Everything You’ve Wanted to Know About In-Flight Medical Emergencies — But Were Afraid to Ask
June 15, 2002
Everything You’ve Wanted to Know About In-Flight Medical Emergencies—But Were Afraid to Ask
Abstract & Commentary
Synopsis: Medical emergencies are infrequent, but likely to become more common. Physicians need to be prepared to assist.
Source: Gendreau MA, DeJohn C. N Engl J Med. 2002;346:1067-1073.
Drs. Gendreau and DeJohn have written an excellent review addressing the many bad medical things that can happen after your plane has taken off. They note that 2 billion people travel by air each year. The number of elderly people traveling is climbing; thus, the opportunities to volunteer your services will likely increase.
Because there are no reporting requirements for airline medical events, no one knows how many actually occur. Studies in the 1980s estimated rates of 30-33 events per day in the United States. A Federal Aviation Administration (FAA) study during 1996 and 1997 reported a rate of 13 events a day. This rate is lower than the earlier rates because it included only events that involved ground-based medical support—that is, the really serious events. If both rates are accurate, about one-third to one-half of in-flight events are serious. These include cardiac, neurological, and respiratory problems. The common nonserious problems include fainting, dizziness, and hyperventilation.
Serious events are extremely costly, since they often require diversion of the airplane and possibly dumping fuel before landing as a safety measure. The cost is estimated to be anywhere from $3000 to $100,000. Cardiac problems are most likely to cause diversions.
Some problems are intrinsic to the environment of the airplane. Most apparent are the effects caused by the decreased air pressure in the cabin. Planes usually fly with a cabin pressure adjusted to an altitude of 5000-8000 feet above sea level. Since gases expand as pressure decreases, gases-filled organs and spaces (the intestines, the middle ear, the sinuses, for instance) also expand. Usually, this causes only minor discomfort (with the exception of that 2-year-old in the row in front of you). A more pressing (pardon the pun) concern is what happens to the partial pressure of oxygen. This reduction in barometric pressure can drop it from 95 mm Hg to 56 mm Hg, which goes unnoticed in healthy people because 56 mm Hg is still on the flat part of the oxyhemoglobin dissociation curve. It is a different story for a passenger with cardiopulmonary disease, who is suddenly experiencing hypobaric hypoxia.
The air in cabins is dry, about 10-20% humidity, which can exacerbate asthma and other respiratory problems. There have been reports of transmission of airborne diseases (for instance, tuberculosis, influenza, and measles) inside airplanes, with the risk increasing in direct proportion to the length of the flight and indirectly to the distance between you and the ill passenger.
A relatively new challenge is the passenger with "air rage." These incidents are on the rise and often associated with consumption of alcohol. Health professionals may be called upon to sedate unruly passengers.
Gendreau and DeJohn provide a helpful section on medical fitness for air travel, along with a table of contraindications to air travel. It includes advice on arranging for supplemental oxygen for passengers with cardiopulmonary disease.
Another section discusses the medical liability issue. Gendreau and DeJohn report that there have been no suits directed against physicians who assist during an in-flight emergency. They also discuss the Aviation Medical Assistance Act, passed by Congress in 1998, that provides limited "Good Samaritan" protection to medical professionals. They include a table of medicolegal recommendations for physicians volunteering assistance during an in-flight medical event.
There is a table that details what equipment airlines are required to carry in their "little black bag," along with mandated additions for April 2004. The equipment approximates a crash cart. Automated external defibrillators (AEDs) must be on all flights with at least 1 flight attendant by April 2004. Also discussed is what assistance can be expected from ground-based medical crews.
The final section details a general approach that health professionals can take to in-flight medical events. It reminds any volunteer that the nature of his or her action is assistance, not taking control. All assistance should be directed to stabilizing the ill passenger until the airplane can land. A volunteer must be prepared to administer oxygen, consult with ground-based physicians, start IVs, and administer medications (aspirin, nitroglycerin, diphenhydramine, dextrose, or epinephrine, for example).
Comment by Allan J. Wilke, MD
The image most of us have of doctors and in-flight emergencies is the mass food poisoning of passengers and crew in the movie Airplane!, attended by Leslie Nielsen’s character, Dr. Rumak (Q: "Surely, you must be joking?" Rumak: "I’m not joking, and don’t call me Shirley."). Dr. Rumak is right; this is no joking matter. The disasters of September 11 have only served to heighten concerns. As physicians, we have a moral and ethical obligation to help sick people, no matter what the circumstances of their illness are. I urge you to read this fine review before your next venture into the friendly skies.
Dr. Wilke, Assistant Professor of Family Medicine, Medical College of Ohio, Toledo, OH, is Associate Editor of Internal Medicine Alert.
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