'Is There a Doctor on Board?' Keeping Quiet vs Stepping Up

Discussion in 'Doctors Cafe' started by Hadeel Abdelkariem, Aug 6, 2018.

  1. Hadeel Abdelkariem

    Hadeel Abdelkariem Golden Member

    Apr 1, 2018
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    Up in the Air: Responding to In-Flight Medical Emergencies
    It might sound like a line out of a Hollywood script, but with an estimated 44,000 in-flight medical emergencies occurring worldwide every year, according to a 2013 study published in the New England Journal of Medicine,[1] physicians flying the friendly skies need to be prepared to respond at 35,000 feet.

    What Are the Odds?
    In-flight medical emergencies on a commercial flight are relatively infrequent, according to the study authors: The occurrence of in-flight medical emergencies is only about 16 per 1 million passengers, according to the study authors. But with some 2.75 billion passengers flying commercial airlines worldwide each year, the odds of being asked to assist with a medical emergency in the air are considerably higher.

    After analyzing data from five domestic and international airlines over a 34-month period ending in October 2010, researchers at the University of Pittsburgh Medical Center (UPMC) concluded that the incidence of in-flight medical emergencies is about 1 per 604 flights.[1] In roughly three quarters of those cases, flight crews requested and received assistance from passengers with medical training, including doctors, nurses, and EMS providers. Nearly half the time (48%) physicians answered the call.

    "Medical emergencies in the air are an everyday occurrence," says Dr Christian Martin-Gill, one of the study's authors. What's more, they're likely to become even more common given the increase in air travel and long-haul flights. Consequently, he says, physician passengers need to know what they may face if they hear the call.

    Despite their training, physicians may be reticent to respond to flight attendants' requests for help. Some may assume or hope that another more qualified passenger will respond, or they may be intimidated by the cramped surroundings and lack of hospital resources. Others may feel that they are not emotionally or physically equipped to respond; perhaps they have been napping, have had a cocktail, or have a debilitating fear of flying. Still others fear legal liabilities, paperwork, or missed connections.

    Dr Robert Tanz understands that hesitation. A Chicago pediatrician and professor at Northwestern University's Feinberg School of Medicine, Dr Tanz was flying home from London more than a decade ago when a flight attendant paged for medical assistance.


    Stepping Up in the Sky
    "I figured that the passenger would be an adult and there would be people more qualified than I was to help," Dr Tanz recalls. Goaded by his teenage daughter, Dr Tanz went to help, as did a pediatric endocrinologist also on board.

    To their surprise, the patient was a child with a peanut allergy who was in respiratory distress. The child's emergency medications were in the family's checked luggage and, although the airplane's medical kit included an epinephrine autoinjector and an albuterol inhaler, the crew and physicians—flying in the near aftermath of 9/11—lacked scissors to cut open the shrink-wrapped packaging. In the end, the two doctors were able to help the patient with an inhaler and epinephrine injector supplied by other passengers.

    "Later when we landed I found out that at least three other passengers on the flight were physicians," he says. "They all had excuses for not getting involved. One was a pathologist who didn't think he could help. One was a retired internist."

    As a result of that experience, Dr Tanz says he no longer hesitates to get involved and has twice responded to in-flight emergencies involving adults suffering cardiac symptoms. In the first case he was able to step away as a better-trained cardiologist likewise responded. In the second, he and a psychiatric nurse administered aspirin and oxygen and monitored the patient's vital signs while communicating with physicians on the ground. The flight was given priority landing status and paramedics took the patient to the hospital. Dr Tanz doesn't know what happened to the man.

    "I'm sure I'm not the right person to help without assistance from the ground for many situations," he says, "but I still have basic knowledge and can follow medical direction better than an average person if needed."

    You Are Not Alone
    That's exactly the message that physicians who provide on-ground emergency support to airlines want medically trained passengers to understand.

    "The first thing that flying physicians need to know is that they are not alone," says Dr Martin-Gill, who works for UPMC, which contracts with 20 airlines to provide medical consultation services. In the air, he says, the first responders are the flight attendants, who the Federal Aviation Administration (FAA) requires to have training in basic first aid, cardiopulmonary resuscitation (CPR), and the use of an automated external defibrillator (AED). In addition, US commercial carriers and the vast majority of international airlines contract with organizations like UPMC to provide emergency medical support from the ground.

    In the event of an in-flight emergency, different airlines follow different protocols, depending on their culture, says Dr Paulo Alves, global medical director of aviation health for MedAire, an International SOS company that provides in-flight medical support to about 60 airlines. Some crews will call supporting physicians on the ground before seeking assistance from healthcare providers on board, while others will first ask for passenger volunteers. Whichever approach the crew takes, on-board physicians should know that trained physicians on the ground are generally available if needed.

    "I'm a frequent flyer and I've probably handled 15 cases while flying myself," says Dr Alves, a cardiologist. "But that doesn't even scratch the surface of the experience of one of our supporting physicians who may have handled literally a thousand of these."

