Sick and dying at 30,000 feet

in-flight medical emergencies sanjay gupta orig nws_00011223
in-flight medical emergencies sanjay gupta orig nws_00011223

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Managing medical emergencies at 30,000 feet 02:36

Story highlights

  • One in every 604 flights involves a reported medical emergency
  • Most are non-life threatening and can be handled by a team of trained professionals

(CNN)You may have heard this announcement before:

"Ladies and gentlemen, a passenger requires medical attention. If there is a physician or medical personnel on board, please identify yourself to a flight attendant."
One in every 604 flights involves a reported medical emergency, according to a 2013 study published in the New England Journal of Medicine. Researchers at the University of Pittsburgh Medical Center calculated that translates into 44,000 in-flight medical emergencies worldwide every year.
The actual number may be much higher, because no mandatory reporting system exists and minor issues are very likely underreported.
The most common problems, according to the data collected, were fainting or feeling dizzy and lightheaded (37%), respiratory symptoms (12%) and nausea or vomiting (10%).
But how are these emergencies handled, especially when they're more complicated or life-threatening?

Ground support

In-flight medical emergencies unfold in the skies above us every day, so many large airline companies spend a lot of time and money training their flight crews on what to do when presented with these types of extraordinary situations.
"The flight attendants are trained as new hires very extensively, and then every year they have recurrent training that includes emergency response," said Barbara Martin, general manager for Air, Crew and Passenger Health Services at Delta Air Lines.
"They are using a medical assistance form to get the key, most important data on signs, symptoms and vital signs," said Martin, who is an occupational nurse by training.
"The pilots and dispatchers on the ground ... are also trained in what the key elements of information are that need to be transmitted to STAT-MD if there's a consult," Martin said. "It's really a team effort."
You've probably never heard of STAT-MD, but the medical professionals at this low-profile University of Pittsburgh Medical Center medical communications center provide ground-based support services for a number of large commercial airlines based in North America.
"We basically provide in-flight consultations for in-flight emergencies, and we also provide fitness-to-fly screening for the airlines for (passengers) on the ground in case there's a question on their ability to go up into the air," said Dr. TJ Doyle, STAT-MD's medical director.
Doyle said they did about 10,000 consults last year, so they're fielding about one or two calls an hour.
"The captain is always in charge," said Doyle. "We make a recommendation based on our expertise and our experience. We've been doing this for a while and we do it quite often. So we'll make a recommendation to the captain on what we think can occur."
In the most extreme cases, that might mean recommending diverting the flight. This occurred in 7.3% of the cases reported in the 2013 study.
Far more often, the issue is something much simpler: a diabetic whose sugar has plummeted, so he or she needs a sip of orange juice. Or perhaps someone is feeling lightheaded and may just need to be administered oxygen.

When the problem is more serious

"If it can happen on the ground, it's going to happen in the air, as well, so we need to be able to respond to that appropriately," said Delta flight attendant trainer Justin Eberle. "Passenger safety is always our number one priority."
All flight attendants working routes in the United States must be trained in CPR and how to use a defibrillator.
"The flight attendants have access to what we call a medical accessory kit," said Martin. "That's got basic equipment in it for taking blood pressure, thermometers, personal protective equipment. If there's a medical volunteer on board, then they're given access to our emergency medical kit, and that kit has resuscitation equipment, IV equipment, medications."
Many airlines require consultation with a ground-based physician, such as STAT-MD, before the emergency medical kit is used. There is only one other prominent medical communications center in the United States called MedAire, based in Phoenix, Arizona.
Kits vary widely in quality. The FAA requires contents such as saline solution, aspirin, antihistamines, epinephrine and nitroglycerine tablets. Some airlines choose to supplement the basic provisions, but supplies and medications are expensive, they take up weight and they have to be replaced when they expire.
It goes without saying, too, that some protocols and procedures are more challenging in the air. A simple stethoscope, for example, is rendered relatively useless in flight because of all the ambient noise.

'Is there a doctor on the plane?'

More useful, often, than the equipment is the expertise of a fellow passenger. Physician passengers provided medical assistance in 48.1% of reported in-flight medical emergencies, according to the 2013 study. Nurses assisted in 20.1% of the cases.
Martin says the number is even higher.
"Over the years, we've seen at least an 80% presence of a physician or RN volunteer," said Martin. "In fact, the most recent year we compiled data on, 2014, we have 90% volunteer by physician or nurse during a medical event."
But what about liability?
"Although U.S. health care providers traveling on registered U.S. airlines have no legal obligation to assist in the event of a medical emergency, ethical obligations may prevail," according to a 2015 study, also published in the New England Journal of Medicine.
"In addition, many other countries, such as Australia and in Europe do impose a legal obligation to assist," according to researchers at the Georgetown University School of Medicine.
To encourage medical professionals to volunteer, Congress passed the Aviation Medical Assistance Act in 1998, which protects providers who respond to in-flight medical emergencies from liability and thus encourages medical professionals to assist.
"This law applies to claims arising from domestic flights and most claims arising from international flights involving U.S. carriers or residents," the authors of the 2015 study wrote. "The AMAA does allow for liability of providers if the patient can establish that the provider was 'grossly negligent' or intentionally caused the alleged harm ... An example of such disregard would be an intoxicated physician treating a patient."

Worst-case scenario

Among in-flight medical emergencies, cardiac arrest is very rare, accounting for only 0.3% of such emergencies, yet it is responsible for 86% of in-flight deaths, according to the 2013 study.
When possible, protocol recommends the deceased passenger should be left in place or placed out of the direct view of other passengers (possibly in the lavatory).
Flight attendants are also advised to relocate nearby customers to alternate seats when possible. A blanket can be used to cover the customer as needed. The flight deck crew is also instructed to inform the airline's operations center to make appropriate arrangements once the aircraft is on the ground.
As with any in-flight emergency, the situation is evaluated on a case-by-case basis and flight attendants are advised to use their best judgment.

Air rage is a real thing, but the biggest problem is much simpler

Psychiatric issues constitute 3.5% of in-flight medical emergencies, according to the 2015 study.
"Potential stressors include a lengthy check-in process, enhanced security measures, delayed flights, cramped cabins and alcohol consumption," the researchers wrote. "Acutely agitated passengers pose considerable safety concerns."
The most common problem in flight, though, is actually dehydration. And there's a reason you feel dehydrated when you travel.
"Passenger aircraft cabins are pressurized (to the equivalent altitude of 6,000 to 8,000 feet) by air pumped through the engines, which results in a relatively arid environment," according to Georgetown University researchers. "As such, many passengers are somewhat dehydrated."
The simplest, but most significant piece of advice: Stay hydrated. That means drinking of plenty of water and avoiding alcohol when you fly.
And if you take any medications, pack them in your carry-on. They won't do you any good in the cargo hold.