In-flight Medical Emergencies Research Articles

A Systematic Review of Pediatric and Adult In-Flight Medical Emergencies.

In-flight medical emergencies (IMEs) are acute onboard events of illnesses or injuries with potential immediate risk to a passenger's short- or long-term health, or life. IMEs are significant events that are related to public safety concerns. With the increasing amount of annual air travel every year, it is expected that the number of encountered IMEs will continue to grow. Thus, it will be critical to develop and implement appropriate measures to manage IMEs with the best possible outcome. Despite the fact that most IMEs are self-limited with no serious adverse events, serious IME can lead to death, disability, or other unfavorable health outcomes, particularly as a result of suboptimal medical care. In this article, we systematically reviewed the published up-to-date evidence on the subject of in-flight emergencies with a specific focus on pediatric population.

Trauma patients are safe to fly 72 hours after tube thoracostomy removal.

Current recommendations for safe air travel following traumatic pneumothorax are 2 to 3 weeks after radiographic resolution. These recommendations are based on several small observational studies and expert consensus, which cite a theoretical risk of recurrence and hypoxia because of decreased oxygen tension at altitude. We sought to systematically study the timing of chest drain removal after traumatic pneumothorax and risk of recurrence in relation to air travel. A retrospective cohort study of consecutively admitted patients who sustained a traumatic chest injury treated with tube thoracostomy over a 5-year period was undertaken. Adult patients with a postremoval expiratory chest x-ray demonstrating absence of pneumothorax and at least a 24-hour observation period before flight were eligible for study. All patients were transferred to a participating medical center for continued care. In-flight medical monitoring was available for all patients. Baseline patient characteristics, interval period from drain removal to flight, in-flight medical records, and incidence of radiographic or clinical recurrence of pneumothorax at the destination facility were recorded. Seventy-three patients who met the inclusion criteria were studied. All were male with a median age of 24 years (interquartile range [IQR], 22-26 years), injury severity score of 30 (IQR, 24-38), and chest abbreviated injury scale value of 3 (IQR, 2-4). The majority of patients sustained a penetrating injury (74%). The median duration of tube thoracostomy was 4 days (IQR, 3-6 days). The median period between thoracostomy tube removal and flight was 2.5 days (IQR, 1.5-4 days). Twenty-nine patients (40%) remained mechanically ventilated during transport. There were no reported in-flight medical emergencies for the entire cohort. There were no reported postflight radiographic or clinical recurrences during the subsequent 30 days. After a 72-hour period of observation, air travel after tube thoracostomy removal appears safe for both mechanically ventilated and nonventilated patients. Therapeutic, level IV.

Flight Attendant's Perspective on the Medical Professional's Presence During In-Flight Cardiopulmonary Resuscitation.

About 95% of the two billion airlines passengers suffered from health issues (1). Furthermore, a call center in North Carolina noted that there were 16 in-flight emergency cases for every 1 million airlines passengers (2). Cardiac arrest is one of these cases, which is a cause for mortality for about 1000 people during the flights (3). Cardiopulmonary resuscitation (CPR) can be demonstrated by the medical professionals or trained people such as flight attendants. Commercial flights usually do not have official medical staffs on board. Hence, whenever there are in-flight medical emergency cases, flight attendants should be trained to manage such cases. Flight attendants themselves are laymen who are trained to do basic medical emergency interventions, that is, even if they intervene in such cases, they cannot take an appropriate decision as the medical professionals. During in-flight cardiac arrest, the flight attendants are mainly responsible to immediately contact the ground staff and voluntary medical professionals on board; besides, they also have a right to perform CPR (4). Certain airlines such as Air Canada and Scandinavian Airlines have policies related to medical supervision. They apply emergency telemedicine that involves emergency specialists as the commander (5). Furthermore, the specialists will assign some instructions for the flight attendants who manage the in-flight medical emergencies (5). In contrast, in Indonesia, in case of any in-flight medical emergency, the flight attendants would announce on call asking for the presence of any medical professionals on board; however, no official medical professionals are recruited on board by the airlines for any medical casualties or emergency. Attendant expressed that the rescuer had many senses while helping people with in-flight medical emergency like shocked while looking at the victim. Contrary, the rescuer also determined to take her responsibility as a cabin crew by helping the victim. Furthermore, she had to manage her dilemma before doing that. The flight attendant has already expressed her suggestion on having in-flight medical professionals so that she can focus on her responsibility as a cabin crew. NBAA (2016) declares that commercial airlines are suggested to make policies that involve medical professionals in managing in-flight medical emergency (6). These will make flight attendants feel comfortable in serving the passengers. Consequently, the flight attendant needs medical companionship while performing CPR on board. Hence, in-flight medical emergency management, which is part of prehospital management, can be guaranteed

