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.
Anaphylaxis
In the event of a severe life-threatening allergic reaction, the FAA-mandated emergency medical kit contains both diphenhydramine and epinephrine. For an adult experiencing anaphylaxis, a responding on-board physician can administer diphenhydramine 50 mg and epinephrine 0.3 mg (using the 1:1000 formulation), both intramuscularly. For patients with bronchospasm, a metered-dose inhaler of albuterol can be given. As anaphylaxis is an acute and potentially lethal condition, diversion of the aircraft would also be appropriate.29
Myocardial infarction
When acute myocardial infarction is suspected, it is appropriate for the provider to give aspirin, with important exceptions for patients who are experiencing an acute hemorrhage or who have an aspirin allergy.30 Supplemental oxygen should likewise be provided if the responding physician suspects compromised oxygenation. As acute myocardial infarction is also a time-sensitive condition, the clinician who suspects this diagnosis should recommend diversion of the aircraft.
Acute psychiatric issues
While approximately 2.4% of on-board medical events are attributed to psychiatric issues,5 there are few tools at the clinician’s disposal in the FAA-mandated emergency medical kit. Antipsychotics and sedatives are not included. The responding physician may need to attempt verbal de-escalation of aggressive behavior. If the safety of the flight is compromised, the application of improvised physical restraints may be appropriate.
Altered mental status
The differential diagnosis for altered mental status is extensive. The on-board physician should try to identify reversible and potentially lethal conditions and determine the potential need for aircraft diversion.
If possible, a blood sugar level should be measured (although the FAA-mandated kit does not contain a glucometer). It may be appropriate to empirically give intravenous dextrose to patients strongly suspected of having hypoglycemia.
If respiratory or cerebrovascular compromise is suspected, supplemental oxygen should be provided.
Unless a reversible cause of altered mental status is identified and treated successfully, it will likely be appropriate to recommend diversion of the aircraft.
Acknowledgment: The authors acknowledge Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine University of Maryland School of Medicine, for her contributions as copy editor of a previous version of this manuscript.
