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In-Flight Medical Emergencies

Essentials

  • When an acute health problem arises on board an aircraft, a voluntary physician or other health care professional must
    • report for duty on request and state their expertise or the kind of tasks they normally do (if there are several volunteers, task division should be agreed collegially in the patient's best interest)
    • help with assessing the patient's condition and exploring the cause of the symptom
    • participate in treating the patient within the scope of their knowhow and functional capacity
    • express their expert opinion on the urgency of treatment and their view on the need for measures such as emergency landing, as necessary (table T1).
  • In treatment situations, the enclosed and limited space, limited availability of equipment for examination and treatment, limited availability of supplemental oxygen and delay in accessing any further treatment must be taken into consideration.

Physician's responsibility and legal protection

  • When a physician volunteers to help in an emergency situation on board an aircraft, their legal responsibility varies depending on several factors, such as the home country of the airline, flight route and location.
  • The principles and legal interpretation prevailing in western countries primarily strive to encourage helping, because help given by a professional is probably better than what lay people can give.
  • In many countries, so-called Good Samaritan laws protect physicians and other helpers from legal responsibility. The prerequisite is that they work in good faith to the best of their knowledge. Physicians must follow commonly approved medical practice.
  • A physician may be held liable if clear carelessness or acting beyond the limits of their capability in providing emergency help can be shown.

Checklist for health care professionals volunteering to treat patients on board an aircraft.

1.Introduce yourself and your background. The airline may require proof of qualifications (such as a medical visiting card or a professional ID card). Make sure of your functional capacity, considering any alcohol consumption, use of hypnotics, short-acting sleeping medicine, other medication or fatigue.
2.Take the patient history as comprehensively as possible, with the assistance of an interpreter, family members or other passengers, as necessary.
3.Recognize high-risk symptoms (such as chest pain, dyspnoea, neurological deficits).
4.Check vital signs and examine the patient as is possible under the circumstances.
5.Inform cabin crew about your clinical assessment and recommendations.
6.Consult the airline's remote medical support, as necessary. The airline may require consultation before using the Emergency Medical Kit (EMK). Any decision on emergency landing will require coordination between the pilot and a ground-based consultant.
7.Give supplemental oxygen or use a defibrillator (AED), as necessary.
8.Document the patient's clinical status and the treatment provided; airlines may have forms for this purpose that need to be filled in.
N.B.Don't try to act beyond your skill level but remember that the help you provide is valuable and better than that provided by non-medical persons.

The aircraft environment

  • For special features of the aircraft environment, see Air Travel and Illness.
  • Commercial airlines carry about 4 billion (thousand million) passengers per year. Statistics show that 1 in 10 000-40 000 passengers have significant medical problems; this is equivalent to about 1 flight in 600. Reporting mild events varies in particular, but severe or fatal events are rare.
  • Air crew are trained regularly on basic resuscitation and first aid. Cabin crew participate in resuscitation and provide first aid but are not allowed to administer the medication in the EMK. Most cases can be handled by simple measures without any medication or need for further treatment.
  • Many airlines have a remote consultation service that air crew can use to consult a physician on the ground. In more demanding or urgent situations, cabin crew can ask any physician or other health care personnel among the passengers for help.

Equipment

  • The International Civil Aviation Organization (ICAO) working under the UN has given a recommendation for first-aid training and medical equipment on board aircraft (table T2). European airlines follow the minimum standards defined by the EASA.
  • In addition to common first-aid supplies, aircraft carry a limited selection of medication for emergencies and often also a defibrillator (AED).
  • The selection varies by country and by airline. The crew will bring the available supplies when needed and master their basic use.

The ICAO recommendation for the contents of medical supplies and medicine kits. In addition, an aircraft may carry a defibrillator (AED) and other supplies as decided by the airline or required by the local aviation authority.

