“Is there a
MEDICAL PROFESSIONAL
ON BOARD this aircraft?”
Challenges at 35.000 ft
Linda E. Pelinka, MD, PhD
Medical University of Vienna
and Ludwig Boltzmann Institute
for Experimental & Clinical Traumatology
Vienna, Austria,
European Union
TRAUMA
Basics
Pathophysiology
Medical Equipment
Common problems
Emergencies
Legal Aspects
Basics
Statistics
Worldwide, ~1 million people are
traveling by air at any given time
>700 million Americans travel by air
in the US
~one per 10-40,000 passengers will
experience an medical emergency.
U.S. Federal Aviation Administration. Moving America safely:
annual performance report 2005. http://www.faa.gov/air_traffic
Sand M et al. Surgical & Medical Emergencies on board European
Aircraft:10189 cases. http://ccforum.com/content/13/1/R3
>50% of passengers age 50
or over have at least one
health issue(s)
Emergencies will become
more frequent
as % of elderly increases
Goodwyn T: In-flight Medical Emergencies: an Overview.
Brit Med J 2000; 321:1338-41
There are more deaths from
in-flight medical emergencies
than from airline accidents.
In 2006:
550 medical diversions
59% were 50 or older
63 passengers died in-flight
National Transportation Safety Board and Med Aire
In the Air,
Health Emergencies rise quietly
USA TODAY, Dec 2008
The death of an AA passenger flying from Haiti to
NYC has cast a spotlight on the growing number of
medical emergencies on commercial jets, a trend
that has escaped public notice because airlines
aren’t required to report such incidents.
A MedAire analysis shows that
such incidents nearly doubled from 2000-2006,
from 19 to 35 per million passengers.
1 of 2
In the Air,
Health Emergencies rise quietly
USA TODAY, Dec 2008
According to analysts, this is due to 2 factors:
79 million baby boomers are entering
retirement, but continue traveling habits
established when they were young.
Flights are going farther and lasting longer.
Av. length of a flight in 2000: 1,233 mi
Av. length of a flight in2006: 1,347
Max flying time today: 20 hrs
2 of 2
“if you are ill, an airplane is the
worst place to be…
“… you are trapped at 35,000 ft.”
David Stempler
President of the Air Travelers’ Association.
Pathophysiology
Setting on Board:
passenger’s point of view
Very cramped everywhere
(seat, restroom)
Three-dimensional
motion of aircraft
Very dry
Dehydration
Hemoconcentration & hyperviscosity
increase risk of thromboembolism
The mild hyperbaric changes during flight
are sufficient to cause increased activation
of coagulation in healthy individuals with
no thrombophilia compared with that in
individuals seated and not moving at
ground level.
Toff WD et al: Effec of hypobaric Hypoxia, simulating Conditions
during long-haul air travel on Coagulation, Fibrinolysis, Platelet
Function and Endothelial Activation. JAMA 2006; 295: 2251-61.
Humidity
Low, typically 10-20%
Low humidity has a propensity to
exacerbate reactive airway
disease and dehydration
Hocking MB: Passengr Aircraft Cabin Air Quality: Trends, Effects,
SocietalCosts, Proposals. Chemosphere 2000; 41:603-15
Commercial cruising altitude
7010-12,498 m
Cabin Pressurization to 2438 m:
What happens?
Atmospheric cabin pressure drops
PaO2 drops from
95(12.7 kPa) to
65mmHg (8.7 kPa)
Oxyhemoglobin sat
drops from
95-100% to 90%
Humpreys S et al: Effect of high Altitude Commercial Air Travel
on O2 Saturation. Anesthesia 2005; 60: 458-60
The passenger cabin is
pressurised to 1524—
2438 m. This reduced
pressure within the
passenger cabin results
in lower syst. PaO2 and
oxyhaemoglobin (oyxhb). For most healthy
passengers, this results
in a decrease in the
arterial partial pressure
oxygen tension.
