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ClinicalReview&Education
JAMA | Review
In-FlightMedicalEmergencies
AReview
ChristianMartin-Gill,MD,MPH;ThomasJ.Doyle,MD,MPH;DonaldM.Yealy,MD
AuthorAudioInterview
IMPORTANCE In-flightmedicalemergencies(IMEs)arecommonandoccurinacomplex Supplementalcontent
environmentwithlimitedmedicalresources.Healthcarepersonnelareoftenaskedtoassist
affectedpassengersandtheflightteam,andmanyhavelimitedexperienceinthis CMEQuizat
environment. jamanetwork.com/learning
OBSERVATIONS In-flightmedicalemergenciesareestimatedtooccurinapproximately1per
604flights,or24to130IMEsper1millionpassengers.Theseeventshappeninaunique
environment,withairplanecabinpressurizationequivalenttoanaltitudeof5000to8000ft
duringflight,exposingpatientstoalowpartialpressureofoxygenandlowhumidity.
MinimumrequirementsforemergencymedicalkitequipmentintheUnitedStatesincludean
automatedexternaldefibrillator;equipmenttoobtainabasicassessment,hemorrhage
control,andinitiationofanintravenousline;andmedicationstotreatbasicconditions.Other
countrieshavedifferentminimummedicalkitstandards,andindividualairlineshave
expandedthecontentsoftheirmedicalkit.ThemostcommonIMEsinvolvesyncopeor
near-syncope(32.7%)andgastrointestinal(14.8%),respiratory(10.1%),andcardiovascular
(7.0%)symptoms.Diversionoftheaircraftfromlandingatthescheduleddestinationtoa
differentairportbecauseofamedicalemergencyoccursinanestimated4.4%(95%CI,
4.3%-4.6%)ofIMEs.ProtectionsformedicalvolunteerswhorespondtoIMEsintheUnited
StatesincludeaGoodSamaritanprovisionoftheAviationMedicalAssistanceActand AuthorAffiliations:Departmentof
componentsoftheMontrealConvention,althoughthedutytorespondandlegalprotections EmergencyMedicine,Universityof
varyacrosscountries.Medicalvolunteersshouldidentifytheirbackgroundandskills,perform Pittsburgh,andtheUniversityof
anassessment,andreportfindingstoground-basedmedicalsupportpersonnelthroughthe PittsburghMedicalCenter,
flight crew. Ground-basedrecommendationsultimatelyguideinterventionsonboard. Pittsburgh,Pennsylvania.
CorrespondingAuthor:Christian
CONCLUSIONSANDRELEVANCE In-flightmedicalemergenciesmostcommonlyinvolve Martin-Gill, MD,MPH,Departmentof
EmergencyMedicine,Universityof
near-syncopeandgastrointestinal,respiratory,andcardiovascularsymptoms.Healthcare Pittsburgh,3600ForbesAve,
professionalscanassistduringtheseemergenciesaspartofacollaborativeteaminvolving IroquoisBuilding,Ste400A,
theflightcrewandground-basedphysicians. Pittsburgh,PA15261(martingillc2
@upmc.edu).
JAMA.2018;320(24):2580-2590.doi:10.1001/jama.2018.19842 SectionEditors:EdwardLivingston,
MD,DeputyEditor,andMaryMcGrae
McDermott,MD,SeniorEditor.
n-flightmedicalemergencies(IMEs)areuniqueeventsforwhich air passenger, air travel, aircraft, airline, aviation, commercial air,
travelingphysicians,nurses,andotherhealthcareprofession- flight, and fitness to fly (n = 14842). Scanning the titles to identify
Ialsmayrendermedicalassistance.Cruisingat35000ftwith appropriateness and searching bibliographies yielded the final
limitedmedicalequipment,oftenhoursawayfromtheclosestmedi- list of relevant articles (n = 765). Each article was assessed for com-
calfacility,createsanunfamiliarcarechallengeformanyhealthcare pleteness of data reporting and importance to management
professionals. This clinical review focuses on IME data and offers andpreventionofIMEs.Basedonthisassessment,atotalof317
guidancetoassistmedicalprofessionalswhomayencounterthese articles were included in the review. Frequency data were
eventsusingbothliteratureandtheauthorsinsightsprovidingair- extracted and means and 95% confidence intervals were calcu-
line care guidanceforIMEs. latedwhenappropriate.
