Friday, June 14, 2013

Is there a Doctor on Board - Medical Emergencies in the Air

A little while ago I was on a flight from the East Coast to the Caribbean.  We were about halfway through our journey somewhere over the Atlantic; I had my seat reclined, a good book in hand, and daydreams of a sunny beach in my head.  All of a sudden the flight attendant announced: "Is there a Doctor on board?, attention everyone we need a doctor".  I sheepishly looked around to see if anyone else was going to the back of the plane.  Having just graduated from medical school last year, I sometimes forget that I'm actually a doctor.  Another passenger got up and made her way to the back.  Phew, my moment of glory (and anxiety) would wait for another flight....Or so I thought.  I few minutes later the same message came on overhead.  This time I walked to the back of the plane where the commotion was.  It turns out the other passenger who had responded was a podiatrist - a foot specialist - and this was not a foot emergency. 

In the back of the plane by the lavatories I saw an elderly woman sitting on the ground looking pale and nauseated.  I introduced myself, got some basic history and then dug into the medical supply kit for a stethoscope and blood pressure cuff.  The kit contained the most basic equipment and I could hardly hear heart sounds over the noise of the engine.  While I was doing this the patient explained to me that she was getting motion sick, was making her way to the bathroom, got lightheaded and sat down in the isle.  Now, in a well stocked emergency room, an older woman with nausea, lightheadedness and weakness might warrant an extensive workup.  In the air however, i felt as if my job was done after collecting the vital signs and a bit of history and providing reassurance.  The lady was escorted to a seat near the bathroom and started to feel better within minutes.  I got a thank you from the flight attendant and later that day I was sitting on the beach.

As a freshly minted ER doctor, this situation got me thinking about in flight emergencies so I decided to do some research.  I had a lot of questions and very few answers.  How many doctors actually respond? Are all medical kits the same?  How often do emergencies occur?  What happens if there is no one on the plane to help? 

Deciding to respond to a medical emergency is a complicated decision for many doctors.  The benefit of responding is clear: potentially saving a life.  The drawbacks however, are less obvious.  Imagine for example you are on a late night long-haul flight across 3 time zones and had a few drinks before boarding.  Would you respond?  Imagine you are a psychiatrist or a pediatrician, would you respond to an elderly man with chest pain?  Imagine you just got done working a 80hr week and are finally on vacation.  Would you really want to "go back to work"?  Consider working in an unfamiliar, noisy and chaotic environment with countless eyes watching and scrutinizing your every move.  These are the decisions that medical professionals must make when deciding to press the call button or not.

Virtually everyone has heard of the "good samaritan law" but there are lots of misconceptions on what it actially means.  Laws vary from state to state and country to country.  Generally the law will protect the medical professional from legal liability except in cases of "gross negligence".  This law however does not make you immune from all legal issues.   If a bad outcome were to occur, you would likely need to still go through the legal process to prove that your actions were justified under the good samaritan law and that you did not commit gross negligence.  Gross negligence is a difficult term to understand and is open interpretation.  It essentially means any action which varies greatly from the standard of practice weather intentional or not.  Take for example that podiatrist mentioned above.  They most likely have never seen a heart attack patient.  Even if they had the best of intentions, if they deviated from the standart ACLS guidelines they may be held liable.  For some physicians, legal considerations are enough for them to turn a death ear towards calls for medical assistance.

With regards to on board medical kits there are basic requirements but there does seem to be great variance between the actual contents of kits.  The required medications include: a non-narcotic pain killer, IV fluids, an antihistamine, an inhaler for asthma, aspirin and nitroglycerin for a heart attack, IV dextrose for low blood sugar, epinephrine for allergic reactions or asthma, and epinephrine, atropine, and lidocaine as an adjunct to CPR. The kits must also contain a stethoscope, manual blood pressure cuff, and an AED.

The exact frequency of medical emergencies on planes has been difficult to estimate.  This is due in part to a lack of reporting.  Airlines are only required to report deaths or medical diversions.  All other emergencies are reported voluntarily. 

There are a few ground based aviation emergency call centers which are staffed by emergency physicians which offer advice to flight crews during in-air emergencies.  These call centers help flight crews manage medical situations when there is not a qualified medical professional on the plane.  The data from these centers was recently published in the New England Journal of Medicine in an article titled Outcomes of medical emergencies on commercial airline flights.  During the study period, medical emergencies occurred at a rate of 16 per 1 million passengers or about 1 per every 604 flights.  Obviously, probability dictates that the longer the flight and the more passengers are on a plane, the more likely a medical emergency is to occur. 

A break down of the outcomes of emergencies in this study were as follows:

Emergency resolved before landing: 31%
EMS requested at landing: 69%
Transported to Hospital 26%
Admitted to hospital 8.3%
Aircraft diversion: 7.3%
Death: 0.029%

For me personally, I will respond to emergencies if i am in the right mind to do so (no alcohol and not overly sleep deprived).  Afterall, I am trained in emergency medicine.  I think this is a decision that every medical practitioner must make on their own, and I do not find any fault in those who do decide not to respond.

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