“This Airbus Has Three Emergency Doctors”

22. August 2017
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Medical emergencies on flights are rare, but they will increase in the future due to the increasing age of passengers and to the greater frequency of pre-existing diseases. How can airlines prepare themselves for this? And what is to be considered when a doctor performs medical assistance on board?

Any physician could be confronted with this: an announcement over the aircraft loudspeaker indicates a medical emergency on board and calls for medically trained passengers to assist. Although life-threatening incidents on flights are rare, they place great challenges on on-board personnel and on those providing voluntary assistance. This is because both the technical equipment and the available professional staff can’t match the emergency equipment in a hospital.

The number of air passengers is increasing worldwide. In 2016 about 3 billion persons travelled on commercial flights. According to previous studies on this topic, a medical emergency event occurs with one in 14,000 to 40,000 passengers. In approximately seven to 13 percent of these cases, the emergency results in an unscheduled interim landing of the aircraft. And about 0.3 percent of those affected die as a result of the emergency.

More people with pre-existing conditions on flights

These figures could continue to rise in the coming years, one reason being that more and more of the elderly and people with pre-existing diseases are on flights. “The issue of medical emergencies on flights will become increasingly important in coming years” says Prof. Dr. Jochen Hinkelbein, president of the German Society for Aerospace Medicine (DGLRM) and emergency physician at the University Hospital of Cologne (Germany).

Be that as it may, there have until now been no guidelines that set out measures for preparing for a medical emergency on board, nor for handling such emergencies. In addition, the frequency, causes and consequences of such emergencies have not been recorded. “This information would, however, be an important prerequisite in order to define the appropriate emergency medical equipment to have on board and the appropriate training measures for the crew, as well as to provide appropriate recommendations for dealing with emergencies”, Hinkelbein and his team say. “We therefore urgently need an international centralised database that systematically records medical emergencies”.

Special equipment on board is often missing

The most common causes of emergencies on flights according to one study are circulatory collapse or a circulatory system instability (presyncope) – both together account for 37 per cent of incidents. In second place are symptoms of the airway (12%) such as dyspnoea, followed by nausea and vomiting (9.5%). 8.5 per cent of those involved were treated in hospital after the incident – mostly due to the suspicion of stroke, respiratory ailments or heart problems. In another study, in which flight physicians were interviewed, cardiovascular disease (40 percent) and neurological symptoms (18 percent) were stated to be the main causes of emergencies on flights.

There is indeed a prescribed set of minimum equipment for medical emergencies on board each aircraft, and the flight crew is required to have been trained to carry out certain emergency procedures as stipulated by the Europe Aviation Safety Agency (EASA). There needs to be a first-aid kit on board and an emergency medical kit as well for aeroplanes with more than 30 seats. Nevertheless, it is not stated to the last detail as to what this kit needs to contain. In the US it is specified that the medical emergency set is to carry a defibrillator and adrenaline for the treatment of a circulatory system shock – in Europe no such regulations exist thus far.

Additional equipment for emergencies can vary significantly from airline to airline. Hence the result of a study by the Hinkelbein research team revealed that the 13 participating German airlines all had the prescribed minimum equipment on board but only four were equipped with a defibrillator and only seven were equipped with an extended medical emergency set. “On the whole, the airlines’ equipment for medical emergencies meets the legal requirements”, says Hinkelbein. However, the equipment is not sufficient for most airlines to be able to deal with specific emergency situations as according to medical guidelines, the researchers write – for instance to deal with an acute heart attack by performing a heart-lung resuscitation.

New guideline: measures for heart failure

One such rare but serious incident on flights is acute cardiovascular arrest: although this represents only 0.3 per cent of medical emergencies on flights, it is responsible for 86 per cent of deaths. A DGLRM working group led by Jochen Hinkelbein has now for the first time developed a guideline which recommends that airlines deal with a cardiac arrest on board. This was presented by the researchers at the beginning of June at the Euroanaesthesia Conference in Geneva. Contacting the individual airlines directly and convincing them to include the respective elements in their emergency action catalogue is the current plan.

