Responding to in-flight emergencies
By Mollie Frost
As this year's meeting ends, some physicians may be wondering what to do if there's an emergency on the plane ride home. Jason Napolitano, MD, FACP, provided many answers during his Friday session, "In-Flight Emergencies: Is There a Doctor on the Plane?"
"Many of you might be thinking, 'I've been on a lot of flights, and I've never had to respond,'" he said. "It's about 1 in 600 flights where someone has a significant enough event where this call would go out."
Syncope or presyncope made up about 37% of nearly 12,000 medical emergencies on commercial airline flights in a study published in May 2013 by the New England Journal of Medicine. Respiratory symptoms also frequently occur (12%) due to hypobaric hypoxemia, as well as the dry air in the cabin, which can trigger chronic obstructive pulmonary disease and asthma exacerbations, said Dr. Napolitano. Nausea and vomiting are also common (10%).
"You might have to recommend aircraft diversion," he added, noting that the captain has ultimate control over this decision. "Luckily, only about 7% of the time where you respond to a medical emergency leads to that recommendation for diversion." Death is also rare, as only 36 deaths were logged in the dataset.
Responding physicians will be protected by Good Samaritan statutes if certain criteria are met, Dr. Napolitano said. "We have pretty significant protection against liability should we be Good Samaritans and hit that call light and help somebody in need, which I'm recommending that we all do," he said.
For these statutes to be in effect, the situation must be a true emergency, the Samaritan must be medically qualified to perform the service, and care must be provided in good faith with no intentional harm to the patient, said Dr. Napolitano, who is a hospitalist at the University of California, Los Angeles, and associate dean for curricular affairs at the David Geffen School of Medicine.
Once offering emergency assistance, a physician has a legal duty to remain with the patient until stabilized or until a clinician with equivalent or higher training takes over, usually on the tarmac upon landing, he noted.
Care must also be rendered free of charge. "I will say that if the airline upgrades you, gives you a free beverage, miles, etc., that doesn't count," Dr. Napolitano said. "It's not like you demanded a fee from the patient before you treated them."
On U.S. airlines, available medical resources include an emergency medical kit, a flight crew trained in CPR and basic first aid, and 24/7 access to board-certified emergency physicians who can provide remote guidance, he said.
While the Federal Aviation Administration requires emergency kits to contain supplies like a sphygmomanometer, stethoscope, IV access equipment, and certain medications (e.g., nonnarcotic analgesics, antihistamines, epinephrine, nitroglycerin tablets), that list hasn't changed in more than 20 years, Dr. Napolitano noted. "Many have advocated to change it."
Additional components that are important but not required include a glucometer, an epinephrine autoinjector, a pulse oximeter, and naloxone, although these may be included in enhanced emergency medical kits, he said. Such kits may also include umbilical cord clamps for delivering a baby mid-flight, "which, to me, would be the scariest of all these emergencies," Dr. Napolitano said.
Finally, he noted that in about half of flights where there's a medical emergency, there's no physician who responds. "In the U.S., there's no law that dictates that you must respond," although Germany, France, and Australia do have such laws, Dr. Napolitano said. "It's more of a code of ethics that most of us would want to help where we can, since we've spent so much time training to do this." ■