"Is there a doctor on board?": Practical recommendations for managing in-flight medical emergencies.

KEY POINTS Hearing the call go out for a doctor at 36 000 feet can be anxiety-provoking for any physician. If health professionals offer their expertise, they may have to manage an unfamiliar clinical scenario, in a foreign and limited environment, without knowledge of the available resources.

Discovering frequent patterns for in-flight incidents

ObjectivesIn order to get a clearer idea of in-flight medical emergencies management, the application of Data mining tools can be useful to facilitate knowledge discovery from data collected by existing studies. The objective of this work is to conceptualize the construction of a Clinical Decision Support System (CDSS) in three stages corresponding to the representation levels necessary to extract knowledge from information and raw data. MethodThe method can be summarized in three parts: (1) in-flight medical incident data search, (2) the validation of this data using Data mining tools, (3) the construction of the CDSS in 3 steps corresponding to the levels of knowledge representation. These three steps will be carried out using tools such as EORCA (Event Oriented Representation for Collaborative Activities) which includes action codification with regard to an ontology and event representation. ResultData processing services provide a good structuration for information about in-flight medical incidents from which useful knowledge can be generated could improve the handling of other incidents by adapting the medical emergency equipments, for example. This structuring can be facilitated by the use of CDSS to fill in any gaps, increase coherency, and provide decision makers with a more complete picture of options that might be involved in a critical situation. ConclusionWe proposed an evolving framework facilitating the description of in-flight medical emergencies with adequate data collection and appropriate information that are required for producing interesting rules and better decisions. The data collected nourishes the organization of information, which can be improved over time by continuous integration of evidence gained from the number of incidents treated. Finally, it is proposed to strengthen requirements concerning the medical equipments available on-board, particularly in the light of knowledge resulting from the selection and approval of interesting rules.

Aviation Nursing and in-Flight Medical Emergencies: Aeromedical Consideration

People travel on commercial Aircraft worldwide on medical, social and economic indications. Although civil aviation industry acts as a fulcrum for the booming Medical Tourism, it encounters increasing number of in-flight medical emergencies in the recent years. Inflight medical events are potentially a significant problem due to aircraft at 30000 feet far from advanced medical care, restricted cabin space and resources. Several studies have shown that every day 0.7 to 3% in-flight medical events occur on board worldwide. Data collected by the Directorate General of Civil Aviation show that between August 2012 and August 2013, there was a total of 46 emergency landings, 38 were because of medical emergencies. The aim of this paper is (i) To assess the present system of cabin crew trained to meet the challenges of in-flight medical emergencies (ii) To evaluate the scientific soundness of Aviation Nursing in future. The objective is (1) To institute proper pre and post medical care in the event of any in-flight medical emergency (2) To reduce the incidence of flight diversion and emergency landing. Reviewing various literatures it was found that many authors have highlighted medical management by the trained cabin crew with the help of physician / paramedics on board, but this author raise one genuine doubt that all physicians on board would not be willing to come forward for such emergencies, it should not be an obligatory favour to tackle medical emergencies on board. Further, no published studies have touched upon the need of ‘Aviation Nursing’ /flight nurse for in flight medical emergencies.

