I fly a lot; in fact, this late in my orthopaedic career, when people ask me what I do best in orthopaedics, I reply, “I fly!” With all the back-and-forth from Memphis or my home on the Gulf coast to AAOS committee meetings and CME courses, I know O’Hare International Airport better than most people know their own garage. The operators of Atlanta’s Hartsfield-Jackson airport love to see me fly, because they know I’m going to miss my connection more than half the time and spend money overnight in Atlanta.
S. Terry Canale, MD
Even being fly-smart or airport-smart, I still get apprehensive when I hear the flight attendant on the plane intercom ask, “Is there a doctor on board this flight? Will you please identify yourself by pressing the attendant call button?”
Let me explain. First, I don’t know what the medical situation is going to be. Second, I don’t know what medical equipment or drugs are available. Third, I don’t know anything about diverting a commercial flight or what ground support is available for consulting and what the liability might be. So naturally, I’m a little nervous about responding.
Furthermore, in the past, I have had two unpleasant experiences answering medical emergencies. One was in an airport and involved a patient with refractory epilepsy who had a seizure; I attended to his airway until the emergency medical technicians (EMTs) arrived, and I ultimately missed my flight. The second incident was an in-flight emergency for a patient who I later surmised had a syncopal episode. A psychiatrist and I answered the call. Believe it or not, the psychiatrist was more useless than I was. He hid behind me while I did mouth-to-mouth and external heart pumping. (This was approximately 20 years ago and automated external defibrillators [AEDs] were not yet available.)
It reminded me of the old definition of a double-blind study: an orthopaedist and a psychiatrist trying to read an EKG! We did not have to divert the flight because the syncopal episode ended when the flight attendant elevated the patient’s feet above the level of his heart. The patient got better, the EMTs met the plane at our original destination, the “Shrink” and I were heroes, and the airline showed its appreciation by giving each of us an $8 meal voucher. So I guess you can see why I’m a bit squeamish about “answering the bell” as a Good Samaritan in the air.
How common are they?
In this issue of AAOS Now, Terry Stanton has done an outstanding job of investigative reporting on medical emergencies on commercial airline flights—the percentage of emergencies, the types of emergencies, and their outcomes. (See cover story, “On Call at 30,000 Feet.”) Recently, the New England Journal of Medicine (NEJM) published an article on this subject, reviewing records of calls to a medical communication center from five domestic and international airlines. This article led to an interview with Dr. Martin-Gill, a physician expert in this field. The article is well worth reading and has relieved me of almost all of my apprehensions about in-flight medical emergencies.
For instance, I now know that there is approximately 1 medical emergency per 604 flights. The most common emergencies were syncope or presyncope (37 percent), respiratory symptoms (12 percent), nausea or vomiting (9.5 percent), cardiac symptoms (8 percent), and seizures (6 percent). Physician passengers provided medical assistance in 48 percent of cases, and aircraft diversion occurred in 7 percent of medical emergencies.
Diversion of a commercial airline to an unscheduled destination is a complex situation involving medical and important operational issues, including the following:
- saving time vs stabilizing the patient
- airport availability
- availability of medical support on the ground
- fuel dumping vs fuel conservation
After physician input is received, the decision to divert usually is made by airline and airport authorities and ground control. Also, most commercial airlines provide “on-the-ground” physician consultation.
Generally, an AED is available on the plane and can be used to monitor the patient’s cardiac rhythm and rate and to deliver a shock if needed. However, the AED was actually used in only 5 percent of the cardiac cases reported. Myself, I’m not expert in delivering a shock with an AED, but I am an expert in receiving a shock, having been brought back from the “other side” twice from ventricular fibrillation, so I guess you can say I’m a great believer in AEDs.
I recently had to use an AED and found that, although it’s a sophisticated piece of equipment, it’s basically idiot-proof. It tells you if a shock is needed and how to apply it (digitized and audio). After the shock, my tennis-partner cousin went from being as cyanotic as the tie I’m wearing to a normal color and normal sinus rhythm. What a great feeling—not only for him, but for me too.
Helping is a great feeling
Speaking of feeling good, I didn’t know that a Good Samaritan provision in the 1998 Aviation Medical Assistance Act protects those physician passengers and medical personnel who volunteer to help in a commercial airline medical emergency.
It’s like I was told one night during an emergency at a Health Volunteers Overseas site: “Dr. Canale, you ain’t much of a hand surgeon, but tonight you are the best, because you’re all we got!”
Armed with the information from Mr. Stanton’s article in AAOS Now and the NEJM review, I no longer have the excuses of not knowing what to expect or what to do to keep me from volunteering. I might be the only doctor on board a flight and, as such, might be all an individual has to help him or her in a medical emergency. I believe that we as physicians have a moral and professional responsibility to act as volunteer responders and Good Samaritans. After all, that’s who we are.
Furthermore, there is no better feeling than hearing the words, “I can feel a pulse,” followed by, “We got him back.” So, from now on, when I hear the call for medical assistance, I won’t hesitate to identify myself and volunteer to help.
For more tales of in-flight emergencies, see “Fourth Time’s a Charm?” an online exclusive.
Share your stories of medical emergencies in the air by emailing Dr. Canale at email@example.com
Peterson DC, Martin-Gill C, Guyette FX, et al: Outcomes of medical emergencies on commercial airline flights. N Engl J Med 2013;368(22):2075-2083.