On a recent flight back to Boston, the woman sitting next to me began to have a panic attack about half an hour before we landed. “Can’t deal with turbulence,” she whimpered, grasping my arm. She closed her eyes and began to mumble a prayer. “It’ll be okay,” I said, trying to talk her down, asking her to take deep, slow breaths. With my free hand, I tried to palpate her racing pulse.
About 2.75 billion people travel on commercial airlines each year. Some of these people are bound to get sick, ranging from something as simple as a cold or a stomach bug to something as emergent as a heart attack. Medical personnel are frequently called upon to assist flight crews with managing such occasions, but the nature of air travel can turn a simple medical problem into a tense situation.
This week’s NEJM investigates medicine in the air, presenting one of the largest and most detailed reports on in-flight medical emergencies and their outcomes. When a medical emergency occurs on a plane, airline personnel will usually contact a partnered call center staffed by emergency room physicians who will provide consultation over radio and satellite. After gathering records from one of these centers, the authors of this week’s study reviewed communications among five domestic and international airlines between January 2008 and October 2010, representing 10% of the global flight volume over that time period.
When emergencies occurred, the authors found that in almost half of all cases, physicians were the primary responders (48%), followed by nurses (20%), then EMS providers (4%). Most frequently, responders addressed syncope (37.5%) followed by respiratory symptoms, then nausea or vomiting. Planes carried numerous medical supplies in a Federal Aviation Administration mandated emergency kit, but responders reached most frequently for oxygen, normal saline, or aspirin. Drugs such as morphine, epinephrine, and dextrose were almost never used.
While treating run-of-the-mill symptoms on a plane can prove to be difficult, dealing with an extenuating circumstance such as a heart attack or stroke may require the provider to potentially ask the pilot to ground the plane before it has reached its original destination. However, such medical conditions presented rarely – cardiac arrest was only witnessed in 0.3% of all emergencies. Still, planes landed early in almost 7% of emergencies.
While flight crews rarely diverted a plane (4%) physicians were most likely to ask the pilot to ground the aircraft early (10%) reflecting the challenge of providing care in unfamiliar settings with limited resources. However, the report suggests that most conditions on planes can be managed simply, through the use of intravenous fluids, supplemental oxygen, and aspirin, with flight diversion reserved for rare cardiac arrests, strokes, or obstetrical emergencies.
Although I knew none of these statistics as we landed in Boston during my recent flight, a differential had run through my mind as I watched the woman with the labored breaths, sweats, and racing heart who sat beside me. She kept her eyes closed, even after we had touched down on the runway. “I’m so sorry,” she apologized later, after the plane had stopped moving. Even if it wasn’t a physician sitting beside her, anyone might have offered her the same comfort that I did. Under the 1998 Aviation Medical Assistance Act, passengers are protected from liability while offering medical assistance. But as medical providers, this week’s report equips us to take the initiative and make informed decisions while delivering clinical care – even under unusual circumstances.
Check out the NEJM Quick Take on in-flight medical emergencies. It’s a lively, animated overview of the study, narrated by NEJM Editor-in-Chief Jeffrey Drazen, and offers some recommendations on how to handle the situation.