Table of Contents
About This Issue
As an emergency clinician, you have special expertise in dealing with acute medical conditions, but when an emergency occurs onboard a commercial aircraft, you need to know the special circumstances of air travel that affect what you can do and what you should do.
Although aircraft are pressurized, what is the typical altitude equivalent of an aircraft in flight, and how might this affect passengers?
With respect to procedures and supplies, what are some of the differences between US-based airlines and international carriers that you might encounter?
What kind of AED would you expect to find? Drugs and supplies?
How does ground-based medical control factor into an emergency? What happens if you disagree with their recommendations?
Are “Good Samaritan” laws effective in protecting emergency clinicians who volunteer to assist?
Is it true that if you accept a thank-you gift, you forfeit your legal protection?
How much responsibility do you have in the decision to divert a plane to obtain medical help for a seriously ill passenger?
Table of Contents
- Case Presentations
- Critical Appraisal of the Literature
- Physiologic Effects of Air Travel
- Aircraft Pressurization
- Air Quality
- Epidemiology of In-Flight Medical Emergencies
- Assisting in an In-Flight Medical Emergency
- Onboard Medical Supplies and Equipment
- Automated External Defibrillators
- Onboard Oxygen
- Additional Medical Equipment
- Space for Patient Treatment
- Medicolegal Risks and Protections
- Ground-Based Medical Control
- Flights Within the United States
- The “Good Samaritan” Laws
- The Aviation Medical Assistance Act
- Flights Outside the United States
- Flight Diversion
- Airlines and Legal Liability
- After the Emergency
- Controversies and Cutting Edge
- Use of Personal Medications
- Accepting Gifts or Payment for Assisting
- Risk Management Pitfalls in Assisting in In-Flight Medical Emergencies
- Case Conclusions
- Tables and Figures
- Table 1. Causes of In-Flight Medical Emergencies
- Table 2. FAA-Mandated Supplies Contained in the Emergency Medical Kit
- Figure 1. Oxygen Saturations at High Altitude
When medical emergencies arise in flight, commercial airline flight crews may ask for help from onboard medical professionals. Qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal reprisal. An understanding of the typically available resources, the hierarchy of authority, and medicolegal precedents can help providers feel confident in responding to these situations. This review addresses the pathophysiology related to air travel and common causes of in-flight medical emergencies and discusses the medications and equipment commonly stocked by commercial airlines. In addition, the complexity of flight diversion and the medicolegal concerns surrounding volunteering to provide medical care are addressed.
You are flying from London Heathrow Airport to New York JFK on British Airways when a flight attendant makes a request over the intercom for medical personnel to respond to an ill passenger. Among the responders is a Basic Life Support-trained EMT, a nurse intensivist, a psychiatrist, and yourself, an emergency medicine physician. The flight attendant informs you that a 53-year-old female passenger in the economy section has become “unresponsive.” Her husband says that she has a history of diabetes, hypertension, and coronary artery disease; has 2 stents; and is currently taking insulin, aspirin, clopidogrel, and metoprolol. On physical exam, she is initially diaphoretic, pale, and lethargic, but quickly regains consciousness and is able to provide some history, and she reports feeling lightheaded prior to losing consciousness. She reports ongoing general weakness and presyncope. She is bradycardic at 35 beats/min but she is alert, with no increased work of breathing. Her neurological exam is nonfocal, and she has a soft abdomen and thready peripheral pulses. You wonder what resources you have available to narrow your differential diagnosis and begin treatment...
You are onboard a flight from Los Angeles to Atlanta. Three hours into the flight, you hear a call on the intercom asking for any available medical providers. You identify yourself as an emergency physician and are asked by the flight attendant for proof of your medical training. You have your hospital ID badge in your carry-on bag, and after showing this to the crew, you are taken to the back of the plane. On assessment, you find a 25-year-old woman lying across 3 seats. She is awake and complaining of abdominal pain. The patient is alert, has diffuse abdominal tenderness with guarding, and states that her last menstrual period was 2 months ago. She is normotensive on exam, but has subjective orthostasis. You are concerned for a ruptured ectopic pregnancy and wonder whether diverting the plane is an option...
You are on board a flight from New York City to Chicago. One hour into the flight, there is a call asking for medical assistance, to which you respond and identify yourself as an emergency physician. The flight attendant indicates that a child has developed difficulty breathing, vomiting, and a diffuse rash, and was removed to the back of the plane. On assessment, you find a 3-year-old girl with stridor, wheezing, and in moderate respiratory distress. When you ask if she has any pain, she says that her tummy hurts. She has a diffuse urticarial rash but normal capillary refill and mental status. Her mother indicates that this started after snacks were passed out, but the girl has no known allergies and she does not own an epinephrine auto-injector. You are concerned that she has anaphylaxis and wonder what treatments are available to you onboard this aircraft...
