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Guidance for managing medical emergencies on aircraft
Last Updated: 2018-02-26
By Will Boggs MD
NEW YORK (Reuters Health) - Medical professionals have various onboard resources that can help them manage in-flight medical emergencies when called to do so.
"Being called to a medical emergency can be an anxiety provoking event," Dr. Alun D. Ackery from Saint Michael's Hospital, Toronto, Canada, told Reuters Health by email. "Physicians should know that they are not alone. There is help both on the ground and in the plane to help manage your patients."
Aircraft passengers who are healthcare professionals, along with members of the flight crew, are important resources for in-flight front-line care, but many may be unaware of the medical equipment on board and the environmental challenges of treating patients on an aircraft.
Dr. Ackery and colleagues provide practical recommendations for managing in-flight medical emergencies in their February 26 CMAJ online report. They draw on examples and resources from Air Canada and WestJet, Canada's two largest air carriers.
The estimated incidence of in-flight medical emergencies varies widely, from 16 events per 1 million passengers to 1 event per 7,700 passengers. The top five causes include syncope/pre-syncope, respiratory symptoms, nausea or vomiting, cardiac symptoms, and seizures.
Aircraft with at least 100 passengers carry a medical kit that contains a variety of equipment (blood pressure cuff, stethoscope, syringes and needles, oropharyngeal airways, and so on) and medications (oral, intramuscular, intravenous, and inhaled) that help medical professionals address a broad range of emergencies.
Medical professionals need to be aware of the limitations of the setting when using this equipment. Because of aircraft noise, blood pressure might be better estimated by palpating the radial artery. And since cabin pressure is maintained to an elevation between 6,000 and 8,000 feet, normal oxygen saturation by pulse oximeter will be only about 90%.
A table in the article summarizes the concentrations and routes of administration for injectable medications included in Air Canada and WestJet medical kits.
Flight attendants should be recognized as critical resources. They are trained in basic first aid, CPR, and the use of an automated external defibrillator (AED), and they are familiar with the aircraft and its emergency procedures. They should be a medical professional's primary contact with the cockpit.
Ground-based medical consulting companies, used by most major airlines, also can support, advise, and direct on-board medical volunteers. In addition, these companies provide guidance to pilots regarding diversion decisions.
Aircraft diversion decisions depend primarily on the medical condition and stability of the patient, and it is ultimately up to the pilot, using information from the flight crew and ground-based medical support team, to make such decisions. The cost of a diversion is estimated to range from $3,000 to almost $900,000.
According to the Canadian Medical Association Code of Ethics, physicians have an ethical responsibility to "provide whatever appropriate assistance (they) can to any person with an urgent need for medical care," but whether they have a legal responsibility to provide emergency medical services in this (or any other) setting depends upon the local jurisdiction.
Neverthless, most jurisdictions protect medical professionals who act as "Good Samaritans" and, according to the authors, no physician who has volunteered assistance is known to have been sued.
"Physicians shouldn't be left in the dark and now have the ability to understand what pieces of equipment and medications are on board a flight," Dr. Ackery said. "Take the time to know (by reading this article and watching the video) your medical equipment and medications."
Dr. Jochen Hinkelbein from Universitaetsklinikum, Cologne, Germany, who recently surveyed physicians on the incidence, nature, and available medical equipment for in-flight medical emergencies, told Reuters Health by email, "The equipment varies significantly depending on the regulations, as well as between the airlines. Additionally, national regulations may require different equipment. We did a study 2 years ago and also found significant variation even between different German airlines. At the moment, we are evaluating European airlines."
"The international regulations are a basis for minimal equipment," he said. "This has to be amended by the airlines depending on their flight profile and emergency incidence."
Dr. William J. Brady from the University of Virginia School of Medicine, in Charlottesville, who has also written about in-flight medical emergencies, told Reuters Health by email, "A commercial airliner is just that, a commercial airliner. Passengers, including traveling physicians, should not expect full medical capabilities on board. This thought is extremely significant in this discussion. Do we expect such on a municipal bus, subway, taxi, etc.? Of course we don't. And we should not."
"What makes a commercial aircraft different is the time difference to definitive care," he said. "On a bus, etc., you are likely minutes away from such medical assistance. An aircraft must first land safely to protect all on board. Of course, rapidly landing is possible in certain parts of the world, but not in others . . . over a large expanse of water or in a remote area of the world."