Issue 43 / 11 November 2013

YOU’RE on your way home from a conference in Europe — somewhere over Bulgaria according to the flight path map on the tiny seatback television — cramped, tired and awake.

Dubious aromas from the nearby lavatory waft in your direction while you lament your decision to buy cheap tickets and spend the conference week sleeping on a friend’s couch. If only you’d waited until after the federal government made the decision to dump the crazy $2000 cap on tax deductions for education expenses to book your flight.

A while later as turbulence rocks the aircraft and you regret your decision to watch the Denzel Washington movie Flight, a detached voice crackles through your headphones: “If there’s a doctor on board, would you please make yourself known to the cabin crew by pressing your attendant call button?”

And so, in keeping with a spate of recent poor choices, you dismiss thoughts of a third glass of wine, reach up and press the button.

Little was known about the true incidence of airline medical emergencies until a study in the New England Journal of Medicine earlier this year shed some light on a problem many of us have experienced and most of us have an opinion about.

About 2.75 billion people travel on commercial airlines annually, with about 44 000 reported in-flight medical emergencies. In roughly half of these incidents, a doctor was on board and responded to a flight crew request for help. Nurses responded in 20% of emergencies and paramedics in 4%. Flight crew dealt with the remainder, either alone or with telemedicine support.

Rarely, but significantly, doctors were called to deal with serious emergencies like seizures or cardiac arrest. In these circumstances, while there is no clear legal obligation to assist, many doctors feel that they have a moral one.

Providing medical care in-flight is a challenging experience, even for trained retrieval teams working in dedicated aeromedical platforms with specialised equipment and standardised procedures. Providing safe and effective care in the cabin of a commercial airliner will put the most confident and experienced of doctors outside their comfort zone.

Cramped conditions, unfamiliar and non-standardised equipment, noise and limited assistance make an airline cabin a tough place to work. Most airlines pressurise their cabins to around 8000 feet (2440 m) above sea level. This reduces the partial pressure of oxygen available which, when combined with dehumidified air, leaves all on board prone to dehydration and fatigue. Importantly it also reduces the cardiorespiratory reserve of people already predisposed to cardiac problems.

Even the air is trying to make your job difficult, but how many doctors understand how to adapt their practice based on these physiological changes?

The environment is not the only challenge. With the increased popularity of flights by carriers based in legal jurisdictions with poorly delineated “Good Samaritan” legislation, fear of litigation is a legitimate concern.

It’s likely that if care is rendered voluntarily and without monetary reward doctors will be protected, assuming no gross or willful negligence. However, these legal frameworks remain untested — add a glass of wine or two to the mix and things could start to get tricky.

The good news is that most emergencies in the air are benign and self-limiting. Generally, responders are required to deal with nothing more severe than a vasovagal episode or simple gastrointestinal upset. In these circumstances, specific training and experience is not as essential as commonsense, which becomes your most important clinical tool.

The other reassuring thing about assisting in-flight is that most major carriers now have a telemedicine link to a specialised medical support agency on the ground. At least this means advice and support is never more than a satellite phone call away.

Nonetheless, things are not easy up in the air. So, keeping up to date with basic and advanced life support skills and asking yourself if you are in a position to provide safe care is probably the most important thing to do before pressing the attendant call button.

Otherwise, sit back, relax, and enjoy your flight.

Dr Simon Hendel is an anaesthesia fellow. He has completed a fellowship in aeromedical retrieval in North Queensland and is currently based in Fiji.

2 thoughts on “Simon Hendel: Flight fate

  1. Robert Hall says:

    I agree that this is a tricky area.  Early in my career I was involved in many aeromedical evacuations in remote Australia, and was struck then by the severe limitations on what you could do, even in a purpose-built, well fitted out aircraft with skilled staff.  Since then, I have responded to several calls for help on commercial aircraft, despite my diminishing clinical skills (I am a public health physician).  There are many things you can’t do, but many you can.  I have sat next to someone with chest pain, giving oxygen and taking his pulse, and hoping all would be well.  I have also dislodged an aspirated piece of food from a blue 2-year old.  Both these events were incredibly confusing—being crowded, short of space, and in the case of the child, not speaking the mother’s language.  I think if I had not responded to the second incident the child may well have died.  I could not agree more about keeping up with life support skills.  I think assessment of one’s capacity to provide useful help is more difficult without knowing the nature of the problem.  And I wonder what the legal situation is when flying over Bulgaria in an aeroplane registered in the United Arab Emirates.

  2. Dr R Bain FRCA, FANZCA says:

    In complete agreement with the above as another aero-medicine anaesthetic practitioner from the past. Be mindful that the Captain has the final say in all the decision making. Your own physical condition at the time is important and chosing not to volunteer could be the correct  but difficult course of action on some occasion. 

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