Methods Observations
Aliterature search was conducted in MEDLINE using PubMed Epidemiology
for English-only articles published between January 1, 1990, and Theestimatedprevalence of IMEs is 1 in 604 flights based on a
June 2, 2018, using the terms air emergency, air emergencies, review of 11920 requested ground consultations from 5 large
2580 JAMA December25,2018 Volume320,Number24 (Reprinted) jama.com
©2018AmericanMedicalAssociation.All rights reserved.
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ReviewofIn-FlightMedicalEmergencies Review ClinicalReview&Education
1
domestic and international airlines from 2008 to 2010. This is Recyclingofairmayalsoexposepassengerstopotentialallergens,
likely an underrepresentation of all IMEs because many minor inci- evenwhenthesourceofallergensisseveralrowsawayfromapas-
dents do not result in consultations. Other IME frequency esti- senger.Althoughtheenclosedandlimited-spaceenvironmentofair-
matesfromindividualairlineswithdatafrom2009to2013ranged craftraisesconcernfortransmissionofcommunicablediseases,44,45
from24to130IMEsper1millionpassengers.2,3Giventhat4billion preexistingexposureisamorecommoninfectioussource.
commercialairline passengers travel worldwide annually,4 it is pos-
sible that 260to1420IMEsoccurdailyworldwide. EmergencyMedicalEquipment
Atotalof14articlesdescribedtherelativefrequencyofmedi- The Federal Aviation Administration (FAA) has minimum re-
cal conditions comprising IMEs aboard commercial aircraft quirements for contents of an emergency medical kit aboard US
1-3,5-15 46
(Table1). Theaggregatefrequencyofmedicalconditionsamong airlines (Table 3). Non-USairlines have different minimum
6,47
49100IMEsshowedthatsyncopeornear-syncopewasthemost requirements, andindividual airlines vary widely in the con-
commonIME(32.7%);othercommonconditioncategoriesin- tents of their emergency medical kits.23 The FAA requires auto-
cludedthosewithgastrointestinal(14.8%),respiratory(10.1%),and matedexternal defibrillators on all airplanes with “a maximum
cardiovascular (7.0%) symptoms. In-flight cardiac arrest was rare payload capacity of more than 7,500 pounds and with at least
(0.2%ofIMEs). oneflight attendant,”46 but automated external defibrillators are
48,49
Diversion refers to altering a flight destination for a medical not currently mandated for European airlines. The FAA-
emergency; based on 14 publications reporting 56599 IMEs mandatedmedicalkitcontainsprotective gloves and equipment
(Table2),diversionoccurredin2515flightswithIMEs(4.4%;95% for a basic medical assessment, hemorrhage control, and initia-
1-3,5-10,13-17
CI, 4.3%-4.6%). tion of an intravenous line (Table 3). The FAA-mandated medical
kit contents also include medications to treat mild pain, allergic
Pathophysiology reactions, bronchoconstriction, hypoglycemia, dehydration, and
Commercialaircraftflyatacruisingaltitude(duringlevelflight)of somecardiacconditions. Commonenhancementstothemedical
30000to40000ft,andpassengercabinsarepressurizedto kit include a glucometer, urinary catheter, and medications for
12 psi to 11 psi, which is equivalent to being at an altitude of 5000 nausea, moderate to severe pain, seizures, and additional cardiac
18-22 indications. Controlled substances are not commonly available in
to 8000ft. This pressurization leads to expansion of closed
gas-containing spaces in the body (eg, sinuses and middle ear) medical kits on US airlines but may be available in kits on some
andnonphysiological gas collections (eg, pneumothorax or fol- non-USairlines.
lowinggastrointestinal,ocular,orintracranialsurgery).23At8000 Commercialaircraft carry oxygen bottles intended for short-
ft of altitude or equivalent, the volume of gas in an enclosed termusebyflight crew during sudden depressurization. Airline
24
space increases by approximately 30% ; altitude changes com- oxygenbottles deliver oxygen to passengers at low (2 L/min) or
monlytrigger discomfort in patients, especially those with exist- high (4 L/min) settings, which may be sufficient to address the
27,50
ing upper respiratory tract inflammation or infection, including needforoxygenatcruising altitudes. These oxygen stores
sinusitis or otitis media. generally do not fully meet the needs of persons with respiratory
Theaircraft cabin has a lower partial pressure of oxygen at alti- failure. The numberofoxygenbottlesonanindividualaircraftvar-
tude,withresultantmildhypoxiainhealthypassengers(decreasing ies, and there is no requirement to carry enough portable oxygen
meanarterialoxygensaturationfrom97%to93%).Thiseffectcan toadministertoapassengerforthedurationofaflight.
