In-flight Medical Emergencies There are only two emotions in

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American Osteopathic College of Occupational and Preventive Medicine2013 Mid Year Educational Conference, Phoenix, Arizona

February 14-17, 2013

In-flight Medical Emergencies

Patricia C. Hunt, DO, MHA, CHCQM,FAOBIM, FAOCOPM

"There are only two emotions ina plane: boredom and terror."~ Orson Welles

A two-pronged approach

• How can I ADDRESSin-flight medicalemergencies?

– What resources areavailable?

– What are the liabilities?

– What constitutes thebest evidence-basedapproach within theseconstraints?

• How can I PREVENT anin-flight medicalemergency?

– Who should not fly?

– How do I assess?

How often DO in-flight medicalemergencies occur?

• According to FAA,domestic travel: 1passenger in 39,600.

• 47% of ill passengerswere sent to an ER.

• 10% of those wereadmitted to thehospital.

• Between 1968 and1988 Air Francereported 1,800 pilotswere incapacitated inflight.

Physiology and Flight

• Jet lag

• Pre-existing diseases– Hypoxia: Pao2=55 mmHg

– Cabin Air Quality is Dry: <10% humidity

– Barometric pressure changes,approximates 8,000 ft.

• Medical equipment

– Pneumatic splints

– Tracheostomy cuffs

– Surgical wounds/drains

• Psychological stress

• Decompression sickness

– “No fly” time.

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American Osteopathic College of Occupational and Preventive Medicine2013 Mid Year Educational Conference, Phoenix, Arizona

February 14-17, 2013

Etiology of in-flight events---Domestic Travel

Most COMMON

• Syncope

• Near syncope

• Hyperventilation

• Vasovagal episodes

LEAST COMMON

• Children– 27% infectious disease

– 15% neurologic

Most SERIOUS

• Neurologic

• Cardiac

• Respiratory

On-Board EmergencyMedical Kithttp://www.jems.com/photos/training/care-air

• Stethoscope

• Sphygmomanometer

• Bag-mask resuscitator

• Oral airways (three sizes required)

• Nitroglycerin (at least 10 tablets); aspirin (atleast four tablets);

• Albuterol : one metered-dose inhaler

• Dextrose 50% (at least 25 grams);

• Injectable 1:1000 epinephrine (2 mg);

• Oral antihistamines (at least four tablets);

• IV antihistamines (at least two amps)

• IV 1:10,000 epinephrine (at least 2 mg),

• Atropine (at least 1 mg total)

• Lidocaine (at least 200mg total)

• 500 ml normal saline,

• An IV drip set, various needles and syringes

One Medic’s Observations

• Auscultation in an aircraft using astethoscope can be difficult dueto ambient engine noise. Palpatesystolic blood pressure.

• Aviation portable oxygen bottles(POBs) generally have only one oftwo fixed settings: "low flow" (2lpm) and "high flow" (4 lpm) forfirst aid purposes anddecompression emergencies,which is far lower than what isnormally used in EMS settings.

• Oxygen tubing for the bag-valvemask resuscitations aren'trequired to be compatible withthese on-board oxygen bottles.

• The AEDs on board aren'trequired to have ECG screenthough ACLS medications areprovided;

• Glucometers aren't mandated inEMKs, despite the requirement tohave dextrose 50%, make itdifficult to identify hypoglycemicemergencies.

Source:http://www.jems.com/article/patient-care/handling-flight-medical-emerge

A General Approach

• NO federal regulationsor guidelines

• Each airline has policies

• Flight crew isresponsible to respondto acute illness

• Health careprofessional’s role is TOASSIST, not take control

• Act to stabilize: use O2,medications/suppliesavailable, lower altitudeof aircraft (to increasecabin pressure)

• Consult with ground-based support

• May suggest flightdiversion

Overview: Worth Reiterating---

• Act within your scope

• Obtain consent, assume implied consentwhere appropriate

• Request the enhanced EMK

• Request and establish communication withground support

• Remember, you can request diversion

• Never officially pronounce

Liability• Good Samaritan Laws (USA)

• Specific by state

• Act in “good faith”

• No acts of “gross negligence or wanton conduct”– Wanton = lewd, gratuitously cruel, immoral

• Aviation Medical Assistance Act:• Federal Law: as of 5/24/06, no individual rendering aid

in the case of an in-flight medical emergency will beliable unless there is “gross negligence or willfulmisconduct.”

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American Osteopathic College of Occupational and Preventive Medicine2013 Mid Year Educational Conference, Phoenix, Arizona

February 14-17, 2013

Liability cont’d

• Receive no monetary compensation

– Travel vouchers, a glass of wine, or a seat upgradeis not considered compensation.

• Must provide care similar to the care of otherswith similar training under similarcircumstances.

Case Discussionsas our time permits

'Boozed-up' plane passenger duct-tapedto his seat to stop rampage: sourcesBy PHILIP MESSING, JOSH MARGOLINand PEDRO OLIVEIRA JR.Last Updated: 9:41 AM, January 5, 2013Posted: 1:41 AM, January 5, 2013

Resources

• www.thelancet.com

– February 19,2009: Medical Issues Associated withCommercial Flight

• www.jems.com

– http://www.jems.com/article/patient-care/handling-flight-medical-emerge

• www.asma.org

– http://www.asma.org/publications/medical-publications-for-airline-travel

Resources cont’d

• http://www.cfp.ca/

– Use the Advanced Search: 2009 vol 55 pg 992

• www.medscape.com

– http://emedicine.medscape.com/article/810246-overview

• www.nejm.com

– http://www.nejm.org/doi/full/10.1056/NEJMra012774 (with subscription)

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American Osteopathic College of Occupational and Preventive Medicine2013 Mid Year Educational Conference, Phoenix, Arizona

February 14-17, 2013