Just When You Thought It Was Safe ...

A number of months ago I had completed a continuing medical education conference on the East Coast and had settled myself into a window seat on the airplane, heading west and homeward. I’m not much of a talker on airplanes, so I was content to relax and sink into a semi-sleep state.

It was about 30 minutes later and probably at a cruising altitude of 35,000 feet that I heard an announcement from the flight attendant asking if there was a physician on board. This, of course, got my attention, and I sat up and turned to look toward the back of the plane. I noticed some activity around one of the passengers but sat back, thinking there was probably a physician on board who would attend to the problem.

A few minutes later, a second announcement was made, asking for any medical personnel. I rang the call button and explained to the flight attendant that I was a physician assistant. Before I could explain further, she had whisked me out of my seat and back to the passenger in distress.

Thanks to many years of work in emergency medicine, it was quite apparent to me that we had a problem. The gentleman, who was clutching at his chest, was about 60 years old and obese, with a grayish skin tone and a look of terror in his eyes. I was able to determine that he was a smoker, had an extended family history of cardiac disease, and had recently gone through a bad divorce: all the answers you don’t like to hear, especially at 35,000 feet.

Providing medical assistance in the back of a cramped airplane above the roar of the engines makes an overcrowded emergency department an ideal treatment setting by comparison. Nonetheless, we administered oxygen, loosened the man’s collar, and tried to calm him as best we could.

A blood pressure cuff and stethoscope were produced for me but, as you can imagine, getting a decent blood pressure with all the fuselage noise was near-impossible. Fortunately, I was able to get a systolic pressure of 100 mm Hg, so all was not lost. An automated external defibrillator (AED), I was told, was available if needed. I was impressed with the first aid and emergency kit that was produced for my use. According to Federal Aviation Administration regulations, all commercial airlines flying in the United States that weigh 7,500 pounds or more and have at least one flight attendant on board must carry an AED and an enhanced emergency medical kit. Flight attendants must also be certified in CPR, including the use of an AED, every two years. Pilots, too, must be trained in the use of the AED.¹

It was about that time that the first officer appeared and asked me what I needed. I responded by saying that what this gentleman needed was for this plane to land and to get him to an emergency department.

My understanding is that a diversion is the captain’s decision after consultation with his or her medical command. Nonetheless, shortly thereafter, we felt a change in the altitude of the plane and within 30 minutes, we had an expedited landing at an airport somewhere in Texas (I never did learn what city we landed in). Two paramedics entered the airplane and carted the man off for more definitive care.

After being thanked by the flight attendant and the first officer, I returned to my seat and attempted to fall back into that blissful near-sleep I had hoped for. Of course, that never happened: My experience had left me wide awake and pondering.

In-flight medical emergencies, I am told, have been occurring more frequently over the years due to the rising number of air travelers, the aging of the US and European populations, and the increasing mobility of people with acute and chronic illnesses. Clinicians may suddenly find themselves in a difficult environment, in front of many onlookers, managing conditions they do not normally treat, with unfamiliar equipment.

Apparently, there are no universal guidelines for managing in-flight medical emergencies among the nearly two billion US and overseas air travelers each year.² The precise incidence of in-flight medical emergencies is unknown because there is no uniform or required reporting system, and flight crews do not routinely report minor in-flight medical incidents that do not require ground medical support. However, a few studies have looked at the number of activations of ground-based emergency medical services for passengers arriving at any given airport. The combined data suggest an incidence of 21 to 25 emergencies per million passengers, with 0.1 to 0.3 deaths per million ­passengers.^2,3

After returning home, I found some good advice in an article in the New England Journal of Medicine. Should you find yourself in a situation similar to mine, Gendreau and DeJohn⁴ suggest that you:

1. Identify yourself to the cabin crew and explain your qualifications.

2. Ask the patient for permission before taking a complete history and performing a thorough physical exam.

3. If necessary, use an interpreter.

4. If the patient is in critical condition, request diversion to the nearest airport.

5. Cooperate with the on-ground medical staff.

6. Keep a detailed written medical record of your patient encounter.

7. Perform only treatments you are qualified to administer.^4,5

Since that time, I have wondered how many stories like this are out there and thought it would be interesting to ask Clinician Reviews’ readers to share their experiences. So, this editorial is a call to you: If you have a story like this, whether it took place on an airplane or the golf course, while you were fishing or attending an athletic event, please share it with us. Limit your story to about 1,000 words and send it to [email protected]. Perhaps we can publish some of your responses on our Web site.

Or if you just want to comment on this editorial, we would also love to hear from you.  

REFERENCES
1. Chandra A, Conry S. Be prepared for in-flight medical emergencies. ACEP [American College of Emergency Physicians] News (August 2010). www.acep.org/content.spx?id=49206. Accessed October 17, 2011.

2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd; Council on Scientific Affairs, American Medical Association. Inflight medical emergencies. Aviat Space Environ Med. 2000; 71(8):832-838.

3. Delaune EF 3rd, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68.

4. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

5. Newson-Smith MS. Passenger doctors in civil airliners: obligations, duties and standards of care. Aviat Space Environ Med. 1997; 68(12):1134-1138.

