Almost everyone grumbles about the current state of airline travel, but physicians and others with medical training shoulder an additional potential challenge when flying: answering a call for assistance should a medical emergency arise in flight.

In-flight medical emergencies are relatively rare. A recent report in The New England Journal of Medicine (NEJM) tracked in-flight incidents from 2008 to 2010 that were relayed to a medical communications center on the ground and tallied one medical emergency per 604 flights. The incidence is low enough to demonstrate that many medical professionals will never be called to attend to an ailing passenger during a flight, yet substantial enough to suggest that physicians traveling on airplanes should maintain awareness of procedures for aiding passengers in distress—assuming they are inclined to volunteer should the call come over the intercom.

Of the 11,920 emergencies that the NEJM study tracked, physician passengers provided assistance in 48.1 percent of them. The most common problems reported were syncope or presyncope (37.4 percent of cases), respiratory symptoms (12.1 percent), and nausea or vomiting (9.5 percent). Just 7.3 percent of the incidents resulted in aircraft diversion, and of patients followed, 25.8 percent were transported to a hospital, 8.6 percent were admitted, and 0.3 percent died.

The most common triggers for hospital admission were possible stroke, respiratory symptoms, and cardiac symptoms.

The study, reported by Drew C. Peterson, MD, and colleagues in the May 30, 2013, issue of the NEJM, is the first to collate information from multiple airlines and to comprehensively track patient outcomes. It provides physician and healthcare professionals with practical advice and information about what to anticipate should an emergency arise on board.

Guidance from the ground
One fact that might not be widely known is that airlines partner with specific healthcare delivery groups on the ground to ensure that medical expertise is available for flight crews and, if applicable, on-board volunteers. Corresponding author Christian Martin-Gill, MD, MPH, an emergency medicine physician, reports that his center at the University of Pittsburgh provides a ground-based resource to 17 commercial airlines. It receives airborne calls for assistance “every hour” that may come from any place in the world.

Dr. Martin-Gill noted that, although volunteers may be concerned about liability, most physicians are aware of the protections afforded by the Aviation Medical Assistance Act and other Good Samaritan laws.

“As long as volunteers do not perform gross negligence or willful misconduct, they have some legal protection from liability,” he said. The act also protects the airlines for allowing volunteers to provide assistance in good faith.

Although physicians are not legally obligated to intervene, the authors write, “we believe that physicians and other healthcare providers have a moral and professional obligation to act as Good Samaritans.”

A greater apprehension among some physicians, including orthopaedic surgeons, may relate to their familiarity and expertise in handling specific emergencies, Dr. Martin-Gill said. “Physicians are in a unique position to help passengers, but the primary complaint of a passenger is often outside a physician’s usual realm of medical care.

“Someone may be complaining of shortness of breath. Even though orthopaedic surgeons are physicians, it may have been 20 years since they took primary care of someone with chest pain. That may result in some angst to provide support. Sometimes physicians on board hesitate to come forward. They may even hear what the complaint is and be reluctant.”

He advises physicians not to hesitate, both because, regardless of specialty, they have distinctive expertise and because of the resources available from ground-based consultants.

“An orthopaedist should feel that it’s OK to volunteer, that there are legal protections, and that assistance is provided as part of a team—flight attendant, pilot, and ground support. The team helps to ensure that mistakes are not made,” he noted.

“Obviously everyone has a different skill set. An orthopaedist may be comfortable with a high-stress situation but not as comfortable with chest pain. The experts on the ground have a wide variety of experience, specifically with how to manage complaints in flight,” continued Dr. Martin-Gill.

“Usually the people on the ground will guide the pilot in making decisions such as whether to divert the aircraft or what medications should be used from the medical kit. Decisions can be made in consultation with these physicians.”

In the typical in-flight emergency scenario, a flight attendant will first notify the pilot of the problem, and the pilot may consult with the ground-based service before calling for a volunteer.