bemorepronouncedorsymptomaticinpassengerswithexisting Severalorganizationsrecommendcontentsforanoptimalmedi-
23-26 51-58
pulmonaryconditions. Passengers with hypoxia or respiratory cal kit. Somehavesuggestedthatcommonemergencymedi-
insufficiency at baseline may benefit from supplemental oxygen at calkitslackadequateequipmentforpediatricemergencies.59,60Rec-
cruising altitude27-29; alternatively, the baseline flow of oxygen may ommendedimprovementsincludestandardizationofcontentand
61 60
needtobeincreasedforthedurationofaflight.Useofaportable locationofequipment, availabilityofpulseoximetry, andaddi-
oxygenconcentratorduringflight needs approval by the airline, a tionalmedications,includinga“majoranalgesic,”56naloxone,60and
62
physicians certification of need, and sufficient battery life, all typi- antibiotics. Despitethesesuggestions,currentbasicemergency
cally coordinatedatleast48hourspriortotheflight.30-32 medicalkitscontainsufficientequipmenttohandlemostIMEs;only
Prolongedsittingandhypoxiamaytriggerdecreasedvenousflow, a minority of cases require a medication or performance of ad-
systemicinflammation,andplateletactivation,whichexplainstheas- vancedprocedures.1
sociation betweenairtravelandvenousthromboembolism,33,34al-
thoughcontroversyexistsregardingtheriskcomparedwiththegen- Ground-BasedMedicalSupport
eral population.34-38 Symptoms of deep venous thrombosis or Ground-basedmedicalsupportcomesfromtrainedmedicalper-
pulmonaryembolismmostcommonlypresenthourstodaysafter sonnel who provide recommendations for IMEs and preflight
39 63
completingairtravel butcanoccuronflightsoflongdurationordur- screenings. Mostairlines contract with third-party entities to
40,41 1,13,15,64,65
ing multiple flights in succession. Theriskoflowerlimbvenous provide this service. WhenanIMEoccursonanaircraft,
thrombosisinhigh-riskpassengersmaybeupto5%perflight,41and a flight attendant notifies the pilot in command; next, that pilot
symptomlessvenousthromboembolismmayoccurinupto10%of establishes radio or satellite telephone communications with the
passengersonflightsoflongduration(ie,>4hours).42 ground-based medical support center and the airline operations
Cabinair,drawnfromanoutsidedryenvironmentataltitudeand center. The flight attendant relays information to and from
pressurizedanddehumidifiedbycyclingthroughtheenginecom- ground-based support via the pilot or through headsets in the
partment,maycontributetodehydrationamongpassengers.21,24,43 cabin. Communication clarity is often a challenge, including
jama.com (Reprinted) JAMA December25,2018 Volume320,Number24 2581
©2018AmericanMedicalAssociation.All rights reserved.
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Clinical Review&Education Review ReviewofIn-FlightMedicalEmergencies
/ wn (11.8)(8.6)(11.1)(28.6)(15.6)(16.6)(29.2)(39.6)(13.1)(15.2)(35.6)(24.2)(29.2)(16.8)(12.3)
ther 969 597 519 148 113 82 92 56 32 062
O Unkno1401 1129 1163 355 469 1 6
b b b
(0.3) (0.5) (0.7)(0.3)(0.5)(0.4) (0.7)(0.3)(0.7) (0.8)(0.5) (0.5)(0.2)
38 52 30 7 15 8 9 3 5 3 1 1
CardiacArrest 120
(0.5)(<0.1)(0.6)(1.4)(1.4)(1.1)(2.3) (2.9) (0.2) (3.9)(2.1) (1.6)(0.7)
61 4 62 56 31 30 46 33 1 15 4 3
Obstetric/Gynecologic 346
(2.2)(2.3)(2.2) (2.8)(4.7)(3.5) (0.8)(2.4) (2.4) (3.7)(1.6)
63 71 10 27 9 7
Allergic265257222 132 798
xication(2.4)(3.2)(6.0)(2.3)(3.7)(3.9)(2.3)(3.1)(3.4) (0.6) (9.2)(1.0) (3.1)(3.5)
chiatric/ 92 84 46 41 38 3 35 2 6
PsyInto287367 616 111 1728
(3.0)(3.1)(6.0) (2.8)(12.2)(14.1) (20.1)(5.3)(9.8)(7.3) (2.9)(13.5) (3.1)(4.8)
auma 54 59 98 60 73 37 11 26 6
r 363 3 3 113 279 3 266 2345
T
(8.8)(4.0)(2.5) (17.9)(13.7)(4.3)(29.0)(4.6)(11.8)(4.3)(0.2)(9.2)(8.3) (4.7)(5.5)
60 32 1 35 16 9
Neurological1050450250727312 120 592 134 2722
a
ascular
v (7.7)(2.3)(6.6) (6.1)(12.5)(7.6)(13.4)(4.6)(22.3)(10.8)(9.1)(11.8)(19.3) (9.4)(7.0)
920 258 675 248 285 215 274 60 253 80 46 45 37 18
Cardio 3414
y
ator(12.1)(15.9)(2.3)(8.8)(11.0)(9.9)(8.5)(11.1)(8.1)(8.1)(13.6)(3.7)(7.8) (6.8)(10.1)
espir 231 359 251 279 173 145 92 60 69 14 15 13
(%) R 1447 1805 4953
.