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Passengers with preexisting lower sea-level
oxy-hb sat have greater
declines during flight.
E.g., a passenger with
mild COPD with a sealevel PaO2 of 70 mm Hg
PaO2 to about 53 mm Hg
or oxy-hb sat of
approximately 84% at a
cabin altitude of 2438 m
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
8
7
6
5
4
Altitude in km
pO2 Drop at various Altitudes
pO2 drop by ~30 mmHg
between sea level and
cabin press. level (2400m)
vs ~4 mmHg
between 6000-8000m)
30
32
34
38
45
54
3
61
69
2
1
0
73
81
89
pO2 in mm Hg
20
40
60
100
80
100
120
mod acc to Stueben, U. Flugmedizin Med. Wissenschaftliche Verlagsges. Berlin, 2008
low cabin pressure
lower alveolar pO2 (55-70 mmHg)
lower arterial pO2 (~90%)
increasing edema
Curdt-Christiansen, C. et al: Principles and Practice
of Aviation Medicine. World Scientific, London, 2009.
Effect of Aircraft-Cabin Altitude
on Passenger Discomfort
Muhm JM et al. N Engl J Med 2007; 357: 18-27
The frequency of reported complaints
associated with acute mountain sickness
(fatigue, lightheadedness and nausea)
increased with increasing altitude and
peaked at 2438 m.
Most symptoms became apparent
after 3-9 hrs of exposure.
Cabins in new Airbus A380,
Boeing 787, pressurized
at 1829 m
Hypoxia
Preexisting cardiac
Cabin pressure
and/or pulmonary
and/or psychological
issues
Mild Hypoxia
68-Year-)ld woman with Chest
Pain during an Airplane Flight
Picard, MH et al. New Engl J Med 2010; 363/27: 2652-61.
History of hypertension and hyperlipidemia
Flight from the Middle East to Europe:
Gradually developing chest pain and pressure,
fluctuating intensity, not radiating. Resolves
spontaenously after several hours
Subsequent flight Europe to U.S.: Chest pain
recurs.
Is Air Travel Safe
for those with Lung Disease?
Coker RK et al. Eur Resp J 2007; 30: 1057-63
This prospective, observational study
showed that 18% of passengers with COPD
have at least mild respiratory distress
during a flight.
Cramped Space
& Immobilization
Have been linked to 75% of all
air-travel cases of venous
thromboembolism
Greatest frequency of
theomboembolism in non-aisle seats
Cesarone MR et al: Venous Thrombosis from Air Travel: the
LONFLIT3 Study – Prevention with Aspirin vs LMWH in high-risk
subjects. Angiology 2002; 53: 1-6.
Thromboembolism
Risk peaks up to four-fold
when flight duration >8 h
Risk factors: Dehydration, immobility,
hypobaric hypoxia, obesity, malignancy,
recent surgery, h/o hypercoagulable state
Oral contraceptives increase risk 16-fold
Business vs coach class no effect on
incidence
Aryal KR & Al-Khaffaf H.
Eur J Vasc Endovasc Surg 2006; 31: 187-99.
Jacobson BF et al. S Afr Med J 2003; 93: 522-528.
Boyle’s Law
The volume occupied by a gas
is inversely proportional
to the surrounding pressure.
Thus,
at cruising altitude, gas in body
cavities expands by 30%:
Boyle’s Law & Barotrauma
Healthy passengers
minor abdominal cramping,
ear pressure
Passengers after recent surgery
Bowel perforation,
wound dehiscence
Guidelines
Delay flying for
12 h after scuba diving (1 dive) w/o deco
24 h after several dives or 1 dive + deco
7-10 dys after diverticulitis
2 wks after major surgery
Medical Guidelines for Airline Travel, 2nd Edn.