A number of months ago I had completed a continuing medical education conference on the East Coast and had settled myself into a window seat on the airplane, heading west and homeward. I’m not much of a talker on airplanes, so I was content to relax and sink into a semi-sleep state.

It was about 30 minutes later and probably at a cruising altitude of 35,000 feet that I heard an announcement from the flight attendant asking if there was a physician on board. This, of course, got my attention, and I sat up and turned to look toward the back of the plane. I noticed some activity around one of the passengers but sat back, thinking there was probably a physician on board who would attend to the problem.

A few minutes later, a second announcement was made, asking for any medical personnel. I rang the call button and explained to the flight attendant that I was a physician assistant. Before I could explain further, she had whisked me out of my seat and back to the passenger in distress.

Thanks to many years of work in emergency medicine, it was quite apparent to me that we had a problem. The gentleman, who was clutching at his chest, was about 60 years old and obese, with a grayish skin tone and a look of terror in his eyes. I was able to determine that he was a smoker, had an extended family history of cardiac disease, and had recently gone through a bad divorce: all the answers you don’t like to hear, especially at 35,000 feet.

Providing medical assistance in the back of a cramped airplane above the roar of the engines makes an overcrowded emergency department an ideal treatment setting by comparison. Nonetheless, we administered oxygen, loosened the man’s collar, and tried to calm him as best we could.

A blood pressure cuff and stethoscope were produced for me but, as you can imagine, getting a decent blood pressure with all the fuselage noise was near-impossible. Fortunately, I was able to get a systolic pressure of 100 mm Hg, so all was not lost. An automated external defibrillator (AED), I was told, was available if needed. I was impressed with the first aid and emergency kit that was produced for my use. According to Federal Aviation Administration regulations, all commercial airlines flying in the United States that weigh 7,500 pounds or more and have at least one flight attendant on board must carry an AED and an enhanced emergency medical kit. Flight attendants must also be certified in CPR, including the use of an AED, every two years. Pilots, too, must be trained in the use of the AED.¹

It was about that time that the first officer appeared and asked me what I needed. I responded by saying that what this gentleman needed was for this plane to land and to get him to an emergency department.

My understanding is that a diversion is the captain’s decision after consultation with his or her medical command. Nonetheless, shortly thereafter, we felt a change in the altitude of the plane and within 30 minutes, we had an expedited landing at an airport somewhere in Texas (I never did learn what city we landed in). Two paramedics entered the airplane and carted the man off for more definitive care.

After being thanked by the flight attendant and the first officer, I returned to my seat and attempted to fall back into that blissful near-sleep I had hoped for. Of course, that never happened: My experience had left me wide awake and pondering.

In-flight medical emergencies, I am told, have been occurring more frequently over the years due to the rising number of air travelers, the aging of the US and European populations, and the increasing mobility of people with acute and chronic illnesses. Clinicians may suddenly find themselves in a difficult environment, in front of many onlookers, managing conditions they do not normally treat, with unfamiliar equipment.

Apparently, there are no universal guidelines for managing in-flight medical emergencies among the nearly two billion US and overseas air travelers each year.² The precise incidence of in-flight medical emergencies is unknown because there is no uniform or required reporting system, and flight crews do not routinely report minor in-flight medical incidents that do not require ground medical support. However, a few studies have looked at the number of activations of ground-based emergency medical services for passengers arriving at any given airport. The combined data suggest an incidence of 21 to 25 emergencies per million passengers, with 0.1 to 0.3 deaths per million ­passengers.^2,3

After returning home, I found some good advice in an article in the New England Journal of Medicine. Should you find yourself in a situation similar to mine, Gendreau and DeJohn⁴ suggest that you:

1. Identify yourself to the cabin crew and explain your qualifications.

2. Ask the patient for permission before taking a complete history and performing a thorough physical exam.

3. If necessary, use an interpreter.

4. If the patient is in critical condition, request diversion to the nearest airport.

5. Cooperate with the on-ground medical staff.

6. Keep a detailed written medical record of your patient encounter.

7. Perform only treatments you are qualified to administer.^4,5

Since that time, I have wondered how many stories like this are out there and thought it would be interesting to ask Clinician Reviews’ readers to share their experiences. So, this editorial is a call to you: If you have a story like this, whether it took place on an airplane or the golf course, while you were fishing or attending an athletic event, please share it with us. Limit your story to about 1,000 words and send it to [email protected]. Perhaps we can publish some of your responses on our Web site.

Or if you just want to comment on this editorial, we would also love to hear from you.  

REFERENCES
1. Chandra A, Conry S. Be prepared for in-flight medical emergencies. ACEP [American College of Emergency Physicians] News (August 2010). www.acep.org/content.spx?id=49206. Accessed October 17, 2011.

2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd; Council on Scientific Affairs, American Medical Association. Inflight medical emergencies. Aviat Space Environ Med. 2000; 71(8):832-838.

3. Delaune EF 3rd, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68.

4. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

5. Newson-Smith MS. Passenger doctors in civil airliners: obligations, duties and standards of care. Aviat Space Environ Med. 1997; 68(12):1134-1138.

