Preparing for an in-flight medical emergency

“If there is a medical doctor onboard, would they please make themselves known to the flight attendant?”

Many of us have heard this announcement and may have been tempted to sink into our seat, hoping to see a zealous emergency-room doctor jumping up to the rescue. For physicians who do not regularly work in ER settings, a reluctance to intervene in emergency situations is understandable. Nonetheless, physicians can take steps to prepare themselves for the next in-flight medical emergency.

The chance of a medical event happening on a flight is approximately 1 in 604, while the chance that a physician will be onboard a commercial flight is close to 50%. Research suggests that the most common in-flight medical emergencies are syncope and presyncope, respiratory symptoms, nausea and vomiting, and possible cardiac symptoms. Potential stroke and cardiac arrest were relatively infrequent.[1]

When assuming care, it is important for the most qualified physician on the flight to assume responsibility. He or she must ensure that the flight crew and others work as a team. This may include moving the patient to a more spacious and accessible area, such as the galley, as well as ensuring control over curious or insensitive passengers. In addition, confirming active licensure by having a smartphone screenshot of your CPSBC registration page may be helpful to verify your medical credentials.

In Canada, onboard emergency medical equipment is required for all commercial flights of more than 100 passengers. In the United States, all flights exceeding 7500 pounds with at least one flight attendant are required to have such equipment. The contents of the medical kits are determined by Transport Canada or the Federal Aviation Administration (FAA) and include specific equipment such as gloves, sphygmomanometers, airway devices, and syringes. Full details on the required contents of in-flight medical kits can be viewed on Transport Canada’s and the FAA’s websites.[2,3]

Although automated external defibrillators (AEDs) are not a requirement in Canada (they are required in the US), AEDs are available on many Air Canada and WestJet flights. The medications carried by each airline include cardiac resuscitation drugs like atropine and epinephrine, acetylsalicylic acid, antihistamines, antiemetics, glucose, and nitro. Supplemental medications, such as sedatives and antipsychotics, may be limited to drugs like valium and haloperidol, which may not be ideal. International flights on overseas carriers may present challenges as the language of labeling may not be standardized. In these situations, flight staff may be of assistance.

Due to ambient noise, it may be difficult to accurately measure blood pressure with a sphygmomanometer, and in these situations, obtaining a palpable radial pulse with deflation would be the next best option.

Pulse oximeters and digital-display blood pressure monitors are not standard medical equipment on most commercial airplanes. In anticipation of need, physicians can consider taking pulse oximeters and wrist-cuff digital-display blood pressure monitors as part of their regular carry-on luggage. These devices are relatively inexpensive and are readily available in most pharmacies in Canada.

Most major airlines contract with medical ground support companies staffed by physicians with aeronautical experience. Such companies offer support and direction and will ask questions pertaining to your qualifications and experience, the patient’s vital signs and symptoms, and your diagnosis and opinion regarding the need for flight diversion. The decision regarding flight diversion will usually be taken by ground support, while the final decision to divert flight rests with the flight captain.

Physicians involved in an in-flight medical emergency are required to fill out onboard incident/report forms. Although the probability of a physician being successfully sued for providing good Samaritan care is extremely low, it is recommended that you take a photo of the completed forms with your smartphone or tablet for legal and documentation purposes.[4]

Smartphone applications, such as airRx, may be a useful resource for physicians. These applications may include useful algorithms, advice for dealing with a death onboard, when it is reasonable to stop CPR, and a list of in-flight equipment and drugs. The more prepared you are, the more ready and confident you will be in the next in-flight medical emergency.  
—Ian Gillespie, MD
—Chris Rumball, MD 
Emergency and Public Safety Committee

Walk With Your Doc this spring
Spring is approaching and so is Move for Health Day on 10 May. During that week (6–14 May) we invite our patients to go for a Walk With Your Doc. As 2017 is Canada’s 150th birthday, we have been challenged to hold 150 Walk With Your Doc events in BC this year. We continue to grow our collaborative efforts for this event, and this year we are working with the Physiotherapy Association of BC and the BC Recreation and Parks Association. For more information visit http://walkwithyourdoc.ca/about. 
—Ron Wilson, MD
Chair, Doctors of BC Athletics and Recreation Committe

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This article is the opinion of the Emergency and Public Safety Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med 2013;368:2075-2083.
2.    Transport Canada. Canadian aviation regulations: 725.91 Emergency medical kit. Accessed 15 February 2017. www.tc.gc.ca/eng/civilaviation/regserv/cars/part7-standards-725-2173.htm....
3.    Federal Aviation Administration. Advisory circular: Emergency medical equipment (2006). Accessed 15 February 2017. www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-33B.pdf.
4.    The Canadian Medical Protective Association. Are there risks to acting as a good Samaritan? Accessed 15 February 2017. www.cmpa-acpm.ca/-/are-there-risks-to-acting-as-a-good-samaritan-.