First-aid kitAntiseptic swabs (10/pack)
Bandage: adhesive strips
Bandage: gauze 7.5 cm × 4.5 m
Bandage: triangular, 100 cm folded, and safety pins
Dressing: for burns 10 cm × 10 cm
Dressing: compress, sterile, about 7.5 cm × 12 cm
Dressing: gauze, sterile, about 10.4 cm × 10.4 cm
Tape: adhesive 2.5 cm, standard roll
Adhesive strips for wound closure
Hand cleanser or cleansing towelettes
Pad with shield, or tape, for eye
Scissors: 10 cm
Tape: adhesive, surgical 1.2 cm × 4.6 m
Tweezers: splinter
Disposable gloves
Thermometers
Mouth-to-mouth resuscitation mask with one-way valve
First-aid manual
Emergency medical kitSphygmomanometer (automatic preferred)
Stethoscope
Airways, oropharyngeal (various sizes)
Bag valve and masks
Syringes (various sizes)
Needles (various sizes)
Intravenous catheters (various sizes)
System for delivering intravenous fluids
Antiseptic wipes
Tourniquet
Needle disposal box
Disposable gloves
Urinary catheter (with sterile lubricant gel)
Gauze dressing
Tape - adhesive
Surgical mask
Emergency tracheal catheter (or large gauge intravenous cannula)
Umbilical cord clamp
Flashlight and batteries
Emergency first-aid medicationAdrenaline 1:1 000
Adrenaline 1:10 000
Antihistamine (inj.)
Antipsychotic drug
Dextrose 50%
Nitroglycerin (tablet or spray)
Major analgesic (i.v./p.o.)
Sedative anticonvulsant (inj.)
Antiemetic (i.v. or p.o., such as ondansetron)
Bronchial dilator and inhaler
Atropine
Glucocorticoid
Diuretic (inj.)
Sodium chloride 0.9% 1 000 ml
Acetylsalicylic acid (aspirin)
Beta blocker (p.o.)

Diversion

  • Decisions on the flight plan and any diversion are always made by the captain.
    • Such decisions depend on the operative conditions (such as the amount of fuel, distance to alternative airports, availability of treatment in the area).
    • When assessing the need for emergency landing, the airline's consultant physician must also be consulted.
  • In most cases, it is justified to continue the flight to the original destination.
    • According to various studies, emergency landing was necessary in 4-7% of serious cases of disease only.
    • Getting initial treatment on the ground or getting the patient into a hospital may take several hours despite emergency landing.
  • Emergency landing may be recommended if the patient
    • does not regain consciousness after fainting or convulsions
    • has persistent chest pain or paralytic symptoms.

Severe vertigo or fainting

  • The most common symptom requiring assessment or treatment (30-40%)
  • Caused by underlying diseases, dehydration, psychological factors, anaemia, decreased partial pressure of oxygen
  • Symptoms
    • Pallor, sweating
    • There may be bradycardia or hypotension of short duration
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
    • Blood glucose (meter from the medical kit or borrowed from passengers)
  • Treatment
    • Lying down with legs elevated
    • Oxygen supplementation, as necessary
    • Fluid administration, oral or intravenous, as necessary; follow-up
  • Need for diversion
    • Rarely necessary
    • Persistent unconsciousness; patient not recovering in 15-30 minutes

Cardiac symptoms

  • Fairly common, 5-10%
  • History of heart disease
  • Symptoms
    • Chest pain, dyspnoea, pain radiating to arms or chin/neck
    • Tachycardia or bradycardia
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2), 12-lead ECG, if available (some airlines have the possibility of sending an ECG to a consultant physician)
  • Treatment
    • In chest pain of cardiac origin, 250 mg ASA chewable tablet and 0.4 mg nitroglycerin sublingually repeated every 5-10 minutes, as necessary
    • Oxygen supplementation, as necessary
    • Consider giving morphine (2-4 mg i.v.) for severe pain not alleviated by other treatment.
  • Need for diversion
    • Symptoms growing worse or persistent, abnormal vital signs

