Is There a Doctor on the Plane?

Joe Lex, MD, FACEP, MAAEMProfessor of Emergency Medicine

Department of Emergency MedicineTemple University School of Medicine

Philadelphia PA USAjoe@joelex.net @JoeLex5

NO COMMERCIALCONFLICTS TO

DECLARE

Physician is traveling on ~85% of US domestic air flightsHordinsky JR, George MH. Utilization of Emergency Kits by Air Carriers. Oklahoma City: Federal Aviation Administration, Civil Aeromedical Institute, 1991/DOT/FAA report AM-91/2

For each flight attendant• Instruction to include performance drills in the proper

use of automated external defibrillators• Instruction to include performance drills in

cardiopulmonary resuscitation• Recurrent training … at least once every 24 months

At least one approved automated external defibrillator, legally marketed in the United States in accordance with Food and Drug Administration requirements.

How Common?

• ~ 1/600 flights• 44,000 of 2.75B passengers / year• Federal Aviation Administration (2000): 13% of

in-flight medical incidents aboard domestic aircraft result in emergency diversion

Peterson DC, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013 May 30;368(22):2075-83.

Emergency landing of domestic flight: $30,000

International flight: $70,000 to $230,000

Most Common Emergencies

Most Common Emergencies

• Lightheadedness or fainting ~37%• Respiratory problems ~12%• Nausea or vomiting ~10%• Cardiac symptoms ~8%• Seizures ~6%• Most common diverting conditions: cardiac,

neurological, respiratory

Other Emergencies

• Laceration ~0.3%• Cardiac arrest ~0.3%• Ear pain ~0.4%• Obstetrical or gynecological symptoms ~0.5%• Headache ~1%• Snakes <<<0.1%

Ground Back-Up

• Phone with MedAire – Tempe, Arizona– 480 333 3700

• Mostly ER Docs - >50 of them• Level I Trauma Center

PREGNANCY?varies from

airline toairline and

domestic vsinternational

Domestic: notwithin 7 days

before orafter delivery

International:Not within 30 Days of due date unless examinedand certified byobstetricianin 48 hours priorto flight

Births and Deaths

• 5 years• 2 airlines in Europe• 613B revenue passenger kilometers• 20% continental / 80% intercontinental• 10,189 in-flight emergencies• 279 diversions• 2 births, 52 deaths

Who Responds to the Call?

• Physician passenger responds in ~48%– But available in up to 85%

• Nurse passenger responds in ~20%• EMT passenger responds in ~5%

Fitness to Fly

Can someone walk 50 yards (46 m) or climb a single flight of stairs without become severely dyspneic?

Medical Guidelines for Airline Travel, 2nd ed. Aerospace Medical Association Medical Guidelines Task ForceAviat Space Environ Med. 2003 May; 74(5 Suppl):A1-19.

Pressure / Oxygen

• Low available oxygen level drops healthy adult’s pO2 to ~90%

• Cabin pressure roughly equivalent to same altitude as Aspen, Colorado (~2400m)

• Low air pressure in cabin expands all air filled spaces by ~30%– Bowel, sinuses, middle ears, pneumothoraces

Managing in flight emergencies. Wallace TW, Wong T, O'Bichere A, Ellis BW BMJ. 1995 Aug 5; 311(7001):374-6.

Procedure Note from Dr Wallace

I advised the patient that she had a serious condition and that an operation was required, but she was too ill to give written consent. With the patient seated in her aircraft seat… the insertion of a chest drain under local anaesthetic was performed…insert chest drain (i.e. 14F catheter with a wire coat hanger trocar) into the left second intercostal space in the mid-clavicular line.

Procedure Note from Dr Wallace

As soon as the drain was connected (Evian bottle with two holes in the cap), air was released from the pleural cavity and within five minutes the patient had almost fully recovered. The patient was left sitting in her passenger seat and settled down to enjoy her meal and the inflight entertainment.Note: the author used a “five star brandy” as disinfectant for the introducer.

US Aviation Medical Assistance Act 1998

“An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”

Countries other than USA??

• Generally under jurisdiction of country where aircraft is registered

• No known cases of lawsuits for responding

1. Incidents rare, diversions rarer2. Births and deaths REALLY rare3. Cabin crew well trained4. AED may save a life5. First aid kit dinky but adequate6. Good Samaritan’s got you covered

… unless you REALLY screw it up7. Hey, you’re an ER doc – you got it

covered

THANK YOUJOE@JOELEX.NET

@JoeLex5