Challenges at 35000 ft Linda E Pelinka MD PhD Medical University of Vienna a nd Ludwig Boltzmann Institute for Experimental amp Clinical Traumatology Vienna Austria European Union ID: 342233
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“Is there a MEDICAL PROFESSIONAL ON BOARD this aircraft?”Challenges at 35.000 ft
Linda E. Pelinka, MD, PhDMedical University of Viennaand Ludwig Boltzmann Institutefor Experimental & Clinical TraumatologyVienna, Austria, European Union
TRAUMASlide2
BasicsPathophysiology
Medical EquipmentCommon problemsEmergenciesLegal AspectsSlide3
BasicsSlide4
Statistics
Worldwide, ~1 million people are traveling by air at any given time>700 million Americans travel by air in the US~one per 10-40,000 passengers will experience an medical emergency.U.S. Federal Aviation Administration. Moving America safely: annual performance report 2005. http://www.faa.gov/air_trafficSand M et al. Surgical & Medical Emergencies on board European Aircraft:10189 cases. http://ccforum.com/content/13/1/R3Slide5
>50% of passengers age 50 or over have at least one health issue(s)Emergencies will become more frequent as % of elderly increases
Goodwyn T: In-flight Medical Emergencies: an Overview. Brit Med J 2000; 321:1338-41Slide6Slide7
There are more deaths from in-flight medical emergencies than from airline accidents.
In 2006:550 medical diversions59% were 50 or older63 passengers died in-flightNational Transportation Safety Board and Med AireSlide8
In the Air, Health Emergencies rise quietly
The death of an AA passenger flying from Haiti toNYC has cast a spotlight on the growing number ofmedical emergencies on commercial jets, a trendthat has escaped public notice because airlinesaren’t required to report such incidents.A MedAire analysis shows that such incidents nearly doubled from 2000-2006, from 19 to 35 per million passengers.USA TODAY, Dec 20081 of 2Slide9
In the Air, Health Emergencies rise quietly
According to analysts, this is due to 2 factors:79 million baby boomers are entering retirement, but continue traveling habits established when they were young.Flights are going farther and lasting longer. Av. length of a flight in 2000: 1,233 mi Av. length of a flight in2006: 1,347 Max flying time today: 20 hrsUSA TODAY, Dec 20082 of 2Slide10
“if you are ill, an airplane is the worst place to be…
“… you are trapped at 35,000 ft.”David Stempler President of the Air Travelers’ Association.Slide11
PathophysiologySlide12
Setting on Board: passenger’s point of view
Very cramped everywhere (seat, restroom)Three-dimensional motion of aircraftVery drySlide13
Dehydration
Hemoconcentration & hyperviscosity increase risk of thromboembolismThe mild hyperbaric changes during flight are sufficient to cause increased activation of coagulation in healthy individuals with no thrombophilia compared with that in individuals seated and not moving at ground level.Toff WD et al: Effec of hypobaric Hypoxia, simulating Conditions during long-haul air travel on Coagulation, Fibrinolysis, Platelet Function and Endothelial Activation. JAMA 2006; 295: 2251-61.Slide14
Humidity
Low, typically 10-20%Low humidity has a propensity to exacerbate reactive airway disease and dehydrationHocking MB: Passengr Aircraft Cabin Air Quality: Trends, Effects, SocietalCosts, Proposals. Chemosphere 2000; 41:603-15Slide15
Commercial cruising altitude 7010-12,498 mSlide16
Cabin Pressurization to 2438 m:What happens?
