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Flying can be physically challenging (and emotionally challenging as you likely have witnessed if you have flown recently), particularly for elderly patients and those with pre-existing medical conditions. Cramped conditions can possibly lead to blood clotting, cabin pressure fluctuations to ear issues, turbulence to nausea and vomiting, the dry environment (humidity levels are about half of what most find comfortable) to dry skin and mucus membranes and possibly dehydration, the relatively low oxygen pressures that cabins are pressurized at (simulating an elevation of 6000-8000 feet above sea level) to hypoxia and cardiopulmonary issues.
MedAire reports that the most common inflight medical events are gastrointestinal/nausea (31%), neurological such as fainting or seizures (26%), respiratory (7%), cardiovascular (5%), and dermatological (5%).
Yet Again
It has happened on the last two commercial flights I have been on, one in April and then again last weekend while returning from a family wedding event in Denver. It has also occurred on numerous previous flights. “It” is the flight attendant’s announcement on the PA system of the plane that emergency medical assistance is needed for a passenger.
Typically, when I board a flight, I study my “cheat sheet” that I keep in my wallet that reviews the nuances of CPR since as a urologist I don’t have much opportunity for this kind of intervention and like to be prepared. Somehow, both on my April and last weekend’s flights I knew that by reviewing the cheat sheet that I was “jinxing” myself and that I was sure to be called upon.
Wouldn’t you know it that during mid-flight on this United flight from Denver to Newark the following public address announcement was made: “If there are any medical personnel on this flight, we require your assistance so please come to the front of the plane immediately.” As a physician, this inflight PA announcement always quickens my pulse because of the concern for the need to address a possible issue that I may not have the greatest familiarity with, being a urologist with focus on the urinary and reproductive tracts. Three physicians showed up – a neurosurgeon, a radiation oncologist, and me. We attended a highly anxious middle-aged male having abdominal pain likely from biliary colic who was scheduled for gallbladder surgery three days later. His main concern was that his gallbladder might rupture. We collaborated and deemed him to be not acutely ill and informed the flight attendant who relayed the message to the captain that neither flight diversion nor calling for emergency services upon landing was necessary. Fortunately, this was an easy situation to handle, unlike many other potential situations that can occur at 39,000 feet elevation above sea level.
In April, on a United flight from Fort Lauderdale to Newark, a similar situation occurred, but as a urologist I deferred to an emergency room physician who I felt was better able to deal with the passenger’s issues. Sometime after the ER doc started attending to this patient there was a PA announcement by the flight attendant seeking Gatorade or any form of electrolytes that passengers might have in their possession that could be used for this patient.
After the April event, it became clear to me how willy-nilly and haphazard the process of seeking in-flight medical assistance is and how the process could be improved to the benefit of passengers, physicians, and the crew and airline. As a physician who was called upon to assist a sick patient, I was clueless as to the contents of the airplane’s emergency medical kit. Does the kit have an EpiPen for an acute allergic attack? Does it have a tracheotomy kit for a choking victim who does not respond to the Heimlich maneuver? Does it have a urethral catheter for a patient in acute urinary retention? Are automatic external defibrillators (AEDs) available on all commercial flights? Is there the wherewithal to start an intravenous line and hydrate a patient and administer intravenous medications? Is there a pulse oximeter? Is there equipment to intubate a patient? Exactly what medications are in the kit?
I had some thoughts about how to improve these often-precarious inflight medical situations and on April 13th sent a letter to the Office of Aviation Consumer Protection that is under the auspices of the U.S. Department of Transportation, located in Washington, DC, detailing specific recommendations.
I proposed that when a physician books a flight, they should have the option of identifying themselves as a physician and the option of volunteering their medical services (being “on call”) during that flight. Medical credentials could be verified in advance. Although not critical, the airline could compensate the physician in some token way, perhaps by an upgrade from economy to business class or a better seat in economy. In advance of the departure, the flight attendants and other crew members would have knowledge of the presence of the physician(s), their seat location(s), and the fact that they could be called upon for passenger aid if needed. That would be efficient and would eliminate the need for a PA announcement that a medical emergency is in progress, which can be distressing to other passengers.