In-Flight Emergency: Altered Mental Status Secondary to Hypoglycemia

Audience: This simulation is appropriate for all emergency medicine learners from medical students to senior residents. Introduction: It has been reported that 1 in every 10,000 to 40,000 passengers on board of a commercial airline will have a medical emergency while in- flight.1 That is roughly 1 out of every 600 flights.2 Many healthcare providers are unaware of the available medical equipment, effects of cabin pressure, and resulting opportunities for medical intervention. But physicians on board may be asked to render medical care for passengers experiencing medical emergencies in-flight. It is important for healthcare providers to be familiar with the most common in-flight medical emergencies and how to best address them. One common emergency that occurs during air travel is hypoglycemia in insulin dependent diabetic patients.3 It has been noted that changes in air and cabin pressures affect the amount of insulin secreted from insulin pumps. One article explains that as the airplane ascends, ambient pressure decreases and air comes out of solution, forming bubbles.3 These bubbles displace insulin in a pump, causing excess delivery.3 Excess insulin delivered during ascent in an airplane may cause hypoglycemia 1-2 hours later while in flight.1,3 The United States Food and Drug Administration states that it addresses such malfunction during the manufacturing of insulin pumps.3,4 However, there have still been reported malfunctions, which occur 40-50 times worldwide per year while in-flight.3 Objectives: By the end of this simulation session, learners will be able to: 1) Discuss the challenges associated with in-flight emergencies. 2) List what is available in United States (US) commercial airline medical kits. 3) Discuss an appropriate differential diagnosis for a patient with altered mental status (AMS). 4) Demonstrate appropriate treatment of hypoglycemia. 5) Describe possible complications in diabetic patients with insulin pumps when flying. 6) Review the legal ramifications of responding to an in-flight emergency. Method: This case can use a high, medium or low-fidelity simulation mannequin or a standardized patient; alternatively, this case can also be used as an oral boards case. Topics: Simulation, diabetes, hypoglycemia, altered mental status, seizure, endocrinology.

Doctor in the sky: Medico-legal issues during in-flight emergencies

More people are travelling by air and in-flight medical emergencies are becoming more common. Some in-flight emergencies require assistance from passenger doctors who act as good Samaritans in the sky. Their liability and the associated medico-legal issues of providing assistance in mid-flight emergencies are unknown. Although provisions exist in theory about good Samaritans on the ground, it is unclear to what extent these doctrines are applicable to good Samaritans in the sky. This article examines the obligations, liability and legal protection of doctors when acting as good Samaritans in mid-flight emergencies, regardless of their nationalities. It examines the jurisdiction, existing legislations, case law in the United Kingdom and compares with their equivalence in the United States and to some extent, with the legal provisions in France. In addition to in-flight emergencies, this article reviews airlines’ liability for injuries sustained by passengers during flight. It is concluded that doctors’ liability is unclear and uncertain, their legal protection is inadequate and inconsistent; airlines’ liability is restricted by the courts. Reforms proposed include legislative enactment and extension of commercial airliners’ insurance to accord the deficient legal protection.

Review of Issues and Challenges of Practicing Emergency Medicine Above 30,000-Feet Altitude: 2 Anonymized Cases

We present 2 anonymized cases to identify issues and challenges associated with long-haul in-flight medical emergencies. The first case involved a middle-aged man with a history of carditis on a systemic steroid who developed vomiting and rigor. Four physicians, including a pediatric intensivist, responded to the emergency call. In the second case, a pediatric trainee who was the only onboard medical personnel was summoned for help when a middle-aged man developed acute shortness of breath while traveling on a commercial flight. The cases illustrate the challenges and issues on the critical decisions of diagnosis, resuscitation, and whether the flight had to be returned or diverted. An extensive literature search is made to summarize the evidence available for these decisions and challenges. Epidemiology and outcomes associated with these medical emergencies are reviewed. In-flight medical emergencies are not rare. Physicians of all disciplines should be prepared to deal with these emergencies and make sensible decisions when equipment and resources are likely to be limited.

In-flight medical emergencies during airline operations: a survey of physicians on the incidence, nature, and available medical equipment.

