Is There a Doctor on Board?
The thought of this title may send shivers down your non-clinical spine. Colleagues often jest that radiologists are loners hiding in a dark room away from civilization, who have little interaction with any patients.
However, we all did an intern clinical year. We earned our keep, even if we have forgotten a lot of the nuances involved.
I do not think it is unreasonable for radiologists to have the basic skills to assist in a medical emergency. Physicians tend to operate in silos where we work with the best in our respective fields, which leads to feeling inadequate when operating outside our usual area of medicine. This post is to relieve some of that anxiety you may experience when you hear about an in-flight emergency played overhead on your next plane trip. First, this post will go through some of the rules involved with inflight medical emergencies, then the equipment airlines have, and finally common in-flight medical problems and how to treat them.
An in-flight emergency can elicit a similar sensation to the discomfort you may feel giving medical advice in an uncontrolled environment like a family gathering.. You should know that first off, you can remain silent. In the United States, you are not legally obligated to assist. However, many likely feel an ethical obligation. Let it be known that many other countries, such as Austraila, do have a legal obligation to assist. Additionally, the U.S. law, the Aviation Medical Assistance Act, also protects physicians from liability in this specific situation, barring any gross negligence such as intoxication.
Another source of anxiety is the uncertainty of equipment available on the plane. Fortunately, the FAA has mandated specific equipment (listed below) with additional bandages or splints. Note the absence of specific equipment of pediatric or obstetrical equipment.
Now to the good part of common in-flight emergencies. A common inflight problem is syncope. It accounts for approximately 1/3 of inflight emergencies. Passengers are somewhat dehydrated due to a slight arid environment and oxygen tension is slightly decreased in flight. Many of these can be treated with fluid resuscitation and positioning of elevated feet. If there is persistent hypotension, IV fluids may be required. A glucometer reading is also important. While most syncope is relatively benign, it is crucial to inquire to cardiac history as devastating cardiopulmonary disease can initially present as syncope. If there is any suspicion of underlying severe disease, diversion should be considered.
As on the ground, dyspnea is a common in flight complaint. As mentioned before, decreased oxygen tension can exacerbate pre-existing pulmonary conditions, particularly common are COPD exacerbations or hypoxia from pulmonary hypertension as altitude increases. Of note, patients with resting oxygen saturation <92% on the ground are advised to fly with additional oxygen (which can be arranged with the airline). An albuterol MDI is available. Additional tools include even descending to lower altitude as cabin pressure is inversely proportional to altitude (Baller move for a radiologist).
Unbeknownst to me prior to writing this, psychiatric emergencies are common inflight emergencies. Like on the ground, it is important to rule out organic causes such as hypoglycemia or hypoxia. It is crucial to know that the inflight kit does NOT contain sedatives. Therefore, improvised restraints may be required for the safety of the patient and fellow passengers (Eeeesh).
Of course, the dreaded cardiac symptoms which can be frustratingly vague. Management of possible acute coronary syndromes is limited in flight. Essentially, aspirin is your only medical treatment. Nitroglycerin is available, however with lack of EKG administration of nitroglycerin has the possibility of exacerbating hypotension in an unknown right-sided myocardial infarction. Supportive treatment again can be administer with IV fluids and supplemental oxygen. Diversion should be strongly considered in any patient with suspicion for acute coronary syndrome, at the least prompt medical evaluation upon landing.
While this is, of course, not entirely inclusive, it can hopefully allow you to become more comfortable with in flight emergencies. As radiologists, we obviously would feel more comfortable treating with in flight radiographs however that role has been delegated to our friends at the TSA. Hey, but at least we see patients more than those pathologists.
For more information, these are extremely helpful:
In-Flight Medical Emergencies During Commercial Travel - The table provided above is from this, as well as much of the information for this blog post.
By Bryce Hansen, MD