Author: Alexis Germain
Picture this. You’re flying to your brand new residency program with your brand new medical degree and your brand new responsibility. The dreaded announcement comes out over the intercom “Is there a doctor on board?”
With an incidence of 1 medical emergency out of every 604 flights, it’s not an entirely unlikely scenario you may find yourself in. And thanks to the Aviation Medical Assistance Act passed by congress in 1998 medical providers assisting during an in-flight emergency are considered good samaritans with liability protection. Simulating the in-flight emergency provides a versatile exercise in which a medical problem must be managed with limited resources, and can prepare students to face the constraints of in-flight medical care.
While the pathophysiology of medical problems in the air is often similar to that on the ground, there are some additional factors to consider. At cruising altitude the cabin is maintained at an air pressure approximating an 8000 ft elevation. Decreased air pressure in the cabin leads to expansion of trapped air and can lead to increased pressure that become significant in patients with recent abdominal or intraocular surgery, a preexisting pneumothorax or pulmonary bleb, sinus infection, or URI. The lower air pressure additionally leads to a mild hypoxia due to lower partial pressure of oxygen. Consider this when assessing shortness of breath, particularly in patients with COPD that may be chronically hypoxic. Prolonged stasis from long distance travel may predispose patients to DVT and pulmonary embolism. Traveling in general may be stressful. Consider dehydration, particularly in cases of syncope.
First step, know what you’re working with! The following items are available on all domestic flights. Note that equipment can be highly variable on international flights.
Contents of Domestic In-Flight Medical Kits
||Sphygmomanometer, stethoscope, gloves
|Airway and breathing
||Oropharyngeal airways, bag-valve masks (3 sizes), CPR masks (3 sizes), Oxygen capable of delivery at 2-4 L/min
||Intravenous administration set, 500 mL saline solution, needles, syringes
||Analgesic tablets, nonnarcotic; antihistamine tablets; antihistamine, injectable; aspirin; atropine; bronchodilator inhaler; dextrose, 50%; epinephrine, 1:1,000 solution; epinephrine, 1:10,000 solution; intravenous lidocaine; nitroglycerin tablets
|Basics First Aid
||Bandages, splints, AED
||Ground based medical support
Flight attendants are certified in CPR
|Maybe (items not required by law, but possibly available)
||Glucometer, antiemetics, anticonvulsants, and additional cardiac medications. Note, controlled substances are not carried on US planes.
SOURCE: Nable JV et al. N Engl J Med. 2015;373(10):939-945, based on FAA requirements for all commercial airliners in the United States.
Ensure your simulation accurately depicts the constraints of in-flight medical care. Define a row and aisle.
1 simulator, 1 patient, 1 flight attendant (acts as the communication to the pilot and may assist with CPR), 1-2 fellow passengers
The most common causes of requests for medical assistance are syncope or pre-syncope (37.4%), respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%). Choose a medical emergency that requires utilization of the on board tools available, and delegation of tasks within the medical response team. For instance a cardiovascular emergency requiring CPR may require the simulator to have a crew member provide compressions, and select a bystander as a timekeeper while he or she places an IV to administer epinephrine. A concise overview of the most common in-flight medical emergencies with suggested management and pertinent history can be found in the 2018 JAMA article titled In-Flight Medical Emergencies: A Review (https://jamanetwork.com/journals/jama/fullarticle/2719313).
A challenge of this scenario is clearly and effectively communicating with the flight crew, pilot, and ground based medical support (GBMS). When an emergency is brought to the attention of the flight crew, they notify the pilot who then contacts ground based medical support. When a request for assistance from a medical provider goes out, the volunteer should approach the flight crew and clearly identify their name and credentials. Once a volunteer becomes involved his or her assessment and recommendations will be relayed down this chain of communication to GBMS. It may be effective to write down the information required to prevent details from being lost in translation.
Also consider how the un-involved passengers may impact the situation. More than ever it is important to maintain control over the scene, provide clear directions, and minimize the crowd around the patient.
Ultimately it is the pilot’s decision whether to continue on as planned with a request for EMS to meet at the gate, request expedited landing at the original destination, or divert and make an emergency landing. The final medical recommendation will come from GBMS. However, advice from medical providers on board can strongly influence the final decision. If the simulator does not provide a recommendation, have the flight crew prompt him or her after an initial history and physical. If the patient requires immediate treatment to prevent loss of life or limb, or is otherwise unstable a diversion may be necessary.
Many factors filter into the pilot’s decision to land the plane. For instance, aircraft often take off with more fuel than safe to land with. A safe landing may require dumping of fuel, which some aircraft are not capable of. In addition to operational concerns, a diverted landing may result in direct costs in the hundreds of thousands of dollars.
Consider adding additional complications to the simulation, particularly if multiple providers are participating. This is an uncontrolled environment in which you are likely to have a large audience. Another passenger may panic creating a distraction, having a lower level provider attempting to take control of the situation, or getting pushback on the decision to divert the plane from crew or ground control.
For additional practice with a case that is already fully written and ready for implementation check out the interactive case at the end of the SIMS Casebook which can be downloaded for free from the Apple Books Library.