Humpreys S et al: Effect of high Altitude Commercial Air Travel on O2 Saturation. Anesthesia 2005; 60: 458-60Atmospheric cabin pressure dropsPaO2 drops from 95(12.7 kPa) to 65mmHg (8.7 kPa)
Oxyhemoglobin
sat drops from 95-100% to 90%Slide17
Silverman D,
Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77(A) The aircraft passenger cabin is normally pressurised to an altitude of 1524—2438 m. This reduced pressure within the passenger cabin results in lower systemic PaO2 and decreased oxyhaemoglobin. For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension from 95 mm Hg (12·7 kPa) to 65 mm Hg (8·7 kPa) corresponding to an oxyhaemoglobin saturation from 95—100% at sea level (A) to 90% at a cabin altitude of 2438 m (B).The passenger cabin is pressurised to 1524—2438 m. This reduced pressure within the passenger cabin results in lower syst. PaO2 and oxyhaemoglobin (oyx-hb). For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension. Slide18
Silverman D,
Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Passengers with pre-existing lower sea-level oxy-hb sat have greater declines during flight. E.g., a passenger with mild COPD with a sea-level PaO2 of 70 mm Hg PaO2 to about 53 mm Hg or oxy-hb sat of approximately 84% at a cabin altitude of 2438 mSlide19
Silverman D,
Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide20
pO2 Drop at various Altitudes
8
7
6
5
4
3
2
1
0
30
32
34
38
45
54
61
69
73
81
89
100
20
40
60
80
100
120
Altitude in km
pO2 in mm Hg
pO2 drop by
~30 mmHg
between sea level and
cabin press. level (2400m)
vs
~4 mmHg
between 6000-8000m)
mod acc to
Stueben
, U.
Flugmedizin
Med.
Wissenschaftliche
Verlagsges
. Berlin, 2008Slide21
low cabin pressure
lower alveolar pO2 (55-70 mmHg)lower arterial pO2 (~90%)Curdt-Christiansen, C. et al: Principles and Practice of Aviation Medicine. World Scientific, London, 2009.increasing edemaSlide22
Effect of Aircraft-Cabin Altitude on Passenger Discomfort
Muhm JM et al. N Engl J Med 2007; 357: 18-27The frequency of reported complaints associated with acute mountain sickness (fatigue, lightheadedness and nausea) increased with increasing altitude and peaked at 2438 m. Most symptoms became apparent after 3-9 hrs of exposure.Slide23
Cabins in
new Airbus A380, Boeing 787, pressurized at 1829 mSlide24
Hypoxia
Preexisting cardiac and/or pulmonary and/or psychological issuesCabin pressureMild HypoxiaSlide25
68-Year-)ld woman with Chest Pain during an Airplane FlightPicard, MH et al. New
Engl J Med 2010; 363/27: 2652-61.History of hypertension and hyperlipidemiaFlight from the Middle East to Europe: Gradually developing chest pain and pressure, fluctuating intensity, not radiating. Resolves spontaenously after several hoursSubsequent flight Europe to U.S.: Chest pain recurs.Slide26
Is Air Travel Safe for those with Lung Disease?
Coker RK et al. Eur Resp J 2007; 30: 1057-63This prospective, observational study showed that 18% of passengers with COPD have at least mild respiratory distress during a flight.Slide27
Cramped Space & Immobilization
Have been linked to 75% of all air-travel cases of venous thromboembolismGreatest frequency of theomboembolism in non-aisle seatsCesarone MR et al: Venous Thrombosis from Air Travel: the LONFLIT3 Study – Prevention with Aspirin vs LMWH in high-risk subjects. Angiology 2002; 53: 1-6.Slide28
Thromboembolism
Risk peaks up to four-fold when flight duration >8 hRisk factors: Dehydration, immobility, hypobaric hypoxia, obesity, malignancy, recent surgery, h/o hypercoagulable stateOral contraceptives increase risk 16-foldBusiness vs coach class no effect on incidenceAryal KR & Al-Khaffaf H. Eur J Vasc Endovasc Surg 2006; 31: 187-99.Jacobson BF et al. S Afr Med J 2003; 93: 522-528.Slide29
Boyle’s LawThe volume occupied by a gas
is inversely proportional to the surrounding pressure.Thus, at cruising altitude, gas in body cavities expands by 30%:Slide30
Boyle’s Law & Barotrauma
Healthy passengers minor abdominal cramping, ear pressurePassengers after recent surgery Bowel perforation, wound dehiscenceSlide31
Guidelines
Delay flying for 12 h after scuba diving (1 dive) w/o deco 24 h after several dives or 1 dive + deco7-10 dys after diverticulitis 2 wks after major surgery Medical Guidelines for Airline Travel, 2nd Edn. Aviat Space Environ Med 2003; 74 (suppl): A1-A19Slide32
