“If there is a physician on board, could you please identify yourself to a flight attendant?” Some estimates suggest that 60% to 70% of physicians have been involved in some sort of in-flight medical emergency. While in-flight medical emergencies are haphazardly recorded and there is little follow up among the airlines, it is estimated that in-flight emergencies occur between 0.4 and 3.4 per 100,000 passenger trips. One study of in-flight emergencies showed approximately 3% were sudden death and some 13% were “significant” cardiovascular problems, including myocardial infarctions and cerebrovascular accidents. Given the number of worldwide flights daily, estimates are that there are approximately 30 in-flight emergencies each day.
The nature and estimated frequencies of in-flight emergencies are shown in Table 20–2. It is clear that older adults will be at greater risk of in-flight emergencies from some, but not all, of these causes. They will have a greater probability of having coronary artery disease (either known or unknown), chronic obstructive pulmonary disease, syncope because of autonomic dysregulation, and perhaps more confusion from various causes such as underlying cognitive impairment or adverse medication side effects. Because the health professional facing an in-flight emergency involving an older adult does not have the diagnostic support to make more than a “best guess” about the cause of the distress, consideration must be given to the illness frequencies shown in Table 20–2 that might account for the observed problem.
Table 20-2.Nature of in-flight emergencies. ||Download (.pdf) Table 20-2. Nature of in-flight emergencies.
|Category (% of All Emergencies) ||Problem (% of Category) |
|Neurologic (16.7%) || |
|Cardiac (15.9%) || |
Suspected infarct (50%)
|Psychiatric (14.9%) || |
Alcohol related (33%)
|Gastrointestinal (10.9%) || |
Abdominal pain (33%)
|ENT (8.9%) || |
Otic barotrauma (50%)
Sinus barotrauma (10%)
|Pulmonary (6.9%) || |
|Trauma (3.9%) || |
Alcohol related (50%)
|Diabetes and hypoglycemia (3.7%) || |
|Symptoms only (8.9%) || |
The health professional can benefit from knowledge about what resources are available in the event of an emergency and a recounting of those resources is in order.
Flight attendants are experienced, trained in emergency procedures, and have some training in emergency first aid. Many have “been there and done that” during in-flight medical emergencies, so consult them early and often!
Most U.S. carriers have an experienced physician trained in emergency medicine and aerospace medicine available for consultation by air-to-ground communication. As a general rule, any emergency where diverting the aircraft for an unscheduled landing is being considered will require approval from this “on-call flight surgeon” as well as the Captain of the aircraft.
All U.S. aircraft having one or more flight attendants will have an automatic external defibrillator (AED) on board. The flight attendants will be trained in its operation. An AED can indicate the cardiac rhythm and will not administer a shock unless the rhythm is one that may respond to the shock.
Most major carriers and all U.S. airlines except “commuter airlines” must have an “Enhanced On-Board Emergency Medical Kit.” This kit contains diagnostic equipment (blood pressure cuff, stethoscope, etc), oropharyngeal airways, intravenous infusion equipment, oral medications, injectables, inhalers and resuscitation equipment including an Ambu bag, laryngoscope and airways. Table 20–3 is a more complete enumeration of the contents.
Larger jet aircraft carry medical oxygen in “walk around” tanks and the number of tanks varies with the size of the aircraft. Each tank supplies approximately thirty minutes of oxygen so extended hours of oxygen support will not be possible. “Commuter airlines” aircraft are not required to carry medical oxygen and will usually not have the “Enhanced Emergency Medical Kit.” Commuter aircraft will, however, have an AED onboard if the aircraft has at least 1 flight attendant.
Table 20-3.Contents of an enhanced on-board emergency medical kit. ||Download (.pdf) Table 20-3. Contents of an enhanced on-board emergency medical kit.
Some older adults have such severe medical problems that flying is not advised. The most common contraindication to air travel is pulmonary insufficiency with chronic obstructive pulmonary disease (COPD) being the most common diagnosis. A PaO2 (partial pressure of arterial oxygen) of less than 70 mm Hg at rest is usually a contraindication to air travel. In essence, any medical condition requiring supplemental oxygen at rest should be carefully evaluated to see if the stress of flying at a cabin pressure altitude of 6000 to 8000 feet can be tolerated. Supplemental oxygen can be arranged on-board and the duration of the oxygen administration is not constrained by the limited amount of emergency medical oxygen on board. Prior arrangements with the airline must be made and consultation with the medical department of the airline must be completed so the appropriate flow rate of the oxygen at altitude can be determined in advance. As a general rule, passengers may not take their personal oxygen tanks on board the aircraft and only certain types of concentrators are approved by the Federal Aviation Administration for use on board. Other medical problems that are contraindications to flying include unstable coronary disease or a recent myocardial infarction (usually said to be 3 weeks prior), recent surgery (2–3 weeks for ear, nose, and throat [ENT], ocular, or gastrointestinal surgery, and several more weeks for orthopedic surgery where DVT risk is increased), significant neurologic disability or recent stroke and behavioral issues caused by cognitive impairment or psychiatric problems.
The question of liability in responding to an on-board medical emergency was somewhat clarified in the United States in 1998 by the passage of the Aviation Medical Assistance Act (Public Law 105-170) which provides some “good samaritan” protection to health professionals rendering aid in a medical emergency in flight. To be covered by this law, the health professional must render care in good faith, be “medically qualified,” be a volunteer and must not accept monetary payment for services rendered. The medical care rendered “must be similar to the care that others with similar training would provide under such circumstances.” The United States, Canada, and the United Kingdom do not require health professionals to volunteer to provide care in an emergency, but many European countries and Australia do. The flag of the airline determines whether health professionals are or are not “required” to provide care. It is clear that enforcement of the “must volunteer” provision is problematic. Some uncertainty about legal jurisdiction in the case of international flights or even domestic flights over various states remains unsettled by case law as few lawsuits against health professionals providing care in medical emergencies in flight are on record. In-flight emergencies are best handled if the provider is aware of the treatment resources available on board the aircraft, is prepared to render care in the face of considerable uncertainty because of the lack of diagnostic information, provides care only “within the scope of a person with similar training,” and understands that, in the final analysis, clinical decisions made at 35,000 feet are often “your best guess.”
Some understanding of the risks of travel by older adults, resources for planning in advance of travel and what resources are available to health professionals in the event of being called to help in a medical emergency will better prepare both the elder traveler and the responding health professional when that “dreaded call” comes over the public address system in the midst of a journey.
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