Caring for Older Adults at 30,000 Feet
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Stefanacci RG. Caring for older adults at 30,000 feet. Clinical Geriatrics. 2012;20(5):24-28.
"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
Inflight Environmental Considerations
Assessment and treatment of older adults in an aircraft is unique for several reasons. Unlike an emergency situation in a public space on the ground, the availability of diagnostic and treatment resources, access to support via 911 and other emergency responders, and availability of a spacious and stable workspace are vastly limited on an aircraft. In addition to these challenges of working at 30,000 feet, the aircraft is also unique in the types of disease manifestations and physiological changes that result within this environment.
An important environmental condition to keep in mind is that the cabin pressure at cruising altitude is set to between 5000 and 8000 feet above sea level, which presents two issues for physicians to consider: hypoxia and gas trapped in body cavities.12 At cruising altitude, all passengers experience some degree of hypoxia. This is the result of the fact that barometric pressure is 760 mm Hg at sea level, with a corresponding partial pressure of oxygen in arterial blood (PaO2) level of 98 mm Hg, whereas the barometric pressure is 565 mm Hg, with a PaO2 of about 55 mm Hg at the typical cabin pressure of 8000 feet.12 If these data were to be plotted on the oxyhemoglobin dissociation curve, a 90% oxygen saturation level would be obtained.12 Although most healthy travelers can compensate for this amount of hypoxia, this may not be true for some older adults who have a cardiopulmonary disease or anemia. In addition, a passenger experiencing a medical emergency in most cases would benefit from supplemental oxygen.
Many airlines will provide therapeutic oxygen for a small fee, but these arrangements need to be made in advance of travel and are especially important for those older adults requiring supplemental oxygen when not traveling. Since travelers are not permitted to carry their own oxygen onto flights, obtaining it through the airline is the only option. In addition, individuals requiring continuous oxygen should be cautioned that airlines only provide oxygen inflight; thus, arrangements should be made if continuous oxygen is required. A list of the cardiovascular indications for medical oxygen during commercial flights is given in Table 2.12
As noted earlier in this section, airplane passengers may also encounter issues at cruising altitude due to trapped gas, as gas trapped in body cavities at sea level will expand by approximately 25% at cruising altitude.13 This may exacerbate such conditions as pneumothorax, pneumocranium, or middle ear pain for passengers with preexisting risk factors. Furthermore, these are diagnoses that may only present themselves at 30,000 feet.
To Divert or Continue On
Perhaps one of the most significant questions that a physician may be asked is whether the flight can continue on to its destination or if it should be diverted to the nearest airport so that the patient can be taken to a hospital. Triage by physicians has been demonstrated to be effective in identifying more serious cases. A 2003 study by DeLaune and colleagues14 found that when a physician was involved in the decision to divert an aircraft, 49% of the emergency cases were admitted to a hospital, compared with only 15% of cases in which there was no input from a healthcare professional.
The decision to divert an aircraft is ultimately the captain’s of the aircraft, but the captain will likely follow the physician’s recommendation, perhaps with additional input from the ground medical team. Oftentimes, ground medical services are being provided by MedAire, Inc., a company that provides 24-hour medical assistance, training, and medical kits to international jet manufacturers and major airlines. MedAire operates a system called the MedLink Global Response Center, which provides onboard physicians with direct call access to emergency care physicians and to other services for managing inflight medical emergencies. MedLink reported managing 19,000 calls for help annually from its call center, based within the emergency unit of the Banner Good Samaritan Medical Center in Phoenix, Arizona.15
Despite the availability of services such as MedLink, air-to-ground communication is sometimes difficult. This is primarily because many airlines have removed phones from cabins and secured cockpit doors following the terrorist attacks on September 11, 2001. Today, information is usually relayed by intercom from the cabin to the pilots, who then pass it along to MedLink on the ground. It has been reported that some airlines are using satellite radios on flights over the Pacific Ocean, putting headsets in the cabin so that flight attendants can directly communicate with physicians on the ground.2
The decision to divert an aircraft is not to be made lightly, as it can cost in excess of $100,000.16 In addition, the diverted aircraft may sustain damages, such as blowing tires during landing because of being overweight from its excess fuel. DeLaune and colleagues14 reported in a 1-year period that there was an incidence of 22.6 medical complaints per 1 million passengers and 0.1 deaths per 1 million passengers. Because diversion can be costly and most onboard medical emergencies are non–life-threatening, it is uncommon for an aircraft to be diverted, with the diversion rate estimated to be between 8% and 13% of all inflight medical emergencies.17
Preparing Patients for Travel
Ideally, many inflight emergencies may be prevented with proper preparation. Prevention starts with the healthcare provider assessing and advising his or her older patients with regard to any preflight medical needs. According to the Aerospace Medical Association (AsMA) Medical Guidelines for Airline Travel, there are many medical conditions that should be addressed in a preflight medical evaluation, including cardiovascular diseases (eg, angina pectoris, congestive heart failure, myocardial infarction [MI]), deep venous thrombosis (DVT), asthma, emphysema, seizure disorder, stroke, mental illness, diabetes, infectious diseases, and conditions for which the patient has undergone recent surgery or that require surgery.12 In a MedAire study, passengers with diabetes, seizure disorders, and cardiovascular and respiratory ailments accounted for approximately 25% of all inflight deaths and almost 33% of medically related flight diversions.2
Patients at Risk of Cardiovascular Events
Physicians should advise their patients who have had a recent uncomplicated MI not to fly until at least 2 to 3 weeks have passed and they have resumed their usual daily activities.11 In contrast, patients who have had a complicated MI should not fly for at least 6 weeks following their MI; those who have undergone coronary artery bypass graft surgery should not fly before 10 to 14 days postoperatively; and those who have had a stroke should wait at least 2 weeks before traveling by air.11 Cardiovascular conditions that present a contraindication to air travel include severe decompensated congestive heart failure, unstable angina, uncontrolled hypertension, uncontrolled ventricular or supraventricular tachycardia, Eisenmenger syndrome, and severe symptomatic valvular heart disease. Mild asymptomatic valvular heart disease presents a relative contraindication to air travel.
