Several months ago, I was on a flight from Tampa to Houston. Traveling a lot for work,
everything seemed fairly normal and routine. It was a large plane with 3 seats on each side and
probably 40 rows. I was assigned a middle seat approximately 12 rows back on the right side of
the plane. I had worked a night shift the night before, so I didn’t really care what seat I got. I just
wanted to sit down. I was pretty tired, and I remember taxiing and takeoff, but then I fell asleep.
The next thing I heard was screaming, and the words , “Is there a Doctor on board?” Everyone
around me was looking toward the rear of the plane, and after I oriented myself, I saw a flight
attendant running down the aisle toward the rear of the plane, with the look of sheer panic on
her face. What I did not realize is that I had been asleep for approximately 30 minutes, and we
were midway over the Gulf of Mexico.
Being an emergency physician for many years, I instinctively jumped over the person sitting
next to me in the aisle seat, as my noise canceling headphones went flying. I then began
running toward the rear of the plane. There were several flight attendants I had to navigate
through, simultaneously letting them know that I was an emergency medicine physician, and
was willing to help. I finally got to the ‘patient’, and knew there was a real problem. He was an
older gentleman, probably in his late 70s. He was slumped over in his seat, diaphoretic, and
ashen in color. He was sitting in an aisle seat, and his wife was in sheer panic sitting next to
him. To make matters worse, the plane was completely full, and most people in the immediate
vicinity were also panicking. I told the flight attendants to get an AED, and take some of the
people that were closest to us, including his wife, to the back of the plane. There was no place
to land, and it was over 30 minutes to the Texas coast.
He was not responsive, and had an extremely weak carotid pulse. With the help of an ICU nurse
who was also a passenger, we got him out of the seat, and onto the floor. The carotid pulse was
intermittent, so we began compressions. The flight attendants brought an ambu bag connected
to an oxygen canister, so the nurse began ventilating. It felt like hours waiting for the AED while
we continued compressions /ventilations. We had no IV access, but at this point, it didn’t matter.
Finally, the AED arrived from the rear of the plane. We had difficulty connecting the leads initially
because the man was soaked in sweat. After drying him off with some napkins, we connected
the pads. He was in ventricular fibrillation, and the AED advised, and then delivered a shock. I
palpated the neck, and felt a strong, but somewhat slow pulse. The man’s color began to return,
and he began to open his eyes. I felt relief. The flight attendants told me we had about 15
minutes to land. We moved the man to the rear of the plane, and I asked the crew to please
have an ambulance waiting. I started talking to him, and found out he was a retired surgeon. I
was thankful to be on the flight, and for the nurse that helped me.
The above encounter illustrates that with knowledge of ACLS / BLS, and basic lifesaving
equipment (AED, ambu bag), good outcomes can be achieved. Without those things this day,
the outcome may have been much different. Most commercial flights have a medical bag that
includes the above items. It likely will also contain certain medications such as aspirin and some
form of nitroglycerin. Some contain medications for allergy related conditions such as an
epi-pen or benadryl. There does not seem to be a standardized kit, and each airline may be
different in terms of what they include.
Crew Training
The other factor to discuss is the medical training of crew / flight attendants. In the U.S.,most
airlines require BLS training, but not ACLS or PALS. What does this mean in terms of real life
application? BLS includes teaching basic lifesaving skills such as CPR, and use of an AED. It
does not include topics covered in ACLS such as IV access and IV medications, interpretation
of different cardiac rhythms, etc. This could potentially be an issue in terms of medication
administration, IV access (if needed), as well as other issues that BLS does not cover. This is
primarily the reason that airline crew are trained to ask if there is a physician or nurse onboard.
Crew is also trained in terms of location of the medical kit, assisting with moving other
passengers around, and administering CPR if needed. These are all essential during an in flight
emergency.
Common Conditions Encountered on Flight
Some of the most common medical conditions that may be seen on a flight include: cardiac
emergencies (heart attacks, arrhythmias – as above), diabetic emergencies such as
hypoglycemia or hyperglycemia, asthma, and allergic reactions. In addition to the equipment
discussed above, other items that may be included in an airline medical kit include: oxygen
canister, nebulizer machine, benadryl, aspirin, prednisone, glucose tablets, epi-pen, IVs
(angiocaths), IV fluids, and others. Some of these things cannot be used / administered by flight
crew, and a physician / nurse should be present.
Five Fears
Another topic that should be discussed include the ‘Five Fears.’ – Fear of Hurting the Victim,
Fear of Incompetency, Fear of Performing CPR incorrectly, Fear of Contracting a Disease, and
Fear of Being Sued. If you are certified in ACLS / BLS / PALS, you are qualified to , at
minimum, perform CPR and apply an AED. If someone is already in an emergent and unstable
situation, the risk of hurting the patient, or performing CPR incorrectly is extremely low as
compared to the risk of not helping, which could mean the difference between life and death. Do
not feel that you are incompetent, as you likely already work in some type of medical setting,
and have more life saving instincts and knowledge than you realize. The simple act of CPR and
AED use , learned in BLS, may very well make the difference between life and death. If
everyone on the aircraft is afraid to assist, the outcome for the patient is likely not going to be
optimal. Under the Aviation Medical Assistance Act of 1998, physicians or nurses who care
for a sick patient in good faith are protected from lawsuits that might arise from care that they
delivered on a flight. The Good Samaritan Act also offers some protection for those who assist
during a medical emergency on a flight. It states that unless someone is guilty of gross
negligence or willful misconduct, they are protected if they step forward to offer medical
assistance.
Preventative Measures
As medical providers, we are in a position to make recommendations to our patients. This may
include advice not to fly at all, if someone has significant issues that could put them at risk while
flying. If , however, they are going to travel, recommendations to be prepared / equipped for
problems that may arise during travel should be made. For cardiac patients, this may be as
simple as reminding them to take aspirin and nitro with them. Remind them to take any
scheduled cardiac meds pre-flight. For asthmatics, an inhaler, or even portable nebulizer are
good ideas. Diabetics should have a means to monitor their blood glucose, as well as their
insulin, and possibly glucose tablets. Those with severe allergies should have an epi pen, and
possibly a prescription for prednisone. They should also alert the flight crew in terms of severe
allergies, as not to be exposed to any food products during flight that may pose a problem.
Simply educating patients on things they may otherwise overlook may prevent many in flight
issues.
Conclusion
ACLS / BLS / PALS education and training can be an extremely useful tool for assisting during
an in flight medical emergency. If the situation is unstable, recommendations to land (if possible)
can be made to the crew. If this is not possible, it is important to get involved, and assist in any
way possible to give the patient the best chance for a good outcome. Being afraid, and deciding
not to assist, could be the difference between life and death for the patient. In the above
scenario, simply providing short term compressions, and connecting an AED saved the patient’s
life. Simply educating patients prior to travel is extremely helpful in terms of preventing a
problem that may be easily prevented. Register for your course today at AffordableACLS.com,
and be prepared on your next airborne adventure.
