In-flight Medical Emergencies

 

In 2018, approximately 2.8 million passengers flew in and out of U.S. airports per day. Twenty-four to 130 in-flight medical emergencies are estimated to occur per 1 million passengers; however, there is no internationally agreed-upon recording or classification system. Up to 70% of in-flight emergencies are managed by the cabin crew without additional assistance. If a health care volunteer is requested, medical professionals should consider if they are in an appropriate condition to render aid, and then identify themselves to cabin crew, perform a history and physical examination, and inform the cabin crew of clinical impressions and recommendations. An aircraft in flight is a physically constrained and resource-limited environment. When needed, an emergency medical kit and automated external defibrillator are available on all U.S. aircraft with at least one flight attendant and a capacity for 30 or more passengers. Coordinated communication with the pilot, any available ground-based medical resources, and flight dispatch is needed if aircraft diversion is recommended. In the United States, medical volunteers are generally protected by the Aviation Medical Assistance Act of 1998. There is no equivalent law governing international travel, and legal jurisdiction depends on the patient's and medical professional's countries of citizenship and the country in which the aircraft is registered.

Approximately 2.8 million passengers flew in and out of U.S. airports per day in 2018.1 An overhead announcement requesting medical assistance at cruising altitude presents a unique situation for any health care professional given the physically constrained, resource-limited environment. The term “in-flight medical event” is often used interchangeably with “in-flight medical emergency” and includes a spectrum of conditions, ranging from minor to serious.2 There is no internationally agreed-upon recording and classification system for in-flight medical emergencies, and prevalence estimates vary between 24 and 130 emergencies per 1 million passengers.35

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Medical volunteers onboard the aircraft should consider ethical factors (e.g., appropriate physical and mental condition to render aid, practice within scope of expertise) in response to a request for medical assistance from a cabin crewmember.2,7,8

C

Expert opinion in the absence of clinical trials

Medical volunteers onboard the aircraft should render aid with confidence that the overall personal legal risk is small unless there is gross negligence or willful misconduct.9,10,13,14,16,17

C

Existing legislation and legal precedence in the absence of clinical trials

Aircraft diversion recommendations should be made by the pilot, flight dispatch, cabin crew, medical volunteers, and ground-based medical support; the decision to divert is ultimately up to the pilot.7,22

C

Expert opinion and consensus guideline in the absence of clinical trials

For the initial management of syncope or near-syncope, the passenger should be placed in a supine position with legs elevated, be given supplemental oxygen, and have blood glucose level checked.7,17,22

C

Expert opinion and usual practice in the absence of clinical trials

For the initial management of dyspnea, pulse oximetry should be checked, supplemental oxygen given, and an inhaled bronchodilator administered as indicated.17,22

C

Expert opinion and usual practice in the absence of clinical trials

Initial management of cardiovascular symptoms such as chest pain or cardiac arrest should include obtaining vital signs, providing supplemental oxygen, administering aspirin and nitroglycerin, and using basic life support techniques.7,17,22

C

Expert opinion, usual practice, and consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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JOCELYN S. HU, MD, is the medical director of the Patient Centered Medical Home at Bayne-Jones Army Community Hospital, Fort Polk, La....

JORDAN K. SMITH, MD, is the medical director of emergency medicine at Christus Mother Frances Hospital, Sulphur Springs, Tex.

Address correspondence to Jocelyn S. Hu, MD, 1585 3rd St., Fort Polk, LA 71459 (email: jocelyn.s.hu.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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3. Dowdall N. “Is there a doctor on the aircraft?” Top 10 in-flight medical emergencies. BMJ. 2000;321(7272):1336–1337.

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9. Aviation Medical Assistance Act of 1998, 49 USC §44701 (1998). Accessed March 8,2020.https://www.govinfo.gov/content/pkg/CRPT-105hrpt456/pdf/CRPT-105hrpt456.pdf

10. Wong M. Doctor in the sky: medico-legal issues during in-flight emergencies. Med Law Int. 2017;17(1–2):65–98.

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15. Kodama D, Yanagawa B, Chung J, et al. “Is there a doctor on board?”: Practical recommendations for managing in-flight medical emergencies. CMAJ. 2018;190(8):E217–E222.

16. International Air Transport Association. Medical Manual. 11th ed. June 2018. Accessed November 22, 2019. https://www.iata.org/publications/Documents/medical-manual.pdf

17. Nable JV, Tupe CL, Gehle BD, et al. In-flight medical emergencies during commercial travel. N Engl J Med. 2015;373(10):939–945.

18. Federal Aviation Administration. Advisory circular 121-33B: emergency medical equipment. January 12, 2006. Accessed October 11, 2019. https://www.faa.gov/documentlibrary/media/advisory_circular/ac121-33b.pdf

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20. International Civil Aviation Organization. ICAO health-related documents. Chapter 6. Aeroplane instruments, equipment and flight documents. Accessed November 13, 2019. https://www.icao.int/MID/Documents/2013/capsca-mid3/ICAOHealthRelatedSARPsandguidelines.pdf

21. Verjee MA, Crone R, Ostrovskiy G. Medical issues in flight and updating the emergency medical kit. Open Access Emerg Med. 2018;10:47–51.

22. Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emergencies: a review. JAMA. 2018;320(24):2580–2590.

23. Sand M, Gambichler T, Sand D, et al. Emergency medical kits on board commercial aircraft: a comparative study. Travel Med Infect Dis. 2010;8(6):388–394.

24. Badawy SM, Thompson AA, Sand M. In-flight emergencies: medical kits are not good enough for kids. J Paediatr Child Health. 2016;52(4):363–365.

25. Aerospace Medical Association. Medical guidelines for airline travel: stresses of flight. September 2014. Accessed November 3, 2019. http://www.asma.org/asma/media/asma/Travel-Publications/Medical%20Guidelines/Stresses-of-Flight-Nov-2014.pdf

26. International Air Transport Association. Death on board. January 2018. Accessed November 28, 2019. https://www.iata.org/contentassets/ccbdc54681c24574bebf2db2b18197a5/death-on-board-guidelines.pdf

 

 

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