The airline asked for a doctor on board. But their protocols hindered care

At 30,000 feet a passenger begins to vomit, has a headache, and feels like she may pass out. She’s an unaccompanied minor. It is the start of a 6-hour flight. You are the physician on board.

This is the scenario I faced recently. In addressing that situation, I saw much room for improvement in how in-air emergencies are handled.

There were delays unlocking the medical kit or contacting the contracted doctor on the ground. It was unclear what care was allowed to an unaccompanied minor. Airline personnel, who routinely use gloves for serving passengers, offered none to volunteer medical personnel. The only place for the vomiting passenger to lie down was in the galley, from where food service continued. (Only later did I realize that I had been standing in vomit for three hours while in the galley.) It is unclear how many other people had stepped in vomit and tracked it across the airplane. The communication chain was: doctor to hostess, hostess to pilot, pilot to doctor on the ground, and back.

On many levels, this is unsafe. We need to take action to improve the system as well as human performance at time of crisis.

Prepare, prepare, prepare

While federal law requires that airline personnel are trained in CPR and renew that training annually, the enforcement of this is not clear. Further, the space limitations and resources available are very different on an aircraft than in a CPR simulation training. This is why residency training programs run “mock codes” where there is a simulated emergency in a real setting or why we have fire drills where evacuation of a building is timed and evaluated.

Identify roles ahead

Within a hospital, when a patient has a life threatening emergency (a “code”), there is a clear team leader and roles are assigned. Prior to take off, the crew in the main cabin should know who is designated to lead coordination of the medical emergency while other crew members focus on their duties towards other passengers. This will improve efficiency and reduce miscommunication. It will ensure the pilot in the cockpit has reliable and consistent communication from the cabin and can focus on his primary job of flying the plane.

Know your resources and have them easily available

Ensuring that a complete and accessible medical kit is present and accessible should be part of a pilot’s checklist that is required before take off. In light of the current opioid epidemic and a recent overdose incident on a plane requiring emergency landing, Narcan should be added to kits .

Know your risks and liabilities

Many high risk activities, from bungee jumping to massages, require disclosures regarding medical conditions. Airlines could consider an option to provide medical risks or history at the time of ticket purchase or check in. Dizziness in someone with a known cardiac condition may be different than in someone who is usually healthy and just vomited five times.

For unaccompanied minors, there should be a standardized form used across the industry for permission to treat in the case of an in-air emergency. This is already done for summer camps and boarding schools.

Identify and share best practices across the industry.

Lufthansa has an interesting model of a “Doctor on board” program where doctors self identify as willing to volunteer. This potentially allows checking of these doctors credentials before take off, which could save the need to see a medical license from the volunteer doctor.

Track events and have ongoing quality improvement

A New England Journal of Medicine review article published in 2013 found a paucity of data and no standardization in how airlines reported medical events. This prevents ongoing quality improvement. Especially with increasing resources applied to anti-terrorism measures and other safety concerns, it is all the more important to ensure that medical safety of passengers is also up to date and effectively addressed.

Bring back the Airfone

Currently, the only communication with the ground is through the cockpit, since the use of the “Airfone” or cabin-to-ground communication has been discontinued. Meanwhile, changes in airline safety requirements mean that the pilot cannot open the cockpit door. There is a “telephone game” between the crew and/or volunteer doctor on board and the “doctor on the ground” that can lead to delays and miscommunication. A method of communication with the ground resources directly from the cabin, where the sick passenger and the team caring for her/him is located, is important for safety.

An ounce of prevention

Multiple factors increase risk of medical emergencies in the air: stress, dehydration, lower oxygen levels, air pressure changes, immobility. Further, increasing restrictions from airlines or security on carry on requirements or liquid allowance exacerbate these. Just as airlines remind people to declare their firearms at the time of check in, some common sense reminders about self care and hydration given to passengers may remind them to avoid crisis occurring when in the air. Airlines also should be mindful about avoiding unnecessary stressors on passengers.

There is a high prevalence of peanut allergy. Even aerosolized peanut dust – that may remain in recirculated air or on seats through multiple flights – can trigger a life-threatening reaction. Allergens like peanuts should be removed entirely from airline menus.

Bringing it all together:

Preparation, teamwork, and on-going quality improvement are best practices that improve safety, efficiency, and positive outcomes. The airline industry is urged to be proactive in preventing emergencies and ensuring the safety and wellbeing of all travelers while protecting everyone from both medical and legal consequences. Lives depend on it.

Additional resources:

Medical guidelines for Airline Passengers https://www.asma.org/asma/media/asma/Travel-Publications/paxguidelines.pdf

Be Prepared for In Flight Emergencies

https://www.acep.org/Clinical---Practice-Management/Be-Prepared-for-In-Flight-Medical-Emergencies/

In-Flight Medical Emergencies during Commercial Travel https://www.nejm.org/doi/full/10.1056/NEJMra1409213

Is There a Doctor on Board? In-Flight Medical Emergencieshttps://www.mdedge.com/ccjm/article/139298/cardiology/there-doctor-board-flight-medical-emergencies

Umbereen S. Nehal, MD, MPH is a former medical director for MassHealth, where she led development of clinical guidelines and value-based care models for 1.8 million Massachusetts Medicaid members. Dr. Nehal has been a content expert for state and national curriculum development for the Connecticut Department of Public Health, Massachusetts Department of Public Health, and the American Academy of Pediatrics. She was invited to moderate a panel discussion with then Surgeon General Regina Benjamin on the National Prevention Strategy, a multi-agency initiative designed to promote health and wellness in all policies, including the transportation industry. Dr. Nehal is a frequent invited stakeholder to the White House for national health policy initiatives.