Aviat Space Environ Med 2003; 74 (suppl): A1-A19
Boyle’s Law &
Effect on Medical Equipment
Gas expansion in
Pneumatic splints
Urinary caths
Feeding tubes
ET tubes (instill water instead of air)
Medical Equipment
Emergency Medical Kit
Device
Stethoscope
Blood pressure cuff
Bag-mask
resuscitator
1 required,
child/infant optional
Oral airways
3 sizes required
Emergency Medical Kit
Drug
Nitroglycerin
10 tablets min.
Aspirin
4 tablets min.
Albuterol
1 metered-dose inhaler
Dextrose 50%
25g min.
Oral Antihistamines
4 tablets min
Iv Antihistamines
2 amps min
Iv Epinephrine 1:1000
2 mg min (allergic react.)
Emergency Medical Kit
Cardiac Resus Drugs
Iv Epinephrine
1:10,000
2 mg total min
Atropine
1 mg total min
Lidocaine
200mg total min
Emergency Medical Kit
Device opt. provided on
intercontinental flights: Tempus IC
State of the Transmits info incl digital pics,
art telemed
video to ground based
monitor
physician
Automated BP cuff, glucometer, capnometer,
12-ld ECG, pulse oximeter
Provides on-screen, step-by-step instructions
Opioids
- Nalbuphine and Morphine –
are provided by some carriers
Emergency Medical Kit
Drugs optionally provided on
intercontinental flights
Ondansetron
Nalbuphine !
Naloxone
Oxygen
Masks and nasal tubes
available on board.
Emergency bottles provide O2
at a fixed rate of 4 liters/min.
Sufficient for 75 min.
Medication and technology
are expensive but may still
be cost-effective
Diversion can cost from
US$10,000 to $100,000
depending on the route
Equipment Challenges
Auscultation (pulm., BP) difficult due to
ambient engine noise. Alternative: radial
pulse palpation for syst BP.
Aviation portable O2 bottles have only 1 of
2 settings: “low”=2 l/min and 4 l/min=“high
flow”, far lower than flow used for EMS.
O2 tubing for bag-valve resuscitation are
not required to be compatible with these
on-board O2 bottles.
Equipment Challenges
AEDs on board not required to have
ECG screen, though ACLS meds are
provided.
When AED does have screen, it is
limited to a leads II/paddles view.
Glucometers not mandatory, though
50% dextrose is. Ask if any passenger
on board would be willing to share
personal glucometer.
Equipment Challenges
Since 9/11, phones have been largely
removed from cabins and cockpit doors
have been secured.
Info must be relayed via intercom
from the back of the plane
or via flight attendant’s headset to pilots,
who then relay info
to doctors on the ground
AED
Automated External Defibrillator
AA first US airline to equip its fleet in
1997, first cardiac arrest save 1998.
Mandatory for US commercial carriers.
(Aviation Medical Assistance Act).
Aircraft with inoperable AEDs are
allowed to make “a few flights” until a
replacement can be found.
AED
Automated External Defibrillator
AEDs are still not mandatory for
European commercial carriers
(European Aviation Safety Agency).
No AEDs on Intercity aircraft in
Europe.
Positioning
the Patient
Remove patient from seat, gripping
him/her from behind.
Positioning the Patient
If possible, position potential
emergencies next to the aircraft’s door
or in the galley, horizontal to flight
direction against front wall.
Make sure all trolleys are secured.
Stueben, U. Flugmedizin/Flight Medicine.
Medizinisch Wissenschaftliche Verlagsgesellschaft Berlin, 2008
Make sure there is enough space behind pat’s
head in case of intubation
Make sure there is enough space beside pat’s
chest in case of cardiac massage
Telemedicine: MedAire
Ground-based service utilized by airlines.
VHF radio or satellite phone contact to ED
physicians at MedAire.
Arizona-based company providing
emergency med advice to airlines carrying
~half of the 768 million passengers on US
flights each year.
Takes responsibility for deciding
if flight diversion is appropriate.
