The following case report details an in‐flight medical emergency (IFME) that occurred during a trans‐continental flight while the authors were en route to a medical conference. The report highlights the necessity for an improved approach to the prevention and management of IFMEs.
An elderly woman was traveling on a trans‐continental flight, in one of the back rows of the plane, when an attendant found her unresponsive and requested medical assistance. Several physicians responded and immediately began cardiopulmonary resuscitation (CPR). An automated external defibrillator (AED) read the patient's rhythm as asystole, and several rounds of epinephrine and atropine were administered. An oropharyngeal airway was placed and a bag valve mask (BVM) was utilized to provide positive pressure ventilation with cabin air. The flight made an emergency diversion and the physicians performed CPR throughout the emergency landing. Upon landing, emergency medical services (EMS) continued resuscitative efforts for 20 additional minutes prior to calling the time of death.
Using Ground‐Based Medical Assistance
With an aging population, an epidemic of chronic illness, larger aircrafts with diminishing leg‐room, and longer flights becoming routine, an increase in the incidence of in‐flight medical emergencies (IFMEs) can be anticipated. However, the lack of a central, standardized, and mandatory monitoring system does not allow this statement to be confirmed.
Recent reports have called for standardized reporting as well as standardized protocols for IFMEs.1,2,3 There must be a federal mandate in the United States, and eventually, international guidelines, to pursue this effort. A recent JAMA commentary by Mattison and Zeidel reflects the disorganization and confusion during an IFME, including the frustration over the lack of means to incorporate lessons learned into future flights.1
Concerns relayed from the airline industry about pursuing standardized reporting include the use of nonmedical personnel to relay medical information, which can complicate event description and medical coding. However, international airlines have already successfully implemented registries of in‐flight events, and such registries have provided significant data that can inform future management.4 We propose that flights use a ground‐based medical assistance company in every IFME. Very few physicians are trained in aviation medicine, and the provision of even standard care in an unfamiliar environment can be daunting, especially if asked to make decisions about diversion. Physicians who have reported on their experiences during IFMEs often express doubt as to whether enough was done for the passengers they have encountered.5 One study on IFME telemedical services showed that ground‐based medical personnel are beneficial in assisting with diversion decisions and that many doctors value this assistance in IFME decision making.6 The Aerospace Medical Association (ASMA) also provides excellent written resources for physicians to prepare for an IFME but these documents are not well publicized and are not practical in time‐sensitive situations.7 Physicians on board can relay necessary information, administer medications, perform any procedures in which they are trained, and assist with coding the event for standardized reporting.
There is no legal mandate for physicians to respond to an IFME, although many consider it an ethical obligation. A 2007 review in Emergency Medicine Australasia details the many laws and industry practices that protect the medical volunteer internationally, but we believe that physicians may still harbor concern about litigation.8 The use of ground‐based personnel may make physicians on board more likely to respond to a situation if they know that they are following established protocols and are under the guidance of physicians trained in aviation medicine.
Updating Emergency Medical Kits
With regards to IFME kits, the Air Transport Medicine Committee of ASMA has the philosophy that “commercial airlines are taxis, not flying emergency rooms.”9 Clearly, logistical and cost constraints must be taken into account while developing an IFME kit. However, patients with an IFME are not easily transported to an emergency room, unlike those in normal taxis. Furthermore, people are more likely to have a medical incident in the air than on the ground because of the inherent medical risks of air travel.10 The stress from travel, altered circadian rhythm, and lower cabin barometric pressure are likely to trigger underlying cardiopulmonary diseases, potentially resulting in a myocardial infarction.11 Low humidity, turbulence, and venous pooling due to immobility put patients at risk for a vasovagal episode, while immobility is a risk factor for thromboembolic events. Additionally, all of these factors can aggravate many other preexisting medical conditions.
The Federal Aviation Association (FAA) requires that US bound and outbound flights contain an emergency medical kit with specified items. However, without mandatory reporting of IFMEs, it is impossible to properly conduct a thorough review of these kits in order to optimize their use and to incorporate lessons learned.
