Emergencies: Medical Mile High Club

div class=”ChapterContextInformation”>


© Springer Nature Switzerland AG 2020
C. G. Kaide, C. E. San Miguel (eds.)Case Studies in Emergency Medicinehttps://doi.org/10.1007/978-3-030-22445-5_29



29. In-Flight Emergencies: Medical Mile High Club



Erica Ross1   and Christopher E. San Miguel1  


(1)
Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

 



 

Erica Ross



 

Christopher E. San Miguel (Corresponding author)



Keywords

Medical emergencies Good Samaritan Law Flight physiology Decompression illness 1998 Aviation Medical Assistance Act


Your flight for Honolulu has just taken off from Los Angeles when you notice some commotion at the front of the passenger cabin. After a few minutes, you hear the flight attendant’s voice over the intercom, “Is there a doctor onboard?”


Learning Points



Priming Questions





  1. 1.

    What are the legal/ethical obligations and risks of a health-care provider assisting with an in-flight emergency?


     

  2. 2.

    What are the environmental factors present during air travel that put passengers at a higher risk of medical issues?


     

  3. 3.

    What support and medical supplies are available onboard an aircraft?


     

  4. 4.

    What are the most common in-flight emergencies, and how should one approach diagnosing and treating a patient at 40,000 ft?


     

  5. 5.

    When and how are planes diverted due to medical emergencies?


     

  6. 6.

    What are the challenges of in-flight medical care?


     

Introduction/Background





  1. 1.

    The true incidence of in-flight medical events is unknown given that there are no standards or minimal requirements for reporting by airlines. The US National Transportation Safety Board requires medical emergencies to be reported if the event requires 48 hours of hospitalization, involves injury to internal organs, or fractures (excluding nose, finger, or toe fractures) [1]. Most studies that evaluate in-flight emergencies acquire data from on-ground medical communication center records. According to one study, significant medical emergencies occur in one passenger per 10,000–40,000 passengers [2]. Another study found that the incidence of reported medical emergencies was one per 604 flights [3]. As the median age of the general population continues to rise and airlines can carry more people per aircraft over further distances, the incidence of in-flight emergencies will likely increase in frequency and severity. Medical professionals should be prepared to face this situation.


     

  2. 2.

    Prior to World War II, most American flight attendants were nurses who were able to handle nearly all in-flight medical emergencies [5]. When this standard changed, the need for medical professional volunteers became increasingly important. Emergency Medicine providers undergo training that allows them to be particularly effective in managing undifferentiated medical problems that may require immediate intervention. This does not mean that the in-flight environment is not still very challenging, as access to diagnostic and treatment modalities is very limited. Fortunately, most medical problems that occur on flights are self-limited and resolve without major treatment or diversion of flight [3]. The mortality rate for in-flight emergencies is ~0.3–1.3% [3].


     

  3. 3.

    Aviation agencies generally provide either mandates or guidelines as to the medical equipment that must be available on commercial airline flights. In the United States, it is mandated that all commercial airline flights that require the presence of a flight attendant and have a payload greater than 7500 lbs have onboard at least one first aid kit, an emergency medical kit, supplemental oxygen, and an automated external defibrillator (AED) [4].


     

Do I Have to Help, and if I Do, Will I Get Sued?





  1. 1.

    There is no legal requirement in the United States, Canada, or the United Kingdom for medical professionals to volunteer when the flight crew requests assistance with an ill passenger. However, Australia and multiple countries within the European Union require medical professionals to assist with in-flight emergencies [5, 6]. The question of which country’s laws apply is a very complicated one without a clear answer. The country in which the airline is based, the flight departure country, and the flight arrival country all have a potential argument to support their laws’ applicability. Many argue that medical professionals have an ethical obligation to assist as able, but as above, this obligation is largely not codified.


     

  2. 2.

    Providers may hesitate to volunteer to help with in-flight medical emergencies due to concern for malpractice liability when offering assistance. However, this concern should not dissuade medical professionals from assisting in these situations. The 1998 Aviation Medical Assistance Act Good Samaritan Provision largely protects health-care professionals from legal liability (at least within the United States).


     



LIABILITY OF INDIVIDUALS—An individual shall not be liable for damages in any action brought in a Federal or State court 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 [7].






  • This statute is much more protective of the medical provider than typical malpractice standards [5]. Examples of actions that are generally thought to rise to the level of gross negligence include rendering aid while intoxicated and practicing beyond their professional scope of practice. Therefore, medical professionals should not assist if they have recently ingested alcohol or CNS depressants.8. Further, medical professionals should practice only within their scope of knowledge and openly communicate with the flight crew their credentials and skill set.



    • There is considerable debate whether receiving a token of gratitude or compensation for medical services voids the protection granted by this federal law. Indeed, many “Good Samaritan” laws explicitly contain language prohibiting the medical professional from receiving any sort of compensation. As you can read, this law does not include any such explicit prohibition. Small tokens of gratitude such as a seat upgrade or frequent flier points are generally thought to be ok, although this has, as far as we are aware, never been confirmed as part of a judicial case. Larger value gifts or cash compensation is thought to be less likely to stand up to judicial review should the medical professional be sued.



      • Perhaps the most telling case law is Baillie v. MEDAIRE INCORPORATED. A man on a British Airlines flight from London to Phoenix complained of chest pain. The crew consulted Medaire Inc., a company who contracted with the airline to provide medical consultation. At their request, a fellow passenger who was a physician examined the man, obtained a history, and reported his findings to the flight crew and the ground-based medical consultants. Ultimately, the medical consultation team did not recommend diversion. Unfortunately, after arrival in Phoenix, the patient was taken to the hospital where it was found that he had suffered a myocardial infarction. He subsequently died 3 months later while awaiting a heart transplant.