Boyle’s Law & Effect on Medical Equipment
Gas expansion inPneumatic splintsUrinary cathsFeeding tubesET tubes (instill water instead of air)Slide33
Medical EquipmentSlide34
Emergency Medical Kit
DeviceStethoscopeBlood pressure cuffBag-mask resuscitator1 required, child/infant optionalOral airways3 sizes requiredSlide35
Emergency Medical Kit
DrugNitroglycerin10 tablets min.Aspirin4 tablets min.Albuterol1 metered-dose inhalerDextrose 50%25g min.Oral Antihistamines4 tablets minIv Antihistamines2 amps minIv Epinephrine 1:10002 mg min (allergic react.)Slide36
Emergency Medical Kit
Cardiac Resus DrugsIv Epinephrine 1:10,0002 mg total minAtropine1 mg total minLidocaine200mg total minSlide37
Emergency Medical Kit
Device opt. provided on intercontinental flights: Tempus ICState of the art telemed monitorTransmits info incl digital pics, video to ground based physicianAutomated BP cuff, glucometer, capnometer, 12-ld ECG, pulse oximeterProvides on-screen, step-by-step instructionsSlide38
Opioids
- Nalbuphine and Morphine – are provided by some carriersSlide39
Emergency Medical Kit
Drugs optionally provided on intercontinental flightsOndansetronNalbuphine !NaloxoneSlide40
OxygenMasks and nasal tubes
available on board.Emergency bottles provide O2 at a fixed rate of 4 liters/min.Sufficient for 75 min.Slide41
Medication and technology are expensive but may still be cost-effective
Diversion can cost from US$10,000 to $100,000 depending on the routeSlide42
Equipment Challenges
Auscultation (pulm., BP) difficult due to ambient engine noise. Alternative: radial pulse palpation for syst BP.Aviation portable O2 bottles have only 1 of 2 settings: “low”=2 l/min and 4 l/min=“high flow”, far lower than flow used for EMS.O2 tubing for bag-valve resuscitation are not required to be compatible with these on-board O2 bottles.Slide43
Equipment Challenges
AEDs on board not required to have ECG screen, though ACLS meds are provided.When AED does have screen, it is limited to a leads II/paddles view.Glucometers not mandatory, though 50% dextrose is. Ask if any passenger on board would be willing to share personal glucometer.Slide44
Equipment ChallengesSince 9/11, phones have been largely
removed from cabins and cockpit doorshave been secured.Info must be relayed via intercomfrom the back of the plane or via flight attendant’s headset to pilots,who then relay infoto doctors on the groundSlide45
AEDAutomated
External DefibrillatorAA first US airline to equip its fleet in 1997, first cardiac arrest save 1998.Mandatory for US commercial carriers. (Aviation Medical Assistance Act). Aircraft with inoperable AEDs are allowed to make “a few flights” until a replacement can be found.Slide46
AEDAutomated
External DefibrillatorAEDs are still not mandatory for European commercial carriers (European Aviation Safety Agency). No AEDs on Intercity aircraft in Europe.Slide47
Positioning the Patient
Remove patient from seat, gripping him/her from behind.Slide48
Positioning the Patient
If possible, position potential emergencies next to the aircraft’s door or in the galley, horizontal to flight direction against front wall.Make sure all trolleys are secured.Stueben, U. Flugmedizin/Flight Medicine. Medizinisch Wissenschaftliche Verlagsgesellschaft Berlin, 2008Slide49
Make sure there is enough space behind pat’s head in case of intubation
Make sure there is enough space beside pat’s chest in case of cardiac massageSlide50
Telemedicine: MedAire
Ground-based service utilized by airlines.VHF radio or satellite phone contact to ED physicians at MedAire.Arizona-based company providingemergency med advice to airlines carrying ~half of the 768 million passengers on US flights each year.Takes responsibility for deciding if flight diversion is appropriate.Slide51
Medical Diversion
Pilot’s decision onlyDepends on weather, appropriate airport facilities, terrain, landing weight, fuel: e.g. impossible right after take off: Weight of aircraft + full tanks exceedsmax weight for landing
(e.g. take off
NYC, earliest
landing Boston)Slide52
Flight diversions due to onboard medical emergencies on an international commercial airline.
