Commercial in-flight medical emergencies: Difference between revisions
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==Background== | ==Background== | ||
*1 per 604 flights<ref name="peterson">Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052</ref> | *Incidence of in-flight emergencies: 1 per 604 flights<ref name="peterson">Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052</ref> (0.3% of cases died) | ||
**For references, there are ~29,000 commercial flights per day in the US alone<ref>NOAA. Air Traffic. http://sos.noaa.gov/Datasets/dataset.php?id=44 Accessed 03/08/2016</ref> | |||
*As the population ages and people travel longer distances, this number is likely to increase<ref>Goodwin T. In-flight medical emergencies: an overview. BMJ : British Medical Journal. 2000;321(7272):1338-1341.</ref> | |||
===Epidemiology<ref name="peterson" | ===Epidemiology<ref name="peterson"/>=== | ||
* | *Syncope or presyncope (37.4%) | ||
* | *Respiratory symptoms (12.1%) | ||
* | *Nausea or vomiting (9.5%) | ||
*Cardiac symptoms (7.7%) | *Cardiac symptoms (7.7%) | ||
*Seizures (5.8%) | *Seizures (5.8%) | ||
| Line 19: | Line 20: | ||
*Arm or leg pain or injury (1.0%) | *Arm or leg pain or injury (1.0%) | ||
*Obstetrical or gynecologic symptoms(0.5%) | *Obstetrical or gynecologic symptoms(0.5%) | ||
Ear pain (0.4%) | *Ear pain (0.4%) | ||
*Cardiac arrest (0.3%) | *Cardiac arrest (0.3%) | ||
*Laceration (0.3%) | *Laceration (0.3%) | ||
==Emergency | ==Emergency Medical Kit== | ||
*The FAA requires all aircraft with >30 passengers to carry an Emergency Medical Kit and an AED<ref name="Bukowski">Bukowski JH, Richards JR. Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues. J Emerg Med. 2016 Jan;50(1):74-8.</ref> | |||
**This requirement is the "minimum acceptable", but some airlines carry more extensive kits | |||
{{EMK}} | {{EMK}} | ||
==Management== | ==Management== | ||
===General Approach=== | ===General Approach=== | ||
*Identify yourself and level of medical training | *Identify yourself and level of medical training to the crew | ||
*Ask a flight attendant to obtain the emergency medical kit (EMK) | *Ask a flight attendant to obtain the emergency medical kit (EMK) | ||
===Patient assessment=== | |||
*Identify chief complaint and HPI | |||
*Obtain vital signs (pulse and blood pressure) | |||
**If you are unable to assess blood pressure by means of auscultation, assess it by palpating the radial pulse | |||
*Assess mental status and perform a focused physical exam based on chief complaint | |||
*If the patient is in cardiac arrest, obtain and apply an automated external defibrillator (AED) | |||
**For patients with a pulse but a suspected cardiac problem, consider applying AED pads to use as a cardiac monitor and rhythm strip (if AED has display screen) | |||
===Management of Syncope or Presyncope=== | ===Management of Syncope or Presyncope=== | ||
*Confirm breathing and pulse | |||
*Move the patient to an aisle or galley, place the patient in a supine position with legs raised, and provide oxygen | |||
*Check vital signs | |||
**Most patients will be hypotensive immediately after the episode | |||
*If the patient has diabetes, a glucometer from the patient or a fellow passenger may be used for glucose assessment. | |||
*Most patients will recover spontaneously within minutes. Give oral fluids when possible | |||
*Consider intravenous fluids only if the patient is persistently hypotensive and cannot take oral fluids or has another indication. | |||
===Management of Chest Pain or Palpitations=== | ===Management of Chest Pain or Palpitations=== | ||
| Line 58: | Line 62: | ||
===Aftercare=== | ===Aftercare=== | ||
*Initiate consultation with the ground-based consultant if not already initiated by the flight crew | |||
*Consider discussing administration of medications or intravenous fluids with ground-based consultant | |||
*Aircraft diversion, ground-based medical assistance, or both should be coordinated with ground-based consultation | |||
*Document the clinical presentation and care rendered and give documentation to medical personnel on arrival at the destination with transfer of care | |||
== | ==Medicolegal Issues== | ||
*Responding to a request for assistance creates a "doctor-patient" relationship<ref name="Nable">Nable JV, Tupe CL, Gehle BD, Brady WJ. In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45.</ref> | |||
*Duty to respond<ref name="Bukowski"/> | |||
