Air Travel Statistics

Handling In

Handling In--flight

flight

Medical Emergencies

Medical Emergencies

Erik S. Gaull, NREMT-P, CEM®_{, CPP}® Cabin John Park Volunteer Fire Department Montgomery County (MD) Fire-Rescue Service

Air Travel Statistics

• United States

– Early 1980s: 300 million pax – 1997: 600 million pax

– 2008: 667 million pax (U.S. DOT Bureau of Transportation Statistics)

• Worldwide

– 1996: 1 billion pax (Aerospace Medical Association)

– 2000: 2 billion pax (UK House of Lords)

– 2007: 2.25 billion pax (International Air Transport Association)

Incidence of IMEs

• AMA – 1:10,000 to 1:40,000 pax

– British Airways – 1:11,000 pax

– Speizer, et al. (1989) – 1:33,600 pax (33/day)

– Cummins & Schubach (1989) – 1:39,600 pax (30/day) • Hordinsky & George (1991) – 3 IMEs/day in US • FAA (2000) – 13 IMEs/day requiring consult • Delaune, et al. (2003) – 1:378 flights

Annual Consultations

Source: MedLink

Suggested Reasons for

the Increase in IMEs

• Increasing numbers of travelers

• Growing elderly population (esp. Baby Boomers) • Air Carrier Access Act of 1986

• Air Carrier Access Act of 1986 • Americans with Disabilities Act of 1990 • Longer-range capabilities of aircraft

Top 5 IME Complaints/Diversions

(according to DeJohn, et al., 1997)

Complaints • Neurological • Syncopal Diversions • OB/Gyn • Cardiac Why? y p • Cardiac • Psychiatric • Respiratory • Neurological • Respiratory • Allergic Reactions

Top 5 IME Complaints/Diversions

(according to Delaune, et al.)

Complaints (62%) • Syncopal • Trauma Diversions (75%) • Cardiac • Neurological • Gastrointestinal • Cardiac • Respiratory g • Gastrointestinal • Syncope • Trauma CO 511, 4/18/09 McAllen, TX ~100’ drop T4-5 fx/disloc. T2 fx

Causes of In-flight Deaths

• Cardiac (56%)

• Predisposing acute medical problem (19%) • Pulmonary (8%)y ( )

• CNS (0.5%) • Trauma (0.5%) • OD/Suicide (0.5%) • Unknown (15.5%) Source: Jagoda & Pietrzak (1997)

Other Noteworthy IMEs

• Psychiatric

– “Air Rage”

• Increased intoxicating effects of alcohol at altitude • Nicotine denial in smokers

• Diabetic

– Injection of insulin prior to take off in expectation of a meal soon thereafter

Incidence of Diversions

• About 8% of IMEs

– Delaune, et al. (2003) – DeJohn, et al. (1997)

• 1:4,754 flights or 210:1 million flights

Challenges to In-flight Care

• Restricted space • Turbulence Hi h i l l • Flight physiology • Minimal assistance Li it d i t • High noise levels

• Language barriers

• Limited equipment • Delayed access to

EMS/hospitals

Flight Physiology

• At 8,000 feet, barometric pressure is 565 Torr

– FiO2(alt)= 21% x 565 Torr = 119 Torr

– FiO2(sl)( )= 21% x 760 Torr = 160 Torr

• PaO_2(alt)decreases to ~56 Torr (Dalton’s Law)

– Normal: 80-100 Torr

– Problematic with impaired cardiopulmonary function or acute or chronic pulmonary trauma (COPD, asbestosis, pneumothorax)

Flight Physiology

(con’t.) Carboxyhemoglobin Dissociation Curve PaO2 (Torr) SaO 2

Flight Physiology

(con’t.)

• SaO2is roughly 85% at 8,000 ft.

• Muhm (2003) – a substantial proportion of older

passengers will manifest a PaO2( lt)at 8 000 ft

passengers will manifest a PaO2(alt)at 8,000 ft.

below the threshold at which supplemental O₂is

recommended

Reducing altitude may correct associated problems!

Flight Physiology

(con’t.)

• Aridity of cabin air

– 10%-20% normally

– Can cause/exacerbate dehydration – Can exacerbate Reactive Airway Disease

Flight Physiology

(con’t.)

