The practical reflexes of a physician responding to an Emergency in an Airplane
I wonder how many of us have found self in a situation, while travelling by airplane, to attend a medical conference or to visit a relative in your native land when suddenly a stewardess jumps on the microphone to request the assistance of a physician for a passenger in distress. It could happen to anybody but you may become involved perhaps in a life and death situation. You raised your hand to be recognized. This happens to me so many times that I forgot to count especially in my numerous flights returning from Haiti. Often, you are the only physician to offer your services. Occasionally many physicians can answer the call of duty but it became easy to leave the place to the more competent to help.
Statistically, according to a study from the University of Pittsburg Medical Center, around one flight on 604 will present with such an opportunity: a medical emergency in space and in the middle of nowhere. Emirates Airlines operated 194,000 flights in 2016 and found 60 emergent cases for the year which required a diversion. What to expect when you are the volunteer responding to the call: Emergent consultations will vary from a light headache to a loss of consciousness to a syncope or pre-syncope (37%) to respiratory problems from shortening of breath (12.5%) to nausea or vomiting (9.5%), and finally cardiac arrest (8%) although rare. Other consultations may be due to seizures disorders (6%) or abdominal pain (4%). There is a low mortality rate reported (.5%).
You have to be prepared when the flight attendant emotionally asks if there is a physician on board of the plane although you are not obligated to render assistance. As a caregiver, I can guarantee you will be feeling that urge and this ethical obligation to help the one suffering.
Your first reflex will be to raise your hand and identify yourself. Report to the flight attendant your qualifications and your area of expertise. You become the good Samaritan protected by the law with a license to treat. In requesting for an emergency kit if available on the flight, you start taking charge in assuming the duty of a physician. Remember that not all airlines may have an adequate kit and often you have to improvise.
Inflight emergencies are on the rise; you will need to be conscious of the fact. In the United States, the Federal Aviation Administration (FAA) mandates that airlines carry a limited supply for medical emergencies in their kits as well as ace bandages and splints. The kits are often deficient in pediatric and obstetric supplies. Sedative and antispasmodic agents are not available and it will be difficult to handle any psychotic patient in distress. On international carriers, you may have more medications available.
Protective gloves, Stethoscope with a Sphygmomanometer will possibly be part of the armamentarium with material to insert an IV line and run fluids. Medications to control hypoglycemia or a hemorrhage or pain, should be close by. Saline fluids, orange juice should also be available. Medications for allergic reactions or asthma crisis can be found in the kits to control bronchospasms or any heart conditions.
As a general aviation rule, any plane carrying 75,000 pounds, needs to have a flight attendant and be equipped with an automated external defibrillator AED). It is a requirement from the FAA. You may be ready to approach the victim in distress once assured of the minimum supply. Be current in your BLS (Basic Life Support) so you have knowledge on how to apply and use a defibrillator. After proper assessing, you may assure that you have a naso-Cannula with oxygen if respiratory support is needed.
You may choose as well to establish contact with a ground-based physician for further recommendations as to administer medications or to perform any procedure. Often you will be asked after evaluation if a plane diversion is necessary. Your medical opinion and your diagnosis will be expected upon request, it but the pilot has the ultimate authority to divert the plane. An incident report should be always written by the flight attendant because Airlines will commonly report the episode once the patient is found stable. I would suggest to take a photo of the forms filled for legal purpose.
Before World War II, all American flight attendants were professional nurses able to appreciate medical issues during emergent calls on flights. This tendency to hire nurses has stopped with the mobilization during the war. Later, travelling nurses started to be hired to assist in flights and initiate such care once they will surface but liability became an issue. This is why, in 1998, Congress passed the Aviation Medical Assistance Act (AAMA) providing liability for on-board healthcare providers who participate in medical assistance. Incidentally, the Federal Aviation Administration was asked to improve its standards for their in-flight medical equipment.
This liability law passed by the Congress is what we commonly call the “Good Samaritan Law”, allowing a medical professional to deliver medical care and be protected, unless gross negligence is committed during the act. It remains difficult to know how often an in-flight medical issue is encountered on a plane because there is no mandatory reporting rule for the flight attendant or the airline. The number of one (1) passenger in distress on 604 flights is surely underestimated because, many of those issues are easily handled on board without involving any consultation at all.
Let us review some principles especially when the relative low air pressure in the cabin can contribute to the development of acute and serious medical issues. Let us as well explore the way Airliners handle such emergent situations:
1- All cabins of a commercial airliners are pressurized and the pressure is kept lower than what we find in-land, on the floor. The pressure is dependent of the altitude which mean that if we are dealing with an altitude of 6,000 or 8,000 feet, the in-flight cabin pressure of 23 or 24 mm Hg remains lower than the pressure we find at the sea level (30 mm Hg). In the plane, the passengers may enjoy a partial pressure of Oxygen of 60 mm Hg while at the level of the sea, he had more than 80mm Hg. This reduction in the O2 pressure will not affect a healthy person but can be detrimental for the one suffering from an underlying pulmonary or cardiac illness. This oxygen dissociation while the plane is gaining in altitude place those passengers at risk and can exacerbate their cardiac or pulmonary symptoms. Once you suffer from chronic obstructive pulmonary disease, it is always recommended to increase the delivery of oxygen at take-off and during the flight in high altitude.