5386 telemed contacts/5yrs.Av. 2.4 diversions recommended/100 callsTelemed decrease 2006-2007 was accompanied by an increase in diversions.Valani R et al, McMaster University, Hamilton General Hospital, Ontario, Canada. Aviat Space Environ Med 2010; 81: 1037-401 of 2Slide53
Flight diversions due to onboard medical emergencies on an international commercial airline.
Most common causes for diversionCardiac (26%)Neurological (20%)Gastrointestinal (11%)Syncope (10%)Valani R et al, McMaster University, Hamilton General Hospital, Ontario, Canada. Aviat Space Environ Med 2010; 81: 1037-402 of 2Slide54
Telemedical Assistance for in-flight Emergencies on Intercontinental Commercial Aircraft
3-yr prospective study, commercial airlineMedical incidents: n=3364 Use of telemedicine: 9% (n=275)Most cases were middle aged, not elderlyNeurological, non-psych telemed cases:27% (n=83, 27 required diversion, 275 did not.No non-diverted patient deterioratedWeinlich M et al, Dept of Trauma Surgery Goethe Univ. Frankfurt, Germany. J Telemed Telecare 2009; 15: 409-13Slide55
Pediatric emergencies on a US-based commercial airline
7-yr retrospective study, commercial airline1 ped call per 20,775 flights2/3 calls in-flight, 1/3 pre-flightMean age 6 yrsMost common complaints: infectious disease, neurological, respiratory emergencies.Moore BR et al, Dept of Ped. & Adolscent Med, Mayo Clinic,Rochester, NY. Pediatri Emerg Care 2005; 21: 725-9.Slide56
Common ProblemsSlide57
How common are medical problems during flight?Minor medical problem not requiring medical assistance: every150
th passengerMedical care: 1 of 10.000 passengersMedical emergency: 1 of 50.000 passengers (~6% cardiac)Slide58
Time Zone Changes & altered Meal Times
Hypoglycemia in insulin dependent diabetics though diabetic meals can be provided. Passengers on other strict drug regimens, (e.g. for epilepsy)Passengers who have packed their medication in the hold. Slide59
Fear of FlyingUnruliness (aggravated by alcohol)
Psychovegetative dysregulation: tachycardia, sweating, hypotension (aggravated by sedatives and/or dehydration)Slide60
Dehydration
Prolonged sunbathing and/or partying on last day of vacationDehydration (e.g. hot location, last minute rush/stress, lack of foreign currency to buy drinks)Cabin pressureSlide61
Dehydration & Dry Atmosphere
Dry cabin atmosphere irritates mucous membranesDuration of flight exacerbates dehydrationDrinking alcohol exacerbates dehydration. Altitude enhances the effect of alcohol, contributing to “air rage,”Slide62
Air Ragehours of dry cabin
atmosphere irritate mucous membranes Drinking extra fluid helps,Drinking alcohol opposite effect. Intoxicating properties enhanced at altitude.smoking ban in nicotine addicts.Slide63
Motion Sickness
SymptomsApathyPallorSweatingOver-sensitivity to noise, smellHypersalivationAggravationAlcoholTurbulenceSudden de- or accelerationNoise, s
mells
HeatSlide64
Vaso-Vagal Syncope
40 % of cardiovascular emergencies on board are syncopes.Most common causes: motion sickness, dehydration, fear of flying.Slide65
Responding to in-flight Medical Events 1
Be prepared to show med credentials or answer questions about degree or trainingObtain consent from affected passenger. Assume implied consent when passenger is incapacitated or unresponsive.Do not fear litigation. Physicians have been deposed, but no litigation has ever been brought forward against a responding physician.Slide66
Responding to in-flight Medical Events 2
Request and establish communication with the airline’s ground med support for advice and consultation regardless of how minor or serious the in-flight event is.Request the enhanced emergency med kit (many airlines initially offer basic first-aid kit) but do not open it unless needed. Each kit has a placard listing contents.Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide67
Hypoglycemia
If conscious, administer oral glucose gelIf unconscious, establish iv accessAdult: administer D50 dextrose (1 amp)Child: dilute D50 dextrose 1:1 with normal saline to prepare D25 dextrose and administer 2 ml/kg Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide68
Motion Sickness:What can you do on board?