Medical Diversion
Pilot’s decision only
Depends on weather, appropriate airport
facilities, terrain, landing weight, fuel:
e.g. impossible right after take off:
Weight of aircraft + full tanks exceeds
max weight for landing
(e.g. take off NYC, earliest landing Boston)
Flight diversions due to onboard
medical emergencies on an
international commercial airline.
Valani R et al, McMaster University, Hamilton General Hospital,
Ontario, Canada. Aviat Space Environ Med 2010; 81: 1037-40
5386 telemed contacts/5yrs.
Av. 2.4 diversions recommended/100 calls
Telemed decrease 2006-2007 was
accompanied by an increase in diversions.
1 of 2
Flight diversions due to onboard
medical emergencies on an
international commercial airline.
Valani R et al, McMaster University, Hamilton General Hospital,
Ontario, Canada. Aviat Space Environ Med 2010; 81: 1037-40
Most common causes for diversion
Cardiac (26%)
Neurological (20%)
Gastrointestinal (11%)
Syncope (10%)
2 of 2
Telemedical Assistance for in-flight
Emergencies on Intercontinental
Commercial Aircraft
Weinlich M et al, Dept of Trauma Surgery
Goethe Univ. Frankfurt, Germany. J Telemed Telecare 2009; 15: 409-13
3-yr prospective study, commercial airline
Medical incidents: n=3364
Use of telemedicine: 9% (n=275)
Most cases were middle aged, not elderly
Neurological, non-psych telemed cases:27%
(n=83, 27 required diversion, 275 did not.
No non-diverted patient deteriorated
Pediatric emergencies on a USbased commercial airline
Moore BR et al, Dept of Ped. & Adolscent Med, Mayo Clinic,
Rochester, NY. Pediatri Emerg Care 2005; 21: 725-9.
7-yr retrospective study, commercial airline
1 ped call per 20,775 flights
2/3 calls in-flight, 1/3 pre-flight
Mean age 6 yrs
Most common complaints: infectious
disease, neurological, respiratory emergencies.
Common Problems
How common are medical
problems during flight?
Minor medical problem not requiring
medical assistance:
every150th passenger
Medical care:
1 of 10.000 passengers
Medical emergency:
1 of 50.000 passengers (~6% cardiac)
Time Zone Changes
& altered Meal Times
 Hypoglycemia in insulin
dependent diabetics though
diabetic meals can be provided.
 Passengers on other strict drug
regimens, (e.g. for epilepsy)
 Passengers who have packed
their medication in the hold.
Fear of Flying
Unruliness (aggravated by alcohol)
Psychovegetative dysregulation:
tachycardia, sweating, hypotension
(aggravated by sedatives and/or
dehydration)
Dehydration
Prolonged sunbathing and/or partying
on last day of vacation
Dehydration (e.g. hot location, last
minute rush/stress, lack of foreign
currency to buy drinks)
Cabin pressure
Dehydration & Dry Atmosphere
 Dry cabin atmosphere irritates
mucous membranes
 Duration of flight exacerbates
dehydration
 Drinking alcohol exacerbates
dehydration.
 Altitude enhances the effect of
alcohol, contributing to “air rage,”
Air Rage
hours of dry cabin
atmosphere irritate mucous membranes
Drinking extra fluid helps,
Drinking alcohol opposite effect.
Intoxicating properties enhanced at
altitude.
smoking ban in nicotine addicts.
Motion Sickness
Symptoms
Apathy
Pallor
Sweating
Over-sensitivity
to noise, smell
Hypersalivation
Aggravation
Alcohol
Turbulence
Sudden de- or
acceleration
Noise, smells
Heat
Vaso-Vagal Syncope
40 % of cardiovascular emergencies
on board are syncopes.
Most common causes:
motion sickness, dehydration, fear of
flying.
Responding to in-flight
Medical Events 1
Be prepared to show med credentials or
answer questions about degree or training
Obtain consent from affected passenger.
