Is there a doctor on board?

When you’re traveling for the holidays, you might hear the call go out for an in-flight medical emergency. If you decide to respond, here’s what you’re likely to encounter — and the resources you’ll have at your disposal.
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Cherilyn Cecchini, MD, had kicked off her shoes and settled into a flight from San Francisco to Washington, D.C., last March when she heard a commotion at the rear of the plane, followed by a request for a doctor. Cecchini, then a pediatric resident at Children’s National Medical Center, rushed to the back where a middle-aged man had passed out.

Fortunately, he came to quickly and Cecchini was able to take a medical history while examining him. The man hadn’t had much to eat or drink for several hours except for a little alcohol. Everything pointed to syncope, probably triggered by dehydration. She treated her patient with fluids for the remainder of the flight and he walked off the plane without assistance.

For Cecchini, stepping up was a no brainer. “If someone needs help, and I'm able to help in even the smallest way given my medical background, then I want to be able to do that,” she says.

In-flight medical emergencies like the one that Cecchini attended to are surprisingly common. A 2013 study in the New England Journal of Medicine (NEJM) found that there is one medical emergency for every 604 flights, though the actual number is likely higher, as not all incidents are reported. Worldwide, about 160 flights a day have an urgent medical matter. And as the U.S. population gets older with more chronic medical illnesses like diabetes and heart disease, most physicians can expect to encounter an emergency in the air at some point.

“In a doctor's life, there are a number of situations where you get an urgent and unexpected phone call or a tap on the shoulder,” says Janis M. Orlowski, MD, MACP, chief health care officer at the AAMC. “This is one of those situations.”

Unlike emergencies that happen on the ground, however, doctors can’t call for an ambulance, and they’re limited to the medical equipment available on board. Understandably they may worry that they’re not up to speed on a passenger’s medical condition — or about the legal ramifications.

Here are a few things for physicians and residents to keep in mind.

Take your own pulse first

“Most of us feel uneasy when the call comes,” says Rachel Zang, MD, an emergency medicine doctor at Cooper University Hospital in Camden, New Jersey, who was called to duty on a flight from Turkey to Rwanda while she was a medical resident at the University of Pennsylvania last year. “You don't know who the patient is, how old they are, what they need, what their complaint is.”

Doctors and residents should allow their anxiety to resolve — and their training to kick in — before they volunteer, Orlowski says, keeping in mind that most emergencies turn out to be minor ones. Only about 7% of medical problems in the air require the plane to land, according to the NEJM study. Zang’s patient just needed something for a headache.

The study found that the most common in-flight medical emergencies are syncope (37%), respiratory difficulties (12%), and nausea and vomiting (9.5%), followed by cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4%). But doctors also see their share of complaints like allergies, anxiety, ear pain, and headaches. Cardiac arrest accounts for just .3% of in-flight emergencies.

Know your resources

All U.S. flights carry oxygen, an automated emergency defibrillator (AED) to re-start a heart in cardiac arrest, and a first-aid kit, which has bandages, splints, and ace wraps. The flight crew should also make available a separate emergency medical kit, which contains a stethoscope, a manual sphygmomanometer, CP masks, an IV kit with 500 cc's of saline solution, dextrose, syringes, aspirin, antihistamines, epinephrine, and nitroglycerin, among other contents.

Monday, November 19, 2018

Inside the airplane’s emergency medical kit

The Federal Aviation Administration requires carriers to include the following items in the plane’s emergency medical kit. Airlines may choose to include additional items.

  • Sphygmomanometer
  • Stethoscope
  • Airways, oropharyngeal in 3 sizes (1 pediatric, 1 small adult, 1 large adult or equivalent)
  • Self-inflating manual resuscitation device with masks in 3 sizes
  • CPR mask in 3 sizes
  • IV Admin Set: Tubing with two Y connectors
  • Alcohol sponges
  • Adhesive tape, 1-inch standard roll adhesive
  • Tape scissors
  • Tourniquet
  • Saline solution, 500 cc
  • Protective nonpermeable gloves or equivalent
  • Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications)
  • Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications)
  • Analgesic, non-narcotic, tablets, 325 mg
  • Antihistamine tablets, 25 mg
  • Antihistamine injectable, 50 mg (single dose ampule or equivalent)
  • Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent)
  • Aspirin tablets, 325 mg
  • Bronchodilator, inhaled (metered dose inhaler or equivalent)
  • Dextrose, 50%/50 cc injectable (single dose ampule or equivalent)
  • Epinephrine 1:1000, 1 cc, injectable (single dose ampule or equivalent)
  • Epinephrine 1:10,000, 2 cc, injectable (single dose ampule or equivalent)
  • Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent)
  • Nitroglycerine tablets, 0.4 mg

