Jordan Johnson, OMS III
The familiar feeling of descent woke me as I emerged from a much needed nap on my flight from Miami to Denver for the 2017 ACOEP Scientific Assembly. I had fallen asleep to the soothing sound of Pathoma, a common occurrence for medical students. However, not even the sultry voice of Dr. Sattar could deafen the orchestra of mumbles and scattered voices that pervaded the cabin. The passenger next to me looked upon my dazed face and informed me that we were going to land in Memphis, TN due to one of the passengers having a medical emergency. Suddenly, I was overcome with uncertainty about how to handle this situation. Although there is only an estimated 0.0017% chance that a medical emergency will happen on your next flight, it is a scenario that all physicians should be prepared for.
Although physicians are not required by law to assist in airborne medical emergencies, the Hippocratic oath confers an ethical responsibility to do so. Nevertheless, if a physician chooses to aid in the care of a passenger, assistance is available. All airlines are required to provide first aid training to the cabin crew, enabling them to respond to various situations with resuscitation techniques, oxygen support, and defibrillation. This training and that of medical control on the ground should be acknowledged by the physician and utilized as needed. Cabin crews are typically required to recertify their on-board medical training every two years.
Airlines are required to carry a surprisingly comprehensive stock of medical equipment. The Federal Aviation Administration requires most commercial passenger jets to carry an Automated External Defibrillator, a basic first-aid kit, a sphygmomanometer, stethoscope, three sizes of oropharyngeal airways, a self-inflating manual resuscitation device with three mask sizes, cardiopulmonary resuscitation masks, intravenous access equipment, alcohol sponges, adhesive tape and scissors, a tourniquet, saline solution, gloves, syringes and needles of varying size, analgesics, antihistamine tablets and injectables, atropine, aspirin, a bronchodilator, injectable dextrose, epinephrine and lidocaine, nitroglycerin tablets, and basic instructions. It is worth mentioning that international airlines are required to have a medical kit available on the flight,but the contents of these kits vary.
Although many physicians may be concerned about legal ramifications after caring for a patient in the air, this fear is largely unfounded. According to a 2016 report by the Aerospace Medical Association, there are no known cases brought against physicians who volunteered in an inflight medical emergency. In the case of US airlines, the Aviation Medical Assistance Act of 1998 also provides legal protection for medically qualified professionals who volunteer unless they are “guilty of gross negligence or willful misconduct.”
Although infrequent, a great variety of emergencies can occur at 40,000 feet. In a study conducted by the University of Pittsburgh Medical Center in 2010 on inflight medical emergencies, 37.4% were related to syncope, 12.1% to respiratory distress, 9.5% to nausea or vomiting, 7.7% to cardiac symptoms, 5.8% to seizures, and 4.1% to abdominal pain. Of the 12,000 inflight medical emergencies that were analyzed, only 7.3% resulted in the airline being diverted away from the destination airport. Many may be tempted to request the plane land immediately regardless of the severity of the patient’s condition, because it is the “safest” course of action. But, this may not always be the best option.
Several factors influence the decision to divert. The patient probably has friends or family at the destination who can provide crucial information about the patient’s history, medications, and even advanced directives. Also, consideration must be given to the idea that diverting a flight from its original destination implies the patient may end up in an unfamiliar region without their usual support system. Finally, if the airport to which the flight is diverted is not near an acute care facility or simply unequipped to accommodate a medical emergency, the patient might have to wait even longer to receive the appropriate care than if the plane had just continued directly to the destination. Perhaps the most practical role a physician can play is recommending to the pilot whether the plane should land immediately to provide emergent care for the patient that resources on-board cannot or to continue to the destination for further management. The necessity of diversion is ultimately up to the pilot of the aircraft. The pilot makes their decision based on the recommendations of a ground control team, the cabin crew, a medical professional involved in the airborne management of the patient if one is available, and a consulting aviation physician if one was contacted. Regardless of the decision, the patient’s health is paramount.
Hopefully this information will inspire confidence in physicians that may be called to act and provide them with a greater understanding of airborne medical emergencies. Don’t be afraid to spread the wings on that caduceus and fly.
- Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368:2075-2083.
- Title 14 of the Code of Federal Regulations (14 CFR) part 121, subpart X; part 121, appendix A.
- Aerospace Medical Association Air Transport Medicine Committee. Medical Emergencies: Managing In-flight Medical Events. Guidance document. July 2016