• Barotrauma/Dysbarism

– Gas in body cavities will expand by as much as 30% at normal flight altitudes (Boyle’s Law: P1V1= P2V2)

R i f l d l l k

• Re-opening of a sealed pulmonary leak • Dehiscence of surgical repairs or healing wounds • Squeezes/Reverse squeezes

– Decompression Sickness

• Divers may become “bent”

Available Assistance

• Crew

– Basic first aid – CPR – AED usage

– General management of emergencies – How to call for help

Available Assistance

(con’t.)

• Passenger Volunteers – MD (8%-85%, 40% according to MedAire) – RN (9%-25%) – EMT/EMT-P (4%) – Other – No one (28% of incidents)

• Hays (1997) – 50% of MDs reluctant to respond

– problem might be outside area of practice – probability of being hampered in rendering care

Aviation Medical Assistance

Act of 1998

(P.L. 150-170)

Sec. 5(b) – “An individual shall not be liable for

damages in any action brought in a Federal or

State court arising out of the acts or omissions of g

the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance is guilty of gross negligence or willful misconduct.”

FAA Rules for Onboard

Medical Equipment

(as of 4/12/04)

• First Aid Kit – 1 to 4 for all passenger aircraft • Emergency Medical Kit – Any aircraft for which a

flight attendant is required flight attendant is required

• AED – Flight attendant required and maximum payload of >7,500 lbs.

FAA Enhanced Onboard

Emergency Medical Kit

• Stethoscope • Sphygmomanometer • OPA (3 sizes) • Gloves • NTG • Diphenhydramine

– Injectable and tablet

• Dextrose G o es

• Syringes and needles • AED

• CPR mask (3 sizes) • BVM w/3 masks • IV kit

• Instructions for use of drugs • Epi – 1:1000 and 1:10,000 • Normal Saline (500 ml) • ASA • Atropine • Bronchodilator inhaler • Lidocaine

Documentation Required to

Access Emergency Medical Kit

• Kits are for the use of physicians

– Captain may authorize its use by non-physicians

• Medical license or certificationMedical license or certification

– A good reason to carry your card or a copy

• Business cards

– May not cut it

Onboard Oxygen

• Limited supply (3,228 L at most) • Limited flow (max. 4 LPM)

– Flow rates determined by altitudeFlow rates determined by altitude – Most cannot power nebulizers

• Drop-down O2

– Cannot drop selectively – Not medical grade

AEDs

• Some airlines may only allow trained airline personnel to attach/operate AEDs

Additional Onboard Resources

• Passenger-carried medications • Sugar sources

• Splinting devices • Splinting devices

General Principles of In-flight Care

• Increase oxygenation

– Lower altitude – Supplemental O₂ – Patient positioning

• Rehydrate

• Valsalva maneuver to relieve squeezes • Treat obvious trauma

• Continued monitoring

Documentation

• Required by FAA

• Airlines have incident report or may have IME report

report

– No PCR forms

• Write the best report you can • How should times be documented?

To divert or not?

Diversion Decision Factors

• Expense

– Fuel and passenger accommodation costs – Passenger inconvenience

– System schedule coordination

• Benefit

– Does the condition really warrant it? – Adequate medical facility at diversion point? – Is ground transportation available?

Diversion Decision Factors

(con’t.)

• Feasibility

– Transoceanic flights

– Runway length vs. aircraft size/weight – Runway construction

– Weight and balance of fuel

– Maximum take-off and landing weights – Time to diversion destination – Weather

Diversion Decisions

• Ultimately, the Captain’s decision

– 97% of time aircrews comply w/MD recommendations to divert

• Made in conjunction with consulting physician • Your role

In-flight Medical Consultation

• Who they are

– MedLink (MedAire) – UPMC

– American and United Airlines in-house MDs – British Airways has satellite video and data links

• What they do

– Lists of diversion airports and medical facilities

• Effecting main cabin contact

IME Category of 1,132

MedAire Consultations

(1996-1997) • Vasovagal (22%) • Cardiac (20%) • Neurological (12%) • Neurological (12%) • Respiratory (8%) • Gastrointestinal (8%) • Trauma (5%)

