We are a globe trotting, increasingly mobile human population. And when we are traveling any sort of distance, especially if it involves crossing oceans, most of us travel by commercial airlines. In fact there were 2.75 billion passenger flights booked last year. That translates into nearly 10 billion passenger hours in the air. With those kind of numbers, it is reasonable to ask “What happens if I get sick up there?”
Well, first of all, your chances of having any sort of emergency are statistically slim. A recent retrospective study of 5 major airlines flying domestic and international routes found that there were 16 medical emergencies for every 1 million passengers. Looking at it another way, there was a medical emergency once in every 602 flights in this study. What were the presenting symptoms of these high flying patients? Fainting or feeling faint occurred in 37%, breathing difficulties in 12%, nausea or vomiting 10%, cardiac symptoms 8%, and seizures 6%.(1)
What is the process that guides medical treatment in the air? Here are the five steps along the way.
1. Initial response: All major airlines require the flight crew be trained in basic medical emergencies. Most of those presenting have mild problems managed by the flight attendants without additional help.
2. Volunteer assistance requested: If the attendant believes the condition to be serious, an announcement is made requesting volunteer assistance from doctors or nurses onboard. The Aviation Medical Assistance Act passed in 1998 includes a Good Samaritan provision, protecting passengers who offer medical assistance from liability, except in cases of gross negligence or willful misconduct.(2) In this study, assistance was provided by physicians (48%), nurses (20%), EMS providers (4.4%), or other health care professionals (3.7%).(1)
3. Equipment support: All airlines maintain a medical kit with equipment and drugs to address basic emergencies. Some airlines maintain an enhanced medical kit which allows more serious interventions or procedures in the air. The contents of these kits are as follows:
4. Medical Support On The Ground: Many airlines now maintain coverage with expert clinicians on the ground who are contacted in a true medical emergency, and who can help guide and support volunteer health professionals in the air. Some airlines require contact to be made in every case where the medical kit is opened.
5. Diversion of Flight: Under certain circumstances, flight captains can divert the aircraft to protect the life of the passenger. In this study, it occurred in roughly 7% of cases.(1) This low percentage reflects both the non-critical nature of many of the emergencies, and the fact that in many international flights there in no convenient alternate landing location available.
So how did the patients in this study fare? Of the 11,920 in-flight medical emergencies in this study, there were 36 deaths (.3%). 30 of these occurred in-flight. In one third of the total cases, the problem was mild and resolved sufficiently so that patients requested no additional care on landing. Roughly 2/3’s of the patients were met by EMS personnel on landing. 37% of these were taken to the hospital for further testing and evaluation, and 9% admitted for care. The major reasons for admission were stroke, cardiac symptoms and obstetrical or gynecologic emergencies.(1)
In general, obstetrical symptoms in-flight were rare, and supported recommendations that air travel is safe up to the 36th week of gestation.(3) Diversion of aircraft occurred in only three cases of women in labor beyond 24 weeks.
In this study, the overall death rate for airborne medical emergencies was .3%. Most were the result of cardiac arrest and accompanying arrhythmias. In the 920 cardiac cases that did not involve an arrest, there were no deaths. Most were treated with oxygen, aspirin, and nitroglycerin.(1) An Automated External Defibrillator (AED) device was commonly used to assess heart rhythm and for defibrillation when indicated. With cardiac arrest in the air, survival rates can be as low as 16%, but are substantially higher with ventricular fibrillation (up to 55%).
So what can each of us do, since we are unlikely to stop flying any time soon. For passengers, come on the plane full hydrated, stay hydrated during the flight, and get up and move around intermittently to aid circulation. Be certain to bring your medications with you, and a list of serious medical conditions you might have. For potential health professional volunteers, be aware that you might be called upon for help in the air. Reread the list of materials listed above, and consider how you might be asked to utilize these with the assistance of a skilled emergency physician providing support on the ground.