Perspectives: Responding to Medical Emergencies When Flying
CDC Yellow Book 2024Travel by Air, Land & Sea
You find your seat, buckle up, and the plane takes off. An hour or so into the flight, you hear the flight attendant’s request over the public address system, “If there are any medical personnel on the flight, please press your flight attendant call button.” As a health care provider on the flight, you ask yourself, “Can I respond? Should I respond?”
Prior to the coronavirus disease 2019 (COVID-19) pandemic, the Federal Aviation Administration (FAA) reported that 2.7 million airline passengers traveled on >44,000 flights daily in the United States. In addition, >4 billion passengers traveled on commercial airlines globally each year, ≈10 million passengers per day. Medical emergencies occur on ≈1 of every 604 flights. The most common emergencies include syncope or presyncope, respiratory symptoms, or nausea and vomiting. For 90% of these emergencies, aircraft continue to their destination. For the remaining 10%, however, aircraft divert to an alternative landing site, most frequently for cardiac arrest, cardiac symptoms (e.g., chest pain), obstetric or gynecologic issues, or possible stroke. Despite the frequency of medical emergencies, the death rate is only ≈0.3%.
MEDICAL SUPPLIES ON AIRCRAFT
The FAA mandates which medical supplies US carrier aircraft flying domestically or internationally must have available onboard. Required medical supplies are listed in the Code of Federal Regulations (14 CFR, Part 121; subpart X, 121.803 and Appendix A). US carrier aircraft with ≥1 flight attendant are required to have a US Food and Drug Administration (FDA)–approved automated external defibrillator (AED), ≥1 first aid kit, and an emergency medical kit (EMK) in the passenger cabin. The number of first aid kits available on an aircraft corresponds to the number of seats: 1 kit for 0–50 seats; 2 for 51–150 seats; 3 for 151–250 seats; 4 for >250 seats.
A list of medications required in the EMK and equipment for administration (e.g., gloves, needles, syringes, adhesive tape, tourniquet) can be found in Box 8-01. A blood pressure cuff, stethoscope, cardiopulmonary resuscitation mask, oropharyngeal airways, and a manual resuscitation device are included for use in the event of a cardiac or pulmonary event.
Box 8-01 Emergency medical kit (EMK) medication list
EMK contents vary among international carriers, despite guidance from the International Civil Aviation Organization (ICAO). In a 2010 study of 12 European-based airlines, none complied with ICAO standards for EMKs.
US Domestic Flights
The 1998 Aviation Medical Assistance Act (AMAA) of the United States protects medical personnel from damages in federal or state court for providing good-faith medical care in the event of a medical emergency. The AMAA does not cover gross negligence or willful misconduct.
Air carriers flagged in some countries (e.g., Canada, the United Kingdom, the United States) do not require clinicians to respond to in-flight medical emergencies. Other countries state that clinicians have an obligation to respond.
When responding to a medical emergency on an international flight, the AMAA might not apply. Furthermore, it is unclear what entity has jurisdiction over liability for care rendered; the country where the aircraft is registered might have jurisdiction, or jurisdiction could be based on the aircraft’s geographic location at the time an incident occurs. In other cases, the medical responder’s licensure country is the jurisdiction for liability. Jurisdiction might depend on whether the flight was in the air or on the ground when the incident occurred. Although most airlines and countries offer protection for Good Samaritans, a clinician responding to an emergency, even if an act of good will, might be at risk of litigation.
THINGS TO CONSIDER BEFORE RESPONDING
Have I consumed alcohol on the flight or before boarding? If you have, reconsider responding—you might be at risk for misconduct.
Am I familiar with how to work an AED?
What is my personal level of comfort and clinical competence to evaluate a person with a medical issue?
Am I flying on an international carrier whose flag is not the United States? The legal ramifications of delivering care to a fellow passenger are not always clear.
Box 8-02 provides a checklist for health care providers responding to in-flight medical emergencies.
Box 8-02 Responding to in-flight medical emergencies: a checklist for health care providers
☐ Be calm and confident.
☐ Ask alert and oriented passengers for verbal consent to treat.
☐ Use flight attendants as assistants, as appropriate. Flight attendants are certified in cardiopulmonary resuscitation (CPR) and in the use of an automated external defibrillator (AED). Ask them for needed items from the first aid kit, EMK, and the AED.
☐ Obtain a medical history, check vital signs, and perform a physical examination appropriate to the problem.
☐ As necessary, ask for ground-based medical consultation for severely ill passengers; ask flight crew or other passengers to assist with translation; ask for medical equipment from other passengers (e.g., glucometer); and ask for other onboard clinician support (e.g., obstetrician if a pregnancy-related issue).
☐ Move patients to an area with more room (and privacy) if it can be done safely.
☐ Notify the crew immediately if the passenger is suspected to have a communicable disease or is severely ill.
☐ Document your clinical encounter on airline-specific forms.
☐ Communicate with the pilot via the cabin crew about the passenger’s condition. The pilot has the responsibility to make the decision about diverting the flight.
Deciding to Respond
For US-licensed health care providers, the decision to respond is a personal one, grounded in ethical obligation. Although the United States offers protections for medical personnel who aid ill passengers in good faith, the nature of the medical issue and the possibility that medications or equipment could be missing from the EMK could create a difficult situation. Always be honest with the flight attendants and the pilot regarding your assessment of the patient’s condition and your degree of comfort with assisting; if needed supplies are not available aboard the aircraft, communicate this immediately. If traveling on an international carrier’s flight, consider both ethics and the flight’s legal jurisdiction.
Do Not Resuscitate
If a traveler has a “Do Not Resuscitate” order, you may choose to heed this. Be aware that individual airline policies might require flight attendants to attempt resuscitation despite this documentation.
Aviation Medical Assistance Act of 1998, HR 2843, 105th Congress (1998). Available from: www.congress.gov/105/plaws/publ170/PLAW-105publ170.pdf.
Emergency medical equipment. 14 CFR §121.803 (2020). Available from: www.ecfr.gov/current/title-14/chapter-I/subchapter-G/part-121/subpart-X/section-121.803.
Federal Aviation Administration. Air traffic by the numbers. Available from: www.faa.gov/air_traffic/by_the_numbers.
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Peterson DC, Martin-Gill C, Guyette FX, Tobias AZ, McCarthy CE, Harrington ST, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368(22):2075–83.
Sand M, Gambichler T, Sand D, Thrandorf C, Altmeyer P, Bechara FG. Emergency medical kits on board commercial aircraft: a comparative study. Travel Med Infect Dis. 2010;8(6):388–94.
. . . perspectives chapters supplement the clinical guidance in this book with additional content, context, and expert opinion. The views expressed do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).