Move patient to seat in the middle of the planeKeep head steadyEyes shutNo alcoholMetoclopramideDimenhydrinateScopolamine patchSlide69
Vasovagal Syncope
Lay pt supineElevate legsApply cold compress to foreheadSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide70
EmergenciesSlide71
Altering Cabin Pressure
Cabins are pressurized but airlines canlegally alter pressure to the equivalent of 8000 ft.Slide72
Emergencies in the Air
Exacerbation of pre-existing medical problems caused the vast majority of in-flight emergencies (65%).Respiratory problems were most common. 50% asthma-related, 33% due to forgotton medication.Syncope accounted for 25% of all incidents and 91% of all new medical problems. Qureshi A, Porter KM. M. Emerg Med J 2005; 22: 658-59.Slide73
Hypertensive Crisis
Urapidil available on all aircraftNitro Spray and/or capsules available on all aircraftOral calcium antagonists available on some aircraftConsider Diff Dg: Stroke, MCI,hemorrhage from ruptured aneurysm, thusMedical diversion if possibleSlide74
Tachycardia
Positioning, oxygen, ivAmiodarone 2 150mg ampsLidocaine 1-1.5 mg/kgLast ditch measure: Defibrillation AED will not discharge below ventriculartachycardia of 180 because its automaticrhythm-detection is programmedaccordingly.Slide75
Arrhythmia
Horizonal positioning aisle, galley, business class seatI.V., fluid, oxygenMonitoring with AEDSedationHave CPR readySlide76
Suspected Myocardial Infarction
O2, Aspirin 325mg poNitroglycerin 0.4 mg subling every 5 min up to three doses or Morphine sulfate 3 mg iv or im.Request cabin altitude reduction to increase cabin pressureSome airlines carry AEDs with a cardiac rhythm display to help assess rhythm.Slide77
Cardiac Arrest
Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77Place AED on patient. Some defibrillators incorporate a rhythm display that can help making decisionsFollow BLS or ACLS resus algorithmsIf resuscitation is stopped because of no return of spontaneous circulation, pt should not be pronounced dead officially on international flights (medico-legal reasons)Slide78
US Government Air Carrier Access Act May 2008
All US-based air carriers and foreign air carrier flights that begin or end in the USA must accommodate passengers who need portable oxygen concentrators.Non-discrimination on the basis of disability in air travel. Final Rule. Fed Regist 2008; 73:27613-27687.Slide79
Bronchial Asthma or COPD
Administer O2 and inhaled bronchodilator (2 puffs per 15 min)Request reduction of cabin altitude to increase cabin pressureSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide80
PneumothoraxThe effect on
pneumothorax was wellpublicised when, on a flight from HongKong to London, Professor AngusWallace relieved a tension pneumothoraxwith the aid of a catheter, coat hanger,and brandy bottle.Wallace WA: Managing in flight emergencies. BMJ 1995; 311:1508Slide81
Acute Allergic Reaction
Diphenhydramine po, im or iv. Adults 25-50 mg, peds 12.5 mg.Severe generalized urticaria, angio-edema,stridor or bronchospasmEpinephrine: Adults 0.3-0.5 ml, peds 0.01 ml/kg/dose 1 in 1000 solution im or sc every 5-10 min as needed. 3 doses in adults, up to 3 doses in peds. Additonal fluids in anaphylaxisSilverman D,
Gendeau M: Medical
issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide82
Acute Abdominal Pain
Consider administering antacidRequest cabin altitude reduction to increase cabin pressure. That increases oxygenation & decreases gas expansion.Administer paracetamol or ibuprofen. Some kits include morphine.Consider administering an anti-emetic. Some kits include Ondansetron.Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77Slide83
