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Am Fam Physician. 2021;103(9):547-552

Related FPM article: What You Need to Know When Called Upon to Be a Good Samaritan

Related letter: In-Flight Medical Emergencies and Medical Legal Issues

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

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

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

In-flight Medical Emergency Basics

Up to 65% to 70% of in-flight medical emergencies are managed by a cabin crew without the assistance of a health care professional.3,6 Crewmembers are trained in individual airline operating protocols, cardiopulmonary resuscitation (CPR), and the use of emergency and lifesaving equipment (e.g., automated external defibrillators [AEDs]) carried onboard.2 If a crewmember requests assistance from a volunteer medical professional, the volunteer should first consider if he or she is in a suitable condition to render aid (e.g., no recent use of alcohol or sleep aids, not fatigued).2 Table 1 summarizes a general approach to in-flight emergencies for volunteer medical professionals.2,7,8 Volunteers should understand that an aircraft in flight is a medically austere environment. For example, aircraft noise may render a stethoscope ineffective for auscultating a manual blood pressure; alternative systolic blood pressure can be measured by the first palpable radial pulse when slowly releasing the pressure in the sphygmomanometer.7

Identify yourself and state your medical qualifications. The airline may require proof of credentials (e.g., business card, licensure documents).
Perform as much of a complete history as possible.
 This may require an interpreter, involvement from family members, or other nearby passengers.
 Identify high-risk symptoms (e.g., chest pain, shortness of breath, focal neurologic deficits).
Obtain vital signs and perform an appropriate physical examination.
Inform the cabin crew of your clinical impression and recommendations.
Initiate ground-based consultation if not already initiated by the flight crew.
 The airline may require consultation before using the emergency medical kit.
 Aircraft diversion and ground-based medical assistance require coordination with the ground-based consultant and pilot.
Administer supplemental oxygen or use an automated external defibrillator as indicated.
Document the clinical presentation and care rendered; the airline may have specific forms to complete.

Physicians assist in 46% to 48% of in-flight medical emergency requests6,7; other skilled medical professionals who respond include nurses (20.1%) and emergency medical services personnel (4.4%).7 Medical volunteers are generally protected when providing medical care during an in-flight medical emergency on U.S. commercial aircraft by the Aviation Medical Assistance Act of 1998, which releases volunteers from liability unless there is gross negligence or willful misconduct.9 There is no equivalent law governing international travel; legal jurisdiction depends on the patient's and volunteer's countries of citizenship and the country in which the aircraft is registered.8,1013 The United States, England, and Canada do not mandate physicians to render emergency medical services in flight,1315 but a legal obligation to assist exists in Australia and many other European countries.10,14 Experts in aviation medicine support the use of medical volunteers for in-flight medical emergencies because the overall personal legal risk is small.16,17 There has yet to be a U.S. case heard in court against a physician-passenger providing medical care during an in-flight medical emergency.10,14

Onboard Medical Equipment

The Federal Aviation Administration (FAA) has mandated that certain medical supplies be available on U.S. commercial aircraft (Table 2)18; similarly, the European Union Aviation Safety Agency and International Civil Aviation Organization have established minimum recommendations for emergency medical kit contents.1820 The FAA requires an AED on aircraft with at least one flight attendant and a capacity for 30 or more passengers.18 No such mandate exists for European airlines; however, many carry an AED onboard.21 Non-U.S. airlines may carry additional controlled substances for analgesia and sedation.19,21 Some U.S. and international airlines have opted to expand their emergency medical kits with additional medications or equipment (Table 3).19,22 If the desired item is not available in the kit, the flight crew can make an overhead announcement requesting the item from other passengers.

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