Medical Events During Commercial Flight

Transcription

1 Medical Events During Commercial Flight James Cushman, MD, MPH, FACS Civilian Aerospace Medicine Resident UTMB Aerospace Medicine Residency Galveston, Texas 84 th Annual Scientific Meeting of AsMA Chicago, IL

2 84 th AsMA Annual Scientific Meeting Disclosure Statement James Cushman, M.D. I have no financial relationships to disclose. I will not discuss off-label use and/or investigational use in this presentation

3 Case History Coach class Honolulu, HI Los Angeles, CA October, 2000 United Flt 53 ~ 2000 to 0700 schedule 2 hours into the flight, an overhead announcement requesting a medical response was made Single MD response, escorted to First Class to find unresponsive elderly male passenger

4 Case History: Unresponsive Passenger United Flt yo male appears older than reported age Initial hx per wife: patient awake, alert, normal 30 minutes earlier, had eaten small snack prior to LOC. Pt not a diabetic No response to verbal, light, then noxious stimuli; eyes in neutral position, appeared reactive Proceeded to rapid exam additional history from wife informing flight attendant of serious nature of problem

5 P.E. Skin warm HR 65 regular at radial pulse, RR 12 regular, shallow? BS equal BP 130/P (palp technique) Abdomen: soft Neuro: GCS = 3, pupils equal, round No response to repeat deep sternal rub

6 Additional Hx from wife Non-contributory Denied cardiac or neurologic history (incl. similar event) Denied husband making any complaints prior to LOC Denied cardiac meds, sedative or hypnotic drug use, etc. At this point, the attendant was informed that the medical situation was serious. Plan: Continue to monitor the patient (airway, supplemental O2, serial VS) while she briefed the captain. DIFFERENTIAL DIAGNOSIS???

7 In-Flight Medical Emergencies No regulatory reporting requirements industry-wide events/day (U.S./FAA) Incidence = 1/35,000 passengers or 1/378 flts Most in-flight incidents are not serious Vasovagal sx: dizziness, hypervent, near-fainting Cardiac, neurologic and respiratory the most serious

8 In-Flight Environment Cabin pressure Assuming 8,000 ft {PaO2 56mm Hg; SaO2 89%} Cabin air quality Humidity 10-20% Prolonged immobilization Passengers out of their routine Potential for violence aboard aircraft

9 In-Flight Medical Emergencies

10 Emergency Medical Kit (NEJM. 2002;346:1067) Type of Equipment Items Quantity Diagnostic Stethoscope 1 Sphygmomanometer 1 Airway Oropharyngeal airway 3 Medications Nitroglycerin (0.4mg tablet) 10 Dextrose (50%, injectable) 1 amp Epinephrine (1:1000 injectable) 2 doses FDA-approved AED 1 Bag-valve device 1 IV infusion kit 1 Normal saline 1 500cc bag Aspirin 4 Bronchodilator inhaler 1 dose

11 In-Flight Medical Emergencies Therapeutic Maneuvers (NEJM 2002) Medical Scenario Unresponsive passenger Chest pain/angina SOB Vasovagal symptoms Increased bodily gas expansion; further increase Pp [O2] Persistent severity of above conditions despite best efforts to stabilize Acceptable Provider Actions Request AED and apply, supplemental O2, consider IV and IV Dextrose Consider ASA, nitrates Consider bronchodilator and supplemental O2 Supportive measures (supine, leg elevation), consider IVF In consultation with pilot, consider decreasing aircraft altitude Recommend aircraft diversion

12 Back to the Patient in First-Class Serial VS and neuro exams performed: Stable Invited into 747 cockpit to brief Cpt., CP Spoke on radio with on-ground medical asset When asked, recommended continue to L.A.

13 Back to the Patient in First-Class MD was provided first class seat and large bottle of water. Serial exams and 1-2 additional updates provided to pilot. Approximately 1 hour prior to landing in CA, the patient awoke. Further history obtained from wife that patient was taking an oral barbiturate for back spasms and may have taken too much medication

14 In-Flight Medical Emergencies Discussion Consider TWO broad categories of medical events: ROUTINE COMMERCIAL FLIGHT CONCERNS INTENTIONAL (e.g. COVERT, VIOLENCE) Matching needs with resources is the correct goal in most consequence management constructs Airline and national security agencies analyze risk in both categories: individual passenger medical risk and risk matrices for national security

15 Risk Matrix Very unlikely Unlikely Possible Likely Very Likely 5 Catastrophic X X 4 Severe X X 3 Moderate X X 2 Minor X X 1 Negligible

16 Summary In-flight medical incidents during commercial flight are rare and usually minor events The average age of air travelers The majority of flights have incidental medical assets on-board Physicians should be knowledgeable about common and potentially severe medical disorders in-flight and resource options available Special topic issues include uniform-registry questions, medical liability concerns, financial impact of diversion, aviation threats and national security responsibilities

17 References Gendreau MA et al: Responding to medical events during commercial airline flights. NEJM, 2002; 346: Delaune EF et al: In-flight medical events and aircraft diversions: One airline s experience. ASEM. 2003;74: DeHart RL. Health issue of air travel. Annu Rev Public Health. 2003;24: Ruskin KJ et al: Management of in-flight medical emergencies. Anesthesiology. 2008;108: Hung KKC et al: Predictors of flight diversions and deaths for in-flight medical emergencies in commercial aviation. Arch Intern Med. 2010;170:

18 References Print/Public Media Sharkey J: That loaded gun in my carry-on? Oh, I forgot. New York Times. September 28, Times Topics: Airport Security. New York Times. October 8, 2012 Cushman JH: Plane diverted after implant claim. New York Times. May 22, 2012