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In-Flight Medical Emergencies A Review
In-Flight Medical Emergencies A Review
JAMA | Review
I
n-flight medical emergencies (IMEs) are unique events for which air passenger, air travel, aircraft, airline, aviation, commercial air,
traveling physicians, nurses, and other health care profession- flight, and fitness to fly (n = 14 842). Scanning the titles to identify
als may render medical assistance. Cruising at 35 000 ft with appropriateness and searching bibliographies yielded the final
limited medical equipment, often hours away from the closest medi- list of relevant articles (n = 765). Each article was assessed for com-
cal facility, creates an unfamiliar care challenge for many health care pleteness of data reporting and importance to management
professionals. This clinical review focuses on IME data and offers and prevention of IMEs. Based on this assessment, a total of 317
guidance to assist medical professionals who may encounter these articles were included in the review. Frequency data were
events using both literature and the authors’ insights providing air- extracted and means and 95% confidence intervals were calcu-
line care guidance for IMEs. lated when appropriate.
Methods Observations
A literature search was conducted in MEDLINE using PubMed Epidemiology
for English-only articles published between January 1, 1990, and The estimated prevalence of IMEs is 1 in 604 flights based on a
June 2, 2018, using the terms air emergency, air emergencies, review of 11 920 requested ground consultations from 5 large
2580 JAMA December 25, 2018 Volume 320, Number 24 (Reprinted) jama.com
domestic and international airlines from 2008 to 2010.1 This is Recycling of air may also expose passengers to potential allergens,
likely an underrepresentation of all IMEs because many minor inci- even when the source of allergens is several rows away from a pas-
dents do not result in consultations. Other IME frequency esti- senger. Although the enclosed and limited-space environment of air-
mates from individual airlines with data from 2009 to 2013 ranged craft raises concern for transmission of communicable diseases,44,45
from 24 to 130 IMEs per 1 million passengers.2,3 Given that 4 billion preexisting exposure is a more common infectious source.
commercial airline passengers travel worldwide annually,4 it is pos-
sible that 260 to 1420 IMEs occur daily worldwide. Emergency Medical Equipment
A total of 14 articles described the relative frequency of medi- The Federal Aviation Administration (FAA) has minimum re-
cal conditions comprising IMEs aboard commercial aircraft quirements for contents of an emergency medical kit aboard US
(Table 1).1-3,5-15 The aggregate frequency of medical conditions among airlines (Table 3). 46 Non-US airlines have different minimum
49 100 IMEs showed that syncope or near-syncope was the most requirements,6,47 and individual airlines vary widely in the con-
common IME (32.7%); other common condition categories in- tents of their emergency medical kits.23 The FAA requires auto-
cluded those with gastrointestinal (14.8%), respiratory (10.1%), and mated external defibrillators on all airplanes with “a maximum
cardiovascular (7.0%) symptoms. In-flight cardiac arrest was rare payload capacity of more than 7,500 pounds and with at least
(0.2% of IMEs). one flight attendant,”46 but automated external defibrillators are
Diversion refers to altering a flight destination for a medical not currently mandated for European airlines. 48,49 The FAA-
emergency; based on 14 publications reporting 56 599 IMEs mandated medical kit contains protective gloves and equipment
(Table 2), diversion occurred in 2515 flights with IMEs (4.4%; 95% for a basic medical assessment, hemorrhage control, and initia-
CI, 4.3%-4.6%).1-3,5-10,13-17 tion of an intravenous line (Table 3). The FAA-mandated medical
kit contents also include medications to treat mild pain, allergic
Pathophysiology reactions, bronchoconstriction, hypoglycemia, dehydration, and
Commercial aircraft fly at a cruising altitude (during level flight) of some cardiac conditions. Common enhancements to the medical
30 000 to 40 000 ft, and passenger cabins are pressurized to kit include a glucometer, urinary catheter, and medications for
12 psi to 11 psi, which is equivalent to being at an altitude of 5000 nausea, moderate to severe pain, seizures, and additional cardiac
to 8000 ft.18-22 This pressurization leads to expansion of closed indications. Controlled substances are not commonly available in
gas-containing spaces in the body (eg, sinuses and middle ear) medical kits on US airlines but may be available in kits on some
and nonphysiological gas collections (eg, pneumothorax or fol- non-US airlines.
