Is there a doctor on board?

January 1, 2012

Managing a patient with a medical emergency while on a commercial airline flight can be a challenge.

Key Points

Any physician who agrees to assist with a medical request on an airplane has a difficult task. He or she must try to provide care with an incomplete history, because this patient will not be known to the clinician and may not even be able to relate a history. The responder will also have to make medical decisions with an incomplete examination, because the patient will not be undressed and often is in a sitting position.

Furthermore, the equipment available on the airplane is likely to be minimal compared to what the clinician is accustomed to having available in a medical office or emergency department. The emergency must often be managed in the cramped quarters of a narrow aisle in an overcrowded airplane. Add in the inevitable engine noise, and the situation is even more difficult. Finally, the responder sometimes lacks the knowledge and confidence to handle many emergencies (eg, when a pediatrician must assist with an adult passenger).

How often do medical emergencies occur on an airplane?

Most of the medical events that occur in the air are minor in nature. Less than half of the medical events in the air are serious enough to require ground-based medical assistance.1 Only 13% are serious enough for the pilot to change course.3 One study reported that 11% of in-flight pediatric cases (or 1 in 240,000 flights) resulted in diversion of the aircraft.4

There is no standardized reporting system, so minor emergencies often are not reported.5,6 Some believe that we need a standardized reporting system for all in-flight emergencies with debriefing of all those involved.7 This might improve the ability of the airline industry and physicians to better manage these events in the future.

Medical emergencies involving children on an airplane are far less common. One study found 1 call to physicians on the ground for every 21,000 flights (222 pediatric calls in 7 years).4

Which emergencies are likely to occur?

Most medical events onboard a commercial flight are not serious. About 65% are related to preexisting problems, 28% to new medical conditions, and 7% to traumatic injury, such as a burn from a hot drink or an injury from falling luggage.8 Fainting, dizziness, and hyperventilation are the most common events. Cardiac, neurologic, and respiratory problems are the most common serious events and account for most flight diversions.3,8-11 Chest pain, asthma, and gastrointestinal (GI) complaints are common.1

Deep vein thrombosis with resulting pulmonary embolism is a concern for passengers on long flights, although the incidence of this is unknown.12 Thromboembolism is more likely on an 8-hour or longer flight, and it occurs more in those passengers who have nonaisle seats where they are less likely to move around the cabin.13,14 However, thromboembolism does not seem to be more likely in the economy seats that may have less leg room than business class.15

Most medical issues involving children on an airplane are related to infectious diseases (27%), neurologic concerns (15%), respiratory issues (13%), GI problems (10%), and allergy (9%).4 Diversions of the aircraft for pediatric emergencies are usually because of a neurologic or respiratory problem (seizure or asthma).

Cabin pressure may contribute to some of the medical emergencies onboard an airplane.1 Cabin pressure on commercial aircraft is adjusted to that found at 5,000 to 8,000 feet above sea level. For most people, this is not a problem, but for those with cardiopulmonary disease, this can increase the risk of hypoxia. As a result of the atmospheric pressure in the cabin, arterial oxygen partial pressure (PaO2) decreases from 95 mm Hg to 60 mm Hg in a normal person.1,16 A 3% to 4% reduction in oxyhemoglobin saturation may be found, which would be trivial in a healthy person but could lead to significant hypoxia in someone with underlying cardiopulmonary disease or compromise. Newer A380 airbuses have a standard cabin altitude of 6,000 feet, improving oxygen levels compared to other aircraft.12