Assume implied consent when passenger
is incapacitated or unresponsive.
Do not fear litigation. Physicians have
been deposed, but no litigation has ever
been brought forward against a
responding physician.
Responding to in-flight
Medical Events 2
Request and establish communication
with the airline’s ground med support for
advice and consultation regardless of how
minor or serious the in-flight event is.
Request the enhanced emergency med kit
(many airlines initially offer basic first-aid
kit) but do not open it unless needed.
Each kit has a placard listing contents.
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Hypoglycemia
If conscious, administer oral glucose gel
If unconscious, establish iv access
Adult: administer D50 dextrose (1 amp)
Child: dilute D50 dextrose 1:1 with
normal saline to prepare D25 dextrose
and administer 2 ml/kg
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Motion Sickness:
What can you do on board?
Move patient to seat in the middle of
the plane
Keep head steady
Eyes shut
No alcohol
Metoclopramide
Dimenhydrinate
Scopolamine patch
Vasovagal Syncope
Lay pt supine
Elevate legs
Apply cold compress to forehead
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Emergencies
Altering Cabin Pressure
Cabins are pressurized
but airlines can
legally alter pressure
to the equivalent of 8000 ft.
Emergencies in the Air
Qureshi A, Porter KM. M. Emerg Med J 2005; 22: 658-59.
Exacerbation of pre-existing medical problems
caused the vast majority of in-flight
emergencies (65%).
Respiratory problems were most common.
50% asthma-related, 33% due to forgotton
medication.
Syncope accounted for 25% of all incidents
and 91% of all new medical problems.
Hypertensive Crisis
Urapidil available on all aircraft
Nitro Spray and/or capsules available
on all aircraft
Oral calcium antagonists available on
some aircraft
Consider Diff Dg: Stroke, MCI,
hemorrhage from ruptured aneurysm, thus
Medical diversion if possible
Tachycardia
Positioning, oxygen, iv
Amiodarone 2 150mg amps
Lidocaine 1-1.5 mg/kg
Last ditch measure: Defibrillation
AED will not discharge below ventricular
tachycardia of 180 because its automatic
rhythm-detection is programmed
accordingly.
Arrhythmia
 Horizonal positioning
aisle, galley, business class seat
 I.V., fluid, oxygen
 Monitoring with AED
 Sedation
 Have CPR ready
Suspected Myocardial Infarction
O2,
Aspirin 325mg po
Nitroglycerin 0.4 mg subling every 5 min
up to three doses or Morphine sulfate 3
mg iv or im.
Request cabin altitude reduction to
increase cabin pressure
Some airlines carry AEDs with a cardiac
rhythm display to help assess rhythm.
Cardiac Arrest
Place AED on patient. Some defibrillators
incorporate a rhythm display that can help
making decisions
Follow BLS or ACLS resus algorithms
If resuscitation is stopped because of no
return of spontaneous circulation, pt should
not be pronounced dead officially on
international flights (medico-legal reasons)
Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77
US Government Air Carrier
Access Act May 2008
All US-based air carriers
and foreign air carrier flights
that begin or end in the USA
must accommodate passengers who
need portable oxygen concentrators.
Non-discrimination on the basis of disability in air travel.
Final Rule. Fed Regist 2008; 73:27613-27687.
Bronchial Asthma or COPD
Administer O2 and inhaled
bronchodilator (2 puffs per 15 min)
Request reduction of cabin
altitude to increase cabin pressure
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Pneumothorax
The effect on pneumothorax was well
publicised when, on a flight from Hong
Kong to London, Professor Angus
Wallace relieved a tension pneumothorax
with the aid of a catheter, coat hanger,
and brandy bottle.
Wallace WA: Managing in flight emergencies. BMJ 1995; 311:1508
Acute Allergic Reaction
Diphenhydramine po, im or iv.
Adults 25-50 mg, peds 12.5 mg.
