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REVIEW JOURNAL

IS THERE A DOCTOR ON BOARD?


IN-FLIGHT MEDICAL EMERGENCIES
You are on a plane in your
way to vacation Do we have obligation to help?

Suddenly a passenger
experiencing medical
emergency

Do we have on board
What should we emergency medical kits?
do?
HISTORY

In 1998, The Aviation Medical Assistance


Act (AMAA) was made to provide liability
protection for on-board health care
provider who render medical assistance
This regulation of hiring
was eliminated by airlines
to support the war effort

Before World War II,


nearly all American Flight
Attendants were nurses
HOW OFTEN DO EMERGENCIES ARISE

• Medical events occur in approximately 1 in every 604 flights*


• Many medical events is likely unrecorded, because:
• Some cases could be handled on board without involving a ground-based consultation
center
• Airlines are not mandated to report such issue
• Mortality rate in-flight is 0,3%

*Based on data from a ground-based consultation center


Most Common Emergencies

Syncope and Presyncope

Respiratory Symptom
23%

Nausea and Vomiting


37%

4% Cardiac Symptom

6%
Seizure
8%

12%
10% Abdominal Pain

Etc
HOW DOES CABIN PRESSURE EFFECTS OUR BODY

• Cabin Pressure in flight is equivalent to that at an altitude of 6000-8000 feet,


about 23-24 mmHg

• At this pressure, passengers have a partial pressure of arterial oxygen (PaO2)


of 60 mmHg (normal at sea level is >80 mmHg)

• People with cardiac or pulmonary illness may be starting further to the left
on the oxygen dissociation curve before gaining altitude, which increase the
risk for acute exacerbation

• Many patients with supplemental oxygen are advised to increase their oxygen
support during flight
HOW DOES CABIN PRESSURE EFFECTS
OUR BODY

• According to Boyle’s Law, as the pressure drops in the cabin after take off, air
trapped in closed space such as our bodies can increase in volume up to 30%

• Clinically pneumothorax during flight has been reported, also patients with recent
ocular or intracranial surgery may be at risk for in-flight complication

• Because of these changes, patients who have undergone abdominal surgery are
advised to avoid flying at least 2 weeks after the procedure
RESOURCES

Medical Kits and


Defibrillator

Consultation
Services
In-Flight Medical
Resources
Other On-Board
Provider

Flight Diversion
MEDICAL KITS AND DEFIBRILLATOR

• Airlines are required to carry basic first aid supplies such as bandages and splints
• Based on Federation Aviation Administration (FAA), airlines should carry medical kits
consisting of this following item:
• Assessment Supplies (Blood Pressure cuff and Stethoscope)
• Acute Interventional Equipment
• Oropharyngeal airway
• Bag valve and CPR mask
• IV administration set
• Saline Solution
• Needles
• Syringes
MEDICAL KITS AND DEFIBRILLATOR

• Medications: • Diphenhydramine, Tablet and injectable


• Acetaminophen • Epinephrine 1:1000
• Albuterol, Metered-Dose inhaler • Epinephrine 1:10.000
• Aspirin • Lidocaine
• Atropine • Nitroglycerin tablets
• Dextrose 50%
MEDICAL KITS AND DEFIBRILLATOR

• The FAA requires at least 1 Automated External Defibrillator (AED) to be


available on each aircraft

• A study involving major US airline found a 40% survival rate to hospital


discharge in patients who received in-flight defibrillator

• The FAA does not require sedative, anti psychotic agents and obstetric
supplies. However, in international carrier, contents of medical kits are highly
variable
CONSULTATION SERVICES

• Most Major airlines can contact ground-based medical consultation services

• This centers are staffed with healthcare provider who can provide advice how
to handle medical event in real time

• Ground based call centers can also communicate with prehospital providers
should a flight need to be diverted
OTHER ON-BOARD PROVIDERS

• Some medical events require the involvement of more than one medical provider

• Responding physicians can also request the assistance of other healthcare


providers on board

• Flight attendants in the US are required to be trained in CPR


FLIGHT DIVERSION

• Critically ill patients or those with time sensitive medical emergencies involve
cardiovascular, neurologic, or respiratory system may require the aircraft to
divert.