lowing gastrointestinal, ocular, or intracranial surgery).23 At 8000 Commercial aircraft carry oxygen bottles intended for short-
ft of altitude or equivalent, the volume of gas in an enclosed term use by flight crew during sudden depressurization. Airline
space increases by approximately 30%24; altitude changes com- oxygen bottles deliver oxygen to passengers at low (2 L/min) or
monly trigger discomfort in patients, especially those with exist- high (4 L/min) settings, which may be sufficient to address the
ing upper respiratory tract inflammation or infection, including need for oxygen at cruising altitudes.27,50 These oxygen stores
sinusitis or otitis media. generally do not fully meet the needs of persons with respiratory
The aircraft cabin has a lower partial pressure of oxygen at alti- failure. The number of oxygen bottles on an individual aircraft var-
tude, with resultant mild hypoxia in healthy passengers (decreasing ies, and there is no requirement to carry enough portable oxygen
mean arterial oxygen saturation from 97% to 93%). This effect can to administer to a passenger for the duration of a flight.
be more pronounced or symptomatic in passengers with existing Several organizations recommend contents for an optimal medi-
pulmonary conditions.23-26 Passengers with hypoxia or respiratory cal kit.51-58 Some have suggested that common emergency medi-
insufficiency at baseline may benefit from supplemental oxygen at cal kits lack adequate equipment for pediatric emergencies.59,60 Rec-
cruising altitude27-29; alternatively, the baseline flow of oxygen may ommended improvements include standardization of content and
need to be increased for the duration of a flight. Use of a portable location of equipment,61 availability of pulse oximetry,60 and addi-
oxygen concentrator during flight needs approval by the airline, a tional medications, including a “major analgesic,”56 naloxone,60 and
physician’s certification of need, and sufficient battery life, all typi- antibiotics.62 Despite these suggestions, current basic emergency
cally coordinated at least 48 hours prior to the flight.30-32 medical kits contain sufficient equipment to handle most IMEs; only
Prolonged sitting and hypoxia may trigger decreased venous flow, a minority of cases require a medication or performance of ad-
systemic inflammation, and platelet activation, which explains the as- vanced procedures.1
sociation between air travel and venous thromboembolism,33,34 al-
though controversy exists regarding the risk compared with the gen- Ground-Based Medical Support
eral population.34-38 Symptoms of deep venous thrombosis or Ground-based medical support comes from trained medical per-
pulmonary embolism most commonly present hours to days after sonnel who provide recommendations for IMEs and preflight
completing air travel39 but can occur on flights of long duration or dur- screenings.63 Most airlines contract with third-party entities to
ing multiple flights in succession.40,41 The risk of lower limb venous provide this service.1,13,15,64,65 When an IME occurs on an aircraft,
thrombosis in high-risk passengers may be up to 5% per flight,41 and a flight attendant notifies the pilot in command; next, that pilot
symptomless venous thromboembolism may occur in up to 10% of establishes radio or satellite telephone communications with the
passengers on flights of long duration (ie, >4 hours).42 ground-based medical support center and the airline operations
Cabin air, drawn from an outside dry environment at altitude and center. The flight attendant relays information to and from
pressurized and dehumidified by cycling through the engine com- ground-based support via the pilot or through headsets in the
partment, may contribute to dehydration among passengers.21,24,43 cabin. Communication clarity is often a challenge, including
jama.com (Reprinted) JAMA December 25, 2018 Volume 320, Number 24 2581
Hung 1 Airline, 60 mo 4068 1310 (32.2) 359 (8.8) 248 (6.1) 727 (17.9) 113 (2.8) 92 (2.3) 56 (1.4) 30 (0.7)b 1163 (28.6)
et al,7 2013
Delaune 1 Airline, 12 mo 2279 348 (15.3) 271 (11.9) 251 (11.0) 285 (12.5) 312 (13.7) 279 (12.2) 84 (3.7) 63 (2.8) 31 (1.4) 7 (0.3)b 355 (15.6)
et al,8 2003
Kim et al,2 1 Airline, 48 mo 2818 510 (18.1) 554 (19.7) 279 (9.9) 215 (7.6) 120 (4.3) 398 (14.1) 111 (3.9) 132 (4.7) 30 (1.1) 15 (0.5)b 469 (16.6)
jama.com
Review of In-Flight Medical Emergencies Review Clinical Review & Education
device issues and relaying of information, making well-articulated vide medical assistance from liability except in cases of gross neg-
exchanges essential. The effect of ground-based medical support ligence or willful misconduct.68 Medical volunteers who seek
on patient outcomes following an IME has not been studied. compensation in return for providing aid (such as money, seat up-
grades, mileage points, or other items of value) may jeopardize their
The Medical Volunteer Role standing under existing immunity laws, although no case law re-
Guided by individual airline policies, airline personnel often seek aid lated to this exists.69
from trained medical professionals, augmenting existing capabili- Flights outside of the United States are governed by a complex
ties. Medical volunteers are not generally required to carry proof of combination of public and private international laws, including the
