Getting better prepared to treat in-flight medical emergencies

"Ladies and gentlemen, is there a physician on board?"

The flight attendant on a flight from Rwanda to Turkey made the announcement no one wants to hear, and Rachel Zang, MD, an Emergency Medicine resident at the Hospital of the University of Pennsylvania, jumped into action.

Zang showed her credentials to the flight crew and was taken to a man in his early 60s who felt nauseous and had a headache, though that took some time to establish. He didn't speak English nor the language of the attendants, so his son had to translate to the crew who then translated into English to Zang. Drugs in the medical kit weren't labeled in English either, only the labels on the kit's lid were. But what if someone had mixed up the medications?

Fortunately, it wasn't a major emergency and the man recovered after Zang gave him Tylenol, allowing the plane to continue without being diverted.

And then it happened again. This time, it was a two-year-old suffering from vomiting and diarrhea on a flight from the United Kingdom to the United States. After realizing there was no oral rehydration packets on board, Zang made her own: one liter of water, six teaspoons of sugar, and a half a teaspoon of salt. Squirting the solution into his mouth every five minutes with an oral syringe did the trick, and the flight continued.

After that, Zang decided now was the time to educate herself more about in-flight emergencies.

"My husband and I travel quite a bit, and we're always on international flights. I've had two incidents and my husband, who is also a doctor, has had two. I just felt like there was this gap in my knowledge," Zang said. "I didn't know what was on airplanes. I didn't know what I could ask for or what other assistance could happen."

So she researched it – learning as much as she could about the laws and what exactly is in those medical kits – and then imparted that knowledge to about 40 other physicians during a recent grand rounds at HUP. Some had gone through it and some hadn't, but all wanted to know more.

"It makes doctors nervous, even ER doctors," Zang said. "They don't know what to expect…and there are just so many variables, so it makes the situation very high stress, even if the medical issue is not a big deal."

Treating In-flight

During her talk, Zang tackled many of the questions she had asked herself. What medical equipment is on board? Am I protected legally for the care I provide? What are the most common illnesses? Will I be required to show credentials?

Every day, about 165 in-flight emergencies occur on the 100,000 or so airplanes that take to the skies around the world, according to the most recent estimates, "so if you travel frequently in the span of your career," Zang said, "you will likely be called."

Today, no federal guidelines exist for physicians in these situations, and there is no mandatory reporting system that tracks in-flight emergencies. A lot of the guidance and estimates come out of medical journals, including the more recent articles in the New England Journal of Medicine from 2015 and 2013.

The U.S. government has taken its own steps to better address emergencies.

In 2001, the Federal Aviation Administration (FAA) required U.S. carriers to have an emergency medical kit, along with an automated external defibrillator (AED), on board all their planes by 2004. The kits are equipped with a stethoscope, a blood pressure cuff, a bag-valve mask for CPR, an IV, needles, syringes, and a host of medications like antihistamine and aspirin, among other items to help treat issues like breathing difficulties, cardiac symptoms, dehydration, or low blood sugar.

But the kits are still relatively limited, Zang said. There are no antiemetics to treat vomiting or nausea, or sedatives to calm someone down. There is also nothing in the kit to treat OB/GYN issues and no pediatric equipment, except for a CPR mask for children. First-aid kits are required, too, and contain typical items like bandages and splints.

A few years before the kits became mandatory, the Aviation Medical Assistance Act of 1998 had already addressed credentials and liability.

Physicians do not legally need to provide credentials; the AMAA just states that the flight crew should believe in "good faith that the passenger is medically qualified." However, an update to that in a 2006 regulatory letter from the FAA said it would be preferable for the flight crew to check for credentials. Zang doesn't go on a trip without them.

U.S. physicians also aren't legally required to respond – which is not the case in Australia and France.

Regarding liability, the Act protects passengers who step forward to offer medical assistance "unless they are guilty of gross negligence or willful misconducts." And they are not responsible if equipment is broken or the plane is not diverted.

Physicians also have the option to communicate with a medical command center to help with an issue on board or to divert the plane to another airport. These are private companies staffed with emergency room specialists on the ground. For example, MedAire, a Phoenix, Arizona-based company that works with over 100 airlines, deals with 70 to 100 emergencies a day.

"I didn't know there was a medical command you could talk to," Zang said. "They know intermediate airports that the plane could be diverted to in order to [deal with] the issue you are having. If I have a patient who is pregnant, it doesn't help us to divert to airport that doesn't have OB."

As far as emergencies go, delivering babies is not high on the list. According to that 2015 NEJM study, the top in-flight emergencies are light headedness/loss of consciousness, respiratory symptoms, nausea or vomiting, cardiac symptoms, and seizures.

Gut Instincts

In the air, physicians are often faced with a make-it-work scenario.

There are no universal standards for in-flight emergencies, so different countries have different protocols and kits – and some are better than others, Zang said. And while the United States' emergency kits may be part of the pre-flight check list, meaning the airplane can't take off without one, how often the equipment or drugs in the kit are checked is less clear, Zang found.

On a recent flight to Fort Lauderdale, Fla., Jennifer Vuich, RN, CCRN, CEN, a clinical nurse in Penn's Emergency Department, and her partner Donelle Rhoads, MD, a surgeon affiliated with Penn's Chester County Hospital, responded to a woman in her 70s who had fallen to the floor near the cockpit. After tending to her for a bit, Vuich realized she no longer had a pulse and started CPR, while another physician kept her airway open, and Rhoads called for an AED.

The woman became responsive but was believed to have gone into cardiac arrest, so Vuich administered aspirin. She also wanted to place an IV in her, but the medical equipment wasn't in a centralized, user-friendly location, she said, and the tubing was of questionable quality, so she decided not to use it.

"I also had to make the decision to not place her on oxygen because there was no way to secure it," Vuich said. "We were sitting directly behind the cockpit door, and it was left me to decide whether or not to risk it."

Thankfully, the plane made an emergency landing at Raleigh-Durham International Airport in North Carolina, where first responders were waiting to take the woman to the hospital. Once the responders placed her on a heart monitor, she was found to be in complete heart block, Vuich said, and received a permanent pacemaker before she was discharged home.

"In a civilian medical emergency outside of a hospital setting, you really just have to go back to the basics and be resourceful," Vuich said. "It may not be as comfortable because you don't have the equipment or diagnostics that you're used to, but you just have to rely on that gut instinct and do what you can." (You can read more about Vuich's experience, including a first-person account from the patient herself, in this month's Presby Bulletin.)

Improving Care

While in-flight emergences aren't specifically covered during medical education and training, there are courses available through some airlines to better prepare physicians, including one called Doctors on Board at Lufthansa.

They also have the option to pre-register on their flights, giving them the opportunity to review what's in the medical kit before takeoff. Over 11,000 physicians are registered.

"They have one of the most extensive programs and medical kits," Zang said.

Medical and aviation organizations have also come together in an effort to improve the level of care in the sky, but nothing has been officially implemented internationally or domestically to reflect that.

The Aerospace Medical Association expert panel and International Air Transport Association have both agreed and released recommendations to update the emergency medical kit in the United States; however, Zang said the FAA has no plans to revisit what the kit contains at this time.

"It has never been updated since [2004]," Zang said, "despite obviously medicine changing in almost the last two decades."