Acute Agitation or Misconduct
Look for med causes (hypoxia, hypoglycemia)If administering a benzo, be aware of poss oversed (passenger taking several substaces)If physical restraint is needed, place restrained individual in left lateral positionMonitor when using chemical or physical restraints. High risk of complications in exerted, agitated passengers fighting restraints: hypoxia, metabolic acidosis, sudden death. Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77Slide84
Seizure
Keep pt away from nearby objectsDo not place anything in pt’s mouthAdminister Diazepam 0.1-0.3 mg/kg iv or im for pediatrics, 5 mg iv or im for adultsSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide85
Extended travel with limited movement & rehydration are
THE recipe for pulmonary embolism.Add factors like birth control pills, obesity, age and/or smoking and you are pretty much an event about to happen.Slide86
Anticoagulants for Air Travel?
No formal guidelines existStill controversial, though RC trials show benefit of LMWH for air travelers at moderate risk who do not take anticoagsAspirin is not recommended alone as prophylaxis for any air traveler.Kuipers S et al: Travel and venous Thrombosis: A systematic review. J Intern Med 2007; 262: 615-634.Slide87
Sudden Loss of ConsciousnessDifferential Diagnosis
Vasovagal syncopeAsystoleHypoglycemic shockApoplectic ischemic/hemorrhagic strokeEpileptic seizureIntoxication (drugs, toxic agents)Slide88
Unresponsive Passenger
Place automated external defibrillator pads on ptEstablish iv accessAdminister O2, D50 dextrose (1 amp) iv for adult or D25 dextrose (2ml/kg) for pediatric, Naloxone 0.1-2 mg iv or im (available on some flights)Follow BLS or ACLS resus algorithmsSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide89
Consider Diversion
Acute coronary syndromeChest painSevere dyspnoeaSevere abdom pain that doesn’t improveSevere agitationStrokeRefractory seizurePersistently unresponsive passengerSilverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77Slide90
Legal AspectsSlide91
Does a medical professional who is a passenger have a duty
to volunteer medical assistance?US, Canada and the UK: NO, unless there is a pre-existing patient relationship.International law: country in which aircraft is registered has jurisdiction. However, country in which incident occurs and country of citizenship of plaintiff or defendant can also have jurisdiction.Hedouin V et al: Medical Responsibility and Air Transport. Med Law 1998; 17: 503-6.Slide92
1. Identify yourself, state your medical qualifications. Some airlines require proof of your medical qualifications.2. Obtain as complete a history as possible, inform passenger and family members (if present) of your impression, obtain consent before initiating any form of examination or treatment. Assume implied consent if pg. is incapacitated.
Medicolegal Recommendations Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.Slide93
3. If consent has been given, carry out an appropriate physical examination. 4.Request an interpreter if the passenger you are assisting does not speak your language. 5. Inform flight crew of your impression.
6. If condition is serious, request aircraft to be diverted to nearest appropriate airport. Medicolegal Recommendations Slide94
7. Establish communication with on-ground med support staff, if available. Respect ground-based physician’s expertise & experience in managing in-flight medical events. 8.Document in writing your findings, impression, treatment, and communicationwith flight crew & on-ground med support.