**There is no legal duty for a physician to respond to an in-flight emergency in the USA, Canada, and the UK (in the absence of a pre-existing doctor-patient relationship) | |||
**In Australia and many European countries, there is a legal duty to respond | |||
*Legal jurisdiction is usually determined by the country in which the aircraft is registered, but the location of the incident may apply as well<ref name="Nable"/> | |||
== | ===United States=== | ||
< | *The Aviation Medical Assistance Act (AMAA) of 1998 provides liability coverage for "medically qualified individuals" who provide medical care aboard an aircraft and imposes a standard of "gross negligence or willful misconduct" | ||
**Covers a wide range of medically trained passengers, including physicians, nurses, PAs, EMTs, etc. | |||
**Provider is not prohibited from accepting compensation in order to receive liability protection under the AMAA<ref name="Nable"/> | |||
<center>________</center> | |||
{{quote|text="An individual shall not be liable for damages in 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 medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct."|sign=Aviation Medical Assistance Act of 1998|source=Public Law 105–170—April. 24, 1998[http://www.medaire.com/docs/default-document-library/aviation-medical-assistance-act-of-1998-.pdf?sfvrsn=0 .pdf]}} | |||
==See Also== | ==See Also== | ||
[[High Altitude Medicine]] | *[[High Altitude Medicine]] | ||
==References== | |||
<references/> | |||
[[Category:Environ]] | [[Category:Environ]] | ||
Revision as of 08:12, 9 March 2016
Background
- Incidence of in-flight emergencies: 1 per 604 flights[1] (0.3% of cases died)
- For references, there are ~29,000 commercial flights per day in the US alone[2]
- As the population ages and people travel longer distances, this number is likely to increase[3]
Epidemiology[1]
- Syncope or presyncope (37.4%)
- Respiratory symptoms (12.1%)
- Nausea or vomiting (9.5%)
- Cardiac symptoms (7.7%)
- Seizures (5.8%)
- Abdominal pain (4.1%)
- Infectious disease (2.8%)
- Agitation or psychiatric symptoms (2.4%)
- Allergic reaction (2.2%)
- Possible stroke (2.0%)
- Trauma, not otherwise specified (1.8%)
- Diabetic complication (1.6%)
- Headache (1.0%)
- Arm or leg pain or injury (1.0%)
- Obstetrical or gynecologic symptoms(0.5%)
- Ear pain (0.4%)
- Cardiac arrest (0.3%)
- Laceration (0.3%)
Emergency Medical Kit
- The FAA requires all aircraft with >30 passengers to carry an Emergency Medical Kit and an AED[4]
- This requirement is the "minimum acceptable", but some airlines carry more extensive kits
Common Airline Emergency Medical Kit Contents[5]
| Medications | Equipment |
| Epinephrine 1:1000 | Stethoscope |
| Antihistamine, inj | Sphygmomanometer |
| Dextrose 50%, inj. 50 ml | Airways, oropharyngeal (appropriate range of sizes) |
| Nitroglycerin tablets or spray | Syringes (appropriate range of sizes) |
| Major analgesic, inj. or oral | Needles (appropriate range of sizes) |
| Sedative anticonvulsant, inj. | IV Catheters (appropriate range of sizes) |
| Antiemetic, inj. | Antiseptic wipes |
| Bronchodilator inhaler | Disposable gloves |
| Atropine, inj. | Sharps box |
| Adrenocortical steroid, inj. | Urinary catheter |
| Diuretic, inj. | System for delivering intravenous fluid |
| Medication for postpartum bleeding | Venous tourniquet |
| Sodium chloride 0.9% (minimum 250 ml) | Sponge gauze |
| Acetyl Salicylic Acid for oral use | Tape adhesive |
| Oral beta blocker | Surgical mask |
| Flashlight and batteries | |
| Thermometer (non-mercury) | |
| Umbilical cord clamp | |
| Basic Life Support cards | |
| List of equipment | |
| Advanced Life Support Guides |
Management
General Approach
- Identify yourself and level of medical training to the crew
- Ask a flight attendant to obtain the emergency medical kit (EMK)
Patient assessment
- Identify chief complaint and HPI
- Obtain vital signs (pulse and blood pressure)
- If you are unable to assess blood pressure by means of auscultation, assess it by palpating the radial pulse
- Assess mental status and perform a focused physical exam based on chief complaint
- If the patient is in cardiac arrest, obtain and apply an automated external defibrillator (AED)
- For patients with a pulse but a suspected cardiac problem, consider applying AED pads to use as a cardiac monitor and rhythm strip (if AED has display screen)
Management of Syncope or Presyncope
- Confirm breathing and pulse
- Move the patient to an aisle or galley, place the patient in a supine position with legs raised, and provide oxygen
- Check vital signs
- Most patients will be hypotensive immediately after the episode
- If the patient has diabetes, a glucometer from the patient or a fellow passenger may be used for glucose assessment.