BackgroundData on the incidence of in-flight medical emergencies on-board civil aircraft are uncommon and rarely published. Such data could provide information regarding required medical equipment on-board aircraft and requisite training for cabin crew. The aim of the present study was to gather data on the incidences, nature, and medical equipment for in-flight medical emergencies by way of a survey of physician members of a German aerospace medical society.Materials and methodsUsing unipark.de (QuestBack GmbH, Cologne, Germany), an online survey was developed and used to gather specific information. Members of the German Society for Aviation and Space Medicine (Deutsche Gesellschaft für Luft- und Raumfahrtmedizin e.V.; DGLRM) were invited to participate in the survey during a 4-week period (21 March 2015 to 20 April 2015). Chi-square test was used for statistical analysis (p<0.05 was considered significant).ResultsAltogether, 121 members of the society responded to the survey (n=335 sent out). Of the 121 respondents, n=54 (44.6%) of the participants (89.9% male and 10.1% female; mean age, 54.1 years; n=121) were involved in at least one in-flight medical emergency. Demographic parameters in this survey were in concordance with the society members’ demographics. The mean duration of flights was 5.7 hours and the respondents performed 7.1 airline flights per year (median). Cardiovascular (40.0%) and neurological disorders (17.8%) were the most frequent diagnoses. The medical equipment (78.7%) provided was sufficient. An emergency diversion was undertaken in 10.6% of the cases. Although using a different method of data acquisition, this survey confirms previous data on the nature of emergencies and gives plausible numbers.ConclusionOur data strongly argue for the establishment of a standardized database for recording the incidence and nature of in-flight medical emergencies. Such a database could inform on required medical equipment and cabin crew training.

Is there a doctor on board? In-flight medical emergencies.

Although not legally required to render assistance in the event of a medical emergency aboard an airplane, physicians have an ethical obligation to do so and should be prepared.

Prognostic Factors for Outcomes of In-Flight Sudden Cardiac Arrest on Commercial Airlines.

In-flight cardiac arrest (IFCA) is a relatively rare but challenging event. Outcomes and prognostic factors are not entirely understood for victims of IFCAs in commercial aviation. This was a retrospective cohort study of airline passengers who experienced IFCA. Demographic and operational variables were studied to identify association in a multivariate logistic regression model with the outcome of survival-to-hospital. In-flight medical emergencies were processed by a ground-based medical center. Subsequent comparisons were made between reported shockable-rhythm (RSR) and reported non-shockable-rhythm (RNSR) groups. Logistic regression was also used to identify predictors for shock advised and flight diversions using a case control study design. Significant predictors for survival-to-hospital were RSR and remaining flight time to destination. The percentage of RSR cases was 24.6%. The survival to hospital admission was 22.7% (22/97) for passengers in RSR compared with 2.4% (7/297) in the RNSR group. The adjusted odds ratio for survival-to-hospital for the RSR group compared to the RNSR group was 13.6 (5.5-33.5). The model showed odds for survival to hospital decreased with longer scheduled remaining flight duration with adjusted OR = 0.701 (0.535-0.920) per hour increase. No correlation between diversions and survival for RSR cases was found. Survival-to-hospital from IFCAs is best when an RSR is present. The percentage of RSR cases was lower than in other out-of-hospital cardiac arrest (OHCA) settings, which suggests delayed discovery. Flight diversions did not significantly affect resuscitation outcome. We emphasize good quality cardio-pulmonary resuscitation (CPR) and early defibrillation as key factors for IFCA survival. Alves PM, DeJohn CA, Ricaurte EM, Mills WD. Prognostic factors for outcomes of in-flight sudden cardiac arrest on commercial airlines. Aerosp Med Hum Perform. 2016; 87(10):862-868.

What to do during inflight medical emergencies? Practice pointers from a medical ethicist and an aviation medicine specialist.

What to do during inflight medical emergencies? Practice pointers from a medical ethicist and an aviation medicine specialist.

