« Sticking Point: How... | Main | What You Didn't... »

Friday Jun 20, 2014

Up in the Air: Responding to Medical Emergencies at 30,000 Feet

I was recently sitting on an airplane when I noticed some commotion a few rows ahead of me. Flight attendants with worried looks on their faces were congregating around a passenger, while others briskly headed to the front and back of the plane.

I signaled to the crew that I was a physician, and after speaking with the embarrassed gentleman who had drawn all the attention and his concerned wife, I quickly determined that the situation was relatively benign. Having started his vacation with a few drinks before boarding and another after take-off, he had passed out briefly, frightening his wife. 

Given that he was a middle-aged and otherwise healthy male who was not on any medications, there was little to be concerned about. He was fine for the remainder of the flight, with his wife watching over his consumption of several cups of water. As a thank you gesture, one of the flight attendants offered me a $100 flight voucher.

Luckily, syncope and presyncope are the most common problems encountered on flights, followed by respiratory symptoms and gastrointestinal complaints.

A colleague of mine, however, was not as fortunate and encountered a much more serious condition -- urosepsis -- on a flight to London. A passenger who had been vacationing in the United States had put off seeking treatment for her urinary symptoms for a few days with the hope of avoiding our health care system. As my family medicine colleague (who was a resident at the time) and another physician (who happened to be an ICU attending) did all they could to care for this woman with the minimal equipment available, they eventually made the decision that the plane needed to be diverted for an early landing. My colleague missed her connecting flight, as did many passengers, and the other physician had to accompany the patient to the local ER because the emergency medical service worker did not want to be held liable for the IV line the ICU physician had inserted before the plane landed.

If you haven’t already encountered a request for medical assistance while flying, it is likely only a matter of time. A recent New England Journal of Medicine study found that the likelihood of having a medical emergency during a flight is about one in 604. Just like anything in medicine, it’s good to be prepared with a basic knowledge of what resources are available and what the expectations are before the situation arises.

First, consider carrying a copy of your license or some form of physician identification. The head flight attendant on my plane took down my information to “call it in,” stating that she would need to confirm that I was, in fact, a physician before I would be allowed to administer any medications, if needed. In most states, you can apply for a professional photo identification card, which will include your name, photo, license number in that state and the expiration date of your license.

Second, understand that the medical equipment on a plane is going to be limited. All flights are required to have an automated external defibrillator and emergency medical kits (EMK) that contain a stethoscope, sphygmomanometer (manual), CPR masks, IV kit with 500 cc's of saline solution, dextrose, syringes, aspirin, antihistamines, epinephrine and nitroglycerin.

Additional medications, such as lorazepam or diazepam (seizures account for about 6 percent of in-flight emergencies), may be available in “enhanced” EMKs, especially on longer flights. One important resource to know about that is often underutilized is what's known as ground consult. You can -- and probably should for any significant medical concern -- request that the pilot alert the airline’s medical team on the ground. Consider making this request earlier rather than later (as is often the case with medical consults) so medical staff on the ground can be apprised of the situation. Whether you will be able to speak to them directly (in the cockpit) or through the flight attendants and pilots relaying the information seems to be flight-/pilot-dependent.

Unfortunately, liability is a very real concern, particularly in scenarios when you're not practicing in your regular clinical setting. Generally, physicians are covered by the Aviation Medical Assistance Act of 1998, which protects physicians who provide in-flight emergency medical assistance in the same way that state Good Samaritan laws do. It goes without saying that you do not have to volunteer if you do not feel comfortable with the situation or are concerned for your own safety. If you have had a few drinks or have taken sedating medications, you need to use your judgment about whether to respond.

Since you are volunteering and not technically on duty, under the 1998 law, you are covered as long as you don't engage in any willful misconduct or commit gross negligence. You should make yourself aware of the law's limitations. Many physicians feel a moral obligation to help in a medical emergency, and, thus, we can find ourselves in these situations.

The New England Journal of Medicine tracked in-flight medical emergency calls reported by five domestic and international airlines from Jan. 1, 2008, through October 2010. During that time, there were nearly 12,000 in-flight medical emergencies. Physician passengers provided medical assistance nearly half the time.

As family physicians who are trained to manage a diverse array of medical conditions across patients' entire lifetimes, we are in a unique position and likely better prepared than subspecialists to address many of the medical needs that can arise on a flight. Still, it is important to practice within your comfort level and to be honest when you feel a case is beyond your skill level. In such cases, using the ground consult option can be helpful. But also remember that if you are the only physician on board, some medical care is better than no medical care.

As for compensation, under most, if not all, state Good Samaritan laws, you are no longer protected from liability if you accept payment for the care you provide during an in-flight emergency. However, it appears that accepting a thank you from the airline, such as an upgrade or flight voucher, does not necessarily prevent you from being covered under Good Samaritan laws. But given that the Aviation Medical Assistance Act is silent regarding payments or gifts from an airline, if you want to completely avoid the issue, you probably shouldn’t accept any reward from the airline.

Lastly, be sure to document the encounter in some way. Get the information you feel you need (you can always ask a flight attendant to record vital signs or other pertinent information during the encounter, if needed) and document it in your medical records or some other way when you return home.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Comments:

Great summary of the issues and risks for "Good Samaritan" doctoring on air flights.

Posted by Linda Prine MD on June 20, 2014 at 02:16 PM CDT #

This is a very informative article. I think about this almost every time I board a plane, so it is nice to know what supplies and resources are typically available. I assume there is oxygen available as well?

Posted by Melissa B. on June 21, 2014 at 07:50 AM CDT #

When I researched this topic 4 years ago after being a passenger on 2 flights during which medical assistance was requested, I came across the information that while on US-operated flights, physicians have the right to choose not to treat, there may be a requirement by law to provide medical assistance on flights operated by airlines of certain foreign countries. A 2012 article published in a German journal by employees of Lufthansa Airlines states, "During flight, 'flag right' is in effect, i.e., the applicable laws are those of the country under whose jurisdiction the aircraft or airline operates: for example, the United States in the case of United Airlines, or the Federal Republic of Germany in the case of Lufthansa. The law in many countries explicitly requires physicians who are present at a medical emergency to provide assistance (the applicable German law is § 323c StGB; similar laws are in effect in France, Australia, and many Asian and Middle Eastern countries, among others). In contrast, British, Canadian, and American law do not require physicians to help in a medical incident on board, unless there is a pre-existing physician-patient relationship." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461894/ Given the Aviation Medical Assistance Act of 1998 in the US, the declaration of assumption of liability offered by many airlines to insure physicians against claims resulting from their medical assistance in flight, and the potential for prosecution in a foreign country for NOT acting, I have come to my own conclusion that offering my help as a physician is the best option in this situation if it were to occur again. There is also an UpToDate review on the topic entitled "Management of inflight medical emergencies on commercial airlines" that addresses these medicolegal issues.

Posted by Emma Smith, MD on June 23, 2014 at 04:04 PM CDT #

Thank you for your responses! Melissa B- there is oxygen on the plane. They brought an oxygen tank out during the flight I was on. And Emma Smith, MD, thank you for that information!

Posted by Margaux Lazarin, DO, MPH on June 30, 2014 at 09:01 AM CDT #

You must be logged in to post a comment. Login

Search This Blog


Sign Up


Subscribe to receive e-mail notifications when the blog is updated.

Email address:

Feeds

Disclaimer

The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.