I also suggested that all emergency medical kits on commercial flights be standardized. Furthermore, there should be adequate medical supplies available in the kit so that the crew does not have to seek supplies from passengers. Importantly, the physician(s) would be apprised of the precise contents of the emergency medical kit in advance of the departure to familiarize themselves with its contents and prepare in advance for a variety of contingencies.
This would be a win-win-win proposition, of benefit to the patient in need of medical care, advantageous to the airline and crew, and helpful to the physician who would be optimally prepared for emergencies. I concluded my letter with the following line: “I sincerely hope that something might come of my proposition. We can do better!”
That letter was written over two months ago and I have yet to receive a response. That’s pretty much what I expected, having previously dealt with the bureaucracy of the federal government. Specifically, I had written the Food and Drug Administration (FDA) after voicing concerns about a defective surgical sling implant that caused serious medical complications in several of my patients. I received a form letter and absolutely no further response from the government. It wasn’t until I had an article published in the Journal of Urology reporting my case series of complications with this device and other urologists reported similar complications that attention was paid to the issue and eventually the device was taken off the market.
I am disappointed with the disorganized and chaotic inflight medical emergency state-of-affairs that exists today. Passengers should be aware that airline policies and procedures for inflight emergencies in the USA are less-than-adequate. I appeal to any reader who might have a governmental aviation connection who might respond to a pragmatic and sensible alternative approach to inflight medical emergencies to contact me.
Only after writing this entry that detailed my experience on these two flights did I do some research on the topic and discovered insightful information written by Mike Arnot, the founder of Border Pass NYC, a New York-based travel brand. I honestly was clueless about any of this prior to reading his words of wisdom.
Apparently, the Federal Aviation Administration (FAA) requires an AED (automatic external defibrillator) on any flight that has 30 passengers or more. They also require an emergency medical kit that must include the following items: blood pressure cuff; non-narcotic pain meds and aspirin; antihistamine; atropine; bronchodilator inhalant; epinephrine for cardiac resuscitation; lidocaine; IV administration supplies; AMBU bag; CPR mask. Often airlines will supplement the basic kit with the following: anti-nausea medication; EpiPen; antacids; furosemide for water retention; glucagon for low blood sugar, naloxone nasal spray for opioid overdoses.
MedAire, founded in 1985 by a flight nurse, is an aeromedical organization located in an emergency room in Phoenix, Arizona. MedAire physicians practice emergency medicine at Banner Medical and rotate fielding inflight calls (approximately 100 per day). Apparently, when an inflight medical emergency occurs, the crew contacts MedAire while also paging to see if there are any medical professionals on board. Supposedly, the aeromedical experts on the ground collaborate with the on-board medical volunteers to assist with the administration of any recommended treatments. However, in all the inflight medical emergencies that I have been involved with, I had never heard of, nor had any contact with this organization.
Bottom Line: Flying can be a fraught activity that can be a challenge to the health of the elderly and those with underlying medical conditions and it is not uncommon for inflight medical emergencies to occur. I have been involved in more than enough of these situations to have learned that the process is haphazard and willy-nilly. As pilots desire protocol and routine as a matter of course, so protocol and routine should likewise be applied to medical emergencies.
Is there a way to do it better? Yes, there certainly is. I propose that physicians could volunteer their services at the time they book their flight so that pilots and crew would be knowledgeable of their presence, availability, and seat location, fostering efficiency and avoiding the need for a PA announcement that might alarm passengers. I propose that such “on call” physicians on the manifest be sent a list of the contents of the emergency medical kit and any other emergency supplies in advance of departure so that they could be thoroughly prepared regarding the limited medical resources available. As a physician, it is my pleasure to be able to contribute my services and help those in need, but the process can be improved and would be a win-win-win for passengers, physicians, and the crew and airline.
