espere a la salida en posicion de atencion en señal de agradecimiento y respeto. Coño gracias medicina bendita que arrebatas a la muerte parte de su trabajo." Gracias mil veces a la mas noble de las profesiones. gracias por permitirme hacer medicina con dignidad y gracias por el respeto al esfuerzo sin esperar nada a cambio" By Dr. Ramón Reyes Diaz, MD
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