Is There a Doctor On Board: In-Flight Medical Emergencies. Robert Lowe MD FACEP

Transcription

1 Is There a Doctor On Board: In-Flight Medical Emergencies Robert Lowe MD FACEP

2 Objectives Understand the frequency and the types of commercial airline passenger Medical Emergencies Understand the Responsibilities and Liabilities in responding to requests for help. Be introduced to the typical Medical Resources available on US Domestic Airlines

3 Travel Advisory: Correspondents Report; Airlines prepare to Fight Heart Attacks Aloft, NY Times Air Transportation Association 578 million passengers 10,500 medical incidents 1 in 55,000 passengers 1 in 780 flights 141 heart attacks 433 chest pains

4 In-Flight Medical Events and Aircraft Diversions: One Airline s Experience Delaune, Lucas, Illig 2 University of Pittsburg Sample Airline July 1, 1999 June 30, Crews instructed to report all in-flight medical events regardless of how minor 100,760,117 passengers 860,521 flights 2279 in-flight medical emergencies

5 What are the odds 2 Medical Incidents 1 in 44,212 passengers 1 in 378 flights 22.8 per million passengers 7 Deaths 1 in 14.4 million passengers

6 What do Others Say the Odds Are 1982 Quantas 4.5 per million passengers Air France 7.9 per million passengers Air Canada 75 per million passengers 1986 Seattle-Tacoma 25.3 per million arrivals LAX 29.8 per million arrivals

7 Types of Events Encountered 2 Syncope 15% Trauma 12% GI 12% Cardio / Chest pain 11% Resp 11% Neuro 6.5% Weakness / malaise 3.7% Vertigo 3% Psych 3% Other 2.9% Allg Rxn 2.8% HEENT 2.8% Change in LOC 2.5% Diabetes 2.4% Headache 1.6% OB/GYN 1.4%

8 Presenting Symptoms in Flight 4 Review of EMS Records Jan 1, 1996 Dec 31, 1996 at Chicago O Hare International Airport Sudden Death 0.67% Syncope 28.0% Chest Pain 10.7% Shortness of Breath 8.1% Seizures 4.3% Trauma 9.8% Abdominal Pain 10.3% Nausea/Diarrhea 12.9% HEENT 5.8% Behavioral/Miscellaneous 9.4%

9 Pediatric Emergencies 5 Jan 1, 1995 Dec 31, 2002 retrospective review of 169 consultations Infectious 27% Neurological 15% Respiratory Tract 13% Gastrointestinal 10% Allergy 9% Psychiatric 5% Trauma 5% Ob/GYN 2% Syncope 2% Diabetes 2% Other 11%

10 Chronic or Acute 6 June 2002 December 2002 from international carrier in the UK (n=507) Exacerbation of Existing problem 65%(330) Respiratory (69) Cardio (46) Abdominal (33) Forgotten Meds (20) New Medical Problem 28%(140) Syncope (128) Abdominal pain (8) Alcohol related (3) Trauma 7%(37) Hot liquid burns (9) Falling luggage (9) Miscellaneous (18)

11 The Bottom Line Clearly there exist the statistical probability of an in-flight medical incident Increased travel volume aging populations prolonged chronic conditions societies expectation of mobility all can be assumed to create an environment of increased likelihood of in-flight medical incidents.

12 Reference 7

13 We re from the Government We re here to help

14 FAA Requirements 3 Medical Kit required since gloves added to requirement April 12, 2004 updated kits required AED required

15 FAA Requirements 3 First Aid Kits Accessible to flight attendants Number based on no. of passenger seats kit 2 kits 3 kits More than kits Emergency Medical Kits Made available to physicians or professionals acting on behalf of physician AED Stored in the passenger cabin

16 First-aid Kits 3 Contents Quantity Adhesive bandage compress, 1-inch 16 Antiseptic swabs 20 Ammonia inhalants 10 Bandage compress, 4-inch 8 Triangular bandage compress, 40-inch 5 Arm splint, non inflatable 1 Leg splint, non inflatable 1 Roller bandage, 4-inch 4 Adhesive tape, 1-inch standard roll 2 Bandage scissors 1

