General

In-flight medical emergencies can be broadly divided into two categories - injury related or health related situations. Injuries can occur as a result of a turbulence encounter, luggage falling from an overhead bin, an onboard altercation or due to burns or scalds resulting from contact with hot liquids or galley ovens. Health issues for a single passenger can range from fainting or shortness of breath to allergic reaction to missed medication to gastrointestinal issues to stroke, heart attack or even death. In very rare cases, food poisoning or a commutable disease may affect an number of passengers at the same time. The article Public Health and Aviation deals with the circumstances of discovery of a commutable disease while enroute and that situation will not be addressed in this article.

When an in-flight medical emergency occurs, immediate access to care is limited. Cabin crew are trained to provide first aid and limited medical assistance but are not qualified to deal with all potential situations. It is, therefore, critical that airlines have protocols in place for actions to be taken in the event of an on-board medical emergency. Adherence to these protocols will help to ensure the best possible outcome for the situation at hand.

Discovery

Cabin crew may become aware of a passenger in medical distress by direct observation. More often, the situation is brought to their attention by the individual, a travelling companion or another nearby passenger.

The first flight attendant at the scene will normally take charge of the patient and alert other cabin crew members who in turn will provide any required assistance inclusive of retrieving any required emergency equipment and advising the Captain of the situation and progressively keeping him/her informed of any changes in patient status.

Flight Crew Response

Flight crew response to an on board medical emergency will depend on the nature of the problem, the degree of urgency for medical intervention and the location and phase of flight in which the situation occurs. Unless the situation is considered immediately life threatening, it is normal that no decisions will be taken until more information is available through an assessment and diagnosis process. However, the flight crew should use the time between first notification and the end of the assessment/diagnosis process to consider their diversion options and the implications of any diversion decision. Consultation with Company operations may be prudent at this stage.

Assessment

The attending flight attendant will immediately do a preliminary assessment of the patient. If the patient is conscious, the flight attendant will use a question and answer protocol (with the help of an interpreter if required) to determine why the patient is in distress. If the patient is not conscious, the preliminary accesssment will include the A,B,C's of first aid:

• Airway (does the patient have an open airway?)
• Breathing (is the patient breathing)
• Circulation (is there a detectable heartbeat)

If the answer to any of these questions is no, appropriate first aid techniques inclusive of artificial respiration or cardiopulmonary resuscitation (CPR), will be initiated.

Diagnosis

For anything other than a very minor medical complaint, the Purser or In-Charge Flight Attendant will normally make a PA announcement asking if there is a doctor or other qualified medical professional (nurse, paramedic etc) on board. If there is a positive response, the medical professional will be asked to assess the patient and to advise the crew of the best course of action.

In the absence of a medical professional (or as a concurrent protocol), many air carriers have a standing arrangement with emergency medical service providers such as MedAire's MedLink or Stat MD. These service providers can be used both pre-flight and in-flight and can be contacted via satellite phone, high frequency (HF) or very high frequency (VHR) radio phone patch through an ARINC station or by means of Aircraft Communications, Addressing and Reporting System (ACARS) equipment. By one of these methods, direct communication with an emergency room/trauma centre physician is possible.

Utilising checklists and forms supplied by the medical service provider, the flight attendants can establish and record the patient's personal history (sex, age, height and weight etc), their medical history (inclusive of pre-existing health issues, medication, previous illnesses or surgeries), their current vital signs (pulse rate, blood pressure etc) and the symptoms that they are manifesting. The pilots will then relay this information to the service provider via one of the communications methods listed above for diagnosis and advice regarding on-board treatment, continuation of the flight or diversion. Should there be a requirement for medical support at the destination or at a diversion airfield, the service provider will also make those arrangements on behalf of the carrier.

Decision

Based on the information provided by the flight attendants, an onboard medical professional or a contracted agency, the Captain will make the decision to either continue the flight to the planned destination or to divert to a closer or otherwise more suitable aerodrome. In general terms, for a given situation, diversion decisions are more likely if there has been no contact with an outside medical service provider. This is due to the fact that a flight attendant, as a non-medical professional, is likely to take the most prudent course of action and over estimate the seriousness of the patient's condition. Even with a qualified medical practitioner on board, for personal liability reasons, that individual is likely to make a diversion recommendation should the case appear at all serious. Irrespective of the continue/divert decision, should the pilot desire ATS priority, declaration of an emergency using the appropriate Emergency Communications protocols should be undertaken without delay.

