In-Flight Emergencies

Author: Kenneth Young, MD
Emergency Medicine Resident
University of Chicago

This post was peer reviewed.
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Hearing the words “Is there a doctor on the plane?” may strike fear or excitement into your heart as an emergency physician (or a welcome feeling of relief as you squeeze out of a cramped middle seat). What are your legal and ethical requirements? What resources are available in the plane or for support from the ground? What legal ramifications could you face, should the patient have a poor outcome? Can you order the plane to land? But first and foremost, do you spring into action or cower quietly in your seat pretending to watch NBC reruns?

First off, you are protected.
The 1998 Aviation Medical Assistance Act dictates that medically qualified volunteers who receive no monetary compensation “shall not be liable for damages…unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”[1, 2, 3] There is also no legal mandate in the US to offer assistance.

Can I order the plane to land in an emergency?
Short answer – no.[4] The FAA does not require air carriers to follow a doctor’s orders or even to let medically trained passengers use the emergency kit. It is up to the discretion of the carrier and its agents whether to allow passengers, even MDs or EMTs, to assist. Be prepared to show qualifications – toss that hospital ID into your wallet along with your boarding pass. Most airlines have medical support staff on the ground, with whom pilots and in-air providers can discuss treatment and diversion options.

What resources will I have?
Unfortunately, even if an EM doc has a well-stocked personal med kit (EMCrit and Dr. Keith Conover have some excellent recommendations here and here [5,6]), those trauma shears and 18 gauge catheters will not be welcome additions to your carry-on. Luckily, the FAA requires most commercial airlines to carry an AED and an emergency medical kit with the following items: [1,4]

Table 1 [4]

Be warned that while flying internationally supplies may be less dependable. A 2010 study looked at 32 European airlines and found that, of the 12 that provided information, zero fully complied with international standards and two were deemed unequipped for a medical emergency.[7]

Some airlines have gone above and beyond and are equipped with equipment that is essentially a mobile tele-monitor complete with BP cuff, glucometer, thermometer, end-tidal co2 monitor, pulse ox, and a 12-lead.[8]

What are the typical in-flight emergencies?
An NEJM review from 2013 looked at several trends in in-flight emergencies. Syncope and presycnope (37%), respiratory symptoms (12%), and nausea/vomiting (10%) were the most common presenting symptoms. Aircraft were diverted in 7.3% of cases, and the highest variables correlating with diversion were AED use and limited training of available providers. The most common cause for hospital admission after deplaning were stroke, respiratory symptoms, and cardiac symptoms (which included chest pain, palpitations, and pacemaker issues).[9]

Take a look at the full list of resources at the bottom of the page – they have some great information and personal stories for docs in the air. Here are a few more tips:

• Table 3 from the NEJM Review outlines a good general approach (here).[9]
• Glucometers are not a required part of the emergency kit, but D50 is.[8] An amp of D50 isn’t going to kill someone (even in DKA) but hypoglycemia can – err on the side of administering, or ask if a diabetic passenger has a glucometer.
• You may not have a 12 lead or a reliable blood pressure to determine right ventricular infarct or hypotension – be careful using nitro.
• Get ground support involved early – they have experience handling in-air emergencies and can help you save a life or, at the very least, prevent your seatmate from missing his connection to Tampa with an unnecessary diversion.[10]
• Remember your partial pressures – a “pressurized cabin” is still not sea-level, and patients with underlying respiratory problems can become hypoxic easily.[1]
• Take a look at the Aerospace Medical Association’s Guide to Medical Emergencies (here).[11]

References
1. Chandra A, Conry S. In-flight Medical Emergencies. West J Emerg Med. 2013;14(5):499-504. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789915/pdf/wjem-14-499.pdf

2. Chandra A, Conry S. Be prepared for In-Flight Medical Emergencies. ACEP News. August 2010. Available At: http://www.acep.org/Clinical---Practice-Management/Be-Prepared-for-In-Flight-Medical-Emergencies/

3. Public Law 105-170: Aviation Medical Assistance Act of 1998 (112 Stat. 47; April 24, 1998). Text from U.S. Government Printing Office. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-105publ170/pdf/PLAW-105publ170.pdf

4. Ballough J. United States Federal Aviation Administration. Advisory circular: Emergency Medical Equipment AC121-33B. Jan 12, 2006. Available at: http://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-33B.pdf

5. Weingart, S. EMCrit Blog. Podcast 117 – Everyday Emergency Kits with Keith Conover. Available at: http://emcrit.org/podcasts/everyday-emergency-kits-keith-conover/. Accessed December 14, 2014.

6. Conover, K. Everyday Emergency Kit Revision 7.1 3/26/2014. Available at: http://www.conovers.org/ftp/Everyday-Emergency-Kit.pdf

7. Sand M, Gambichler T, Sand D, Thrandorf C, Altmeyer P, Bechara FG. Emergency medical kits on board commercial airlines: a comparative study. Travel Med Infect Dis. 2010 Nov;8(6):388-94.

8. Liao M. Handling In-Flight Medical Emergencies. Journal of Emergency Medical Services. 3 June 2010. Available at: http://www.jems.com/article/patient-care/handling-flight-medical-emerge

9. Peterson D, Martin-Gill C, Guyette F et al. Outcomes of Medical Emergencies on Commercial Airline Flights. NEJM 20 May 2013 368;22. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1212052

10. Gounder C. Medical Emergencies at 40,000 Feet. The Atlantic 4 April 2013. Available at: http://www.theatlantic.com/health/archive/2013/04/medical-emergencies-at-40-000-feet/274623/

11. Aerospace Medical Association. Medical Emergencies: Managing In-flight Medical Events. Available at: http://www.asma.org/asma/media/asma/Travel-Publications/In-flight-medical-events-guidance-document.pdf. Accessed December 14, 2014.