No
total.
Condition,(13.6)(19.5)(12.6)(32.2)(11.9)(19.7)(9.8)(10.7)(8.0)(23.3)(7.8)(15.5)(14.6)(35.6)(14.8)the
y 90 4 59 28 68
b 271 554 201 140 173 .
s Gastrointestinal1625221412861310 7268 t within
s s
IME arre
Conditionof
yncope(37.4)(41.1)(52.1)(15.3)(18.1)(1.7)(4.7)(22.4)(28.0)(25.2)(16.3)(3.6) (14.7)(32.7) categorie
S 34 62 62 7 28 cardiac
Medicalrequencyyncope/446346485307348 510 254 208 128 059
y F S Near- 16 light
b medical
s . in-f
No tedother
encie s, of
IME .
y repor
920 326 189 744 507 380 192 191 100 f
Emerg 4068 2279 2818 2042 1312 1132 o
otal11 10 s
T 11 49
emergenccase
Medical mo mo mo mo mo mo mo mo mo mo o mo mo mo independent
34 60 12 12 m 12 ted
108 60 12 48 72 36 , 6 120 , 12 include
light Details t t medical
notrepor
In-F lighto
f Airlines,Airline,Airlines,Airline,Airline,Airline,Airline,Airline,Airlines,AirporAirline,Airline,AirporAirline,dare
o Study5 1 2 1 1 1 1 1 5 1 1 1 1 1 in-fs s
y , case
14 case
IME t
12 s
requenc 2, 11, , 15 asculararre
F 2013 2011 2009 2013 2003al 2002 2015 2000al ter 2001 v
.
1 1, 5, 6, 7, 8, et n 9, 3, 10, et Por 13, Schubach, viation:
e
able al al al al al v al esaplialal al otal CardioCardiac
T SourcePetersonetMahonyetSandetHungetDelauneetKim2017SiretKetDeJohnetChan2002Qureshiand2005SzmajeretCumminsand1989Baltsezak,2008TAbbreab
2582 JAMA December25,2018 Volume320,Number24 (Reprinted) jama.com
©2018AmericanMedicalAssociation.All rights reserved.
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ReviewofIn-FlightMedicalEmergencies Review ClinicalReview&Education
Table2.FrequencyofAircraftDiversionsforIn-FlightMedicalEmergencies
Total No. of In-Flight No.(%)[95%CI]
Source StudyDetails MedicalEmergencies WithDiversions
1
Petersonetal, 2013 5Airlines, 34 mo 11920 875 (7.3) [6.9-7.8]
Mahonyetal,52011 1Airline, 108 mo 11326 276 (2.4) [2.2-2.7]
Sandetal,62009 2Airlines, 60 mo 10189 279 (2.7) [2.4-3.1]
16
Valani et al, 2010 1Airline, 60 mo 5386 220 (4.1) [3.6-4.6]
Hungetal,72013 1Airline, 60 mo 4068 46 (1.1) [0.8-1.5]
17
Weinlichetal, 2009 1Airline, 36 mo 3364 94 (2.8) [2.3-3.4]
2
Kimetal, 2017 1Airline, 48 mo 2818 15 (0.5) [0.3-0.9]
Delauneetal,82003 1Airline, 12 mo 2279 181 (7.9) [6.9-9.1]
9
Sirvenetal, 2002 1Airline, 72 mo 2042 312 (15.3) [13.7-16.9]
Kesapli et al,3 2015 1Airline, 36 mo 1312 22 (1.7) [1.1-2.5]
10
DeJohnetal, 2000 5Airlines, 12 mo 1132 145 (12.8) [10.9-14.9]
Szmajeretal,132001 1Airline, 120 mo 380 37 (9.7) [6.9-13.2]
14
CumminsandSchubach, 1Airport,12mo 192 7 (3.6) [1.5-7.4]
1989
15
Baltsezak, 2008 1Airline, 12 mo 191 6 (3.1) [1.2-6.7]
Total 56599 2515 (4.4) [4.3-4.6]
deviceissuesandrelayingofinformation,makingwell-articulated videmedicalassistancefromliabilityexceptincasesofgrossneg-
exchangesessential. The effect of ground-based medical support ligence or willful misconduct.68 Medical volunteers who seek
onpatientoutcomesfollowinganIMEhasnotbeenstudied. compensationinreturnforprovidingaid(suchasmoney,seatup-
grades,mileagepoints,orotheritemsofvalue)mayjeopardizetheir
TheMedicalVolunteerRole standing under existing immunity laws, although no case law re-
Guidedbyindividualairlinepolicies,airlinepersonneloftenseekaid latedtothisexists.69
fromtrained medical professionals, augmenting existing capabili- FlightsoutsideoftheUnitedStatesaregovernedbyacomplex
ties.Medicalvolunteersarenotgenerallyrequiredtocarryproofof combinationofpublicandprivateinternationallaws,includingthe