Severe generalized urticaria, angio-edema,
stridor or bronchospasm
Epinephrine: Adults 0.3-0.5 ml, peds 0.01
ml/kg/dose 1 in 1000 solution im or sc every 510 min as needed. 3 doses in adults, up to 3
doses in peds.
Additonal fluids in anaphylaxis
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Acute Abdominal Pain
Consider administering antacid
Request cabin altitude reduction to
increase cabin pressure. That increases
oxygenation & decreases gas expansion.
Administer paracetamol or ibuprofen.
Some kits include morphine.
Consider administering an anti-emetic.
Some kits include Ondansetron.
Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77
Acute Agitation or Misconduct
Look for med causes (hypoxia, hypoglycemia)
If administering a benzo, be aware of poss
oversed (passenger taking several substaces)
If physical restraint is needed, place restrained
individual in left lateral position
Monitor when using chemical or physical
restraints. High risk of complications in exerted,
agitated passengers fighting restraints: hypoxia,
metabolic acidosis, sudden death.
Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77
Seizure
Keep pt away from nearby objects
Do not place anything in pt’s mouth
Administer Diazepam 0.1-0.3 mg/kg
iv or im for pediatrics, 5 mg iv or im
for adults
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Extended travel with
limited movement & rehydration are
THE recipe for pulmonary embolism.
Add factors like birth control pills,
obesity, age and/or smoking
and you are pretty much
an event about to happen.
Anticoagulants for Air Travel?
No formal guidelines exist
Still controversial, though RC trials
show benefit of LMWH for air
travelers at moderate risk who do not
take anticoags
Aspirin is not recommended alone as
prophylaxis for any air traveler.
Kuipers S et al: Travel and venous Thrombosis: A systematic
review. J Intern Med 2007; 262: 615-634.
Sudden Loss of Consciousness
Differential Diagnosis
Vasovagal syncope
Asystole
Hypoglycemic shock
Apoplectic ischemic/hemorrhagic
stroke
Epileptic seizure
Intoxication (drugs, toxic agents)
Unresponsive Passenger
Place automated external defibrillator
pads on pt
Establish iv access
Administer O2, D50 dextrose (1 amp) iv
for adult or D25 dextrose (2ml/kg) for
pediatric, Naloxone 0.1-2 mg iv or im
(available on some flights)
Follow BLS or ACLS resus algorithms
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Consider Diversion
Acute coronary syndrome
Chest pain
Severe dyspnoea
Severe abdom pain that doesn’t improve
Severe agitation
Stroke
Refractory seizure
Persistently unresponsive passenger
Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77
Legal Aspects
Does a medical professional
who is a passenger have a duty
to volunteer medical assistance?
US, Canada and the UK: NO, unless there
is a pre-existing patient relationship.
International law: country in which aircraft
is registered has jurisdiction. However,
country in which incident occurs and
country of citizenship of plaintiff or
defendant can also have jurisdiction.
Hedouin V et al: Medical Responsibility and Air Transport.
Med Law 1998; 17: 503-6.
Medicolegal Recommendations
1. Identify yourself, state your medical
qualifications. Some airlines require proof of
your medical qualifications.
2. Obtain as complete a history as possible,
inform passenger and family members (if
present) of your impression, obtain consent
before initiating any form of examination or
treatment. Assume implied consent if pg. is
incapacitated.
Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.
Medicolegal Recommendations
3. If consent has been given, carry out
an appropriate physical examination.
4.Request an interpreter if the
passenger you are assisting does not
speak your language.
5. Inform flight crew of your impression.
6. If condition is serious, request aircraft
to be diverted to nearest appropriate
airport.
Medicolegal Recommendations
7. Establish communication with on-ground
med support staff, if available. Respect
ground-based physician’s expertise &
experience in managing in-flight medical
events.
8.Document in writing your findings,
impression, treatment, and communication
with flight crew & on-ground med support.
9. Do not use any treatment that you do
not feel confident administering.
