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.
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.
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.
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, are highlighted.
Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta.
Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases.
Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve.
Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this.
Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify!
Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls.
Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati.
Nachi: And I think you have a bit of a disclosure for this month...Show More v
Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years.
Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too.
Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - 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 concerns.
Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help.
Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights.
Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet.
Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60.
Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness.
Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures.
Nachi: So there must be guidelines for those recent post-op for flying - right?
Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room.
Nachi: Then why are people always getting sick after flying…?
Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back.
Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day.
Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away.
Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology.
Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions.
Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at.
Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies.
Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies.
Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions.
Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology.
Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases.
Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control.
Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board.
Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies.
Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome.
Jeff: Just as on the ground, shockable rhythms do well with good BLS care. And lastly, airlines also have a portable oxygen tank in addition to the emergency oxygen that is stored in the event of cabin depressurization. The exact quantity varies, but portable cylinders are certainly available.
Nachi: So next we have to talk about a topic that I’m sure many of you have wondered about - what are the medico-legal risks of intervening?
Jeff: As with most incidents of concern over medico-legal risk, we really just shouldn’t be too concerned over the potential legal ramifications. Though we’ll get into specifics, the short answer is that you should definitely volunteer your services - there are lots of protections in place with a paucity of case reports of legal actions against medical volunteers who volunteers in flight.
Nachi: Perhaps most importantly, remember that ultimately the captain is in charge and you are functioning in a strict advisory capacity. Remember that most airlines can handle most emergencies with their ground based medical control, their typical staff, and predefined protocols - you are an added bonus.
Jeff: For many ED providers, functioning as a consultant will be unfamiliar.
Nachi: If I’m a consultant, I’m going to demand a WBC before seeing the patient, as I’m fairly certain that’s rule number 1 in consultant school...
Jeff: It’s actually rule #12, now get out of your seat and come see the patient…. But back to medicolegal issues. In the US, health care professions are protected by the good Samaritan law and the 1998 federal aviation medical assistance act.
Nachi: The Good Samaritan law provides legal protection to medical providers who perform their services in response to medical emergencies outside of the hospital. The exact verbiage of the law differs from state to state, but all 50 states have some version of it in their legislation.
Jeff: Similarly the aviation medical assistance act applies to “medically qualified individuals and offers broad medico-legal protection to the airlines in the event that a medical volunteer is accused of malpractice as well as to medical providers who respond to an in-flight emergency.”
Nachi: More specifically, the act states that “...an individual shall not be liable for damages arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”
Jeff: That’s a bit of a mouth full to get out. But basically, you need to remember that the AMAA protects you from everything shy of gross negligence. Because of this, there have been no reports to date of a medical professional falling below that standard.
Nachi: There is one caveat to all of this though: don’t forget about your own mental status - for example if you have taken any sleeping aids or had any alcoholic drinks. Though this may not preclude you completely from rendering care, do so only with extreme caution.
Jeff: And I don’t think we were clear enough about this up front. Up until this point we have mostly talked about US based flights. Flights run by International airlines are a somewhat different ball game for a number of reasons. First, medication kits will vary widely. Many will carry medications similar to those mandated by the FDA, but there certainly is no international standard. Next, the availability of ground based medical consultation is similarly widely variable, with many in the middle east contracting for this service and almost no airlines in Africa offering such services.
Nachi: And lastly, with respect to legal risk - the international laws also vary widely. According to French law, for example, a French physician who does not volunteer may be committing willful negligence. Similar laws exist in Germany, Australia, and Canada. However proving you were there and refused to provide care would be quite difficult. And lastly, it’s unclear how to determine which countries’ laws apply when - for example, is it the sending country’s laws, the receiving country’s laws, or the country whose airspace you are currently in?
Jeff: All excellent points. Next, we are moving to my favorite topic of the article - diversion. This is a tremendously complicated topic and I think the authors handled it quite well. Remember, the decision to divert is multifactorial and you are only there to communicate your medical opinion about the passenger - leave the decision for diversion up to the flight crew. I cannot stress this enough. Getting on the radio with the pilot and ground based medical control and demanding a diversion is often very unhelpful and simply not the right approach and can really be quite costly.
