Dr Ian Hosegood, Medical Director for Qantas Airways gives a great talk on In-Flight Medical Emergencies, including common complaints, what you can and can't do, diversions, and might even touch on how to get an upgrade

1. In-flight medical emergencies (IFMEs):
epidemiology and management
Ian Hosegood
Qantas Group Medical Director
Sep 2014

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Overview
Aviation / aircraft environment
Epidemiology of in-flight medical
emergencies (IFMEs)
Medical diversions – causes and costs
Current controls for in-flight medical
emergencies
Policies, equipment, training
Involvement of medically qualified volunteers
Current issues and activities including telemedicine

5. Aviation environment and medical issues
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Personal factors
•Pre-existing illness
•Anxiety
•Medication use
•Alcohol
Demographic issues
•Ageing travelling population
Airport factors
•Walking long distances
Aviation factors
•Cabin Altitude
•Pressure changes
•Immobility
•Low humidity
•Vibration
•Fatigue
•Circadian dysrhythmia

6. Bow-tie risks and control points for IFMEs
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Latent issues
Missed
medication
Inadequate
preparation
Commence flight
unwell
Exertion in
terminal
Turbulence /
Pressure change
Hypoxia /
Immobility
Hazards / Causes
Consequences
Exacerbation
of existing
condition
Physiological
stresses of
flight
Unknown or
unpredictable
condition
Illness first
presents
inflight
Incorrect
diversion
decision
Poor Health
outcomes
Failure to
divert
Significant
Costs
Inadequate
equipment
Inadequate
diversion
options
Inadequate
diagnosis
and / or
treatment
Operational
disruption
Customer
impact
Medical emergency
causes Threat and error management Consequences
Inadequate
expertise
or
knowledge
IFME
Medico-legal
Liability
Reputational
damage

7. The Altitude - Pressure Environment
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Outside air
Air-conditioning
packs
Cabin air
distribution
Outflow
valve
Mixing Chamber
Filtration
and
recirculation
system
Flight deck
air distribution
Ozone
Converter
Cabin conditioning system

9. Typical Cruise Cabin Pressure Schedule
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Resulting Cabin Altitude
at Cruise Depends on
Airplane altitude
Cruise Cabin
Pressure Schedule
Constant Diff Pressure

10. Example Cabin Pressure Flight Profile
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Example Flight Profile
Airplane
Operation
Cabin
Operation

11. Pressure and Volume with altitude
Altitude (ft) Pressure (mmHg) Dry Gas Vol Saturated Gas Vol *
Sea Level 760 1.0 1.0
4,000 656 1.16 1.17
6,000 609 1.25 1.27
8,000 543 1.4 1.44
13,000 380 2.0 2.14
33,700 190 4.0 4.99
*using: (P1 - PH2O) / (P2 - PH2O) =V2/V1
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12. Relationship between alveolar PO2, altitude and Hb saturation
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13. % of healthy pax predicted to manifest a PaO2alt < 50mmHg by age and altitude
Predicted arterial oxygenation at commercial aircraft cabin altitudes.
Muhm,,JM. Aviat Space Environ Med. 2004 Oct;75(10):905-12.
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Age 65yr
Age 55yr
Age 45yr
Age 35yr
Age 25yr

14. In-flight medical incidents incidence
•Literature review by Gendreau MA, DeJohn C.(2002)
•Varies from 1/39600 pax to 1/11000 pax dep. on reporting
• Vasovagals = 22% of total
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•LAX arrival study (1989)
•260 pax (0.003% of the 8,735,000 arrivals) symptoms in-flight
•137 required ED assessment , 25 admitted, 7 in-flight deaths
•Ground-to-air medical assistance study (DeJohn, 2000)
•1,132 IFMIs on 5 US airlines, (8 per million enplanements
•179 passengers required hospital assessment, 173 admitted
•Ground-air assistance study (Peterson NEJM 2013)
•11,920 cases
•Syncope/presyncope 37% of cases
•26% seen at hospital 8% admitted, 0.3% died

15. Benchmarking IFMIs; telemedicine usage
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IFMIs - Diversions
Delaune et al. (2003) 1.
•210 medical diversions per million flights (1/4754 flights)
• 7.9% of ‘incidents’ resulted in a diversion
•Chest pain/cardiac, neurological, GIT, syncope & trauma made up 75% of diversions
DeJohn (2000)2.
•Diversion in 13% IFMIs (1/1 million pax carried)
•Top 4 causes (descending order): Cardiac(45%), neurological, vasovagal & respiratory
• 19% “probably unnecessary in light of subsequent follow-up information.”
Peterson (2013) 3
•11920 IFMEs (1 per 604 flights)
•Diversion in 7.3%
1. In-flight Medical Events, ASEM 2003
2. The Evaluation of In-Flight Medical Care Aboard Selected U.S. Air Carriers: 1996 to 1997 May 2000
3. Outcomes of medical emergencies on commercial airline flights. NEJM 2013 368:2075-83

17. Diversions: correlation vs RPKs and enplanements
• Correlation closer per individual passengers carried than for revenue passenger kilometres
• Medaire data for Industry:
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• 22,574 telemedicine cases
• 525 diversions (2.3%)

18. Incidence of in-flight deaths and diversions: international airline metadata
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IFMIs are uncommon events
Serious IFMEs are very
uncommon
Diversions are rare
Deaths on-board are
exceedingly rare
Year
No.
Airlines
Diversions Deaths BRPK
0.34
0.05
QF
Diversions
/ BRPK
Deaths /
BRPK
2007 16 733 93 1381 0.53 0.07
2008 21 701 68 1545 0.45 0.04
2009 26 781 110 1602 0.49 0.07
2010 24 791 135 1748 0.45 0.08
2011 24 761 146 1823 0.42 0.08
2012 24 783 183 1889 0.41 0.10
2013 24 774 165 1983 0.39 0.08

19. Benchmarking Diversions
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20. Diversion decision considerations
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Medical urgency – time considerations
• Time to definitive care, not time to land
Diversion destination characteristics:
• Operational issues
-Airport, Nav Aids, ATC, Ground Handling
-Runway, taxiway, towbar
-Captain +/- IOC
• Medical facilities available
-Medlink advice - accurate database
-Capabilities, quality

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Potential
Arctic
diversion
airports

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Longyear Airport, Spitzbergen
Longyearbyen airport, Svalbard

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Costs of medical diversions
Broad range of costs from tens of thousands (for an isolated ‘gas and go’) up to hundreds of
thousands (for a network disruptive event) depending on factors below.
Some unusual diversions into unsuitable airfields e.g. on polar / trans-pacific routes have cost
over $1M AUD.
July 2012-Jun2014 data – 26% of all aircraft diversions due to medical causes
Components of costs to consider:
Fuel costs
o Dump fuel, diversion and extra take-off
Landing fees and ground handling fees
o Terminal, gating, ramp, refuelling,
o Ambulance and hospital fees may be charged initially
Passenger costs
o Missed connections / transfers – opportunity revenue loss seats
o Accommodation & meals, taxis, clothes
o Compensation – high in the EU (100s of pounds)
o Rebook on other carrier
o Intangible loyalty costs – missed business, meetings etc
o Knock onto pax through entire schedule
o In the US there are high costs ($27 K per pax) for > 3hr delays
Crew costs
o Diversion crew out of hours
o Additional flight hours or callout costs
o Lost productivity from schedule knock onto other flights
o Accommodation and meals
Aircraft costs
(diversion often leads to MEL issues on restart – aircraft ‘dead’ on
landing)
o Direct Engineering/repair costs (home port)
o 3rd party engineering costs (alternate)
o Ferry engineer in (as happens often with A380)
o Ferry parts
o Ferry in new aeroplane (uncommon)
Network / schedule costs
o Depends if flight is cancelled or delayed
o Cancelled flight significantly higher, replacement a/c etc.
Organisational costs
o Compensation claims
o Recognition costs for medical assistants
o Medical services and safety department costs
o Lost time dealing with complaints / rebooking
o Legal fees

24. Qantas typical annual medical data
20 million passengers carried
6000 Medical Incidents (1:3000 pax)
30-40 Diversions (45% cardiac)
2-4 Deaths
0 Births
5-10 uses of AED (2-4 shocks, 1-2 saves)
5-10 legitimate uses of Qantas adrenalin auto-injector
100-150 IVs set up in-flight
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25. Analysis of incidents: by use of medical kit
By diagnostic category 2013-2014
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Neurological in detail
Bell's Palsy Convulsion CVA
Dizziness
faint
headache
Migraine
Seizure
(epileptic)
Seizure
(unknown
aetiology)
Stroke or TIA
Vasovagal
Syncope
Allergy /
Immunological
Cardiac
Endocrine
Neurological /
Neurosurgical
ENT
Envenomation
Substance abuse /
intoxication
Gastrointestinal
Renal / Urological
Psychiatric /
Psychological
Other Infectious
diseases
Orthopaedic /
Musculoskeletal
Ophthalmological
OB/GYN
Haematological
Respiratory
Trauma

26. Analysis of medical kit usage: continuous improvement
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Physicians Kit – Top 25
reasons for opening
2011-2012
Physicians Kit –
Top 30 drugs &
devices used
2011 to 2012

27. Diagnostic categories: aircraft diverted
Cardiovascular and (non-vasovagal) neurological cases are a small proportion of overall IFMEs but the most
significant causes for diversions
Cardiovascular issues account for 40-50% of diversions
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28. In-flight Medical Emergencies
Management and controls