        • The man’s wife, on behalf of his estate, sued British Airlines, the physician onboard, the medical consultation company (Medaire Inc.), and the two individual physicians who provided consultation as part of their role with the consultation company.



        • Both British Airlines and the physician onboard reached a settlement with the man’s estate.



        • Medaire Inc. and the two physicians who provided consultation from the ground were eventually both dismissed on legal grounds that are beyond the scope of this chapter. That dismissal is currently being appealed.



        • Most revealing, however, is a federal’s judge’s ruling on a Motion for Judgment on the Pleadings filed by the defendants. Medaire Inc. and the two consultation physicians argued that they should be protected under the 1998 Aviation Medical Assistance Act Good Samaritan Provision. The judge ruled that their relationship as contractors with the airline to provide medical consultation was fundamentally different than that described in the provision; namely, that they were not volunteers and they were not present on the aircraft. The judge further states, “For clarification, here the individuals that would be immune from liability under the Act are the crewmembers and the physician who provided aide to Mr. Baillie while in the air, not Defendants.” [9] Unfortunately, in this case, the onboard physician had already reached a settlement agreement.



    • A 2002 review stated that the authors were unaware of any legal action ever being brought against a physician who assisted with an in-flight medical emergency [10]. We are similarly unaware of any cases brought against a physician who assisted with in-flight medical emergency going to trial. This does not, however, take into account physicians who may have been named in a lawsuit and subsequently dismissed or those who may have settled outside of court, as in the above case. While we believe the risk of being named in a lawsuit from assisting in an in-flight medical emergency is very low (and the risk of losing is even lower), we cannot say that the risk is nonexistent.




  1. 3.

    Airlines are not considered a covered entity as defined by HIPAA, and so medical providers are able to legally speak to the flight crew and ground-based consultants about the patient’s medical issues [11]. However, the provider should still attempt to protect the patient’s privacy and modesty as much as possible during an in-flight emergency.


     

Physiology/Pathophysiology





  1. 1.

    Most commercial airlines have a cruising altitude of ~30,000–45,000 feet above sea level. This altitude allows for better fuel efficiency, less turbulence, and lower chance of inclement weather [11]. For perspective, Mount Everest is ~29,000 feet above sea level. The passenger cabin is pressurized to be equivalent to approximately 6000–8000 feet above sea level [1]. This is comparable to a small peak by mountain standards but is still significantly higher than the elevation at which most people live. An aircraft structure made suitable to allow a passenger cabin to be pressurized to sea level pressure would be too heavy to fly [11].


     

  2. 2.

    The low cabin atmospheric pressure affects the partial pressure of gasses. The low pulmonary artery oxygen tension that is present during flight decreases the affinity of hemoglobin for oxygen, to the point where even healthy individuals can have arterial oxygen saturations as low as 89%. The body compensates by increasing minute ventilation and cardiac output with mild hyperventilation and tachycardia. Patients who are chronic smokers or have conditions such as COPD and congestive heart failure may be unable to illicit or handle the body’s natural compensation mechanisms [1].


     

  3. 3.

    At the low barometric pressures within the passenger cabin, gas expands (per Boyle’s Law). Gas expanding within closed body cavities can cause pain, and passengers may complain of ear, sinus, and bowel discomfort [12]. Further, passengers must be careful about traveling within certain timeframes post intra-abdominal, eye, neurologic, and middle ear surgical procedures, as these surgeries can introduce small amounts of air into these cavities. If passengers are unaware or do not heed these restrictions, complications such as pain, wound dehiscence, or worse conditions may occur [11]. Gas expansion at low pressure can also affect air-filled medical devices such as tracheostomy tubes, feeding tubes, urinary catheters, and pneumatic splints, causing discomfort and malfunction [11].


     

  4. 4.

    Other circumstances present in-flight can cause a variety of medical issues. Low cabin humidity, which helps prevent airplane corrosion, can cause dry eyes and dehydration and exacerbate reactive airway disease [11, 12]. Immobility and cramped seating can put passengers at risk for thrombus formation [16]. Decompression sickness is a risk for those who have recently been scuba diving. Moreover, close contact places passengers at a higher risk of contracting communicable respiratory infections [1, 11].


     

Making the Diagnosis





  1. 1.

    General approach to any patient [3, 5, 8]


     

../images/463721_1_En_29_Chapter/463721_1_En_29_Figa_HTML.png




  1. 2.

    The most valuable diagnostic tool at your disposal is the one that you carry with you everywhere; your brain! History and physical exam are the major diagnostic clues for in-flight emergencies. However, completing a high-quality physical exam can be difficult due to limited space, poor light, and a noisy cabin [11]. In the United States, emergency medical kits must be equipped with a stethoscope and sphygmomanometer, but that is the extent of mandated diagnostic tools. Some airlines may carry medical kits with other supplies such as a glucometer or a thermometer, but this is not required. Further, some automated external defibrillators (AED) carried by airlines may have telemetry capabilities that can be used for cardiac monitoring in a nonarrest situation, but the sophistication of the AED is not standardized between airlines. It may be possible to utilize equipment such as a glucometer from another passenger, but always consider the cleanliness of the device and the possibility of blood-borne pathogen risk [13, 16].

    Only gold members can continue reading. Log In or Register to continue

Mar 15, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Emergencies: Medical Mile High Club

Full access? Get Clinical Tree

Get Clinical Tree app for offline access