Navigating the Challengesof In-flight Emergencies
Melissa L. P. Mattison, MDMark Zeidel, MD
S THE FLIGHT BEGINS ITS DESCENT
A CALL COMES
over the intercom: “Is there a physician onboard?” Three internists traveling together to ameeting respond. A woman has lost conscious-ness. She is incontinent and unresponsive, with a strongpulse and intermittent breathing. The physicians ulti-mately determine the patient has hypoglycemia and a sei-zure. It takes multiple requests before the flight attendantsprovide the physicians with the emergency medical kit. When the kit arrives, the flight attendants disappear, andthe physicians search in vain for glucagon or intravenousdextrose. The physicians massage oral glucose gel into thepatient’s buccal mucosa, and the seizure eventually stops.After landing, the cabin crew records the names and con-tact information of the physicians, with no discussion of the incident.Other reports have recounted physicians having chal-lenging experiences with in-flight medical emergencies.
Likephysiciansintheseotherreports,thesephysiciansfacedchallenges in providing care: the physical space was diffi-cult to work in, the emergency medical kit was not imme-diatelyavailableforuse,thephysicianswereunfamiliarwithitscontents,andtheflightattendantswereabsentformuchof the episode.Thequalitymovementinhealthcarehasfocusedincreas-inglyonstandardizationofprocessesofcaretoimprovere-liability and patient safety. Ironically, key concepts in thismovement, such as root cause analyses of poor outcomesandnearmisses,originatedintheairlineindustry;theseap-proaches have so improved aviation safety that there werenofatalitiesonUSdomesticflightsin2010.
JudgingfromeventssuchastheemergencylandingontheHudsonRiver,as well as other incidents, flight attendants are well trainedin emergency landings and evacuations. Because of im-provedaviationsafety,mostindividualflightattendantswillnever experience an emergency landing or evacuation dur-ing their careers. By contrast, in-flight medical emergen-ciesoccurfrequently.Yetthekindsofapproachesthathaveimproved flight safety have not been extended to provid-ingoptimalcareforpassengerswhobecomeacutelyillwhileon board airplanes.Available evidence suggests there is significant room toimprove and standardize the care that is provided topatients during in-flight medical emergencies. A surveyof European airlines identified 10000 in-flight medicalemergencies during a 5-year period.
The study notedthat each airline had its own reporting system and proto-col. Even though emergency medical kits are mandatedto contain certain medications and equipment, the actualkits vary from airline to airline.
The US Federal AviationAdministration (FAA) mandates that flight attendantsreceive training “to include performance drills, in theproper use of AEDs [automated external defibrillators]and in CPR [cardiopulmonary resuscitation] at least onceevery 24 months.”
However, the FAA “does not requirea standard curriculum or standard testing.”
Many air-lines also contract with a commercial on-ground supportcompany that can, in theory, offer radioed, real-timemedical advice.To improve the chances that passengers who become illduring air travel will do well, airlines and their regulatorscould take steps similar to what they have done to ensureflightsafetyforallflightsunderFAAjurisdictionincludingthe following.First,astandardizedrecordingsystemforallin-flightmedi-calemergenciesshouldbeadopted,withmandatoryreport-ing of each incident to the National Transportation SafetyBoard, the organization responsible for reviewing safetyevents and recommending changes to practice. This ap-proachshouldincludeasystematicdebriefingofanyonedi-rectlyinvolvedwiththein-flightmedicalemergency.Wher-ever possible, this debriefing should happen immediately;otherwise, follow-up telephone interviews should be con-ducted. The debriefing will help improve the recording of theincidentaswellashelpdefinehowtoimprovethehan-dling of such incidents. Collecting these records and dis-seminatinglessonslearnedmayhelpimprovethecaregivenduring in-flight medical emergencies throughout the do-mestic airline fleet.Second, based initially on expert recommendations andlater on the results of reporting, the optimal content of thefirstaidkitsonairplanesshouldbedetermined,withaman-
DepartmentofMedicine,BethIsraelDeaconessMedicalCenter and Harvard Medical School, Boston, Massachusetts.
Melissa L. P. Mattison, MD, Beth Israel Deaconess MedicalCenter, 330 Brookline Ave, Boston, MA 02215 (firstname.lastname@example.org).
©2011 American Medical Association. All rights reserved.
Published online May 6, 2011