“Is there a MEDICAL PROFESSIONAL - PowerPoint Presentation

Slide1

“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; 321:1338-41Slide6
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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

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7

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1

0

30

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45

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73

81

89

100

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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