Be Prepared for In-Flight Medical Emergencies

ACEP News
August 2010

By Amit Chandra, M.D., and Shauna Conry, M.D.

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

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

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

Source: Aerospace Medical Association

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.

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."

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.

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.

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

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