According to the AsMA, physicians should make several travel recommendations for their patients with cardiovascular conditions, one of which is that they carry enough cardiac medication for their entire trip, including sublingual nitroglycerin tablets, and keep these medications in their carry on luggage.11 Another recommendation is that patients keep a list of their medications, including dosage and timing, and adjust dosing intervals to maintain their regular frequency when crossing time zones. Additionally, patients should carry a copy of their most recent electrocardiogram and their pacemaker card if they have a pacemaker. Generally, it is advisable for patients to contact their airline concerning special needs, such as oxygen and wheelchair access, and to consider special seat requests, such as near the front of the plane, close to the restrooms, or with extra leg room.
Patients at Risk of Deep Venous Thrombosis
Special precautions may also be needed for older adults at especially high risk of developing a DVT, especially if there will be prolonged immobilization due to a long flight (>6 hours).11 Although DVT itself is not a dangerous condition, it can have life-threatening complications, such as pulmonary embolism or venous thromboembolism. There are numerous factors besides a patient’s age that may put him or her at risk of developing a DVT. These risk factors include blood disorders that affect clotting tendency, cardiovascular diseases, current malignancy or history thereof, recent major surgery or trauma to the lower limbs or abdomen, and a personal or family history of DVT. For such individuals, possible preventive options include taking aspirin or low-molecular-weight heparin, depending on the level of risk, and wearing compression stockings.
Patients With Diabetes
Although airline travel should not pose a significant problem for patients whose diabetes is normally well controlled, proper preparation remains beneficial. Besides recommending that diabetic patients pack enough supplies to test their blood-glucose levels for the duration of their trip, physicians can make other specific recommendations to their patients.11 For example, they should advise individuals who normally take insulin once daily before breakfast to take their standard dose at the usual time of the day, regardless of whether travel is east or west. For diabetic individuals traveling east across time zones, upon arrival, the individuals’ day will be shorter, and so it may be necessary to take fewer units of insulin. While traveling west across time zones, the individuals’ day will be longer, and they may require additional insulin injections or an increased dose of an intermediate-acting insulin. It is a good idea for individuals with diabetes to have their wristwatch unadjusted during flight so that it shows the time at the point of departure, making it easier to judge the spacing between meals. Also, if needed, special diabetic meals should be requested well in advance of the travel date.
Patients With Psychiatric Disorders
Persons with psychiatric disorders that lead to behaviors that are unpredictable and aggressive should not travel by air until these behaviors are well controlled, as these individuals can pose a danger or be disruptive to others onboard. Generally, patients with a psychiatric disorder can become upset by the common irritations of travel, such as crowding with strangers, lack of privacy, and delays.11 If a patient with a psychiatric disorder, such as dementia, must travel by air, a capable and knowledgeable flight companion (ie, caregiver, family member) should accompany him or her. Physicians can offer the patient and his or her travel companion several travel recommendations.11 For example, since patients with dementia often experience sundowning syndrome (ie, an increase in abnormal behaviors at a certain time of the day, typically in the late afternoon, evening, or night), the timing of flights should be taken into account to avoid the patient being in the air during this time. As for prescribing a medication to a patient to assist with behavior, it has been recommended that one never prescribe a medication for inflight use unless the patient has used it before and is familiar with its effects. Obviously, inflight is no time to discover an untoward medication reaction.
Patients With Less Complex Disorders
Physicians can also make useful recommendations to ensure the comfort of their traveling geriatric patients with disorders that are not potentially dangerous to fly with, but that can pose a nuisance, such as hearing impairment and urinary frequency or incontinence. Patients with hearing aids may become frustrated by their decreased ability to hear in flight due to background noise in the cabin. These patients should be advised to turn their hearing aids down because high volume reduces sound discrimination. As for those with urinary frequency or incontinence, an aisle seat, preferably close to the restrooms, is advised. If the patient’s urinary frequency is related to a medication, such as a diuretic, dose adjustments may be warranted. Patients with urinary incontinence may consider wearing and packing additional absorbent pads or wearing a portable urinary catheter. Although it is important for patients to stay hydrated during their flight, they should be reminded that not all beverages are created equal. Water is the best choice. Caffeinated beverages (eg, coffee, soda, tea) and alcohol are diuretics and can aggravate an already overactive bladder; thus, these should be avoided.
As an increasingly aging population takes to the skies, the management of health issues inflight will increase. It is therefore vital for geriatric healthcare providers to be well versed both in preparing older adults for air travel and in being ready to respond to medical emergencies that occur on aircraft. For more information on preparing older adult patients for air travel, there are two especially helpful resources that have been prepared by the AsMA. These include Useful Tips for Airline Travel and Medical Guidelines for Airline Passengers, which are both available through their Website at www.asma.org.
Being prepared for general medical emergencies by knowing the specific issues involved in care at 30,000 feet is sure to be a valuable skill set. So when the alert goes out from the crew—typically with four rings of the call bell—the situation will definitely benefit from having a prepared physician.
The author reports no relevant financial relationships.
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