The Federal Aviation Administration mandates what the kit contains but has not updated the list of contents since 2001, Zang says. That means that some medications that are no longer used, such as lidocaine for cardiac arrest, are still in the kit.

The omissions are more concerning. “I could not find a glucometer or thermometer, and that's what I needed first,” Cecchini says.

“The third most common in-flight medical emergency is vomiting, and there are no antiemetics in the kit,” adds Zang. She carries Zofran when she travels in case it’s needed.

Flight attendants are trained in CPR and the use of the AED, so physicians aren’t on their own. More important, all U.S. airlines have an emergency consulting agency standing by to assist from the ground.

“Within a few minutes, you have a trained physician who's an expert in in-flight medical emergencies who can gather information about what's happening on board, explore the best options, and provide recommendations, whether it's for treatment on that aircraft or diverting the plane,” says Christian Martin-Gill, MD, MPH, medical command physician for the STAT-MD Communications Center at the University of Pittsburgh Medical Center, one of two centers in the United States providing on-call medical assistance to commercial airlines. “Even if it's a medical student with limited knowledge, they have decision support from the ground.”

That said, treating a passenger on a plane can be difficult. In addition to a lack of space, “it's very difficult to hear the pulse, take a blood pressure, and hear the breath sounds in the chest and abdominal sounds on a plane in motion,” admits Gregory Eastwood, MD, professor of bioethics and humanities and professor of medicine at State University of New York Upstate Medical University College of Medicine in Syracuse, New York, who has responded to airborne emergencies seven times.

Understand the legal landscape

Physicians reluctant to respond to a medical crisis may worry about their liability. But under the Aviation Medical Assistance Act of 1998, doctors who treat a sick patient in good faith are protected from lawsuits that might arise from the care they delivered on a plane. “It’s analogous to the Good Samaritan laws that apply on the ground,” says Eastwood. The law applies in North America and on U.S. carriers, wherever they fly.

The decision to divert a plane is never made by the doctor who volunteered to help. Only the pilot can make that determination, typically in consultation with the medical professionals on the ground.

Physicians may be asked for their credentials during medical emergencies, although by law they are not required to produce them. “I encourage physicians to fly with at least a Xeroxed copy of the badge that they wear to the hospital every day — something that shows your face and that you’re a doctor,” Zang says.

Consider the moral and ethical dimensions

Physicians who are the most removed from hands-on patient care may be the most hesitant to step in in an emergency. But “anybody is better than nobody,” says Eastwood, emphasizing doctors’ ethical obligation to assist.

However, physicians should use common sense. Those who are inebriated or have taken a sedative or sleeping pill should think twice before stepping up, for instance, particularly if other doctors have responded to the call.

“I believe that doctors have a duty to respond,” Orlowski adds. “But you should never do anything that you haven’t been trained to do.”

Angelica Zen, MD, then a pediatric resident at the David Geffen School of Medicine at UCLA, just reached that benchmark when she was traveling home from her Bali honeymoon in 2015. When flight attendants requested a doctor for a woman complaining of abdominal pain, Zen responded and was shocked to see that the passenger was in active labor. “My residency training was basically everything but OB, and I only caught at most two babies in my OB-GYN rotation in med school,” she says.

The flight was still over the ocean and five hours from any airport, however, so Zen improvised. “The medical kit had an umbilical cord clamp, scissors, and sterile gloves, and we used airline blankets to create a drape for privacy,” she says. Just as the plane descended to a runway in Alaska, the baby’s head crowned and the doctor delivered a healthy girl. “I never expected anything like this to happen,” she says. “But when you’re under pressure, your training just kicks in. If I’m called to another emergency, I’ll be ready.”