Diversion

The decision to continue or to divert will be based, primarily, on the condition of the patient and the proximity of the planned destination. However, in some cases, it may be more prudent to divert to a location which is actually further away than the planned destination. This could occur in the case where the destination is remote with little or no medical support capability.

There are numerous factors that the flight crew should consider when planning and executing a diversion. Given the potential urgency of a medical situation, the crew should start considering their options when first informed that there is a passenger with a medical issue. When choosing a diversion airfield, considerations can be listed under three primary categories; medical, operational and commercial. A partial listing for each of the categories is as follows:

• Medical
  • How urgent is the situation? Is an immediate landing required or could a more suitable but further diversion be considered.
  • What services will be required? Medical staff at airport, ambulance, hospital, specialist facilities - are they available at or close to the contemplated diversion?
• Operational
  • Aircraft weight - is the aircraft below maximum landing weight? Will fuel dumping or an overweight landing be required?
  • Aerodrome facilities - is the planned diversion suitable in terms of runway length (for both landing and the subsequent departure), approach capability and parking?
  • Weather - is the weather at the diversion aerodrome suitable?
  • Ground support - does the diversion airfield have the required ground support equipment (GSE) inclusive of steps, baggage handling capability, towing capability etc for the aircraft type.
  • Customs - if required, are customs services available?
  • Fuel - is fuel available?
  • Crew Duty Day - will the diversion result in an inability for the crew to continue to planned destination?
• Commercial
  • Is it possible to divert to an airfield that is normally serviced by the Company?
  • Which diversion choice will cause the least schedule disruption?
  • Are replacement crew members available at the planned diversion?
  • Should the crew be unable to proceed due duty day, is accommodation available for the crew and, if no replacement crew is available, for the passengers?

On-Board Medical Equipment

Regulations on what emergency equipment must be carried and what optional equipment can carried vary by National Aviation Authority. In all cases, one or more first aid kits (FAK) will be on the aircraft. These contain most of the items that might be required to deal with a non life threatening injury such as a burn, cut or broken bone. Cabin crew are fully trained in emergency first aid procedures.

Therapeutic oxygen is also universally carried, normally in portable oxygen cylinders fitted with a regulator and mask. Cabin crew are trained to administer oxygen to passengers experiencing breathing difficulties or are manifesting other symptoms for which supplemental oxygen is appropriate.

An Automated External Defibrillator (AED) is carried on board most commercial aircraft for heart related emergencies. Cabin crew are trained and qualified in the use of this equipment and are also trained and qualified in CPR (cardiopulmonary resuscitation).

A physician's kit or emergency medical kit, containing various drugs and both diagnostic and invasive medical instruments, is carried on board many commercial aircraft. Cabin crew are not trained or qualified to administer drugs and the contents of this kit can only be accessed and administered by a licensed medical practitioner, should one be on board. Typically, a physician's kit will contain some or all of the following (Source: Aerospace Medical Association):

• Medications
  • Epinephrine 1:1,000
  • Antihistamine, injectable (inj.)
  • Dextrose 50%, inj. 50 mL (or equivalent)
  • Nitroglycerin tablets or spray
  • Major analgesic, inj. or oral
  • Sedative anticonvulsant, inj.
  • Antiemetic, inj.
  • Bronchial dilator inhaler
  • Atropine, inj.
  • Corticosteroid, inj.
  • Diuretic, inj.
  • Medication for postpartum bleeding
  • Normal saline
  • Acetylsalicylic acid for oral use
  • Oral beta-blocker
  • Epinephrine 1:10,000
• Equipment
  • Stethoscope
  • Sphygmomanometer
  • Airways, oropharyngeal
  • Syringes
  • Needles
  • IV catheters
  • Antiseptic wipes
  • Gloves
  • Sharps disposal box
  • Urinary catheter
  • Intravenous fluid system
  • Venous tourniquet
  • Sponge gauze
  • Tape adhesive
  • Surgical mask
  • Flashlight and batteries
  • Thermometer (nonmercury)
  • Emergency tracheal catheter
  • Umbilical cord clamp
  • Basic life support cards
  • Advanced life support cards

Related Articles

• Passenger Medical Emergencies: Guidance for Controllers
• Automated External Defibrillator (AED)
• Public Health and Aviation
• Food Poisoning

Further Reading

• An Analysis of In-flight Passenger Injuries and Medical Conditions, ATSB Safety Report, October 2006
• Outcomes of Medical Emergencies on Commercial Airline Flights, US National Libray of Medicine, National Institute of Health
• Management of inflight medical emergencies on commercial airlines, J. Pine & M. Prout via UpToDate (clinical decision support resource)