Commercial in-flight medical emergencies

Background
  • Incidence of in-flight emergencies: 1 per 604 flights[1] (0.3% of cases died)
    • For reference, there are ~29,000 commercial flights per day in the US alone[2]
  • As the population ages and people travel longer distances, this number is likely to increase[3]

Epidemiology[1]

Emergency Medical Kit
  • The FAA requires all aircraft with >30 passengers to carry an Emergency Medical Kit and an AED[4]
    • This requirement is the "minimum acceptable", but some airlines carry more extensive kits

Common Airline Emergency Medical Kit Contents[5]
MedicationsEquipment
Epinephrine 1:1000Stethoscope
Antihistamine, injSphygmomanometer
Dextrose 50%, inj. 50 mlAirways, oropharyngeal (appropriate range of sizes)
Nitroglycerin tablets or spraySyringes (appropriate range of sizes)
Major analgesic, inj. or oralNeedles (appropriate range of sizes)
Sedative anticonvulsant, inj.IV Catheters (appropriate range of sizes)
Antiemetic, inj.Antiseptic wipes
Bronchodilator inhalerDisposable gloves
Atropine, inj.Sharps box
Adrenocortical steroid, inj.Urinary catheter
Diuretic, inj.System for delivering intravenous fluid
Medication for postpartum bleedingVenous tourniquet
Sodium chloride 0.9% (minimum 250 ml)Sponge gauze
Acetyl Salicylic Acid for oral useTape adhesive
Oral beta blockerSurgical mask
Flashlight and batteries
Thermometer (non-mercury)
Umbilical cord clamp
Basic Life Support cards
List of equipment
Advanced Life Support Guides

Management

General Approach
  • Flight crew is responsible for responding to medical emergencies in flight - your role is to offer assistance, not to take control[6]
  • Identify yourself and level of medical training to the crew
  • Ask a flight attendant to obtain the emergency medical kit (EMK)

Patient Assessment
  • Identify chief complaint and perform HPI and appropriate focused physical exam
  • Obtain vital signs - emergency medical kit will have sphygomomanometer
    • Measuring BP by palpation may be easier than auscultation in flight
  • If the patient is unresponsive or in cardiac arrest, obtain and apply an automated external defibrillator (AED)

Management Options
  • Goal is to keep patient stable until the flight lands[6]
  • Management should be based on your assessment and evidence-based best practices, but within the confines of the resources available on board
    • e.g. angina/chest pain may be given aspirin (± NTG), hypoglycemic episodes may be given PO or IV dextrose, vasovagal syncope may be given PO fluids or placed in leg-elevated position, etc.
  • Be aware of available options
    • Emergency medical kit, oxygen, and AED
    • May ask crew to lower altitude of plane (increases cabin pressure)[6]
    • May request to speak with ground-based physician consult service
    • May request diversion of flight to closer airport (ultimate decision rests with captain)

Medicolegal Issues
  • Responding to a request for assistance creates a "doctor-patient" relationship[7]
  • Duty to respond[4]
    • There is no legal duty for a physician to respond to an in-flight emergency in the USA, Canada, and the UK (in the absence of a pre-existing doctor-patient relationship)
    • In Australia and many European countries, there is a legal duty to respond
  • Legal jurisdiction is usually determined by the country in which the aircraft is registered, but the location of the incident may apply as well[7]

United States
  • The Aviation Medical Assistance Act (AMAA) of 1998 provides liability coverage for "medically qualified individuals" who provide medical care aboard an aircraft and imposes a standard of "gross negligence or willful misconduct"
    • Covers a wide range of medically trained passengers, including physicians, nurses, PAs, paramedics, EMTs, etc.
    • Provider is not prohibited from accepting compensation in order to receive liability protection under the AMAA[7]
________

"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."

—Aviation Medical Assistance Act of 1998, Public Law 105–170—April. 24, 1998.pdf

See Also

References
  1. Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052
  2. NOAA. Air Traffic. http://sos.noaa.gov/Datasets/dataset.php?id=44 Accessed 03/08/2016
  3. Goodwin T. In-flight medical emergencies: an overview. BMJ : British Medical Journal. 2000;321(7272):1338-1341.
  4. Bukowski JH, Richards JR. Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues. J Emerg Med. 2016 Jan;50(1):74-8.
  5. Thibeault C et al. Emergency medical kit for commercial airlines: an update. Aviat Space Environ Med. 2007 Dec;78(12):1170-1.PDF
  6. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002 Apr 4;346(14):1067-73.
  7. Nable JV, Tupe CL, Gehle BD, Brady WJ. In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45.
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