- Most patients will recover spontaneously within minutes. Give oral fluids when possible
- Consider intravenous fluids only if the patient is persistently hypotensive and cannot take oral fluids or has another indication.
Management of Chest Pain or Palpitations
- Check vital signs
- Provide oxygen
- If chest pain may be cardiac in origin, administe aspirin
- If systolic blood pressure is more than 100 mm Hg, consider administering sublingual nitroglycerin every 5 minutes
- Check blood pressure after each dose
- If the AED has monitoring capabilities, consider its use to evaluate the cardiac rhythm and evidence of ST-segment changes in the limb leads
- If symptoms resolve with the above measures, aircraft diversion is not typically required. Ground-based consultation can assist with diversion decisions
Aftercare
- Initiate consultation with the ground-based consultant if not already initiated by the flight crew
- Consider discussing administration of medications or intravenous fluids with ground-based consultant
- Aircraft diversion, ground-based medical assistance, or both should be coordinated with ground-based consultation
- Document the clinical presentation and care rendered and give documentation to medical personnel on arrival at the destination with transfer of care
Medicolegal Issues
- Responding to a request for assistance creates a "doctor-patient" relationship[6]
- Duty to respond[4]
- There is no legal duty for a physician to respond to an in-flight emergency in the USA, Canada, and the UK (in the absence of a pre-existing doctor-patient relationship)
- In Australia and many European countries, there is a legal duty to respond
- Legal jurisdiction is usually determined by the country in which the aircraft is registered, but the location of the incident may apply as well[6]
United States
- The Aviation Medical Assistance Act (AMAA) of 1998 provides liability coverage for "medically qualified individuals" who provide medical care aboard an aircraft and imposes a standard of "gross negligence or willful misconduct"
- Covers a wide range of medically trained passengers, including physicians, nurses, PAs, EMTs, etc.
- Provider is not prohibited from accepting compensation in order to receive liability protection under the AMAA[6]
"An individual shall not be liable for damages in 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 medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct."
—Aviation Medical Assistance Act of 1998, Public Law 105–170—April. 24, 1998.pdf
See Also
References
- ↑ 1.0 1.1 Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052
- ↑ NOAA. Air Traffic. http://sos.noaa.gov/Datasets/dataset.php?id=44 Accessed 03/08/2016
- ↑ Goodwin T. In-flight medical emergencies: an overview. BMJ : British Medical Journal. 2000;321(7272):1338-1341.
- ↑ 4.0 4.1 Bukowski JH, Richards JR. Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues. J Emerg Med. 2016 Jan;50(1):74-8.
- ↑ Thibeault C et al. Emergency medical kit for commercial airlines: an update. Aviat Space Environ Med. 2007 Dec;78(12):1170-1.PDF
- ↑ 6.0 6.1 6.2 Nable JV, Tupe CL, Gehle BD, Brady WJ. In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45.