A number of months ago I had completed a continuing medical education conference on the East Coast and had settled myself into a window seat on the airplane, heading west and homeward. I’m not much of a talker on airplanes, so I was content to relax and sink into a semi-sleep state.

It was about 30 minutes later and probably at a cruising altitude of 35,000 feet that I heard an announcement from the flight attendant asking if there was a physician on board. This, of course, got my attention, and I sat up and turned to look toward the back of the plane. I noticed some activity around one of the passengers but sat back, thinking there was probably a physician on board who would attend to the problem.

A few minutes later, a second announcement was made, asking for any medical personnel. I rang the call button and explained to the flight attendant that I was a physician assistant. Before I could explain further, she had whisked me out of my seat and back to the passenger in distress.

Thanks to many years of work in emergency medicine, it was quite apparent to me that we had a problem. The gentleman, who was clutching at his chest, was about 60 years old and obese, with a grayish skin tone and a look of terror in his eyes. I was able to determine that he was a smoker, had an extended family history of cardiac disease, and had recently gone through a bad divorce: all the answers you don’t like to hear, especially at 35,000 feet.

Providing medical assistance in the back of a cramped airplane above the roar of the engines makes an overcrowded emergency department an ideal treatment setting by comparison. Nonetheless, we administered oxygen, loosened the man’s collar, and tried to calm him as best we could.

A blood pressure cuff and stethoscope were produced for me but, as you can imagine, getting a decent blood pressure with all the fuselage noise was near-impossible. Fortunately, I was able to get a systolic pressure of 100 mm Hg, so all was not lost. An automated external defibrillator (AED), I was told, was available if needed. I was impressed with the first aid and emergency kit that was produced for my use. According to Federal Aviation Administration regulations, all commercial airlines flying in the United States that weigh 7,500 pounds or more and have at least one flight attendant on board must carry an AED and an enhanced emergency medical kit. Flight attendants must also be certified in CPR, including the use of an AED, every two years. Pilots, too, must be trained in the use of the AED.¹

It was about that time that the first officer appeared and asked me what I needed. I responded by saying that what this gentleman needed was for this plane to land and to get him to an emergency department.

My understanding is that a diversion is the captain’s decision after consultation with his or her medical command. Nonetheless, shortly thereafter, we felt a change in the altitude of the plane and within 30 minutes, we had an expedited landing at an airport somewhere in Texas (I never did learn what city we landed in). Two paramedics entered the airplane and carted the man off for more definitive care.

After being thanked by the flight attendant and the first officer, I returned to my seat and attempted to fall back into that blissful near-sleep I had hoped for. Of course, that never happened: My experience had left me wide awake and pondering.

In-flight medical emergencies, I am told, have been occurring more frequently over the years due to the rising number of air travelers, the aging of the US and European populations, and the increasing mobility of people with acute and chronic illnesses. Clinicians may suddenly find themselves in a difficult environment, in front of many onlookers, managing conditions they do not normally treat, with unfamiliar equipment.

Apparently, there are no universal guidelines for managing in-flight medical emergencies among the nearly two billion US and overseas air travelers each year.² The precise incidence of in-flight medical emergencies is unknown because there is no uniform or required reporting system, and flight crews do not routinely report minor in-flight medical incidents that do not require ground medical support. However, a few studies have looked at the number of activations of ground-based emergency medical services for passengers arriving at any given airport. The combined data suggest an incidence of 21 to 25 emergencies per million passengers, with 0.1 to 0.3 deaths per million ­passengers.^2,3

After returning home, I found some good advice in an article in the New England Journal of Medicine. Should you find yourself in a situation similar to mine, Gendreau and DeJohn⁴ suggest that you:

1. Identify yourself to the cabin crew and explain your qualifications.

2. Ask the patient for permission before taking a complete history and performing a thorough physical exam.

3. If necessary, use an interpreter.

4. If the patient is in critical condition, request diversion to the nearest airport.

5. Cooperate with the on-ground medical staff.

6. Keep a detailed written medical record of your patient encounter.

7. Perform only treatments you are qualified to administer.^4,5

Since that time, I have wondered how many stories like this are out there and thought it would be interesting to ask Clinician Reviews’ readers to share their experiences. So, this editorial is a call to you: If you have a story like this, whether it took place on an airplane or the golf course, while you were fishing or attending an athletic event, please share it with us. Limit your story to about 1,000 words and send it to [email protected]. Perhaps we can publish some of your responses on our Web site.

Or if you just want to comment on this editorial, we would also love to hear from you.  

REFERENCES
1. Chandra A, Conry S. Be prepared for in-flight medical emergencies. ACEP [American College of Emergency Physicians] News (August 2010). www.acep.org/content.spx?id=49206. Accessed October 17, 2011.

2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd; Council on Scientific Affairs, American Medical Association. Inflight medical emergencies. Aviat Space Environ Med. 2000; 71(8):832-838.

3. Delaune EF 3rd, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68.

4. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

5. Newson-Smith MS. Passenger doctors in civil airliners: obligations, duties and standards of care. Aviat Space Environ Med. 1997; 68(12):1134-1138.