theirmedicallicense,althoughthisvariesbyindividualairlinepolicy. WarsawConvention,MontrealConvention,andTokyoConvention.69
Volunteerswhohaveabusinesscardorlicensuredocumentsready In addition to differences in “Good Samaritan” volunteer protec-
tosharemayallayconcernsbyflightteamsaboutabilitytoaid.More tions,whicharenotpresentinmanyothercountries,thedutytore-
importantly,medicalvolunteersmusthonestlyconsidertheirown spondalsovaries by country. For example, in the United States,
capabilityofprovidingmedicalcare,andiftheychoosetodoso,they Canada, England, and Singapore, there is no legal duty for an off-
66 69-71
shouldnotbeundertheinfluenceofalcoholorotherdrugs. Inone dutymedicalprofessionaltoassistduringanIME. Conversely,
study, approximately half of IME aid was by a physician, 25% by a Australia and many European countries require physicians to ren-
nurseorotheremergencypersonnel,and25%byflightcrewalone.1 der assistance during IMEs as defined by case law and civil law
69,72,73
If multiplepotentialvolunteersexist,acollegialconversationabout codes. Regardlessofapplicablelaws,physiciansoftenfeelan
74
capabilitiesisoptimal;forinstance,aspecialistphysicianmaybeless ethical duty to act. According to one study, only 1 case has oc-
capabletoassessandmanageapatientwithanIMEthananother curredintheUnitedStatesinvolvingaphysicianbeingsuedforas-
medicalvolunteerwithtrainingandexperiencemoredirectlylinked sisting in an IME, and that case was dismissed without hearing.69
tothesymptomsorcondition. Considering existing legal protections and international require-
Inmostcases,theprimaryroleofamedicalvolunteeristogather ments,medicalassistancerenderedbyacapablephysicianisoflittle
information, assess an ill or injured passenger, aid with communi- personal legal risk and is supported by experts in aviation
1,56,63,66
cations with any ground-based support, and potentially adminis- medicine.
termedicationsorperformprocedures.Flightcrewparticularlyseek
therecommendationsofground-basedmedicalexpertsbeforeuse AircraftDiversion
ofmedicationsorequipmentfromtheemergencymedicalkit,con- Diversion, which involves changing a landing destination because
sidering the variability in training and experience of onboard of an IME, is appropriate for several types of medical emergency.
67
volunteers. Medicalvolunteersmaybeaskedtoprovidearecom- Acommercialaircraftisnotamedicalfacility,haslimitedonboard
mendation,butaconsultingground-basedphysicianusuallymakes medical equipment, and has no dedicated medical personnel on
afinalrecommendationaboutcare.Thekeytosuccessisforevery- boardwhocanadequatelyaddressallevents.However,thedeci-
oneinvolvedtocontributetheirexpertiseaspartofacollaborative sion to divert involves consideration of multiple factors, many
team,withthesolegoalofensuringthebestinterestofthepatient unknowntoanonboardmedicalvolunteer.Aircraft commonly
withtheIMEinconsiderationofallpassengersonboard. take off with more fuel than is safe for landing; immediate diver-
sion soonafterdeparturemayrequiredumpingalargeamountof
LegalandEthicalConsiderationsforMedicalVolunteers fuel into the atmosphere (a feature not available in many newer
In the United States, the Aviation Medical Assistance Act (also re- aircraft). The closest possible diversion airport may not have
ferredtoasa“GoodSamaritan”shield)protectspassengerswhopro- appropriate medical capabilities to manage a patient, negating a
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