    US Flights Count on Volunteers
    While some countries have duty-to-respond regulations that will apply to their airline carriers, US carriers depend on volunteers. A physician needn't be trained in emergency medicine to provide valuable assistance, says Dr Martin-Gill. A podiatrist or a pathologist might not be comfortable starting an IV, he says, and that's okay. She is still better trained to assess a patient and provide care in ways that a typical passenger wouldn't be. Most patients don't require major interventions; simply laying them down and providing oxygen and hydration helps most.

    "The care you can provide as a medical authority on board is generally what is needed," he says. "Healthcare providers in the air need to feel comfortable with what they have experience in."

    Dr Margaux Lazarin, who practices family medicine in the Bronx, New York, wishes she'd known that medical support was available when she responded to her first in-flight emergency in 2013. Although the patient in that situation recovered quickly after passing out, Dr Lazarin says it would have been reassuring to know she had backup had she needed it. "You feel completely out of your environment when you respond," she says. "And you feel very much alone. You're in vacation mode, not doctor mode, and you feel a lot of pressure to make an accurate assessment, because diverting a flight could really impact a lot of people."

    While on-board physicians may feel that weight, Dr Martin-Gill underscores that pilots guided by dispatchers—not physicians responding to a page—are ultimately responsible for deciding whether to divert an airplane, as they must consider numerous factors, such as fuel load, proximity of the nearest airport, and the types of medical facilities located there. "There is collaboration," he says, "but it's the pilot's ultimate decision."

    Likely Scenarios and Resources
    Physicians who do respond to the request for assistance need to know the situations they're likely to face and the resources available to them.

    Of the nearly 12,000 in-flight medical emergencies that UPMC researchers analyzed, more than a third (37.4%) were syncope or presyncope. Respiratory symptoms accounted for 12.1% of medical emergencies, followed by nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%).

    Beyond that, "it's really a smattering of anything that can show up in an ED," says Dr Martin-Gill, with emergencies including infectious disease, psychiatric symptoms, allergic reactions, possible stroke, trauma, diabetic complications, obstetric symptoms, and lacerations. Only a small fraction (7.3%) of medical emergencies resulted in an aircraft being diverted, and less than 1% (.3%) resulted in death. Of the patients who died, the vast majority (31 of 36) suffered cardiac arrest.

    While in-flight medical resources may be Spartan compared with those of a metropolitan ED, Dr Martin-Gill says the analysis shows that flight crews and the volunteers assisting them generally have the resources they need to address most emergencies.

    Since April 2004, the FAA has required airlines with a capacity of more than 7500 pounds—typically those accommodating 30 passengers or more and at least one flight attendant—to carry an AED, a basic first-aid kit for wound care, and an emergency medical kit. The FAA mandates that at least one kit on board must include a sphygmomanometer, stethoscope, three sizes of oropharyngeal airways, a self-inflating manual resuscitation device with three mask sizes, CPR masks, IV equipment, alcohol sponges, adhesive tape and scissors, a tourniquet, saline solution, gloves, syringes and needles of varying size, analgesics, antihistamine tablets and injectables, atropine, aspirin, a bronchodilator, injectable dextrose, epinephrine and lidocaine, nitroglycerine tablets, and basic instructions for use of the drugs in the kit.[2]

    Legal Protection for Good Samaritans
    In addition to medications and tools, "medically qualified" professionals who volunteer in good faith and receive no monetary compensation have Good Samaritan liability protection under the Air Carrier Access Act of 1998.

    The act specifies:

    An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.[3]

    If Not You, Then Who?
    Stepping forward to help a fellow passenger is nerve-wracking, doctors say: Not only are you not in doctor mode when the call goes out, but you don't know the nature of the emergency to which you're responding.

    But Drs Tanz and Lazarin say that the ethical imperative to help outweighs those concerns.

    "We talk a lot about the medical/legal side of being a doctor," says Dr Lazarin. "But for most physicians there is a moral and ethical question here. I think the question is not so much, 'Do I provide my services or not?' but 'Is this within my scope and do I have the skills?'"

    To that question, Dr Alves says, the answer is, "Yes."

    In-flight patient care is based on a synergistic model, he says. Physicians on the ground are ready to direct the care, but they can do so much more effectively if they have help from trained passengers. "In the synergistic model, anyone can help. The ground support needs a trained set of eyes and hands; a dentist or a veterinarian can help because they are better trained than the average member of the public, but you don't need to be out of your comfort zone."


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  2. Jorge Alonso Lopez Carrasco

    Jorge Alonso Lopez Carrasco Young Member

    Jan 9, 2019
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    I helped a teenager just after landed, he was pale skin and sweeting, no response, few to say I was lighting pupils no response with carotid pulse ok! So, after few seconds he woke up feeling dizzy!

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