Caring for Older Adults at 30,000 Feet
"If there is a doctor onboard, would you please make yourself known to a member of the flight crew?” This announcement is heard daily on US flights, so it is likely that a physician traveling frequently by air will receive a call for help at some stage in his or her career. In fact, with aging baby boomers increasingly taking to the skies for longer flights, inflight emergencies have been growing. From 2002 to 2005, studies showed that the rate of inflight deaths doubled.1 This is consistent with a study that reported that the rate of medical emergencies on commercial flights nearly doubled between 2000 and 2006, from 19 to 35 per 1 million passengers.2 While cardiac issues account for a majority of inflight deaths, vasovagal syncope (a temporary loss of consciousness) is the most common inflight emergency.3 The Flight Safety Foundation studied inflight medical care aboard selected US air carriers from 1996 to 1997 and recorded 1132 medical incidents, of which 22.4% were caused by vasovagal syncope, 19.5% by cardiac events, and 11.8% by neurologic events.4 In contrast, a study of inflight emergencies on British Airways flights reported a different pattern of diagnoses, finding that 25% were related to gastrointestinal problems and fewer than 10% each were from cardiac, neurologic, or vasovagal issues.5
In a 1991 Federal Aviation Administration (FAA) study, physician travelers were available in 85% of reported inflight medical emergencies.6 Despite the high likelihood of being involved in an inflight emergency, little education is available to prepare healthcare providers for the unique environment of dealing with a medical emergency at 30,000 feet. This article provides an overview of what physicians can expect to encounter if called upon to assist during an inflight emergency. It also provides some travel recommendations that physicians should share with their older adult patients to help prevent such medical emergencies from occurring when they travel by air.
Responsibilities of Onboard Physicians
The law governing any event happening on an aircraft is usually the law of the country in which the aircraft is registered, except when the aircraft is on the ground. For the United States, the actions of volunteer physicians are described in the Aviation Medical Assistance Act of 1998.7 The Act includes provisions limiting the liability of volunteer physicians who attempt to assist with inflight medical emergencies, as there are examples in which airlines faced litigation when the advice of passenger doctors was deemed to be incorrect.7 Another guide to physician inflight involvement is written in the World Medical Association International Code of Medical Ethics: “A physician shall give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care.”8
Airlines consider physicians who respond to calls for assistance as volunteers, and as such, passenger physicians complement the flight crew rather than override them. As a result, the physician is not expected to perform duties that the flight crew is trained to handle. Cabin crew receive training in a number of emergency skills, including use of automated external defibrillators (AEDs), and are one of several sources of help available to the medical volunteer, who is not expected to work alone. Because only qualified persons can administer drugs, the flight crew may ask for identification to verify credentials, such as a business card or wallet medical card.
Onboard Medical Equipment
The Aviation Medical Assistance Act of 1998 set out to direct the administrator of the FAA to reevaluate the equipment contained in medical kits carried by commercial airlines, and to make a decision regarding requiring AEDs to be included.7 On April 12, 2001, in response to the Act, the FAA issued a final rule requiring airplanes that weigh more than 7500 lb and have at least one flight attendant to carry AEDs and enhanced emergency medical kits.9
Automatic External Defibrillators
Although AEDs are part of the emergency medical kit, many airlines require that only their trained crew operate these devices to ensure continuity of protocols. When use of an AED is required onboard, volunteer physicians should work to complement the skills of the trained crew. Although used infrequently, the presence of these devices on flights is essential because they can have a dramatic impact on outcomes. The effectiveness of AEDs inflight was described in a study by Page and colleagues.10 The authors reported that between June 1, 1997 and July 15, 1999, one US airline carrier used an AED on 191 passengers inflight and on nine people in an airport terminal, meaning the device was used once for every 3288 flights by this carrier. Transient or persistent loss of consciousness was documented in almost 50% of these passengers, with the remaining persons having needed the device primarily because of chest pain. Ventricular fibrillation was electrocardiographically documented by the AED in a total of 14 individuals, and the device terminated every episode with the first shock in 13 of these individuals (defibrillation was withheld in one individual per the family’s request). The rate of survival after defibrillation to discharge from the hospital was 40%,which compares favorably with the rate of survival to discharge among patients who received a defibrillator shock in other out-of-hospital settings.10 Perhaps the most important point for physicians to consider is that AEDs have been found to be safe when used as a monitor, and in no case in Page and colleagues’ study10 was an inappropriate shock recommended or delivered.
Enhanced Emergency Medical Kits
The enhanced emergency medical kit has been developed to facilitate provision of emergency care by individuals with rudimentary emergency training, ensuring adequate and appropriate care is provided even in the absence of an experienced healthcare professional. Before the FAA’s final ruling, the only medication required onboard by the FAA was 50% dextrose, nitroglycerin, diphenhydramine, and epinephrine. For a list of items that emergency medical kits are currently required to contain, see Table 1.11