9. Do not use any treatment that you do not feel confident administering.Medicolegal Recommendations Slide95
The Aviation Medical Assistance Act
Passed by Congress in 1998Specifically protects physicians, state-qualified EMTs, paramedics, nurses and physician assistants.Slide96
The Aviation Medical Assistance Act
“ An individual shall not be liable for damagesin 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 med emergency unless the individual, whilerendering such assistance, is guilty of grossnegligence of willful misconduct.”Slide97
The Aviation Medical Assistance Act
Limits liability for volunteering physicians under the assumption that they act in good faith, receive no monetary compensation and provide reasonable care.Gifts, such as seat upgrades and liquors are not considered compensation.Pertains to events that occur within US airspace and aircraft registered within the US. Slide98
Many airlines indemnify volunteering physicians.Written confirmation is provided by the captain upon request.
Cocks R and Liew M: Commercial Aviation, in-flight Emergencies and the Physician. Emerg Med Australas 2007; 19: 1-8.Slide99
Keep in mind that “good Samaritan” statutes protect you only from liability
for actions that other competent persons with similar trainingwould take under similar circumstances.Medicolegal Recommendations Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.Slide100
Never officially pronounce a passenger dead, even if you assess
that resuscitation is futile and cease treatment, especially on international flights.Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77Slide101
Up in the Air – Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.We were flying from the East Coast to the West. Aboutmidflight, a lady behind us reached frantically for thebaggage bin. She was trying to get her husband’soxygen tank. He looked about 70, eyes closed, righthand clutching his chest, grimacing in pain. Suddenly,his grimace faded and his arm dropped. Leaning over, I felt for a pulse. There was none. Aflight attendant approached. “I am a physician,” I said.“Let’s get him down to the floor.”Slide102
Up in the Air – Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.We were flying from the East Coast to the West. Aboutmidflight, a lady behind us reached frantically for thebaggage bin. She was trying to get her husband’soxygen tank. He looked about 70, eyes closed, righthand clutching his chest, grimacing in pain. Suddenly,his grimace faded and his arm dropped. Leaning over, I felt for a pulse. There was none. Aflight attendant approached. “I am a physician,” I said.“Let’s get him down to the floor.”Slide103
Up in the Air – Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.We lifted him into the aisle. I shined a pocketflashlight on the dimly lit scene. He had stoppedbreathing; no pulse. Three other passengers joined us, an anesthesiologist, an oncologist and a surgeon. Mywife ran the code, I provided chest compressions, theanesthesiologist bagged the patient, the oncologistmanaged the equipment, the surgeon put in an i.v. andthen injected epinephrine intracardially.Slide104
Up in the Air – Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.We followed the protocol suggested by the AED. Itdid not discharge: its rhythm-detection program foundno rhythm that might be treated with defibrillation.The monitor showed a wide complex bradycardia withwhich we could not associate a palpable pulse. After25 minutes of basic cardiac life support, there was stillonly pulseless electrical activity. The 5 physiciansagreed:it was time to stop and declare the patient dead.Slide105
Up in the Air – Suspending Ethical Medical Practice
Shaner, M. New Engl J Med 2010; 363/21: 1988-89.The flight attendant explained that if we stopped CPR,the airline’s protocol would require the cabin crew tocontinue it. In other words, CPR was going forwardwhatever we decided. We chose to continue it ourselves so that the fourflight attendants could attend to their duties during anemergency landing.We landed 45 min later. The patient died the same day.Slide106
TAKE HOME MESSAGESSlide107
Dehydration
Low HumidityMild HypoxiaPre-existing med ConditionBoyle’s LawSlide108
Keep in mind that
airlines canlegally alter pressure to the equivalent of 8000 ft.Slide109
Consider Diversion
Acute coronary syndromeChest painSevere dyspnoeaSevere abdom pain that doesn’t improveSevere agitationStrokeRefractory seizurePersistently unresponsive passengerSilverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77Slide110
“good Samaritan” statutes protect you only from liability
for actions that other competent persons with similar trainingwould take under similar circumstances.Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.Keep in mind that