Emergências médicas em voos comerciais: uma revisão de literatura

Considerando o ambiente de cabine em voos comerciais como potencial cenário de emergências médicas, e conhecendo o crescente número de passageiros no Brasil e no mundo, torna-se importante o estudo a respeito de repercussões deste ambiente em indivíduos com morbidades comumente encontradas na população e reportadas nos atendimentos durante o voo. O objetivo foi observar a prevalência de registro das principais complicações das enfermidades mais comuns na população geral durante viagens em voos comerciais. A busca foi realizada por meio dos descritores “inflight medical emergencies” e emergências médicas a bordo, no banco de dados da BVS, que resultou em 62 artigos, PubMed, 17 artigos, UpToDate, 5 artigos, Infraero, 11 resultados, SBC, 1 resultado. Também foram realizadas buscas nos bancos de dados disponibilizados pela ANAC, ICAO, ASMA. Focou-se em desordens respiratórias, cardiovasculares, gastrointestinais, não havendo consenso de porcentagens para as respectivas incidências na literatura, porém essas pertencendo ao rol das comumente reportadas. Outros aspectos peculiares do atendimento nesse microambiente foram citados, como protocolo de procedimento de comunicação de emergência durante o voo e registro de atendimento dos mesmos. Observou-se a falta de estudos mais extensos e quantitativamente robustos para os aspectos abordados, estando essa assertiva presente em todos os artigos encontrados. Com o exposto, concluiu-se pela necessidade desses estudos, bem como por maior divulgação de informações acerca desses atendimentos pelas companhias aéreas e órgãos regulamentadores.

Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues

BackgroundAs the prevalence of air travel increases, in-flight medical emergencies occur more frequently. A significant percentage of these emergencies occur when there is no certified physician, nurse, or paramedic onboard. During these situations, flight crews might enlist the help of noncertified passengers, such as medical students, dentists, or emergency medical technicians in training. Although Good Samaritan laws exist, many health care providers are unfamiliar with the limited legal protections and resources provided to them after responding to an in-flight emergency. Case ReportA 78-year-old woman lost consciousness and became pulseless onboard a commercial aircraft. No physician was available. A medical student responded and coordinated care with the flight crew, ground support physician, and other passengers. After receiving a packet (4 g) of sublingual sucrose and 1 L i.v. crystalloid, the patient regained pulses and consciousness. The medical student made the decision not to divert the aircraft based on the patient's initial response to therapy and, 45 min later, the patient had normal vital signs. Upon landing, she was met and taken by paramedics to the nearest emergency department for evaluation of her collapse. Why Should an Emergency Physician Be Aware of This?Emergency physicians are the most qualified to assist in-flight emergencies, but they might not be aware of the medicolegal risks involved with in-flight care, the resources available, and the role of the flight crew in liability and decision making. This case, which involved a medical student who was not given explicit protection under Good Samaritan laws, illustrates the authority of the flight crew during these events and highlights areas of uncertainty in the legislation for volunteer medical professionals.

Pulmonary Artery Pressure Response to Simulated Air Travel in a Hypobaric Chamber.

Hypoxia-induced elevation in pulmonary artery pressure during air travel may contribute to the worldwide burden of in-flight medical emergencies. The pulmonary artery pressure response may be greater in older passengers, who are more likely to require flight diversion due to a medical event. Understanding these effects may ultimately improve the safety of air travel. We studied 16 healthy volunteers, consisting of a younger group (aged <25 yr) and an older group (aged >60 yr). Using a hypobaric chamber, subjects undertook a 2-h simulated flight at the maximum cabin pressure altitude for commercial airline flights (8000 ft; 2438 m). Higher and lower altitudes within the aeromedical range were also explored. Systolic pulmonary artery pressure (sPAP) was assessed by Doppler echocardiography. There was a progressive increase in sPAP which appeared to be biphasic, with a small initial increase and a larger subsequent rise. Overall, sPAP increased by 5±1 mmHg from baseline to 35±1 mmHg at 8000 ft, an increase of 18%. The sPAP response to 8000 ft was greater in the older group than the younger group. This study confirms that pulmonary artery pressure increases during simulated air travel, and provides preliminary evidence that this response is greater in older people. Advancing age may increase in-flight susceptibility to adverse pulmonary vascular responses in passengers, aircrew, and aeromedical patients.

AsMA Medical Guidelines for Air Travel: Reported In-Flight Medical Events and Death.

