My Diaries/3rd June,2023 drdeepakgupta@gmail.com

Is there a doctor in Flight ?

In flight Medical Incidents ( IFMI)/ /emergencies at 35000 feet height

1st June, 2023 ( Delhi- Munich, LH 763) 0300 hrs. – A 60 yr. old gentleman from Amritsar noted to have seizure lasting for

1 minute 2 hrs. after flight take off. ( informant -wife)

Message from flight crew– There is a medical emergency in flight. Is there a doctor in flight?

• Response : One paramedic from Germany and one

Neurosurgeon from India responded. No ED physician present in flight/responded. Response time – immediate

• Action taken : Identified myself as a doctor registered with MCI to Air crew and to patient wife, consent to offer help taken verbally. Detailed history taken to rule out cardiac event, blood sugar tested ( 150 mg% by colorimetry), BP 130/84, SaO2 91% by pulse oximeter, Pulse Rate 84/min. Patient conscious but dull/drowsy. Vomited once. Sensorium improved to normal in 5 min. Tab Ondansetron 4 mg given with glass of juice. Patient remained well, no further seizure and no flight diversion needed.

• Doctors who volunteer to help the crew manage the incident should remember to ‘ do no harm’ and practice within the limits of their training and knowledge

IFMIs are uncommon events .

An inflight medical emergency is defined as a medical occurrence requiring the assistance of the cabin crew. It may or may not involve the use of medical equipment or drugs, and may or may not involve a request for assistance from a medical professional travelling as a passenger on the flight. Thus it can be something as simple as a headache, or a vasovagal episode, or something major such as a myocardial infarction or impending childbirth.

Inflight medical incidents can result from the exacerbation of a pre-existing medical condition, or can be an acute event occurring in a previously fit individual.

• Serious IFMIs are very uncommon. Flight diversions are extremely rare ( many unnecessary often due to cardiac issues 45-50%, followed by neurological, pregnancy, respiratory issues). Only 55% patients need admissions (in flight diversion cases)

• Decision to diversion is taken by pilot in consultation with ground ED team of airline after being advised by physician on board . Cost of diversion : 3000 – 900,000 USD ( 300,000 INR to 7.38 crore INR)

Do you know? : 2.75- 3 billion passengers worldwide fly each year. 1 in flight medical event takes place out of 600 flights ( 1 event / 14000 passengers). As per British airway statistics, call for in flight

Is there a doctor in Flight ? In flight Medical Incidents ( IFMI)/ /emergencies at 35000 feet height. @drdeepakguptans

My Diaries/3rd June,2023 drdeepakgupta@gmail.com

medical advice happens once in 160 flights, medical diversions once in every 7700 flights. The incidence is comparatively low, although the media impact of an event can be significant. One major international airline has reported 3022 incidents occurring in something over 34 million passengers carried in 1 year.

What happens at 36000 feet height ? : Modern commercial airliners fly with a cabin altitude of between 4000 and 8000 feet (1200 and 2400m) when at cruising altitude, which means a reduction in ambient pressure of the order of 20% compared with sea level and a consequent reduction in blood oxygen saturation of up to about 10%. The cabin air is relatively dry ( increases risk of bronchial spasm)

Although the main problems relate to the physiological effects of hypoxia and expansion of trapped gases, it is important to remember that the complex airport environment can be stressful and challenging to the passenger.

Common conditions seen during IFMI/ i- flight emergencies :

• Syncope/presyncope : Loss of consciousness – Most benign ( vasovagal syncope) and

regain good pulse and breathing and consciousness.- put him in supine for few more

minutes before putting him on sitting position.

• Diarrhea and /or vomiting : Ondansetron/Dimenhydrinate , Oral fluids, ORS ( sugar + salt

solution), iv saline ( exceptional cases only) ( 1-2 bottles are stored on board)

• Bronchospasm/asthma exacerbations : Bronchodilators with spacers help.

• Tension Pneumothorax : Treatable condition if diagnosed correctly

• Congestive heart failure/pulmonary edema : Diuretics, Management of high BP

• Angina pectoris/myocardial infarction : one of staff often trained for AED and so physician

often not required for AED.