Commercial airlines provide an increasingly common means of transportation. More than 4 billion passengers are expected to fly in 2019, and more than 60,000 medical emergencies are expected to occur during commercial flights.1 Emergency clinicians who work with acutely ill patients may have had the experience of boarding an aircraft and wondering what they would do if a medical emergency occurred. Should you respond? What kinds of medications and equipment are aboard? Would you be legally protected if something went wrong? These questions can be paralyzing and prevent otherwise highly trained medical personnel from delivering life-saving care. This issue of Emergency Medicine Practice will familiarize the traveling emergency clinician with the roles, equipment, and protections available to them when they are called upon to respond to an in-flight medical emergency.
Critical Appraisal of the Literature
A literature search was performed in PubMed using the terms in-flight emergency, IFE, and travel medicine and identified approximately 60 pertinent publications. The majority of the available publications were review articles, with a small number of papers focused on the incidence and outcomes of in-flight medical emergencies. Given the nature of the topic, most of the available literature is retrospective in nature. Some of the more robust publications analyzed cases that were recorded at commercial physician-directed medical communication centers. Typically, these centers will have a contract with individual airlines and provide online medical control. In the United States (US), most major airlines have a contract with one of these centers, but there is no requirement that an airline have this type of arrangement. Because there are no national or international governmental databases containing these reports, this type of analysis appears to represent the strongest evidence currently available.
In addition to our literature search, we searched for and reviewed pertinent publications from the US Federal Aviation Administration (FAA), the International Air Transport Association (IATA), and other governing organizations. We also reviewed various electronic and social-media-based resources, including podcasts, using FOAM Search.We used additional online resources, including news reports, online travel resources, blogs, message boards, and individual reports. Finally, we reviewed various reports from the lay press involving legal implications of in-flight medical emergencies and, when available, reviewed published reports from legal proceedings.
Risk Management Pitfalls in Assisting in In-Flight Medical Emergencies
7. “I am concerned I won’t be able to direct the pilot whether or not to divert the plane.”
When responding to an in-flight medical emergency, you function primarily as an adjunct to the airline’s existing procedures. Airlines have protocols for the majority of scenarios that may occur in flight, and deviating from these protocols can increase their legal risk. At times, your personal opinion may not align with the airline’s plan of action. If this happens, it is reasonable to speak with the online medical control or the captain, but ultimately you function as a consultant, not the primary decision-maker.
8. “I helped the flight crew medicate a combative passenger who appeared to be psychotic and was attempting to open the door to the cockpit.”
Airlines have standing protocols to deal with combative or otherwise disruptive passengers. While a combative passenger may have an underlying mental health diagnosis, if at all possible, clinicians should allow flight crews to follow their existing protocols rather than offering to provide chemical sedation.
10. “I declined an upgrade to business class after the resolution of an in-flight medical emergency because I did not want to be seen as accepting payment and thus be liable for litigation.”
Airlines may offer you some type of reward or compensation following an in-flight medical emergency. To date, there are no reported cases where accepting this type of offer jeopardized a provider’s medicolegal protection.
Tables and Figures
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, arehighlighted.
- Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368(22):2075-2083. (Retrospective review; 11,920 in-flight medical emergencies)
- Cottrell JJ. Altitude exposures during aircraft flight. Flying higher. Chest. 1988;93(1):81-84. (Prospective evaluation; 204 commercial flights)
- Toff WD, Jones CI, Ford I, et al. Effect of hypobaric hypoxia, simulating conditions during long-haul air travel, on coagulation, fibrinolysis, platelet function, and endothelial activation. JAMA. 2006;295(19):2251-2261. (Prospective evaluation; 73 healthy volunteers)
- Muhm JM, Rock PB, McMullin DL, et al. Effect of aircraft-cabin altitude on passenger discomfort. N Engl J Med. 2007;357(1):18-27. (Prospective hypobaric study; 502 adult patients)
- Coker RK, Shiner RJ, Partridge MR. Is air travel safe for those with lung disease? Eur Respir J. 2007;30(6):1057-1063. (Prospective observational study; 616 patients)
- Thibeault C, Evans AD, Dowdall NP. ASMA medical guidelines for air travel: fitness to fly and medical clearances. Aerosp Med Hum Perform. 2015;86(7):656. (Literature review)
- Gupta JK, Lin CH, Chen Q. Risk assessment of airborne infectious diseases in aircraft cabins. Indoor Air. 2012;22(5):388-395. (Modeled approach to air pathogen transport in commercial airlines)