For instance, with regards to airway equipment, current FAA guidelines require only an oropharyngeal airway, emergency tracheal catheters, and a BVM. During the aforementioned flight, there were several anesthesiologists attending to the patient; however, the oxygen canister and the BVM could not be connected, and neither a laryngeal mask airway (LMA) nor an endotracheal tube was available. Through the addition of an LMA and a connector for the oxygen supply to the BVM (both only a few dollars more per flight), physicians would be in a much better position to adequately ventilate patients during an IFME.
The Ethics of Calling a Code In‐Flight
On our flight, the physicians discussed calling the code after performing CPR on the patient with no shockable rhythm for 30 minutes in‐flight; 2012 guidelines put forth by the International Air Transport Association state that in such a circumstance, the patient can be presumed dead and CPR ceased.12 Additionally, the plane may not require diversion. Continuing CPR throughout the rough landing of an aircraft could also put medical personnel at risk for injury. In some cases, physicians have been instructed by flight crews to perform CPR against the physicians' judgment.13 This case demonstrates the challenges of practicing ethical and sound medicine while weighing the safety of patients, physicians, and all passengers when making decisions during IFMEs.
Respecting a Patient's Privacy and Modesty
Medical knowledge of an IFME patient should be treated with care. In our case, flight attendants disclosed elements of the patient's medical history and death to some passengers. While medical privacy regulations do not apply to flight crews, privacy of passengers must be encouraged as a matter of professionalism. As many passengers witnessed the prolonged code, medical ethicists in conjunction with the airline industry should develop standard communication for such cases.
In addition, a patient's modesty needs to be considered in IFMEs. In this case, passengers were able to watch the physicians perform CPR in the back of the aircraft. In addition, owing to logistical issues, EMS transported the patient through the aisles of the aircraft while fully exposing the patient from the pubic symphysis superiorly. When EMS took over resuscitation efforts, the jetway had been pulled away from the plane and all of the passengers on the left side of the aircraft were also able to observe the attempted resuscitation. Simple procedures such as holding up a blanket, draping the patient, and closing flight windows should have been undertaken. The lack of standardized protocols as well as the provision of care in an unfamiliar environment led to a loss of the dignity that would have been normally afforded to this patient as well as creating distress among the captive plane population.
IFMEs are likely to be more common than believed as a result of nonmandatory and noncentralized reporting of these incidents, and are also likely to increase in frequency. It is vital that measures be undertaken to maximize good outcomes. Standardized reporting and protocols must be implemented including the routine use of ground‐based medical assistance personnel. Inexpensive and modest changes in IFME kits can improve patient care. Airlines and physicians must also consider the ethical consequences of these incidents. The airline industry exhibited significant leadership in developing some of the key concepts adapted by the medical community within the realm of improving patient safety. Both communities must now extend their interest and efforts in providing optimal care to their passengers and patients by exploring methods to minimize risks and improve the outcomes of future IFMEs.
We would like to thank P. Méndez, MD, Associate Professor of Medicine and Assistant Dean of Clinical Curriculum at University of Miami Miller School of Medicine (UMMSM), R. Schwartz, MD, Professor and Chair of the Department of Family Medicine and Community Health at UMMSM, and S. Banks, MD, Assistant Professor and Residency Program Director of Clinical Anesthesiology at UMMSM, for providing their medical services on board the flight and for their contributions to this manuscript. We wish to also recognize M. Marrero, MD, Chair and Program Director of the Department of Anesthesiology at the University of Puerto Rico School of Medicine and E. Roldan, MD, the Immediate Past Chief Executive Officer and President for the Jackson Health System in Miami for their help in the delivery of care during the code. Additionally, we would like to thank K. Goodman, PhD, Director of UMMSM's Bioethics Program for his insight on the ethical considerations discussed in this manuscript. We would also like to thank the flight attendants and pilot for their fortitude and compassion throughout the flight.
Declaration of Interests
The authors state they have no conflicts of interest to declare.