The Aviation
Medical Assistance Act
Passed by Congress in 1998
Specifically protects physicians,
state-qualified EMTs, paramedics,
nurses and physician assistants.
The Aviation
Medical Assistance Act
“ 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
med emergency unless the individual, while
rendering such assistance, is guilty of gross
negligence of willful misconduct.”
The Aviation
Medical Assistance Act
Limits liability for volunteering physicians
under the assumption that they act in good
faith, receive no monetary compensation and
provide reasonable care.
Gifts, such as seat upgrades and liquors are not
considered compensation.
Pertains to events that occur within US airspace
and aircraft registered within the US.
Many airlines indemnify
volunteering physicians.
Written confirmation is provided by
the captain upon request.
Cocks R and Liew M: Commercial Aviation, in-flight Emergencies
and the Physician. Emerg Med Australas 2007; 19: 1-8.
Medicolegal Recommendations
Keep in mind
that “good Samaritan” statutes
protect you only from liability
for actions that other competent
persons with similar training
would take under similar
circumstances.
Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.
Never officially
pronounce a passenger dead,
even if you assess
that resuscitation is futile
and cease treatment,
especially on international flights.
Silverman D, Gendeau M: Medical issues associated with
commercial flights. The Lancet 2009; 373/9680: 2067-77
Up in the Air –
Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.
We were flying from the East Coast to the West. About
midflight, a lady behind us reached frantically for the
baggage bin. She was trying to get her husband’s
oxygen tank. He looked about 70, eyes closed, right
hand clutching his chest, grimacing in pain. Suddenly,
his grimace faded and his arm dropped.
Leaning over, I felt for a pulse. There was none. A
flight attendant approached. “I am a physician,” I said.
“Let’s get him down to the floor.”
Up in the Air –
Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.
We were flying from the East Coast to the West. About
midflight, a lady behind us reached frantically for the
baggage bin. She was trying to get her husband’s
oxygen tank. He looked about 70, eyes closed, right
hand clutching his chest, grimacing in pain. Suddenly,
his grimace faded and his arm dropped.
Leaning over, I felt for a pulse. There was none. A
flight attendant approached. “I am a physician,” I said.
“Let’s get him down to the floor.”
Up in the Air –
Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.
We lifted him into the aisle. I shined a pocket
flashlight on the dimly lit scene. He had stopped
breathing; no pulse. Three other passengers joined us,
an anesthesiologist, an oncologist and a surgeon. My
wife ran the code, I provided chest compressions, the
anesthesiologist bagged the patient, the oncologist
managed the equipment, the surgeon put in an i.v. and
then injected epinephrine intracardially.
Up in the Air –
Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.
We followed the protocol suggested by the AED. It
did not discharge: its rhythm-detection program found
no rhythm that might be treated with defibrillation.
The monitor showed a wide complex bradycardia with
which we could not associate a palpable pulse. After
25 minutes of basic cardiac life support, there was still
only pulseless electrical activity. The 5 physicians
agreed:it was time to stop and declare the patient dead.
Up in the Air –
Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.
The flight attendant explained that if we stopped CPR,
the airline’s protocol would require the cabin crew to
continue it. In other words, CPR was going forward
whatever we decided.
We chose to continue it ourselves so that the four
flight attendants could attend to their duties during an
emergency landing.
We landed 45 min later. The patient died the same day.
TAKE HOME
MESSAGES
Dehydration
Low Humidity
Mild Hypoxia
Boyle’s Law
Pre-existing med Condition
Keep in mind that
airlines can
legally alter pressure
to the equivalent of 8000 ft.
Consider Diversion
Acute coronary syndrome
Chest pain
Severe dyspnoea
Severe abdom pain that doesn’t improve
Severe agitation
Stroke
Refractory seizure
Persistently unresponsive passenger
Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77
Keep in mind that
“good Samaritan” statutes
protect you only from liability
for actions that other competent persons
with similar training
would take under similar circumstances.
Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.