• Cardiac arrest ( adult/children) : European Resuscitation Committee and the American Heart Association endorses early defibrillation as the standard of care for a cardiac event both in and out of the hospital setting. However, the protocol includes early transfer to an intensive care facility for continuing monitoring and treatment, which is not always possible in the flight environment. Some types of AED have a cardiac monitoring facility, and this can be of benefit in reaching the decision on whether or not to divert. For example, there is no point in initiating a diversion if the monitor shows asystole, or if it confirms that the chest pain is unlikely to be cardiac in origin. Lives have been saved by the use of AEDs on aircraft and diversions have been avoided, so it could be argued that the cost-benefit analysis is weighted in favour of carrying AEDs as part of the aircraft medical equipment. Nonetheless, it is important that unrealistic expectations are not raised. An aircraft cabin is not an intensive care unit and the AED forms only a part of the first-aid and resuscitation equipment.

• Seizures : Seizures if lasting > 5 min- inform crew of medical emergency. Most seizures self-limiting, help person into a resting position in a single reclining seat. Lie the person down across the seats with the head and body turned on one side, ensure airway is clear and breathing is not obstructed.. Arrange pillows /blankets to prevent the persons head from hitting unpadded areas.

• Stroke

• Hypoglycemia/Hyperglycemia : More common in diabetics. If blood sugar < 50 mg% – Oral

sugar / 50% dedtrosse50ml can be given

• Severe pain ( renal colic/ ureteric colic/biliary colic/fractures): Oral/inj analgesics can be

given

• Emergency delivery : Umbilical clamps now available, Shoe laces have been used to tie

umbilical cord on board

Is there a doctor in Flight ? In flight Medical Incidents ( IFMI)/ /emergencies at 35000 feet height. @drdeepakguptans

My Diaries/3rd June,2023 drdeepakgupta@gmail.com

• Air-sickness

• Anaphylaxis

• Sinus/ Middle ear disease : Oral decongestant before travel , nasal decongestant spray

during flight just before descent. first trimenster pregnancy : intranasal steroids instead

of topic decongestants .

• Head injuries, burns and scalds

Top 5 causes : Syncope/presyncope ( 40%), Respiratory symptoms ( 12%), Nausea/vomiting ( 10%), Cardiac symptoms ( 8%) , Seizures ( 6%)

Coronary artery disease : If acute chest pain without hypotension : ASA (Aspirin) 325 mg or 4 tablets of 75 mg, NTG 0.4 mg sublingually ( repeated 3 times at 5 minutes if no relief of chest pain. STEMI vs Angina : Chest pain of STEMI is persistent, longer, intense and not relieved by rest /sublingual NTG, chest discomfort , dyspnea, diaphoresis, palpitations,

Remember : With STEMI ( < 30 min : thrombolysis , > 90 min : PCI )

Anaphylaxis : Diagnosis : > 2 organs involved : Skin/mucosa, Cardiac/respiratory/ GIT symptoms or Hypotension With SBP < 90 mm Hg after exposure to allergen). Children : 0.01mg.g or 0.1 o-0.3 ml )

• 1: 1000 Epinephrine 0.3-0.5 ml intramuscular ( thigh), Repeat after 10-15 min if no response.

• Diphenhydramine 25-50mg im (relieve skin symptoms, no immediate effect on reaction,

shorten duration of reaction).

• Steroids ( MPA) prevent biphasic reaction ( 1-2 mg/kg daily ). 1-2 days)

Why more common : Longer flights , elderly population with preexisting medical conditions( Relative hypoxia, , lower relative humidity – physiological stressors). Pressured cabin set at 7000 ft ( O2 saturation 90% Normal) oxygen saturation low, most patients who develop in flight emergency have pre-existing conditions /sickness/ dehydrated prior.

How to measure blood pressure in flight : Automated BP monitors, Return of pulse ( radial) for SBP, return of waveform on pulse oximeter. Stethoscope ( heart sounds/breath sounds) often not heard well in noisy aircraft cabin.

Do you know : Oxygen canisters ( low flow 2 L/min, high flow 4 l/min) with non-breathing mask, even with high flow 100% Fio2 will not be available.

Flight Environment and effects of altitude :

Relative Hypoxia equivalent to 5000-8000 feet at 36000 altitude ( pressurized cabins): In airspace, relative hypoxia (= 16-17% O2 at sea level exists), saturation normally drops by 10%, pO2 at cruising altitude is usually well tolerated in normal individuals. Problems can arise in those with respiratory or cardiac impairment. Impact of lower pO2 heightened by the nature of oxygen dissociation curve. Air travels take place in troposphere ( innermost concentric shell around the Earth ( -56 C, Atmospheric pressure declines exponentially from 760mm Hg at sea level ( 18000 Ft : 380, 36000 ft : 190), SpO2 85-91% usually doesn’t cause symptoms. Commercial air vehicles fly at 36000 to reduce turbulence and air drag ( for fuel economy). Air-cabins are thus pressurized so that the effective altitude to which occupants are exposed is much lower than that at which they are flying.

