Air Travel Emergencies and the Physician Passenger

Abstract & Commentary

By John P. DiMarco, MD, PhD, Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville.

Source: Peterson, DC. Outcomes of medical emergencies on commercial airline flights. N Engl J Med 2013;368:2075-2083.

Most physicians who travel will encounter one or more emergencies during air travel. This paper reviews the experience of a medical communication center that serves five domestic and international airlines over a 34-month period. The communication center is contracted by subscribing airlines to provide medical consultations using radio or satellite telephone communications. It is staffed by emergency physicians who are trained in telemedicine and the management of in-flight medical emergencies. For each event, data were entered into an electronic database. Follow-up data were obtained from airline personnel.

During the study period, the communication center received calls about 11,920 in-flight medical emergencies. There were an estimated 744 million airline passengers during this period for a rate of 16 medical emergencies per 1 million passengers. The incidence of medical emergencies was one per 604 flights. The most commonly reported problems were syncope and presyncope (37%), respiratory symptoms (12%), and nausea and vomiting (10%). Seizures (5%) and possible stroke (2%) were also notable reasons for the emergency. The aircraft was diverted in 875 of the 11,920 (7.3%) cases. The rest of the flights continued to their original destination. For 31% of the passengers involved in the initial medical emergencies, the situation had resolved by landing and emergency medical service (EMS) personnel were not requested. Of the patients who were met by EMS personnel, 37% were transported to a hospital emergency room and 901 patients were admitted to the hospital. There were 36 deaths that resulted from these medical emergencies and 30 occurred during flight. The mean age of passengers who died was 59 ± 21 years with a range of 1 month to 92 years. There were 61 obstetrical or gynecologic emergencies in this study. Of these, 61% occurred in pregnant women at < 24 weeks of gestation who had signs of possible miscarriage. Eleven cases involved women in labor > 24 weeks gestation and three of these resulted in aircraft diversion. Flight personnel requested and received on-board assistance by physicians (48%), nurses (20%), EMS providers (4%), and other health care professionals (4%). Aircraft diversion and hospitalization rates were higher if the assistance of medical personnel was requested, probably reflecting the more serious nature of the events. The most common reasons for hospital admission were possible stroke, respiratory symptoms, and cardiac symptoms. The most commonly used medications were oxygen, intravenous saline, and aspirin. Antiemetics were used in patients with nausea and vomiting, and patients who received an antiemetic had a lower rate of aircraft diversion. An automatic external defibrillator (AED) was applied in 137 patients. The most common reasons for AED application were syncope or presyncope and chest pain. An AED was applied in 24 cases of cardiac arrest, but a shock was delivered in only five cases with one return of spontaneous circulation. Eight other initially unconscious patients in whom an AED was applied had spontaneous return of circulation even though no shock was indicated or delivered.

The authors conclude that health care professionals who travel on commercial flights should be prepared for a potential role as a volunteer responder to in-flight medical emergencies. A knowledge of the common problems encountered and the resources available on planes would be valuable in this situation.

Commentary

I always dread the overhead announcement asking, “Is there a physician on the flight?” when I’m traveling, but it’s happened to me at least a half dozen times. When I responded, the experience has been highly variable. On several occasions, I was one of a large group of responders, and an anesthesiologist or an emergency medicine doctor took over the situation quite efficiently. On two other occasions, I had to deal with prolonged chest pain episodes and had to decide whether the aircraft should be diverted. Fortunately, I’ve yet to be confronted with an obstetric emergency while flying. In that case, I might put the AED on myself! What is clear to me is that physicians are likely to be called upon to render assistance and they should be willing and at least minimally prepared to do so.

This paper outlines the medical emergencies that one is likely to be confronted with during travel. Physicians should also go to the online supplement to look at the list of medications and tools available in medical kits on board. Even without recent training or experience in emergency or critical care, many of us will be able to work with the ground consultant in managing the situation. In some instances, a serious emergency will be managed with more direct routing, bypassing the usual air traffic control delays. This shortens flight time and diversion will only rarely be necessary. However, even under ideal conditions, it may be quite some time before the plane can be landed anywhere safely, and we should all be willing to step in to bridge this gap when asked.