The guideline includes the following measures:

  • All aircraft should be equipped with a defibrillator or at least an ECG device.
  • The crew should complete a first-aid training period (if possible every six months) which includes training for heart-lung resuscitation.
  • The emergency equipment and its location should be mentioned in the pre-flight safety statements.
  • After a (presumed) cardiac arrest, the aircraft’s staff should call for medical assistance as soon as possible through loudspeaker announcement.
  • If possible, the cardiopulmonary resuscitation should be performed by two people.
  • As soon as spontaneous circulation is observed in the patient, the aircraft should land at the nearest airport.

Further emergencies: severe allergic reactions and asthma attacks

Besides cardiac diseases, allergies and asthma can lead to emergencies on flights – for instance severe asthma or a severe allergic reaction. “Little is known about the frequency of such emergencies. But we are afraid that this topic has not yet received the attention required”, writes an international researcher team led by Mario Sánchez-Borges from the Centro Médicodocente La Trinidad in Caracas (Venezuela). For example, studies estimate that two to four percent of the medical problems on flights are caused by allergies. The specific conditions of a flight may favour asthma attacks or allergic reactions. This relates in particular to the lower oxygen content and the low humidity in the cabin.

It is therefore important to record the incidence of allergic and asthma-related emergencies as well as options for prevention and treatment in future studies. “In addition, risk passengers and airlines should follow the necessary measures to prevent such emergencies and to treat them appropriately”, Sánchez-Borges and his team emphasise. Up until now, the equipment for treating such emergencies in the aircraft has been limited.

The researchers say that many airlines have now introduced strategies for dealing with such incidents. However, they say there are currently no standardised sets of measures for all airlines. “Here, working together with specialised physicians, evidence-based recommendations should be developed”, say the researchers led by Sánchez-Borges. It would be useful, for example, for the emergency kit to carry corticosteroids, antihistamines and Beta-2 agonists for the treatment of an acute asthma attack.

What should one watch out for when one actually performs medical help?

Anyone who is a physician should not hesitate to provide medical assistance in an emergency on board – even if such a situation can be a severe stress. “One should be aware that this assistance can significantly improve the outcome of emergencies”, Hinkelbein stresses. “That is why one should in any case provide assistance”. Volunteer helpers will almost never have to deal with any negative consequences, he says. “The risk of being held liable for a potential negative outcome is virtually impossible”, says the scientist. “Here various laws provide protection for emergency responders on board”.

Anyone who is willing to provide medical assistance during a flight can already acquire information before departure about which medicines and medical devices are on board. “If an emergency occurs, the assisting physician should first inquire where the materials are”, Hinkelbein says. “It’s additionally a good idea to carry an identifying document as a doctor”.

Over the further course, the helper should regularly consult with the flight captain, give him information about the condition of the patient and advise him whether an unscheduled intermediate landing is necessary. Yet the decision resides ultimately with the captain.

“Anyone who provides assistance in the aircraft should be aware that an emergency is usually manageable but the available options when doing so are often limited”, Hinkelbein says. “In the end everyone should help as much as is possible in this unusual environment”.

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4 comments:

Dr Walter Serino
Dr Walter Serino

The risks and the costs of accepting growing number of passengers affected by multiple co-morbidities, both on medium and long-haul flights should be carefully evaluated. In most cases a single passenger acute clinical event will cause disruption to hundred of others, under various forms: disruption of on board routine, emergency change of destination, lengthy delays and so on.
Cynical as it may sound, I believe that the rules of acceptance into medium and long term flights should be significantly tightened with exclusion of the frankly unwell patients and of those with high morbidity risks. Airlines should for once prioritize the collective rights of other passengers to enjoy a timely and non disrupted journey and forgo the greed of immediate revenue.
Besides, it is obvious that the costs of managing such events is often higher than the loss of revenue.

#4 |
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Excellent paper; all airlines should follow these recommendations!

#3 |
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Christian Lauwers
Christian Lauwers

Very interesting. Nevertheless: I have been asked to help 4 times so far and always for rather psychiatric problems, no others. One a panicking women (Condor), one an acute depression (Aeroflot), one a subacute psychotic development (Uni Air? Taiwan) and once a couple believing to be on the wrong flight (Sabena at the time, SN-airlines). In all cases things remained under control (being a psychiatrist was helpfull). In none of the cases there wasn’t any appropriate medecine on board and the staff was kind but totally unprepared.

#2 |
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dierckx.walter@gmail.com
dierckx.walter@gmail.com

Sincere thanks for this message, I’m a (retired) emergency dr. myself.

#1 |
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