their medical license, although this varies by individual airline policy. Warsaw Convention, Montreal Convention, and Tokyo Convention.69
Volunteers who have a business card or licensure documents ready In addition to differences in “Good Samaritan” volunteer protec-
to share may allay concerns by flight teams about ability to aid. More tions, which are not present in many other countries, the duty to re-
importantly, medical volunteers must honestly consider their own spond also varies by country. For example, in the United States,
capability of providing medical care, and if they choose to do so, they Canada, England, and Singapore, there is no legal duty for an off-
should not be under the influence of alcohol or other drugs.66 In one duty medical professional to assist during an IME.69-71 Conversely,
study, approximately half of IME aid was by a physician, 25% by a Australia and many European countries require physicians to ren-
nurse or other emergency personnel, and 25% by flight crew alone.1 der assistance during IMEs as defined by case law and civil law
If multiple potential volunteers exist, a collegial conversation about codes.69,72,73 Regardless of applicable laws, physicians often feel an
capabilities is optimal; for instance, a specialist physician may be less ethical duty to act.74 According to one study, only 1 case has oc-
capable to assess and manage a patient with an IME than another curred in the United States involving a physician being sued for as-
medical volunteer with training and experience more directly linked sisting in an IME, and that case was dismissed without hearing.69
to the symptoms or condition. Considering existing legal protections and international require-
In most cases, the primary role of a medical volunteer is to gather ments, medical assistance rendered by a capable physician is of little
information, assess an ill or injured passenger, aid with communi- personal legal risk and is supported by experts in aviation
cations with any ground-based support, and potentially adminis- medicine.1,56,63,66
ter medications or perform procedures. Flight crew particularly seek
the recommendations of ground-based medical experts before use Aircraft Diversion
of medications or equipment from the emergency medical kit, con- Diversion, which involves changing a landing destination because
sidering the variability in training and experience of onboard of an IME, is appropriate for several types of medical emergency.
volunteers.67 Medical volunteers may be asked to provide a recom- A commercial aircraft is not a medical facility, has limited onboard
mendation, but a consulting ground-based physician usually makes medical equipment, and has no dedicated medical personnel on
a final recommendation about care. The key to success is for every- board who can adequately address all events. However, the deci-
one involved to contribute their expertise as part of a collaborative sion to divert involves consideration of multiple factors, many
team, with the sole goal of ensuring the best interest of the patient unknown to an onboard medical volunteer. Aircraft commonly
with the IME in consideration of all passengers on board. take off with more fuel than is safe for landing; immediate diver-
sion soon after departure may require dumping a large amount of
Legal and Ethical Considerations for Medical Volunteers fuel into the atmosphere (a feature not available in many newer
In the United States, the Aviation Medical Assistance Act (also re- aircraft). The closest possible diversion airport may not have
ferred to as a “Good Samaritan” shield) protects passengers who pro- appropriate medical capabilities to manage a patient, negating a
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2584 JAMA December 25, 2018 Volume 320, Number 24 (Reprinted) jama.com
Figure 1. Management of In-Flight Medical Emergencies: Syncope, Gastrointestinal, Respiratory, Cardiovascular, Strokelike, and Seizure
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Figure 2. Management of Specific In-Flight Medical Emergencies: Trauma, Psychiatric, Substance Abuse, Allergy, Obstetric, and Cardiac Arrest
2586 JAMA December 25, 2018 Volume 320, Number 24 (Reprinted) jama.com
farction, aortic dissection, or pulmonary embolism that would need Cardiac arrest Cardiac arrest (ventricular fibrillation, ventricular
tachycardia, asystole, pulseless electrical activity), syncope
diversion. In the event of persistent pain, abnormal vital signs, or on- or other cause of collapse (see above)
going respiratory distress, diversion is an option. Substance abuse Misuse of or withdrawal from opioid, alcohol,
and misuse benzodiazepine, or stimulant
For a passenger with a possible seizure, a history of seizures
Psychiatric issue Anxiety, depression, grief reaction, psychosis,
or use of antiepileptic medications helps define probability of posttraumatic stress disorder, personality disorders,
occurrence and potential recurrence. Rapid return (seconds) to a somatization
normal mental status suggests a nongeneralized seizure or vaso-
motor syncope rather than convulsive seizures. A few myoclonic treated with epinephrine and oxygen. If available from an en-
jerks alone are not specific for seizure, as many individuals have hanced medical kit, corticosteroids may be administered.