Gastrointestinal symptoms

  • Common, 15-20%
  • Symptoms
    • Nausea, vomiting, diarrhoea, abdominal pain
    • Bleeding is rare
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
  • Treatment
    • Antiemetic or antidiarrhoeal medication and oral fluid administration for patients with a normal level of consciousness
    • I.v. fluid administration, if oral fluid administration is not possible
    • Antacids for dyspepsia
  • Need for diversion
    • Rarely necessary
    • Constant vomiting, severe pain, bleeding

Paralytic symptoms

  • Mild neurological symptoms (headaches, vertigo) are quite common and can usually be easily treated.
  • Severe cerebrovascular disorders (suspicion of stroke or TIA) during flights are quite rare but they are, together with chest pain and persistent convulsions, among the most common causes of emergency landing.
  • History of neurological symptoms, migraine tendency
  • Symptoms
    • Speech disturbances, unilateral facial symptoms, weakness of limbs / difficulty holding limbs up
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
    • Neurological assessment
  • Treatment
    • Oxygen supplementation, as necessary
  • Need for diversion
    • Permanent new neurological deficits suggesting stroke

Respiratory distress

  • A common symptom (10-15%)
  • History of previous symptoms, any predisposing factors, such as recent scuba diving
  • Gas in the body expands by about 30% at the maximum flight altitude, particularly affecting cavities containing air, such as the nasal sinuses, middle ear and intestine. Rare problems include
    • expansion of pneumothorax or gas remaining elsewhere in the body after surgery
    • decompression illness after scuba diving immediately before the flight.
  • Venous thrombosis or pulmonary embolism usually only appear several hours or days after travelling, not during the flight, except for long-distance flights or ones with several intermediate stops.
  • Symptoms
    • Dyspnoea, significant oedema
    • Signs of infection
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
    • Neurological assessment
  • Treatment
    • Oxygen supplementation, 2-4 l/min with nasal cannula, if SpO2 is below 92%
    • In the case of obstruction, repeated inhalation of a bronchodilator and, as necessary, administration of a glucocorticoid (prednisolone or equivalent, 20-40 mg p.o.)
  • Need for diversion
    • Constant severe dyspnoea or need for oxygen supplementation exceeding the available resources

Convulsions

  • Rare (0.2%)
  • History of disease
  • Symptoms
    • Loss of consciousness, duration and type of convulsions, loss of bowel or bladder control
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
    • Neurological assessment
  • Treatment
    • Lateral position
    • Parenteral (or buccal) benzodiazepine, as necessary
  • Need for diversion
    • Persistent or recurrent convulsions, persistent post-convulsive state

Injuries

  • Rare (< 0.5%), most commonly burns from hot liquid, small ulcers or contusions
  • Symptoms
    • Open wounds, tenderness, malposition, active bleeding
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
    • Intensity of pain (1-10)
  • Treatment
    • Direct pressure on the bleeding area, a tourniquet in the case of excessive bleeding from a limb
    • Splinting of long bone or joint injuries
    • Analgesics
  • Need for diversion
    • Significant injury; active, uncontrolled bleeding
    • Confusion following head injury (falling) or neurological asymmetry, particularly if the patient is on anticoagulant therapy

Allergic reaction

  • Uncommon (2-4%), severe reactions are rare; food (such as nuts) is one of the most common causes
  • History of diagnosed allergies
  • Symptoms
    • Duration and seriousness
    • Oedema in the respiratory tract, respiratory difficulties
    • Generalized urticaria
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
  • Treatment
    • Antihistamines, the patient's own symptomatic medication
    • For more serious symptoms, adrenaline and oxygen, possibly a glucocorticoid
  • Need for diversion
    • Persistent anaphylaxis, medication of no help