Gas Expansion ( 20-30%) : It becomes a problem only if there is a ‘ trapped gas’ e.g., Pneumothorax ( recent post traumatic pneumothorax in last 2 weeks), ENT problems, Orbit following retinal surgery, retained abdominal, thoracic or intracranial gas following surgery.

Is there a doctor in Flight ? In flight Medical Incidents ( IFMI)/ /emergencies at 35000 feet height. @drdeepakguptans

My Diaries/3rd June,2023 drdeepakgupta@gmail.com

Do you know ? : At 8000 ft, 5% fall in ischemia threshold ( HR x SBP at the ECG threshold for ischemia). After elective percutaneous angioplasty, one can fly after 2 days. At low risk after ST elevation MI ( STEMI) – age < 60 yrs., no signs of heart failure, normal EF, no arrythmias – can fly after 3 days. ( others after 10 days). Non STEMI MRI ( travel only after angiography and revascularization).

Advice to passengers : Avoid excess alcohol and caffeine containing drinks and remain mobile and exercise legs. Postpone your air travels if you have had recent illness ( especially cardiac or respiratory illnesses)

Advice to Physicians on board :

Treat passenger best with seated. Do not panic , Do not hide yourself from helping , Create space, Turn on cabin lights, recruiting additional help, contact ground based telemedicine early, Open 2 way communication with pilot to make safest decision for all passengers must.

Indemnity : Although the crew are trained to handle common medical emergencies, in serious cases they may request assistance from a medical professional travelling as a passenger. Such assisting professionals are referred to as Good Samaritans. Cabin crew members attempt to establish the bona fides of medical professionals offering to assist, but much has to be taken on trust. The international nature of air travel can lead to complications in terms of professional qualification and certification, specialist knowledge and professional liability. An aircraft in flight is subject to the laws of the state in which it is registered, although when not moving under its own power (i.e. stationary at the airport) it is subject to the local law. Some countries (e.g. USA) have enacted a Good Samaritan law, whereby an assisting professional delivering emergency medical care within the bounds of his or her competence is not liable for prosecution for negligence. In the UK, the major medical defence insurance companies provide indemnity for their members acting as Good Samaritans. Some airlines provide full indemnity for medical professionals assisting in response to a request from the crew, whereas other airlines take the view that a professional relationship is established between the sick passenger and the Good Samaritan and any liability lies within that relationship. To the end of 2016, there is no record of any successful action for negligence or professional malpractice arising out of a Good Samaritan act on board a commercial airliner.

Follow up : Airlines are always grateful for assistance willingly offered by medical professionals travelling as passengers, particularly when the costs and inconvenience of an unscheduled diversion are avoided. For reasons of indemnity it is inappropriate to pay a full professional fee to the Good Samaritan. Follow-up of the passenger after disembarkation is frequently difficult, because he or she is no longer in the care of the airline and becomes the responsibility of the receiving hospital or medical practitioner.

Problems faced by physicians : Unfamiliar clinical scenario, Foreign and limited environment, no idea of available resources, no assistance often ( flight crew with in flight medical emergency course often seek help from physicians/surgeons ( who receive little or no training), airline policies, legal/ethical issues

Before helping, Check your eligibility – Ensure you are not drunk to discharge your duties, you ask airline for legal responsibility. Do not attempt to practice beyond your expertise, but remember your expertise is better than any non-health professional and your help may be valuable. Document your findings and treatment and keep a copy with you. Remember : No individual physician has to date being sued for assisting a sick traveler Remember physicians are protected from liability. Note – Patients often carry their own medications. Take a proper history from relative of patient always.

Death on board : Consult when to stop resuscitation . Follow IATA guidelines provided by crew.

Is there a doctor in Flight ? In flight Medical Incidents ( IFMI)/ /emergencies at 35000 feet height. @drdeepakguptans

My Diaries/3rd June,2023 drdeepakgupta@gmail.com

Drugs often available in medical kit

For feedbacks, suggestion : Pls write to

Dr Deepak Gupta, Professor Neurosurgery, drdeepakgupta@gmail.com Twitter : @drdeepakguptans

Is there a doctor in Flight ? In flight Medical Incidents ( IFMI)/ /emergencies at 35000 feet height. @drdeepakguptans