Is There a Doctor Onboard? Medical Emergencies at 40,000 Feet

Injuries and medical emergencies among international travellers

BACKGROUND

Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings.

METHODS

We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled).

RESULTS

All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur.

CONCLUSIONS

Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.

Medical Legal Implications When Providing Emergency Care on a Commercial Flight

INTRODUCTION: U.S. airlines often request a healthcare professional to volunteer to assist an ill passenger. Litigation from a Good Samaritans care of an in-flight medical emergency (IME) is considered improbable. The 1998 Aviation Medical Assistance Act (AMAA) encourages health care professionals to volunteer with indemnity for standard and good medical care. It does not offer legal or financial assistance. Our review explored the legal support malpractice companies and U.S. airlines provide if litigation is initiated for IME care. Malpractice insurance policies can differ on IME coverage. We found most private practice physicians policies include IME. Medical institutions may have policies restricting their physicians coverage to the institutions location. Those without malpractice coverage will need to retain and pay for a legal defense to demonstrate no gross negligence and no willful misconduct. The physicians, airline crews, and on-ground IME documentation support should be retained by the Good Samaritan especially for a pediatric or adolescent ill passenger. U.S. airlines consider a Good Samaritan medical volunteer as a passenger and do not extend legal assistance. This contrasts with some foreign airlines that do provide liability protection. Knowledge of the malpractice policy IME coverage is essential prior to traveling by air. After completing care for an ill passenger, physicians should generate their medical documentation and request the IME documentation generated by the airline and on-ground medical expert. We also believe U.S. airlines should assume responsibility to provide legal assistance to a Good Samaritan physician in the event of IME litigation.de Caprariis PJ, Di Maio A. Medical legal implications when providing emergency care on a commercial flight. Aerosp Med Hum Perform. 2021; 92(7):588592.

Medical Events on Board Aircraft: Reducing Confusion and Misinterpretation in the Scientific Literature

INTRODUCTION: A topic in aviation medicine that attracts much attention from the scientific community as well as from the media concerns medical incidents on board commercial airline flights. It was noticed that many papers on the subject were written by authors whose specialization was outside that of aviation medicine and that they sometimes made basic errors concerning the application of scientific principles of the subject. A review was undertaken to determine if there were any patterns to the observed errors and, if so, to consider whether recommendations might be provided that could reduce their frequency.METHOD: A literature search was undertaken of MEDLINE using PubMed for English-only articles published between January 1, 1974, and February 1, 2019, employing the following search terms: air emergency, air emergencies, air passenger, air travel, aircraft, airline, aviation, commercial air, flight, and fitness to fly. In addition, other relevant papers held in the personal collection of the authors were reviewed.RESULTS: Many cases of misinterpretation or misunderstanding of aviation medicine were found, which could be classified into eight main categories: references; cabin altitude; pressure/volume relationship; other technical aspects of aircraft operations; regulations; medical events; in-flight deaths; and automated external defibrillator.CONCLUSION: Papers were identified as having questionable statements of fact or of emphasis. Such instances often appeared to result from authors being unfamiliar with the subject of aviation medicine and/or the commercial aviation environment. Simple steps could be taken by authors to reduce the future rate of such instances and recommendations are provided.Thibeault C, Evans AD. Medical events on board aircraft: reducing confusion and misinterpretation in the scientific literature. Aerosp Med Hum Perform. 2021; 92(4):265273.

Impact of an Electronic App on Resident Responses to Simulated In-Flight Medical Emergencies: Randomized Controlled Trial

BACKGROUND

Health care providers are often called to respond to in-flight medical emergencies, but lack familiarity with expected supplies, interventions, and ground medical control support.

OBJECTIVE

The objective of this study was to determine whether a mobile phone app (airRx) improves responses to simulated in-flight medical emergencies.

METHODS

This was a randomized study of volunteer, nonemergency resident physician participants who managed simulated in-flight medical emergencies with or without the app. Simulations took place in a mock-up cabin in the simulation center. Standardized participants played the patient, family member, and flight attendant roles. Live, nonblinded rating was used with occasional video review for data clarification. Participants participated in two simulated in-flight medical emergencies (shortness of breath and syncope) and were evaluated with checklists and global rating scales (GRS). Checklist item success rates, key critical action times, GRS, and pre-post simulation confidence in managing in-flight medical emergencies were compared.

RESULTS

There were 29 participants in each arm (app vs control; N=58) of the study. Mean percentages of completed checklist items for the app versus control groups were mean 56.1 (SD 10.3) versus mean 49.4 (SD 7.4) for shortness of breath (P=.001) and mean 58 (SD 8.1) versus mean 49.8 (SD 7.0) for syncope (P<.001). The GRS improved with the app for the syncope case (mean 3.14, SD 0.89 versus control mean 2.6, SD 0.97; P=.003), but not the shortness of breath case (mean 2.90, SD 0.97 versus control mean 2.81, SD 0.80; P=.43). For timed checklist items, the app group contacted ground support faster for both cases, but the control group was faster to complete vitals and basic exam. Both groups indicated higher confidence in their postsimulation surveys, but the app group demonstrated a greater increase in this measure.

CONCLUSIONS

Use of the airRx app prompted some actions, but delayed others. Simulated performance and feedback suggest the app is a useful adjunct for managing in-flight medical emergencies.

The Aircraft Cabin Environment

Travel by air is a safe means of transport, but from the physiologic point of view it is a means of putting people at risk as well as a potential means of spreading infectious disease. Atmospheric pressure falls with altitude and above about 10,000 feet, blood desaturation leads to hypoxia. The aircraft cabin is pressurized to maintain an effective altitude below 8000 feet, which provides adequate protection for healthy travelers. Those individuals with cardiopulmonary impairment or other conditions affecting fitness to travel should seek advice from the airline in consultation with their medical provider. People are the primary source of microorganisms in aircraft cabins and are the most important reservoirs of infectious agents on aircraft. Recirculated cabin air is filtered to remove microorganisms, but this does not prevent person-to-person spread of infectious disease in vulnerable people. The World Health Organization and Centers for Disease Control and Prevention produce guidelines; and people with febrile illnesses should postpone air travel.