Nachi: All of this is so interesting. I can’t believe you do this and divert planes.... Can you go into a bit more detail about everything the pilot considers when they are deciding to divert?
Jeff: So there’s quite a bit, but I can touch on some of the main considerations. First, you have to consider the medical needs of the passenger - can he or she be temporized to get to the destination? Is there a suitable airport for diversion with an accessible local hospital with the required resources? Logistically, you need to find an airport that can not only safely accommodate the plane you are on but also one in which the airline can refuel and guarantee that the passengers and crew are safe. Remember, if you are on an A380, there are only so many airports with runways long enough for a safe landing. Fun fact: planes also take off heavy - with tons of fuel that will be burned prior to landing. Say you were to take off from London, bound for the US. To turn around and land back at London Heathrow, you may have to literally dump thousands of gallons of fuel to get the plane to a safe weight for landing. Alternatively, you may have to fly in circles for some time to burn fuel off in planes that cannot dump. A heavy landing necessitates a thorough maintenance overhaul of the landing gear and can cost the airlines not only money but significant time, which is equally as valuable.
Nachi: Speaking of cost - while exact costs are unknown, one airline estimates that the cost can be as high as $600,000 - we are not dealing with small numbers here...
Jeff: No definitely not. That’s why it’s so frustrating when medical volunteers demand the plane divert without talking through the medical scenario with the crew and ground based control - often temporizing measures are adequate.
Nachi: And we alluded to this earlier - Physicians advise diversion more frequently at 9% of the time followed by EMS providers and nurses. When the airlines are left to their own means, they divert at rates roughly half that - just 5% of the time. At half a million dollars for some diversions, and an overall very low level of morbidity and mortality, a 50% reduction amounts to massive savings for possibly no clinical difference.
Jeff: I can’t stress this enough - you are a consultant, helping the captain and the ground based medical control to come to most appropriate plan of action. When your advice causes the airlines to deviate from their standard protocols, that’s where they potentially run into trouble.
Nachi: There are just two controversies to discuss this month and I actually think they are extremely pertinent. The first one relates to using personal medication or medications from other passengers. Given the relative paucity of medications in most airline medical kits, it may occur to you that someone else may have a helpful medication on board. While there is no strict rule against this, it could result in an increased level of scrutiny if there is an adverse event. So consider this a last resort.
Jeff: The next controversy to discuss is the issue of gifts. There is a widespread belief that accepting gifts from the airlines would void legal protections. To date, there is ample airline-based data to suggest that medical providers’ legal protections are not negated in the event that the airlines wanted to reward a medical volunteer. Additionally, there are no reported cases of providers losing legal protection for receiving compensation for their services in flight.
Nachi: Interestingly, some international carriers even offer points or other bonuses for registering as a medical volunteer. While I’m hesitant to call this controversy a myth, it seems like there isn’t much evidence to support it.
Jeff: Agreed, don’t expect a gift, but if you do receive one, you can keep it and enjoy it without concern for your legal protections.
Nachi: Alright so that wraps up the new material for this special edition of EMplify - let’s close out with some key points and clinical pearls.
Jeff: Aircraft cabins are typically pressurized to about 8000 ft, resulting in a 4-10 point drop in oxygen saturation in healthy adults as well myalgias, fatigue, and generalized discomfort on long haul flights.
Nachi: Only 50% of the cabin air is recirculated. When recirculated, it is subjected to HEPA filtration, which is adequate to prevent infection by airborne pathogens but not the infectious respiratory viruses, which are spread by droplets.
Jeff: Dehydration on long flights is likely due to inadequate water intake and the increased use of diuretics such as caffeine and alcohol.
Nachi: There is about 1 in-flight emergency per 11,000 passengers or 1 in 604 flights. Syncope and cardiac events are most common followed by GI, respiratory, and neurologic events.
Jeff: Most in-flight emergencies are minor. When EMS is requested upon arrival, roughly 1/3rd are transported and less than 10% are admitted, with mortality estimated at 0.3% of cases.
Nachi: AEDs are required on all US-based flights.
