9th January 2019, Dr John Goswell
According to a recent article in JAMA, in flight emergencies occur in about 1:600 flights. This comforting statistic should allow doctors to relax and enjoy their holidays. Not so for me. I have answered the call “Is there a doctor on the plane” twice now, even though I am not a “frequent flier”. The first of these was about 5 hours into a 12-hour trans-Pacific flight. A lady had collapsed when she got up to go to the toilet. The staff kept her on her side and then gave her oxygen when she did not recover. They moved a few passengers in order to create some room. Note that this meant some time had passed by the time the call went out for medical assistance.
The patient, I observed, was an older woman, perhaps about 70 years of age, lying on the floor with her head towards the exit door. There was barely enough room to examine her. She appeared clammy, pale and cold. Her pulse was fast and thready. She could understand me and answer simple questions but her English was limited. She spoke softly, which created difficulties hearing her over the engine noises. She barely responded to my questioning but preferred to lie there on the floor with her eyes closed. She gave a history that she had felt unwell and thinking that she would vomit, got up quickly to go to the toilet. She became weak and fell to the ground. She denied any chest pain/tightness, dyspnoea or parasthesiae.
She denied any past illnesses but I noted that she was on some medications. The brand names were mostly unfamiliar, but one ended in “pril”and another was Xanax, so it was likely that she was being treated for hypertension and anxiety. She confirmed that she had panic attacks in the past, however, stated that this was not a panic attack. By this time her pulse had become strong and regular but she was no better. I realised that she did not have simple syncope as initially expected. She was able to move all limbs and had normal pupils, reacting normally to light.
I had called for the medical kit and the defibrillator. The medical kit appeared well stocked. There was a sphygmomanometer and a stethoscope. The latter was useless. The pitch of the engine noise matched that of the heart and Koratkoff sounds and the engines were much louder, rendering auscultation useless. Her systolic pressure by palpation only was 130mmHg. Her colour returned but she was not feeling any better and was not prepared to move an inch.
A glucometer reading showed a normal blood sugar. A little later, she developed some tachypnoea and she felt dizzy. A paper bag was used on the assumption that she was starting to hyperventilate and this worked well, however she did not feel well enough to get up.
General practice is the art of managing uncertainty. At this point I had all the information that I was likely to get but still had no diagnosis. Worse case scenarios were considered; AMI, PE or CVA. I administered aspirin and sublingual Isordil with no apparent benefit. At this point the Captain wanted to know if he should divert to Hawaii. As we would be within about one hour of Hawaii for the next two hours it was determined to observe the patient for a while. Before the end of this period, the Captain consulted with ground medical support and a decision was made by them to continue to Sydney.
Continuing to manage her on the floor between seats was not a good option. It took two of us to get her up to first class, where she could lie down on a bed. Her observations remained stable, but she remained unwell. Hours later, she needed to go to the bathroom. She required assistance to get there. I was pleased to see that she did not lock the door. After I assisted her back to her bed, she said she was very dizzy and finally the penny dropped. Further questioning confirmed that she had vertigo. I gave her 10mg of Stemetil orally (which I had happened to pack in my own cabin luggage!) and this helped her. She slept and rested the rest of the way to Sydney and was then taken by ambulance for further assessment.
Things I have learned:
- It is horribly hard to practice medicine on a plane. Stethoscopes can’t be used.
- History taking is difficult between the noise and the language difficulties.
- Conditions in-flight can be very cramped. A collapsed patient in a seat in “cattle class” will be impossible to treat in situ and will need to be moved into the aisle. Even then, there is little room. These circumstances and lack of privacy can make it difficult to do a full examination.
- What is in the plane’s medical kit might be all that you have available. This can vary from airline to airline.
- In the JAMA article, the most common emergency events are syncope (33%), gastro-intestinal (15%), respiratory (10%), cardiovascular (7%) and neurological (5%).
- It generally takes considerable time to land a plane, even in an emergency. Even if close to an airport, landing, taxiing and getting to a medical facility is unlikely to occur in less than one hour, so for a cardiac arrest, the life or death issues will occur on the plane.
- Diverting a plane to a nearby airport can entail dumping large quantities of fuel (eg 30,000 litres) into the atmosphere.
- Patients from other countries can have medications which have unfamiliar names (or medications which we do not have in Australia).
- It is good to discuss issues with the flight attendants, as they can be very helpful. The Captain can consult with medical support on the ground to assist with medical decisions. These people are experienced in mid-flight emergency situations. They can be helpful with the hard decisions (whether to divert the plane) and can reduce your liability and your stress levels. You are not the only person making that decision.
- The chances of a major health event in flight is 1:600. In 50% of cases there will be a doctor on board.
- One should always carry the AHPRA card to identify yourself as a doctor if needed.
- It is embarrassing to show the AHPRA doctor identification as it is a flimsy piece of plasticised cardboard, which does not look very professional. I have written to AHPRA to request proper plastic cards but to no avail.
- The ethical consideration of helping someone in need is straight forward. The medico-legal aspects, however, could be tricky. By law, we are required to respond to an emergency in Australia. Does this extend to international flights? Be aware that prior consumption of alcohol by the doctor increases his/her liability, but might not reduce his/her responsibility if there is no-one else on board who can help.
- Planes should have stationery specific for recording your findings and management and this should be requested and you should keep a copy.
Things I don’t know:
- Whether a mid-Pacific LA to Sydney flight is under Australian jurisdiction or American. Does it depend upon the departure point or the ownership of the plane?
- Whether medical defence or the Australian Civil Liability Act (Good Samaritan Act) covers a doctor in these circumstances?
Christian Martin-Gill, MD, MPH; Thomas J. Doyle,MD, MPH; Donald M. Yealy,MD, In-Flight Emergencies: A Review, JAMA. 2018;320(24):2580-2590. doi:10.1001/jama.2018.19842
Access this abstract here.