17 Emergency Medical Kit 3 Contents Sphygmomanometer 1 Stethoscope 1 Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent) CPR mask (3 sizes) 1 pediatric, 1 small adult, 1 large adult or equivalent 3 IV Admin Set: Tubing w/ 2 Y connectors 1 Alcohol sponges 2 Adhesive tape, 1-inch standard roll adhesive 1 Tape scissors Tourniquet 1 Saline Solution, 500 cc 1 Protective nonpermeable gloves or equivalent Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications) Syringes (1-5cc, 2-10 cc, or sizes necessary to administer medications) 4 3 Quantity 1:3masks 1 pair 1 pair 6

18 Emergency Medical Kit 3 Contents Analgesic, non-narcotic, tablets, 325 mg 4 Antihistamine tablets, 25 mg 4 Antihistamine injectable, 50 mg, (single dose ampule or equivalent) 2 Atropine. 05 mg, 5 cc (single dose ampule or equivalent) 2 Aspirin tablets, 325 mg 4 Bronchodilator, inhaled (metered dose inhaler or equivalent) 1 Dextrose 50%/50 cc injectable, (single dose ampule or equivalent) 1 Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent) Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent) Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent) Nitroglycerin tablets, 0.4mg 10 Basic Instructions for use of the drugs in the kit Quantity

19 Got Oxygen? There are Emergency supplies available on the aircraft. Passengers can make prearrangements with most airlines with 48 hour advance notice. FAA / some airlines will allow a patient s pre-approved oxygen concentrator on-board with the patient.

20 Legal obligations of the Airline Special relationship exists between the common carrier and its passenger A common carrier has a duty to exercise the highest degree of care to safely transport its passengers and to protect them while in transit Boyette vs.. TransWorld Airlines 1997 quoting Collier vs. Bi-State Dev Agency AED lawsuits have been successfully waged against airlines for failure to provide the device prior to the FAA updated requirement to carry the device.

21 What s an Airline to Do? A niche Medical industry has developed to serve this requirement. Commercial medical kits On-line Medical Consultation

22 Medical Control MedAire Inc. / MedLink - Phoenix, AZ Lists 90 commercial airlines, numerous corporate flight programs and luxury yachts as customers. University of Pittsburg Mayo Clinic - Rochester Minnesota In-House Medical Teams American, United Airlines

23 Medical Supplies Banyan Medical Kits MedAire Kits

24 Contents of 2004 FAA Enhanced Medical Kit Ampules Benadryl 1ml (2) Epinephrine 1ml (2) Inhalant Albuterol 17gr (1) Oral Medications Acetaminophen (4) Aspirin (4) Diphenhydramine (4) Nitroglycerin (25) Prefilled Syringes Atropine Sulfate 5ml (2) Dextrose 50% 50ml (1) Epinephrine 10ml (2) Lidocaine 2% 5ml (2) Airway Equipment Airway, Pedi (1) Airway, Small Adult (1) Airway, Large Adult (1) Manual Resuscitation Ambu Bag (1) Mask, Pedi (1) Mask, Small Adult (1) Mask, Large Adult (1) CPR Mask Adapter (1) Misc. Equipment Alcohol Sponges (2) Gloves (1 pr.) Scissors (1) Tape (1) Tourniquet (1) Monitoring Equipment Sphygmomanometer (1) Stethoscope (1) I.V. Equipment I.V. Catheter 20ga x 1" (2) I.V. Set w/y-site & clave (1) Sodium Chloride, 500ml bag (1) Needles & Syringes 3cc, 22ga x 1" (2) 3cc, 25ga x 5/8" (2) 18ga x 1 1/2" (1) 20ga x 1 1/2" (1) 22ga x 1 1/2" (1) Reference Materials AHA Algorithm Book (1) EMK Contents Placard (2) Seals: Red, Yellow, Green (1 ea)