Medical Guidelines for Airline Travel provide information that enables healthcare providers to properly advise patients who plan to travel by air. Although there are no publicly available databases providing information on the number of in-flight medical emergencies, the few studies published in the literature indicate that they are uncommon. Minor illnesses such as near-fainting, dizziness, and hyperventilation occur more frequently. However, serious illnesses, such as seizures and myocardial infarction, also occur. In-flight deaths are also rare.

Management of in-flight medical emergencies: are senior medical students prepared to respond to this community need?

IntroductionIn-flight medical emergencies on commercial aircraft are common in both domestic and international flights. We hypothesized that fourth-year medical students feel inadequately prepared to lend assistance during in-flight medical emergencies. This multicenter study of two U.S. medical schools obtains a baseline assessment of knowledge and confidence in managing in-flight medical emergencies.MethodsA 25-question survey was administered to fourth-year medical students at two United States medical schools. Questions included baseline knowledge of in-flight medicine (10 questions) and perceived ability to respond to in-flight medical emergencies.Results229 participants completed the survey (75% response rate). The average score on the fund of knowledge questions was 64%. Responses to the 5-point Likert scale questions indicated that, on average, students did not feel confident or competent responding to an in-flight medical emergency. Participants on average also disagreed with statements that they had adequate understanding of supplies, flight crew training, and ground-based management.ConclusionThis multicenter survey indicates that fourth-year medical students do not feel adequately prepared to respond to in-flight medical emergencies and may have sub-optimal knowledge. This study provides an initial step in identifying a deficiency in current medical education.

Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline flights worldwide.

We conducted this study to characterize in-flight pediatric fatalities onboard commercial airline flights worldwide and identify patterns that would have been unnoticed through single case analysis of these relative rare events. Retrospective cohort study of pediatric in-flight medical emergencies resulting in fatalities between January 2010 and June 2013. A ground-based medical support center providing remote medical support to commercial airlines worldwide. Children (age 0-18 yr) who experienced a medical emergency resulting in death during a commercial airline flight. None. There were a total of 7,573 in-flight medical emergencies involving children reported to the ground-based medical support center, resulting in 10 deaths (0.13% of all pediatric in-flight emergencies). The median subject age was 3.5 months with 90% being younger than 2 years, the age until which children are allowed to travel sharing a seat with an adult passenger, also known as lap infants. Six patients had no previous medical history, with one suffering cardiorespiratory arrest after developing acute respiratory distress during flight and five found asystolic (including four lap infants). Four subjects had preflight medical conditions, including two children traveling for the purpose of accessing advanced medical care. Pediatric in-flight fatalities are rare, but death occurs most commonly in infants and in subjects with a preexisting medical condition. The number of fatalities involving seemingly previously healthy children under the age of 2 years (lap infants) is intriguing and could indicate a vulnerable population at increased risk of death related to in-flight environmental factors, sleeping arrangements, or yet another unrecognized factor.

Air Travel and Pneumothorax

The number of medical emergencies onboard aircraft is increasing as commercial air traffic increases and the general population ages, becomes more mobile, and includes individuals with serious medical conditions. Travelers with respiratory diseases are at particular risk for in-flight events because exposure to lower atmospheric pressure in a pressurized cabin at cruising altitude may result in not only hypoxemia but also pneumothorax due to gas expansion within enclosed pulmonary parenchymal spaces based on Boyle's law. Risks of pneumothorax during air travel pertain particularly to those patients with cystic lung diseases, recent pneumothorax or thoracic surgery, and chronic pneumothorax. Currently available guidelines are admittedly based on sparse data and include recommendations to delay air travel for 1 to 3 weeks after thoracic surgery or resolution of the pneumothorax. One of these guidelines declares existing pneumothorax to be an absolute contraindication to air travel although there are reports of uneventful air travel for those with chronic stable pneumothorax. In this article, we review the available data regarding pneumothorax and air travel that consist mostly of case reports and retrospective surveys. There is clearly a need for additional data that will inform decisions regarding air travel for patients at risk for pneumothorax, including those with recent thoracic surgery and transthoracic needle biopsy.