Is there a doctor on board? In-flight medical emergencies
ABSTRACT
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.
KEY POINTS
- The exact incidence of medical emergencies aboard airplanes is unknown, but they occurred in 1 in 604 flights in 1 study, which is likely an underestimate.
- The relatively low air pressure in the cabin can contribute to the development of acute medical issues.
- In the United States, the Federal Aviation Administration mandates that airlines carry a limited set of medical resources.
- The Aviation Medical Assistance Act protects responding providers against liability except in cases of “gross negligence.”
- You the physician can recommend that the flight be diverted to the closest airport, but only the captain can make the actual decision.
Consultation services
Most major airlines can contact ground-based medical consultation services during flight.10 These centers are staffed with healthcare providers who can provide flight crews with advice on how to handle medical events in real time. Healthcare providers can likewise discuss specific medical issues with these services if they respond to an in-flight medical event. Ground-based call centers can also communicate with prehospital providers should a flight need to be diverted.
Other on-board providers
Some medical events require the involvement of more than one medical provider. Other physicians, nurses, and prehospital providers are often also on board.22 Responding physicians can also request the assistance of these other healthcare providers. Flight attendants in the United States are required to be trained in cardiopulmonary resuscitation (CPR).23
Flight diversion
Critically ill patients or those with time-sensitive medical emergencies may require the aircraft to divert from its intended destination. As may be expected, medical emergencies suspected to involve the cardiovascular, neurologic, or respiratory system have been shown to most likely result in aircraft diversion.5,24 Approximately 7% of in-flight medical events in which a ground-based medical consultation service is contacted result in diversion.5
While an on-board responding physician can make a recommendation to divert based on the patient’s acute medical status, only the captain can make the ultimate decision.4 On-board healthcare providers should clearly state that a patient might benefit from an unscheduled landing if that is truly their assessment. In addition to communicating their clinical concerns with the flight crew, the responding physician may also be able to discuss the situation with the airline’s ground-based consultation service. On-board physicians can make important contributions to the assessment of illness severity and triage decisions.
MEDICOLEGAL ISSUES
No legal duty to assist
US healthcare providers are not legally required to respond to on-board medical emergencies on US-based airlines. Canada and the United Kingdom also do not require providers to render assistance. But the General Medical Council (the regulatory body for UK doctors) states that doctors have an ethical duty to respond in the event of a medical emergency, including one on board an aircraft. Other countries, notably Australia and some in the European Union, require healthcare professionals to respond to on-board medical emergencies.10
Regardless of potential legal duties to assist, healthcare providers are arguably ethically obliged to render assistance if they can.
Aviation Medical Assistance Act
The extent of an American healthcare provider’s liability risk for assisting in a medical emergency on a plane registered in the United States is limited by statute. The 1998 AMAA provides liability protection for on-board medical providers who are asked to assist during an in-flight medical emergency. This statute covers all US-certified air carriers on domestic flights and would likely be held to apply to US aircraft in foreign airspace because of the general rule that the law of the country where the air carrier is registered applies to in-flight events.
Under the AMAA, providers asked to assist with in-flight medical emergencies are not liable for malpractice as long as their actions are not “grossly” negligent or intended to cause the patient harm.25 This is distinguishable from a standard malpractice liability scenario, in which the plaintiff only needs to show ordinary negligence. In a traditional healthcare setting, a provider has to act within the “standard of care” when assessing and treating a patient. If the provider deviates from the standard of care, such as by making an error in judgment or diagnosis, the provider is legally negligent. Under traditional malpractice law, even if a provider is minimally negligent, he or she is liable for any damages resulting from that negligence. Under a gross negligence standard, providers are protected from liability unless they demonstrate flagrant disregard for the patient’s health and safety.
Postflight issues
A provider who undertakes care should continue to provide care until it is no longer necessary, either because the patient recovers or the responsibility has been transferred to another provider. At the point of transfer, the healthcare provider’s relationship with the patient terminates.
The provider should document the encounter, typically using airline-specific documentation. The responding physician needs to be mindful of the patient’s privacy, refraining from discussing the event with others without the patient’s authorization.26
