Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls

Table of Contents

 

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?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Physiologic Effects of Air Travel
   1. Aircraft Pressurization
   2. Air Quality
6. Epidemiology of In-Flight Medical Emergencies
7. Assisting in an In-Flight Medical Emergency
   1. Identification
   2. Onboard Medical Supplies and Equipment
      1. Medications
      2. Automated External Defibrillators
      3. Onboard Oxygen
      4. Additional Medical Equipment
      5. Space for Patient Treatment
8. Medicolegal Risks and Protections
   1. Ground-Based Medical Control
   2. Flights Within the United States
      1. The “Good Samaritan” Laws
      2. The Aviation Medical Assistance Act
   3. Flights Outside the United States
9. Flight Diversion
   1. Airlines and Legal Liability
10. After the Emergency
11. Controversies and Cutting Edge
    1. Use of Personal Medications
    2. Accepting Gifts or Payment for Assisting
12. Summary
13. Risk Management Pitfalls in Assisting in In-Flight Medical Emergencies
14. Case Conclusions
15. Tables and Figures
    1. Table 1. Causes of In-Flight Medical Emergencies
    2. Table 2. FAA-Mandated Supplies Contained in the Emergency Medical Kit
    3. Figure 1. Oxygen Saturations at High Altitude
16. References

Abstract

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.

Case Presentations

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...

Introduction

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

References

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.

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