In-Flight Emergencies

Epidemiology:

Prevalence of in-flight emergencies: 1 in 604 flights from literature review between 2008-2010 of five domestic and international airlines representing 10% of the global passenger volume at that time
Types of in-flight emergencies when a single cause could be identified:
- Syncope/near syncope (32.7-37.4%)
- GI including nausea/vomiting (9.5-14.8%)
- Respiratory including asthma exacerbations (10.1-12.1%)
- Cardiovascular (7.0%) including cardiac arrest (0.2%)
- Other (Psych/intox, allergy, ob/gyn, other/unknown)
In-flight emergencies rely on one large decision point: can the flight continue to its intended destination or does the situation require alternative landing plans, aka “diversion”?
- Physician passengers provide medical assistance in approximately 48% of in-flight medical emergencies
- When in-flight emergencies occur, the pilot staff consult with an on-ground aviation medical team to assist with decision making regarding diversion
- Flight attendants are trained in CPR and AED use
- 4-7.3% of in-flight emergencies required diversion (about 1 in 8,300 flights)
- Approximately 25% need post-flight transportation to a hospital
- 6% of all in-flight emergencies required hospitalizations with a mortality of 0.3%
  - Most common admission criteria included possible strokes, respiratory distress, and cardiac symptoms

Pathophysiology:

Passenger cabins (pressurized to 11-12 PSI) can cause volumes of gas to expand by up to 30% and can trigger discomfort in closed systems, physiologic gas-containing spaces of the body (sinuses, middle ear) or non-physiologic potential spaces (pneumothorax, potential spaces created following GI/ocular/intracranial surgery)
Partial pressure of oxygen decreases at altitude (in healthy patients: as large a drop in mean arterial oxygen saturation as 93% from 97%)
Weak case report and small-powered VTE risk profile analyses suggest increased platelet activation/venous stasis in conjunction with non-insignificant hypoxia as etiology of increased VTE risk

First Aid/Emergency In-Flight Medical Kits:

FAA Code of Regulations, Title 14, part 121 subpart X Section 121.803
1 kit for 0-50 passengers; 2 kits for 51-150 passengers; 3 kits for 151-250 passengers; 4 kits for 250+ passengers
Contents of each kit below (notice absence of pediatric or obstetric supplies)

Good Samaritan Law:

In the United States, physicians are under no legal obligation to assist in in-flight medical emergencies
The Aviation Medical Assistance Act (1998) provides Good Samaritans with protection from lawsuits alleging negligence “unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct”
- For example, a physician passenger could be considered grossly negligent if the physician was intoxicated due to alcohol or sedative ingestion on the flight
Of note, the physician provider must receive no monetary compensation: do not accept upgrades, travel vouchers, or travel miles
The Aviation Medical Assistance Act also protects American airline companies from liability in seeking physician provider assistance if the flight crew “in good faith” believes the provider is medically qualified
Intercontinental flights rely on the laws of the country in which the airline is based
- For example, Australia, France, and Germany legally mandate that physicians provide aid (or else face fines or prison)

References:

https://jamanetwork.com/journals/jama/fullarticle/2719313 (Meta-analysis of epidemiology/pathophysiology of in-flight emergencies)

https://www.cmaj.ca/content/164/7/1037.long (postulation of VTE risk profiles in air travel)

https://www.cordem.org/globalassets/files/curricular-toolkit/good.samaritan/good.samaritan.laws.summary.handout.pdf

https://www.law.cornell.edu/cfr/text/14/121.803 (FAA Guidelines on Emergency Medical Equipment)

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