Outcome and Disposition

of 1,132 MedAire Patients

• Improved (60%) – Unrelated to the presence of a physician • Unchanged (12%) • RMA (30%) • Airport (26%) • ER (17%) • Unchanged (12%) • Worsened (2%) • Unreported (26%) ( ) • Hospital (15%) • Canceled (9%) • Unreported (2%) • DOA (1%)

Case Study #1 (1990)

• ~80 y/o wheelchair-bound female • Flight from Denver to Portland

• Over Montana c/o syncope incontinence • Over Montana c/o syncope, incontinence

– BP Ð80, tachycardic, febrile

• O2via mask, no I.V., too obtunded for p.o. fluids

• Emergency landing

– Breathing improved on ground (not sea level)

• Dx: Urosepsis, released after 5 days

Case Study #2 (1995)

• Call for assistance made prior to push-back • Flight from HK to London aboard a 747 • 39 y/o female c/o swelling in R forearm • 39 y/o female c/o swelling in R forearm • Hx: pt. fell from motorcycle en route to airport • Dx: possible fx R forearm

Case Study #2

(con’t.)

• Post takeoff, injury site splinted w/Sam splint • 45 min. later, pt. c/o L-sided CP

– Further exam revealed poss fx 2-4 ribsFurther exam revealed poss. fx 2 4 ribs – Injectable analgesic prepared but not given

• Pt. resp. distress w/tachypnea

– Unable to auscultate or purcuss chest – Tracheal deviated to R

Case Study #2

(con’t.)

• Dx: tension pneumothorax

• O2via mask

• Unable to consult w/ground physician • Unable to consult w/ground physician • EMK contained

– Scapel

– Sharp, pointed scissors – 14 ga urinary catheter – Lignocaine

Case Study #2

(con’t.)

• Gathered make-shift equipment

– Heated hand towels (sterile drapes) – Coat hangar (trochar for catheter)

Evian water w/holes in cap (underwater seal drain) – Evian water w/holes in cap (underwater seal drain) – Oxygen tubing (connect catheter to drain) – Cellophane tape

Case Study #2

(con’t.)

• Chest drain inserted

– Air released immediately

– Pt. almost fully recovered w/in 5 minutes

• 8 hrs. later, pt. again c/o CP and dyspnea

– Bottle (chest drain seal) was improperly positioned – Repositioned w/good results

• Chest X-ray revealed 30% pneumothorax • Hospital recovery was uneventful

Case Study #3 (2002)

• Flight from U.S. to Frankfurt, diverted to Amsterdam

• Airport paramedics find 70 y/o female on floor of Airport paramedics find 70 y/o female on floor of

galley w/ IV in a.c. and O₂@4 LPM via N/C

attended to by EMed MD and RT

• Event: Halfway across Atlantic, pt. c/o rapid

onset severe headache and nausea Ævomiting;

no LOC

Case Study #3

(con’t.)

• CC: Severe headache, feels cold

• Exam: No ABC problems, BP 140/80, P 80R,

EKG NSR SaO298% shivering motor/neuro x

EKG NSR, SaO298%, shivering, motor/neuro x

4 quad, PERLA • Hx: Diabetes • Rx: Oral ADM

Case Study #3

(con’t.)

• Hosp: Eval and CT Scan • Dx: Migrane complications • Tx: Fit to fly letter and released • Tx: Fit-to-fly letter and released

• 747 towed to parking ramp; refueled; pax catered; fresh crew flown in to replace crew; paperwork (flight plan, etc.)

• Pt. taxi to airport; returned to plane by AMS station manager

Case Study #4 (1998)

• Flight from Boston to Washington, DC • Pt. suffered a seizure during taxi • Take off aborted

• Take-off aborted

• Pt. removed by ambulance

Contraindications

to Air Travel

• Uncomplicated MI within prior 3 weeks • Complicated MI within prior 6 weeks

• Unstable anginag

• Severe, decompensated CHF • Uncontrolled hypertension • CABG within prior 2 weeks

Contraindications

to Air Travel

(con’t.)

• CVA within prior 2 weeks • Uncontrolled V-Tach or SVT

• Eisenmenger’s Syndrome (R-L shunt, VSD)g y ( , )

• Severe, symptomatic valvular heart disease

Source: Aerospace Medical Association, 1997

• Any condition that could be affected by expansion of body gases

• Within 7 days of delivery

– Prevent onboard delivery

Thank You!

[email protected]