- Dillingham G. Aviation safety: more research needed on the effects of air quality on airliner cabin occupants. Report to the Ranking Democratic Member, Subcommittee on Aviation, Committee on Transportation and Infrastructure, House of Representatives. GAO-04-54. United States General Accounting Office: Washington, DC; 2004. (Technical assessment of air quality on commercial aircraft)
- Leder K, Newman D. Respiratory infections during air travel. Intern Med J. 2005;35(1):50-55. (Literature review)
- Poumerol G, Wilder-Smith A, eds. WHO Report: International Travel and Health. Situation as on 1 January 2012. Geneva, Switzerland: World Health Organization; 2012. (World Health Organization report)
- Baltsezak S. Clinic in the air? A retrospective study of medical emergency calls from a major international airline. J Travel Med. 2008;15(6):391-394. (Retrospective review; 12 months of in-flight medical emergencies)
- Sand M, Bechara FG, Sand D, et al. Surgical and medical emergencies on board European aircraft: a retrospective study of 10189 cases. Crit Care. 2009;13(1):R3. (Retrospective review; 10,189 medical emergencies)
- Szmajer M, Rodriguez P, Sauval P, et al. Medical assistance during commercial airline flights: analysis of 11 years experience of the Paris Emergency Medical Service (SAMU) between 1989 and 1999. Resuscitation. 2001;50:147-151. (Data analysis of patient files; 380 medical emergencies, 350 million total passengers)
- Epstein CR, Forbes JM, Futter Cl, et al. Frequency and clinical spectrum of in-flight medical incidents during domestic and international flights. Anaesth Intensive Care. 2019;47(1):16-22. (Review of medical data; 3555 medical emergencies, 27 million total passengers)
- Federal Aviation Administration. Advisory circular: emergency medical equipment. 1/12/2006. Accessed August 10, 2019. (Government regulation)
- Federal Aviation Administration. 14 CFR Appendix A to Part 121, First Aid Kits and Emergency Medical Kits. Federal Aviation Regulations - Title 14 Part 121. Washington, DC: US Government Printing Office; 2011. Accessed August 10, 2019. (Government regulation)
- Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med. 2000;343(17):1210-1216. (Retrospective review; 200 in-flight medical emergencies)
- Federal Aviation Administration. Pack Safe: Oxygen (compressed or liquid). 2013. Accessed August 10, 2019. (Government report)
- Hellenic Republic Ministry of Transport & Communications, Air Accident Investigation & Aviation Safety Board. Aircraft Accident Report: Helios Airways Flight HCY522 Boeing 737-31S at Grammatiko, Hellas on 14 August 2005. 2006. Accessed August 10, 2019. (Greek government report)
- Sand M, Gambichler T, Sand D, et al. Emergency medical kits on board commercial aircraft: a comparative study. Travel Med Infect Dis. 2010;8(6):388-394. (Prospective survey; 32 airlines)
- Braida M. Ground-Based Medical Support (GBMS) for Airlines. An Additional Link in the System. (PowerPoint presentation). CAPSCA Middle-East Meeting 2015. Accessed August 10, 2019. (United Nations International Civil Aviation Organization Agency report)
- Stewart PH, Agin WS, Douglas SP. What does the law say to Good Samaritans?: a review of Good Samaritan statutes in 50 states and on US airlines. Chest. 2013;143(6):1774-1783. (Literature review)
- Aviation Medical Assistance Act of 1998, Pub. L. 105-170, Apr. 24, 1998, 112 stat. 47, Sec. 5. Washington DC: National Archives and Records Administration; 1998. (US Government report)
- Klauer K, L’Hommedieu Stankus J. Do we need a new standard of proof in medical malpractice cases? ACEP Now 2014. Available at: https://www.acepnow.com/article/need-new-standard-proof-medical-malpractice-cases/. Accessed August 10, 2019. (Online medical journal)
- Johnson v. Omondi GA Sup Ct. decided Nov. 14, 2013, p. 7. O.C.G.A. § 51-1-4 2013. Accessed August 10, 2019. (Literature review)
- Wong M. Doctor in the sky: medico-legal issues during in-flight emergencies. Medical Law International. 2017;17(1-2):65-98. (Literature review)
- Dedouit F, Tournel G, Barguin P, et al. Medical liabilities of the French physician passenger during a commercial air flight. Med Sci Law. 2007;47(1):45-50. (Review)
- Kovac C. Airline passenger dies after being sedated by doctor. BMJ. 1999;318(7175):12. (Case report)
- Wikipedia. Yakutsk Airport. Accessed August 10, 2019. (Wikipedia article)
- No author listed. Emirates Reveals the Real Cost of Medical Diversions for an Airline. Posted February 8, 2017, www.airlineratings.com. Accessed August 10, 2019. (Website news article)
- Levingston I. Is There a Doctor Aboard? Airlines Often Hope Not. Posted May 29, 2018, www.bloomberg.com. Accessed August 10, 2019. (Online news report)
- Krys v. Lufthansa German Airlines 1997. Accessed August 10, 2019. (Legal summary)
- Cardona C. Family’s Suit Blames American Airlines for Passenger’s Death After In-Flight Emergency. www.dallasnews.com. Posted April 2018. Accessed August 10, 2019. (Online news report)
- Sand M, Morrosch S, Sand D, et al. Medical emergencies on board commercial airlines: is documentation as expected? Crit Care. 2012;16(2):R42. (Prospective survey; approximately 1300 airlines)
- Turkish Airlines. Smiling Doctors: A Huge Thank-you to the Doctors who Help us in the Skies. Accessed August 10, 2019. (Airline website article)
- Rewards or Compensation for Inflight Medical Emergencies. www.airliners.net. Posted 2016. Available at: https://www.airliners.net/forum/viewtopic.php?t=1338705 Accessed August 10, 2019. (Aviation website forum)
- Flying Doctors Want Automatic Upgrades. news.bbc.co.uk. Posted December 17, 1998. Accessed August 10, 2019. (News report)
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