Responding to In-flight Medical Emergencies

Last spring, on a non-stop flight from Miami back to San Diego, I was the only physician on board when the call “Is there a doctor on board?” went out from a flight attendant. By the time the call was repeated by the pilot over the intercom system, I was trying to wake myself up and already making my way from the back of the coach section toward the first class seats.

It turned out that the head of a Southern California-based, multi-state law firm had experienced what I diagnosed as a vasovagal reaction. Upon arriving to “patient’s” seat and identifying myself (at which time two registered nurses, who had also just arrived to the scene, said “thank you” and quickly scurried back to their seats), I examined the middle-aged gentleman. He was demonstrating a depressed mental status and had his face in an airline-supplied “barf bag.” I quickly established that this slightly cold and clammy man had relatively stable vital signs, before requesting an oxygen mask and tank, and placing a #20 gauge upper extremity intravenous line.

While treating the gentleman, who was already beginning to look better, I was asked for my California medical license card, which was given to the pilot along with a small questionnaire establishing my medical credentials and diagnosis of this patient. The pilot later came out to meet me. I had been asked to stay in first class next to the patient for the remainder of the flight (the lady in that seat gladly agreed to go back and sit in my seat). I had the patient talking and smiling and resting comfortably. He still felt a bit nauseous, so we decided to slowly drip in the two 500 cc 0.9 NS IVF bags (that were the only intravenous fluids on the plane) until we arrived at Lindberg Field. It turned out that this attorney’s personal paralegal was flying with him; we recognized each other, as I had recently given her a labor epidural for the delivery of her child, which, she reminded me, was a “godsend.”

When we arrived in San Diego, my new patient and friend walked out of the plane looking great; out of routine, he was greeted by an EMT who had been called to see if he needed anything and perform a routine exam.

I enjoyed being able to help out, get to know the pilot and flight attendant staff, and become friends with my new patient and his companion. There were, however, some interesting observations made about the state of preparedness — or lack thereof — on this airplane. After some later research, I found similar conditions existed on all major airlines and that many major airlines had recently cut back on the contents of their medical kits out of economic necessity. Here is some of what I learned:

The medical kit I was given had one ampule of epinephrine, IV supplies and two rubber tourniquets, one 500 cc. 0.9 NS IVF bag, gauze, band aids, two #20 gauge jelco catheters, nitroglycerine tablets, one vial of 50 mg. Benadryl, two 10 cc. syringes with two #19 gauge hypodermic needles, a tube of anti-bacterial ointment, a manual blood pressure cuff, two pairs of large (the flimsy plastic type) gloves, and a stethoscope. It was accompanied by a small oxygen tank and a clear oxygen face mask. There were a total of two such kits on the airplane.

The plane itself was supposed to have one early-model, portable, automated, external cardiac defibrillator device (they had decided not to upgrade to the fully automated, newer model), but I was told that the one on my flight was broken. There were no anti-arrhythmic meds, no anti-emetic drugs, and clearly no pharmaceuticals to carry out an ACLS type resuscitation. Interestingly, as we approached the airspace over Phoenix, Arizona (where this airline had its emergency room contact physician on the ground), the pilot came back to tell me that the ER doc had requested we give the patient intravenous “Benadryl” and consider landing at the Phoenix airport instead of continuing on for another 45 minutes to San Diego. I completely disagreed with this recommendation as the patient was looking great and had, at no time, demonstrated any indication of an allergic reaction. As I expressed my opinion, the pilot was smiling and nodding his head in agreement. He laughed and said, “I agree with you doc. We’ve had a history of some strange opinions from that emergency room physician over the years!”

A review of The New England Journal of Medicine (Volume 346:1067-1073, April 4, 2002, Number 14) revealed the following statistics:

• In-flight emergencies occur in roughly 1 out of every 33,600 to 39,600 U.S. flights.
• This correlates to roughly 30 to 33 emergencies on airline flights in the United States each and every day.
• The vast majority of in-flight “emergencies” are vasovagal episodes.
• Thirteen percent of all airline medical emergencies result in “diversions” to land the plane and treat the patient on the ground (of these, 46 percent are cardiac in origin, 18 percent are neurologic events, and 6 percent are respiratory events).

Some other interesting facts:

• The cabin pressure on most commercial planes may often contain a barometric pressure of 5000 to 8000 ft. above sea level, despite the fact that the plane is likely to sustain altitudes of three to five multiples above this level for most of the flight. This effects a decrease in the partial pressure of arterial oxygen from about 95 mm Hg. to about 56 mm Hg., resulting in a 4 percent reduction in the oxygen carried by the blood. The risk of “hypobaric” hypoxemia in patients with advanced pulmonary disease, however, is very real.
• Boyle’s Law states that air and gas in cavities of the body will expand in direct proportion to decreases in cabin pressure. Passengers who have recently had surgery are at the potential risk of wound dehiscence due to gas expansion in surgical site tissues.
• Airline cabin humidity is low (10 to 20 percent range); this can exacerbate reactive airway disease.

According to the Federal Aviation Administration (FAA), the minimum medical supplies required to be on commercial aircraft is as follows — depending on the number of passengers, there must be one to four first-aid kits; the first aid and medical kits must be readily accessible to the flight attendant staff:

• First-aid kit containing:
  • bandages
  • compresses for applying pressure, moisture, heat, or cold
  • antiseptic swabs
  • arm and leg splints
  • tape
  • scissors.
• Medical kit (for use only by licensed medical professionals) containing:
  • blood pressure cuff
  • stethoscope
  • plastic airways to deliver oxygen to help with breathing
  • nitroglycerin tablets for chest pain
  • dextrose solution for hypoglycemia
  • epinephrine for asthma or allergic reactions
  • injectable diphenhydramine HCl for serious allergic reactions
  • hypodermic needles
  • protective latex gloves.

Speaking to several commercial pilots, I was apprised of the fact that about 75 percent of all in-flight emergencies are minor and handled by the flight attendants themselves. It is obvious that the mandated supplies for a true medical emergency are rather meager, and frankly, inadequate to sustain many conditions until a patient can be stabilized and/or further treated on the ground. In fact, one could argue that beginning to treat a passenger with some medications, but without the full arsenal of drugs at one’s disposal, is a potentially slippery slope. Even the presence of latex gloves (although not on my flight) and latex stoppers in medication vials could predispose a treated latex-sensitive passenger to a life-threatening allergic reaction. I found it odd that diphenhydramine was the only medication on board to treat an allergic reaction, as clearly the presence of both H1 and H2 blockers and an intravenous corticosteroid have been documented to be helpful in such circumstances.

Nevertheless, I found my in-flight experience assisting a fellow airline passenger with a medical “event” to be rewarding, and the flight attendant staff to be extremely responsive and helpful. A familiarity with what is available to a physician responding to a “Is there a doctor on board?” call may be valuable the next time you travel.

References:

• Urwin, A., Ferguson, J., McDonald, R., Fraser, S. (2008). A five-year review of ground-to-air emergency medical advice. J Telemed Telecare 14: 157-159
• Shepherd, B, Macpherson, D, Edwards, C M B (2006). In-flight emergencies: playing The Good Samaritan. JRSM 99: 628-631
• Zuckerman, J. N (2002). Recent developments: Travel medicine. BMJ 325: 260-264
• Gendreau, M. A., DeJohn, C. (2002). Responding to Medical Events during Commercial Airline Flights. NEJM 346: 1067-1073