Jeff: Airlines have a limited supply of supplemental oxygen for use in medical emergencies in addition to that provided to the entire plane in the event the cabin becomes depressurized
Nachi: All US airlines have some form of ground-based medical assistance. Ultimately any decisions are the responsibility of the pilot in command – medical volunteers function in a strictly advisory capacity.
Jeff: Medical volunteers are protected by both the Good Samaritan law and the 1998 Aviation Medical Assistance Act.
Nachi: The Aviation Medical Assistance Act protects medically qualified individuals, unless they are guilty of gross negligence or willful misconduct.
Jeff: International laws and protections vary widely. In some European countries, for a physician to not offer their services during an in-flight emergency may constitute willful negligence.
Nachi: The decision to divert is multifactorial and can cost as much as $600,000 in some circumstances.
Jeff: When physicians and EMS providers respond to in-flight emergencies, diversion rates are nearly double that of when the airlines work solely with their ground based support, increasing diversion events from 5% to 9%.
Nachi: It is largely a myth that accepting any gift or payment after responding to an in-flight emergency would void your legal protections; the AMAA has no language regarding compensation and to date there are no such reported cases of lost legal protection.
Jeff: And that’s the end of this months episode of EMplify: Assisting With Air Travel Medical Emergencies. This also marks the end of our run as your hosts. Over the past 3 years, we’ve thoroughly enjoyed hosting EMplify and having the unique opportunity to share high quality evidence based medicine with you all. As health care continues to move towards a quality over quantity paradigm, understanding evidence based practice will be increasingly more important.
Nachi: We thank you all for giving us your ears and your time to help hone your clinical practice. Naturally, a big thanks also goes out to all of the contrubutors to Emergency Medicine Practice -- authors, peer reviewers, and of course the kind and thoughtful staff at EB Medicine.
Jeff: We have no doubt that Dr. Ashoo, who will be taking over, will keep you on the edge of your seat as he brings new material to you. Couldn’t be more excited to have him as our successor.
Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%.
Jeff: The [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net.
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Edlow JA, Gurley KL, Newman-Toker DE. A new diagnostic approach to the adult patient with acute dizziness. J Emerg Med. 2018;54(4):469-483. (Review article)
Edlow JA. Diagnosing patients with acute-onset persistent dizziness. Ann Emerg Med. 2018;71(5):625-631. (Review article)
Paul NL, Simoni M, Rothwell PM, et al. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65-71. (Prospective population-based study; 1141 stroke patients)
Atzema CL, Grewal K, Lu H, et al. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol. 2015;79(1):32-41. (Retrospective population-based cohort; 41,794 discharged ED dizzy patients)
Kerber KA, Meurer WJ, Brown DL, et al. Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology. 2015;85(21):1869-1878. (Prospective surveillance study; 272 discharged dizzy ED patients)
Arch AE, Weisman DC, Coca S, et al. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke. 2016;47(3):668-673. (Retrospective cohort study; 485 patients)
Kerber KA, Morgenstern LB, Meurer WJ, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med. 2011;18(6):619-626. (Chart review; 1091 patients)
Grewal K, Austin PC, Kapral MK, et al. Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study. Stroke. 2015;46(1):108-113. (Retrospective cohort study; 41,794 patients)
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Drs. Nachi Gupta and Jeff Nusbaum are practicing emergency physicians in two busy EDs in the US. Join Jeff, a former firefighter, and Nachi, a former mathematician, as they take you through the September 2019 issue of Emergency Medicine Practice: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls (Ethics CME).
Get quick-hit summaries of hot topics in emergency medicine. EMplify summarizes evidence-based reviews in a monthly podcast. Highlights of the latest research published in EB Medicine's peer-reviewed journals educate and arm you for life in the ED.
Matthew DeLaney, MD, FACEP, FAAEM; Christopher Greene, MD, MPH
Jeffery Hill, MD, MEd; Ryan Knight, MD
September 1, 2019
September 30, 2022
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Ethics CME credit
Date of Original Release: September 1, 2019. Date of most recent review: August 10, 2019. Termination date: September 1, 2022.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2019. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 1 Ethics CME credit.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. DeLaney, Dr. Greene, Dr. Hill, Dr. Knight, Dr. Mishler, Dr. Toscano, Dr. Jagoda, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
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