How Do I Handle an In-flight Emergency?

Patient Presentation
A pediatrician was awoken early in the morning on an international airline flight by loud sobbing a few rows away.
A few minutes later the flight attendant called for any available medical personnel.
The pediatrician found a 19-21 year old female who was crying hysterically.
The patient had woken up, started to cry and now could not stop.
Her mother stated that she had been previously well but was physically tired from an extensive trip.
She also had been emotionally stressed from working 2 jobs, having a sibling move away and was now returning to start college within a few days.
Her mother said that she was otherwise well and had never done anything like this before.
As far as the mother knew her daughter did not use drugs or medications and was not currently sexually active.
The pertinent physical exam showed a sobbing young adult. Pulse was ~110 beats/minute, respiratory rate was ~40 breaths/minute.
Blood pressure could not be audibly taken due to the noise of the aircraft and only an approximate palpable blood pressure of 120/70 could be obtained because she kept moving.
Her coloration and capillary refill could not be assessed as there was poor lighting in the cabin and the emergency flashlight had a slightly yellow-tint to the lens.
Her skin had no obvious rashes.
Her lungs were clear and her heart had no obvious abnormalities but auscultation was difficult because of the engines’ noise.
The diagnosis of a probable anxiety disorder including a panic attack, hyperventilation, and emotional instability possibly contributing was made.
The patient was given supplemental oxygen and was verbally assisted to concentrate on her breathing and to slow it down.
This she could do for several minutes, she would start to calm, and then she would begin another sobbing episode.
The flight purser came to the pediatrician wanting to know if he should call for emergency personnel to meet the plane as they were near landing.
No decision regarding diversion of the plane had to be made.
After a routine landing, the patient was carried off the plane by paramedics and taken away by ambulance.

Estimates of in-flight emergencies vary because there currently are no consistent standards for measuring them.
Estimates range from 0.003% to 0.0005% (i.e. 1/333-1900 flights per year). Based on studies from the United States this translates into 13-33 emergencies/day.

Luckily most in-flight emergencies are not serious and most do not require evaluation or treatment by ground personnel.
Overall, vasovagal episodes such as dizziness, fainting or near fainting and hyperventilation are the most common. The most serious overall are cardiac, neurological and respiratory problems.
Estimates of in-flight deaths in the United States are 21-72/year with most being elderly passengers and are attributed to cardiac or pulmonary problems.

One study of pediatric in-flight emergencies found that pediatric patients accounted for 9.2% of all in-flight consultations to a ground-based medical consultation team.
The average age was 6.8 years, and the most common reason for ground consultation was for infectious disease problems (i.e. varicella, fever, otitis media).
Other common problems were neurological (i.e. seizures), pulmonary (i.e. asthma), gastrointestinal and allergic problems. The most common medication used in-flight was diphenhydramine.
The most common reasons for airline diversion were seizures and asthma. Airline diversions for pediatrics were not common but it was estimated that the diversions costs $1.25 million per year.

Recommendations for supplies and medications in the airplane’s emergency medical kit are provided by the Aerospace Medical Association. In the United States all aircraft with 30 or more passengers must have an emergency medical kit. Many airlines also carry supplemental kits with additional medications and supplies.
An additional medication source on board are the other passengers who can be asked to voluntarily provide their own medications.

Learning Point
As most in-flight emergencies will be for adult patients, a pediatrician may not feel as comfortable volunteering to help.
The Aviation Medical Assistance Act provides for limited “Good Samaritan” protection. The care provider should volunteer, provide care rendered in good faith and provide care that others with similar training would provide.
Voluntary medical personnel should not expect monetary compensation. The airlines may voluntarily offer a gift such as an upgraded seat, travel voucher, wine etc. which is not considered compensation.

Many airlines also provide direct communication with ground-based medical personnel who can assist the flight crew and volunteer medical personnel with evaluation, treatment options, and use of the emergency medical kit.
Decisions regarding diversion of the airplane rest with the pilot, but the volunteer medical personnel and the ground-based medical crew may be asked to provide recommendations to the pilot.

Although the airplane is pressurized, it is not pressurized to sea-level.
Therefore people with pulmonary or respiratory problems may have them exacerbated in-flight particularly if the flight is long.
For some patient’s, their oxygen dissociation curve lies unusually close to the steep part of the curve, and the decreased cabin pressure movesit along the steep aspect of the curve.
Also, air inside body cavities will expand with the decreased cabin pressure (i.e. Boyle’s law). Increasing the cabin pressure or descending to a lower altitude may improve both problems and therefore improve the patient’s condition. Supplemental oxygen is usually also available.

Patients with angina should be treated with aspirin and nitrates.

Unresponsive patients should be given oxygen, IV dextrose and have the automatic external defibrillator applied. Arrhythmias that require cardioversion can then be detected and cardioversion attempted. The defibrillator can also act as a general heart monitor.

Allergic reactions can be treated with diphenhydramine and in some cases epinephrine.

Patients with psychiatric emergencies such as acute agitation, psychosis or violence should be considered for sedation with benzodiazepine.

Vasovagal episodes can be treated by raising the patient’s legs and using cold compresses to the forehead.

Most or all of the medications listed should be in the emergency medical kit.

Questions for Further Discussion
1. What are the contraindications for airline travel?
2. At what age can a newborn travel in a plane?
3. What instructions should a pediatrician provide to families with children with chronic medical conditions regarding airline travel?
4. What is the airline industry standards for providing foods containing peanut and/or tree nuts?
5. In what other situations does “Good Samaritan” protection apply?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Panic Disorder and Anxiety.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Gendreau MA, DeJohn C.
Responding to medical events during commercial airline flights.
N Engl J Med. 2002 Apr 4;346(14):1067-73.

Moore BR, Ping JM, Claypool DW.
Pediatric emergencies on a US-based commercial airline.
Pediatr Emerg Care. 2005 Nov;21(11):725-9.

Thibeault C, Evans A; Air Transport Medicine Committee, Aerospace Medical Association.
Emergency medical kit for commercial airlines: an update.
Aviat Space Environ Med. 2007 Dec;78(12):1170-1.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice

    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    November 3, 2008