2- We all studied the Boyle’s law in which the volume of a gas is inversely proportional to its pressure. After take-off, the pressure in the cabin drops and the air trapped in an enclosed space like the human body, can increase in volume up to 30%, producing medical ramifications, like in a pneumothorax. The same can happen with patients who recently have undergone abdominal surgery and the pressure in the peritoneal cavity will increase. Often, such patients may be advised to postpone any travel two or three months following the procedure. Other patients with recent ocular or intracranial surgery are also at risk for similar complications. The same changes can be encountered in the elderly patients when they are taken to the skies with chronic problems. New airplanes can fly longer without re-fueling and as airlines compete to offer the world’s longest non-stop flights, we are constantly wondering what may happen if a fellow passenger experiences serious medical problems. These long flights certainly increase the physiologic stresses on many especially the baby boomers. A study published in the New England Journal of Medicine brings the top in-flight medical emergencies as above mentioned already with a statistic of 16 events per one million passengers.
3- A Canadian study from Air Canada, reviewed in-flight consultations which resulted in death between the years 2014 and 2016 where roughly half of the victims were managed by a medical personnel (physician, nurse or paramedic) and half were managed by flight attendants alone. Passengers who are healthcare providers and flight attendants were found to be of resource in providing care. This airline started to show video on how to look for vital signs on such in-flight patients and the difficulty to appreciate the breath sounds or the blood pressure when pressure in the cabin fluctuates
4- A trained physician with active basic Life support (BLS) or advanced cardiac life support training is well equipped to handle a cardiac-pulmonary emergent consult. The proper use of an automated external defibrillator (AED) will improve the survival rate of any passenger suffering from a cardiac arrest. A major US airline has submitted statistics which claim a 40% survival rate after hospital discharge on patients who have benefited from an in-flight defibrillation. They may have not survived the cardiac arrest. They conclude that placing an AED in a commercial aircraft is a cost-effective public health intervention. Remember also that maintenance of the AED is important and a periodic check on a functional battery is mandatory. A well-known example was the actress Carrie Fisher who suffered a heart attack at the end of an eleven-hour United Airline flight from London to Los Angeles. The flight crew was alerted on the incident and a medical personal and others reportedly administered first aid and CPR while she remained unresponsive. No defibrillator was on board and once the plane landed, an emergency professional took over the care. The actress passed away some days later. The AED may have been beneficial in saving her life. Soon, it was noted that all airliners crew underwent advanced first aid training to handle most situations.
5- Some airlines like Lufthansa started a program assuring a “Doctor on board” that encouraged physicians to place their name on a list of those willing to be called in case of an in-flight medical problem. This plan, soon covered partner airlines like Austrian and Swiss. More than 10,000 physicians, most located in Europe and North America signed on for the program. They were not paid but received perks for their services.
6- Emirates is the world largest long-haul airline and this Dubai-based organization puts it cabin crew to a rigorous practical training so they can help whether there is a doctor or not on board. Basic Life Support, Childbirth, Trauma, and all other conditions already discussed can be handled appropriately. Pilots also get special training especially in hypoxia. This airline carries also a lot of equipment in their emergency kits and the crew is well trained to use a defibrillator. They also use a telemedicine unit. They have a 24/7satellite medical advisory service able to communicate the crew with consultants on the ground. Voice communication, transmission of EKG’s, Blood Pressure are performed from their telemedicine capability. Passengers in the medical field on board are allowed to participate in the rescue.
7- It is expensive when one become sick during these long flights. The Emirates estimate expenses between 65,000 to 780,000 dollars every time it happens taking in consideration the cost of fuel, flight catering, landing and ground handling fees, air navigation, passenger re-booking costs and extra cost on overtime for cabin and crew. The Emirates Executive Vice-President Abel Redha states that the company may never be able to recuperate the costs but the safety of the passengers comes first.
In conclusion, in-flight medical emergencies are becoming more common in complex environment with limited medical resources. Often, health personnel are asked to assist a flight attendant in responding to the need of an affected passenger. We do not have extensive experience in this field and often we have little amount of supply at our disposal. If medical volunteers who respond to in-flight medical emergencies benefit from the provision of the Good Samaritan Law in the United States and in Canada, it may not be always the same outside of these countries because the law can change from country to country.
In Europe, it is different, Lufthansa is the only airliner which state clearly on its site, that it takes the responsibility to offer liability to the medical personnel involved in the rescue. A University of Pittsburg study discovered that one third of 1% of mid-flight medical emergencies resulted in death. You may get safer in the skies when travelling on Emirates with the comfort and a trained crew able to handle any emergencies. This is the message that at least such airline would like you to diffuse about their readiness to offer a safe trip when you are ready for a faraway destination. It may become interesting to request the same information from our local airliners offering short flights in our beloved country of Haiti. It is certainly a project that I would like to explore, having so many times taken the skies to Cap-Haiti in our medical missions.
In brief, it is imperative that a medical volunteer identifies himself/herself in presenting his/her background skills and expertise once ready to perform an inflight assessment or to report the clinical findings to a ground-based medical support personnel through the flight crew. The ground-based recommendations ultimately guide the interventions on board. This is grossly what I wanted to divulge to any AMHE healthcare personnel travelling the skies.
Maxime Coles MD
1- Jose V Nable MD, MS, NRP: Christina L Tune MD, Bruce D Gehle JD, William Brady MD: “In-Flight Medical Emergencies”. Cleveland Clinic Journal of Medicine. June 2017; (6): 457-462.
2- Martin-Gill C, Doyle T J, Yealy DM: In-Flight Medical Emergencies: A Review. JAMA 2018 Dec 25; 320(24) 2580-2590.
3- Romano, Andrea: “The Most Common Medical emergencies on Flights and How to Treat them”. Mach 5, 2018.
4- Lauren Mc Mab: What goes on during a medical emergency on a flight. 2017 Feb 17