Psychiatric symptoms

  • Uncommon (3%)
  • History: psychiatric illness and previous symptoms, medication or other use preceding the event
  • Symptoms
    • Anxiety, agitation, psychotic symptoms
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
    • Interview, observation
  • Treatment
    • Calming by being present and verbally
    • The patient's own medication, benzodiazepines or haloperidol, if available
  • Need for diversion
    • Aggressiveness, threat to the safety of other passengers and staff

Labour and delivery

  • Very rare; flying is usually not allowed in late pregnancy (see also Air travel and assessment of fitness to fly Air Travel and Illness)
  • Symptoms
    • Vaginal bleeding, imminent delivery
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
  • Treatment
    • In the case of scant bleeding, follow-up
    • In the case of abundant bleeding (low blood pressure, tachycardia), i.v. fluids, as necessary
  • Need for diversion
    • Ongoing labour, persistent significant bleeding or worsening abdominal pain

Intoxicants, withdrawal symptoms

  • History: type of intoxicant, amount taken and time of use, symptoms and mood
  • Symptoms
    • Respiratory distress
    • Abnormal level of consciousness, agitation
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2)
  • Treatment
    • In the case of opioid overdose or respiratory depression of other cause, respiratory support using a bag (mask or oral airway)
    • Naloxone, if available (rarely on European aircraft)
    • Diazepam for delirium
  • Need for diversion
    • Persistent respiratory distress or aggression

Cardiac arrest

  • Rare; nearly 50% recover from ventricular fibrillation
  • Symptoms
    • Unconsciousness
    • Respiratory movements absent or abnormal (gasping, snoring)
  • Diagnosis
    • Vital signs (blood pressure, heart rate, respiratory rate, SpO2) absent
  • Treatment
    • Compression-only cardiopulmonary resuscitation
    • Semiautomatic defibrillator (AED) as soon as possible
    • Adrenaline, 1 mg i.v.
    • Resuscitation should be stopped if the patient is still apnoeic and pulseless more than 30 minutes after beginning resuscitation.
  • Need for diversion
    • As descending from a cruising altitude to the airport will take more than 30 minutes, if resuscitation does not restore circulation during that time, the prognosis is practically non-existent.

    References

    • Hu JS, Smith JK. In-flight Medical Emergencies. Am Fam Physician 2021;103(9):547-552. [PubMed]
    • Martin-Gill C, Doyle TJ, Yealy DM. In-Flight Medical Emergencies: A Review. JAMA 2018;320(24):2580-2590. [PubMed]
    • Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009;373(9680):2067-77. [PubMed]
    • Medical Manual. 12th Edition. International Air Transport Association (IATA) 2020. ISBN 978-92-9264-250-1. http://www.iata.org/en/publications/medical-manual/
    • Mahony PH, Myers JA, Larsen PD, et al. Symptom-based categorization of in-flight passenger medical incidents. Aviat Space Environ Med 2011;82(12):1131-7. [PubMed]
    • Borges do Nascimento IJ, Jerončiž A, Arantes AJR, et al. The global incidence of in-flight medical emergencies: A systematic review and meta-analysis of approximately 1.5 billion airline passengers. Am J Emerg Med 2021;48():156-164. [PubMed]
    • Potin M, Carron PN, Genton B. Injuries and medical emergencies among international travellers. J Travel Med 2024;31(1): [PubMed]
    • Cummins RO, Schubach JA. Frequency and types of medical emergencies among commercial air travelers. JAMA 1989;261(9):1295-9. [PubMed]
    • de Caprariis PJ, de Caprariis-Salerno A, Lyon C. Healthcare Professionals and In-Flight Medical Emergencies: Resources, Responsibilities, Goals, and Legalities as a Good Samaritan. South Med J 2019;112(1):60-65. [PubMed]
    • Nable JV, Tupe CL, Gehle BD, et al. In-Flight Medical Emergencies during Commercial Travel. N Engl J Med 2015;373(10):939-45. [PubMed]
    • Chandra A, Conry S. In-flight Medical Emergencies. West J Emerg Med 2013;14(5):499-504. [PubMed]

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