“The flight attendant will ask if a doctor or a nurse is on board,” Dr. Martin-Gill explained. “Flight attendants have training in first aid, CPR, and the on-board defibrillator, but they don’t typically have much experience in assessing vital signs or doing a real medical assessment. Someone who can do that can be very important and can provide information to the ground consultants, who can make a recommendation.

“Many of the interventions are quite basic,” he noted. “Beyond that, it is up to a person’s training—for example if the patient needs an intravenous line, that’s really dependent on the person’s training and comfort level.”

When the call comes
The article provides a set of guidelines for physicians who volunteer to assist in emergencies. As in any incident, patient assessment is the first step, with a check for high-risk symptoms. In obtaining vital signs, “If unable to assess blood pressure by means of auscultation, assess it by palpating the radial pulse,” the authors advise.

If the patient is in cardiac arrest, the caregiver should obtain and apply the on-board automated external defibrillator (AED) along with epinephrine. For patients with a pulse but a suspected cardiac problem, use of the AED should be considered if it has monitoring capabilities.

For patients with chest pain, if systolic blood pressure is greater than 100 mm Hg, consider administering sublingual nitroglycerin every 5 minutes, checking blood pressure after each dose.

The volunteer should initiate communication with ground consultants if the crew has not already done so and discuss recommendations for interventions, such as administration of medications or intravenous fluids. Similarly, decisions about possible diversion should be made in coordination with pilots and the ground. In cases of chest pain, typically diversion is not required if symptoms resolve.

For the most common complaint of passengers—syncope or presyncope—the patient should be moved into an aisle or galley area and placed supine with legs raised, and oxygen should be provided. Oral fluids should be given when possible. If the patient has diabetes, a glucometer from the patient or another passenger can be used for assessments.

Generally, syncope incidents resolve rather quickly, the article notes. “The good news is that most of these cases do very well with simple intervention—with hydration and a little time,” said Dr. Martin-Gill. “Even someone who might look diaphoretic or hypotensive because they just passed out may be alert and able to drink liquids within 5 minutes. Most cases don’t require the plane to be diverted or anything beyond medical assistance once the passenger arrives at the destination.”

Given the expense and inconvenience of an aircraft diversion, the decision to make an unscheduled landing is not taken lightly. But, said Dr. Martin-Gill, when the medical circumstances warrant diversion, nobody balks.

“There are many considerations in diverting an aircraft, including financial considerations,” he said. “But in my experience, the airlines don’t hesitate when a passenger needs immediate medical assistance; the pilots are cognizant of putting the health of their passengers first and foremost. I’ve never experienced hesitation other than safety.”

He noted that operational considerations might prevent or delay a diversion. For instance, an airplane that has just taken off may not be able to land immediately due to the weight of its full fuel load.

The authors of the article conclude: “On the basis of our findings, we believe that airline passengers who are healthcare professionals should be aware of their potential role as volunteer responders to in-flight emergencies. We also advocate systematic tracking of all in-flight emergencies, including hospital care and other outcomes, to better guide interventions in this sequestered population.”

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

• In-flight medical emergencies occur in about 1 in 600 flights.
• Most emergencies are not life-threatening and do not require diversion of the flight.
• Good Samaritan laws offer protection to physicians who volunteer to treat ailing passengers.
• Airlines maintain arrangements with on-ground medical professionals to coordinate onboard emergency care.

Additional information

1. Online extra “Fourth Time’s a Charm?”
2. Peterson DC, Martin-Gill C, Guyette FX, Tobias AZ, McCarthy CE, Harrington ST, et al. Outcomes of Medical Emergencies on Commercial Airline Flights. N Engl J Med 2013; 368(22):2075-83
3. Mattison MP, Zeidel M. Navigating the Challenges of In-flight Emergencies. JAMA. 2011;305(19):2003-2004. doi:10.1001/jama.2011.618.