these with syncope of any cause. If a well-described seizure Obstetric emergencies are a small proportion of IMEs (0.7%)
stops, the passenger may remain less responsive for 15 to 30 min- (Table 1) but can be distressing for both the mother and the medi-
utes; ongoing observation is the plan for this common scenario. cal volunteer, who is unlikely to have experience managing obstet-
Single-event seizures in which the passenger recovers usually do ric emergencies. Most health care professionals recommend no fly-
not necessitate a diversion; multiple or ongoing seizures or failure ing in commercial aircraft beyond 36 weeks’ gestation for single
to recover from a postictal state should prompt consideration of pregnancies or beyond 32 weeks for multiple gestations.56 Vaginal
diversion options. bleeding or abdominal pain before 20 weeks’ gestation does not typi-
Most trauma on commercial airlines is minor and appropri- cally require diversion or specific interventions during the flight be-
ately addressed with content in the emergency medical kit. Head yond coordination of emergency medical services personnel on ar-
injuries from falls or tumbling luggage are best assessed for loss of rival. Pregnancy complications after 20 weeks’ gestation or initiation
consciousness, persistent head or neck pain, scalp wounds, and of labor should prompt an urgent call to ground-based medical sup-
any neurological symptoms. Passengers without these factors port to consider diversion.
and with only minor discomfort may be rechecked later in flight For a patient with suspected cardiac arrest, resuscitate using
or at the destination. standard cardiopulmonary resuscitation approaches.85 Provide chest
A variety of psychiatric symptoms may manifest on board an air- compressions at a rate of 100/min to 120/min in adults with 1 breath
plane, from simple anxiety to acute psychosis.75,76 Anxiety may also every 5 to 6 seconds or use compression-only cardiopulmonary re-
produce physical symptoms (eg, chest pain, shortness of breath). suscitation. Apply an automated external defibrillator as soon as pos-
Patients may cause disruption and be threatening to other passen- sible. If capable, place an intravenous line and administer epineph-
gers, a challenge in the enclosed environment of an aircraft.77-79 Most rine, 1 mg (0.1 mg/mL) every 5 minutes. Lidocaine, 100 mg
cases of acute agitation or anxiety can be managed through verbal intravenously, is an option for persistent ventricular fibrillation or ven-
calming techniques. Consider administration of a patient’s own medi- tricular tachycardia in adults. Termination of resuscitation may be
cation if taken for anxiety and carried on board. The FAA- appropriate after 20 to 30 minutes of resuscitation without return
mandated emergency medical kit has little content that could be used of circulation.86
for agitation.
Allergic reactions often occur in flight but are rarely serious, ac- Prevention of IMEs
counting for 1.6% of IMEs (Table 1).80 Food-related allergies are the The most effective way to address IMEs is to prevent them. The
most common inciting cause of symptoms, especially peanuts or tree risk of syncope increases with dehydration in the setting of a low-
nuts,80-83 and other allergens may include exposure to traveling humidity environment, pressure changes, and exhaustion. Travel-
pets84 and other environmental allergens. Specific treatment for al- ers should hydrate often and eat scheduled meals and snacks dur-
lergic reaction includes diphenhydramine. Anaphylaxis may be ing travel, especially with connecting or extended flights.
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Physicians and nurses assisting flight travel plans for patients with flight (preferably 150% of flight time) to account for unforeseen
chronic medical conditions should consider and educate patients delays. Parents traveling with children should bring medications
on the effects of altitude, need for routine medications, and in pediatric formulations because these are not commonly avail-
potential occurrence of medical emergencies. For example, glu- able in emergency medical kits.
cometers are not part of the FAA-mandated emergency medical For patients with acute or other specific medical conditions, the
kit contents; a patient with diabetes should carry a glucometer, International Air Transport Association recommends appropriate
glucose supplements, and diabetes medications on board. time intervals for fitness to travel, which are available online.56 For
Passengers at risk of symptomatic hypoxia need to have a por- other conditions, health care professionals should consult with flight
table oxygen concentrator for the flight. Multiple studies and medical transport experts.
suggest that the hypoxic challenge test (exposure to 15%
oxygen in nitrogen) correlates better with in-flight hypoxia than
preflight oximetry, forced expiratory volume in 1 second, or the
Conclusions
commonly used 50-m test (ability to walk 50 m).87-89 However,
the hypoxic challenge test is not routine or commonly available. In-flight medical emergencies most commonly involve near-
A reasonable estimate of need for in-flight oxygen can use pub- syncope and gastrointestinal, respiratory, and cardiovascular symp-
lished equations and a passenger’s ground-level PaO2 and PaCO2 toms. Health care professionals can aid during these emergencies
measurements.90,91 Passengers with portable oxygen concentra- as part of a collaborative team involving the flight crew and ground-
tors should have battery life that exceeds the duration of the based physicians.
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Disclosure of Potential Conflicts of Interest. Drs 8. Delaune EF III, Lucas RH, Illig P. In-flight medical et al. Altitude exposures during commercial flight:
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