• Approximately, 7% of in-flight medical events in which a ground-based medical


consultation is contacted result in diversion

• Responding physician can make a recommendation to divert based on the


patient’s acute medical status. However, only the captain can make the ultimate
decision
MEDICOLEGAL ISSUES

1. No legal duty to assist


• US, Canada, and UK healthcare providers are not legally required to respond to on-
board medical emergencies
• General Medical Council (the regulatory body for UK doctors) states that doctors
have an ethical duty to respond in the event of medical emergency
• Australia and some in the european union require healthcare professional to respond
to on-board medical emergency
• Regardless of potential legal duties to assist, healthcare providers are ethically obliged
to render assistance if they can
MEDICOLEGAL ISSUES

2. Aviation Medical Assistance Act (AMAA)


• The AMAA provides liability protection for on-board medical providers who are asked to assist
during an in-flight medical emergency
• Under AMAA, providers asked to assist with inflight medical emergencies are not liable for
malpractice as long as their actions are not “grossly” negligent to cause harm
MEDICOLEGAL ISSUES

3. Postflight Issues
• Provider who undertakes care should continue to provide until the patient recovers
or the responsibility has been transferred into another provider
• The provider should document the encounter using airline-specific documentation
and protects the patient’s privacy
SUGGESTED RESPONSE

• Healthcare provider who wish to respond must first determine if they are sufficiently
capable of providing care and state his/her qualifications to passenger and flight
personnel
• Volunteer provider should obtain patient’s consent for evaluation and treatment
• If the patient has a critical medical needs, volunteers can recommend flight diversion,
while medical care provider should perform the treatment.
• After landing, providers should supply prehospital personnel with communication.
However, it is appropriate to accompany the patient to hospital
SPECIFIC CONDITIONS

• The list of possible acute medical issues is extensive. Here are a few of them:
1. Trauma
• Responding physician should assess for potential life-threatening injury, such as
extrimity fracture or blunt head injury
2. Gastrointestinal Issues
• Acute GI issues such as nausea and vomiting are often reported
• Responding physician should consider if the condition is benign such as
gastroenteritis or has more serious condition such as AMI
• Providers can initiate IV fluid therapy for passengers who show signs of hypovolemia
SPECIFIC CONDITIONS

3. Cardiac Arrest
• Provider should immediately begin CPR and use on-board AED to defibrillate a
potentially shockable rhythm
• If the patient is resuscitated, the physician should recommend diversion of the flight
4. Anaphylaxis
• In the event of severe allergic reaction, for an adult patient, a responding physician can
administer diphenhydramine 50 mg and epinephrine 0.3 mg 1:1000 IM from the
medical kit
• for patients with bronchospasm, a metered dose inhaler of albuterol can be given
SPECIFIC CONDITIONS

5. Myocardial Infarction
• When AMI is suspected, it is appropriate to give aspirin as long as the patient does
not allergic to aspirin and does not experiencing acute hemmorhage
• Supplemental oxygen should be provided
• Responding physician should recommend diversion of the aircraft
6. Acute Psychiatric Issues
• 2.4% on board medical events
• Anti psychotic and sedative are not included in medical kit, so the responding
physician need to attempt verbal de-escalation of aggressive behavior
• If the safety of flight is compromised, improvised physical restraint may be needed.
SPECIFIC CONDITIONS

7. Altered Mental Status


• Responding physician should try to identify reversible cause and potentially lethal
condition
• Blood sugar level should be monitor if possible. However, if the patients strongly
suspected having hypoglycemia, it may be appropriate to administer IV Dextrose
empirically
• Unless a reversible cause of altered mental status is identified and treated successfully,
it is appropriate to recommend diversion of the aircraft
KEY POINTS

• The exact incidence of medical emergencies in airplanes is unknown, but they


occurred in 1 in 604 flights in 1 study, which is likely an underestimate
• The relatively low air pressure in cabin can contribute to development of
acute medical issue
• In US, FAA mandates that airlines carry a limited set of medical resources
• The AMAA protects responding provider against liability except in cases of
”gross negligence”
• Physician can recommend that the flight be diverted, but the ultimate decision
is in the captain
THANK YOU