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.
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.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of the article. (2) Mail or fax the CME Answer And Evaluation Form (included with your June and December issues) to EB Medicine.
Hardware/Software Requirements: You will need a Macintosh or PC to access the online archived articles and CME testing.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies.