In-Flight Medical Emergencies: A Review
- Written by
Is There a Doctor on Board?
One of the most frightening things for me is to hear the question, "Is there a doctor on board?" My mind races. It could be any medical condition ranging from stomach upset to aortic dissection, and I am supposed to deal with it at 35,000 feet, and I might even have to order the plane to land? Frightening, indeed. Well, the good news is that this article looks at this problem scientifically, and, in the end, it is not that scary.
These authors screened 14,842 articles, and the data on in-flight medical emergencies (IMEs) were good enough data in 317 articles to be included in this review. Overall, 1 in 604 flights had an IME. But this most likely is an underestimation because many minor events are not reported. Furthermore, the data did not go beyond 2010, and since then more elderly people are flying, and hence the number of events is most likely higher.
The good news is that in-flight cardiac arrest was only 0.2% of the IMEs. The most common IME was syncope or near-syncope at 32.7%. After that, it was gastrointestinal conditions at 14.8%, respiratory at 10.1%, and cardiovascular conditions at 7.0%. The need to divert the plane occurred only 4.4% of the time.
Our Role
The article points out that our role is to assess the patient within our practice expertise. So, we should state what we do—family doctor, orthopedic surgeon, etc—so that people will understand our capabilities and limitations. The primary goal is to collect information, assess the patient, and then relay this to the ground-based physician. You can make suggestions, but, in the end, the ground-based physician is really calling the shots. Think of yourself as a fellow and the staff physician still has the final say. Now, in the less serious cases, we can make many of simple decisions.
Diverting the Plane
The article also tells us that we don't decide to land the plane. The pilot and the airline’s control center decide to land or not to land, but they do rely on the information and opinion from us and from the ground-based physician. So, thankfully, the final decision is not made by us.
What Is the Physiology Behind These IMEs?
The plane is flying at 30,000 to 40,000 feet, but the cabin pressurization is only to 5000 to 8000 feet—so, not to sea level. This means that the arterial oxygen saturation is reduced, which would explain why COPD and angina patients get into trouble. This might also explain some of the syncope and presyncope cases. In addition, passengers have not eaten, so hypoglycemia and/or dehydration may also contribute. Anxiety and claustrophobia could also exacerbate the situation.
The reduced pressurization also allows the gas in the body to expand. The authors point out that, at 8000 feet, gas will expand by 30% compared with being at sea level. This could explain the gastrointestinal complains of bloating, pain, nausea, etc. Also, sinus spaces and the inner ear can all be affected.
This article has very nicely created cue cards for the 12 common conditions, which detail how to assess and how to manage them on board an airplane. This is worth keeping for easy reference. Also, the emergency kits on the planes are different in different countries, and Table 3 lists all the things that are mandated in the US so that we can be aware of what is available on board a US plane.
Liability
In the US, there is the “Good Samaritan” shield, which protects us against liability; however, we are not protected in the case of gross negligence, willful misconduct, or if you ask for money or compensation from the patient or the airline because then you are no longer a "Good Samaritan." Europe does not have the Good Samaritan protection. Also, in Europe and Australia, you must help whereas in the US, Canada, England, and Singapore, there is no legal duty to help. But I think most of us will still rise to the occasion.
Reduce IMEs by Assessing Your Patients Before They Fly
We can all help reduce the number of IMEs by assessing our own patients before they fly. How is their COPD or angina? Do they need supplemental oxygen? Do they need mild sedatives for anxiety? The list goes on, but you can see how we can help reduce IMEs in our own patients with a bit of proactive advice.
So, overall, this article has made me feel calmer. I know that, based on the numbers, I will be called upon at some point to help a fellow passenger, but I also know that I will have lots of back up and lots of support, so I will not be alone. I can also help you by making sure that my patients do not become an IME on your flight. So, happy flying to us all.
IMPORTANCE
In-flight medical emergencies (IMEs) are common and occur in a complex environment with limited medical resources. Health care personnel are often asked to assist affected passengers and the flight team, and many have limited experience in this environment.
OBSERVATIONS
In-flight medical emergencies are estimated to occur in approximately 1 per 604 flights, or 24 to 130 IMEs per 1 million passengers. These events happen in a unique environment, with airplane cabin pressurization equivalent to an altitude of 5000 to 8000 ft during flight, exposing patients to a low partial pressure of oxygen and low humidity. Minimum requirements for emergency medical kit equipment in the United States include an automated external defibrillator; equipment to obtain a basic assessment, hemorrhage control, and initiation of an intravenous line; and medications to treat basic conditions. Other countries have different minimum medical kit standards, and individual airlines have expanded the contents of their medical kit. The most common IMEs involve syncope or near-syncope (32.7%) and gastrointestinal (14.8%), respiratory (10.1%), and cardiovascular (7.0%) symptoms. Diversion of the aircraft from landing at the scheduled destination to a different airport because of a medical emergency occurs in an estimated 4.4% (95% CI, 4.3%-4.6%) of IMEs. Protections for medical volunteers who respond to IMEs in the United States include a Good Samaritan provision of the Aviation Medical Assistance Act and components of the Montreal Convention, although the duty to respond and legal protections vary across countries. Medical volunteers should identify their background and skills, perform an assessment, and report findings to ground-based medical support personnel through the flight crew. Ground-based recommendations ultimately guide interventions on board.
CONCLUSIONS AND RELEVANCE
In-flight medical emergencies most commonly involve near-syncope and gastrointestinal, respiratory, and cardiovascular symptoms. Health care professionals can assist during these emergencies as part of a collaborative team involving the flight crew and ground-based physicians.
No comments:
Post a Comment