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27 An Event Occurs Crew handling of minor problems Basic Training Pilot in Command Patch link to Medical Control Fall back procedures Announcement Requesting Volunteers

28 Will You Respond? Is there a duty to respond?

29 Will You Respond? Obligation Most would argue that a legal duty does not exist

30 Will You Respond? Obligation Most would argue that a legal duty does not exist However

31 Will You Respond? Obligation Most would argue that a legal duty does not exist However That s our technical obligation and part of the publics trust in us that we will respond as best we can Dr. Priscilla Ray, Chairwoman of the council on ethical and judicial affairs of the AMA Los Angeles Times web site latimes.com June 11, 2006.

32 Will You Respond? Parts of Europe and Australia have laws that set an expectation of response International law states the country of aircraft registry has jurisdiction

33 Issues - Licensure Licensure Exactly which state are we in?

34 Issues - Authority Captain is in ultimate command of aircraft at all times. I recommend shared medical command with Medical Control

35 Issues - Liability 1998 Aviation Medical Assistance Act Good Samaritan protection to medically qualified passenger that offers assistance Must be a volunteer Receive no compensation Render care in good faith Render care similar to others with same training in same circumstance

36 Issues - Liability New England Journal of Medicine Review Article To our knowledge, no litigation has been brought to date against a physician who has rendered assistance during an in-flight medical event 7

37 Issues - Liability New England Journal of Medicine Review Article To our knowledge, no litigation has been brought to date against a physician who has rendered assistance during an in-flight medical event 7 Letter to the Editor Dr. Noel responded to emergency in transatlantic flight asthma attack, coded, CPR for 2 hours, died After I had several sessions with a lawyer, reviewed documents, and provided a deposition, I was finally dismissed from the lawsuits on the basis of good Samaritan protection 8

38 Issues - Liability New England Journal of Medicine Review Article To our knowledge, no litigation has been brought to date against a physician who has rendered assistance during an inflight medical event 7 Letter to the Editor Dr. Noel responded to emergency in transatlantic flight asthma attack, coded, CPR for 2 hours, died After I had several sessions with a lawyer, reviewed documents, and provided a deposition, I was finally dismissed from the lawsuits on the basis of good Samaritan protection 8 Author s response The system works Umbrella protection from Medical Control or Airlines might be available

39 Reference 7

40 Some Rules Young Skywalker Share Medical Control with the ground physician Other passengers are resources Nurses, PA s, Paramedics, Drug reps, respiratory therapists, Priests Medications and supplies from passengers Think outside the box ED Docs are the best at this Err on the side of caution Consider recommending diversion EMS to meet the aircraft Tell your group/ partners when you return

41 Sit Back, Relax, and Enjoy the Flight

42 References 1. Travel Advisory: Correspondents Report; Airlines prepare to Fight Heart Attacks Aloft, New York Times, June 7, Delaune, et.al. In-Flight Medical Events and Aircraft Diversions: One Airline s Experience, Aviation, Space, and Environmental Medicine, Vol 74 No.1 pp62-68, January Department of Transportation / Federal Aviation Administration. Emergency Medical Equipment. 14 CFR part , edition. 4. Chan, et. al., Medical Emergencies at a Major International Airport: In-flight Symptoms and Ground-based Follow-up, Aviation, Space, and Environmental Medicine, Vol 73 No.10 pp , October Moore, et. al., Pediatric Emergencies on a US-Based Commercial Airline, Pediatric Emergency Care, Vol 21 No.11 pp , November 2005.

43 References 6. Qureshi, et. al., Emergencies in the air, Emerg Med J 2005;22: Gendreau, et. al., Responding to Medical Events During Commercial Airline Flights, New Engl J of Med, Vol 346, no. 14, pp , April 4, Noel, Letter to the Editor, New Engl J of Med, Vol 347, no. 7, pp 535, August 15, 2002.