29. Risks and Controls for in-flight medical emergencies
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Latent issues
Missed medication
Inadequate preparation
Commence flight unwell
Exertion in terminal
Turbulence /
Pressure change
Hypoxia /
Immobility
Hazards / Causes
Consequences
Exacerbation of
existing condition
Physiological stresses
of flight
Unknown or
unpredictable condition
Illness first presents
inflight
Incorrect diversion
decision
Poor Health
outcomes
Failure to divert
Increased Costs
Inadequate
equipment
Inadequate
diversion options
Inadequate
diagnosis and / or
treatment
Operational
disruption
Customer disruption
IFME Precursors
Threat and error management
Consequences
Inadequate
expertise or
IFME knowledge
Medico-legal
Liability
Reputational damage
Pre-flight controls:
• Provision of information (pax and doctors)
• Travel clearance guidelines and clearance
system (MEDA and gate clearances)
• Provision of support for travel (wheelchair,
oxygen, stretchers, ambulance transfers)
At the gate controls:
• Training for airport staff and cabin crew
• Gate clearances
In-flight controls:
•Provision of first aid training for crew
•Medical equipment including physician’s kit,
oxygen, AED, glucometer etc
•24/7 ground based telemedicine service
Post flight controls:
•Reward and feedback system for medically
qualified volunteers
•Customer care and medico-legal follow-up

30. http://www.qantas.com.au/travel/airlines/medical-assistance/global/en
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Medical Travel Clearances
Travel clearance form
• Completed by treating doctor
• Screened by ‘special handling department’
following protocol
• Published guidelines consistent with IATA
and AsMA recommendations
• Medical department clearance for certain
conditions
• 7000-8000 passengers submit MEDIFs
• < 1 per year of those cleared have a
significant incident on board

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Therapeutic Oxygen
For onboard emergencies:
• Bottle supply is strictly limited and intended for crew emergency use.
• Known requirement must be pre-arranged
Prearranged supply of oxygen
• 2 or 4L per minute
-Continuous or intermittent
• Demand (prongs) or constant flow (with reservoir bag)
• Minimum notice of 48 hours
• POCs – Personal portable oxygen concentrators (specific types)
allowed on board with physician declaration form
-Website outlines approved models
-May be hired
• Tracheostomy patients need to supply own adapters eg ‘Swedish nose’

33. Stretcher cases and commercial retrievals
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Stretchers have regulatory requirements
• secure, not impede exit, adequate restraint
Takes up 6 rear seats + escort seats
• Escort, (medical/non-medical) responsible for patient care
• Cost high but << dedicated air ambulance
• Most stretcher cases via an air ambulance service
• Currently no stretcher bridge
• NETS cases challenging due space
• F/J class alternative – flatbed
• Medical modules (A380)
Medical equipment
• Must be approved by the airline
• Medical power outlets available at specific locations
• must be operable by dry cell batteries.
• Lithium batteries require pre-approval

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24/7 Telemedicine Service
Medlink (International SOS)
Based in Hospital ED, Phoenix, Arizona
Utilises in house staff
Utilised by multiple aviation and maritime organisations
>22000 aircraft calls per annum
Qantas has contracts for
• 24/7 Air-ground support
• Crew outstation medical support
• Crisis interventions
Many other similar providers worldwide:
e.g. Stat-MD, SAMU Paris, REGA, Tokyo Marine Medical Services, Stockholm Radio,
Airport Medical Services Schiphol

35. Medical Qualified Volunteers (MQVs)
Likelihood of involvement?
• Any IFMIs 1/39600- 1/11000 pax
= 1 in every 20-72 A380 flights
• IFMIs warranting Medlink calls 8 per 1M pax
= 1/277 A380 flights
• Diversions currently 1 / 4754
= 1/2377 A 380 flights
Response
• At least one doctor responds in 40-85% of long haul
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flights
Considerations
• Competence / recency in emergencies
• Fitness (alcohol, fatigue)
• Willingness / concern re liability

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IFMIs and MQV involvement
DeJohn The Evaluation of In-Flight Medical Care Aboard Selected U.S. Air Carriers: 1996
to 1997
In-flight diagnoses were in close agreement with hospital discharge diagnoses, and
patients’ conditions generally improved, implying that in-flight medical care delivery
is generally well managed.
“There did not appear to be a significant difference between patient improvement
and the presence or absence of a physician on board”
physicians volunteered 40% of the time and were associated with the highest
diversion rate among in-flight medical care providers and an increase in the % of
diversions.
“The data suggest that oxygen, supportive care, and close patient monitoring were
associated with an improvement in patient condition.
In-flight death rate was lower than similar studies where no expert medical advice
service was available whilst diversion rate remained the same
Delaune et al Aviat Space Environ Med. Jan 2003 In-flight medical events and aircraft
diversions: one airline's experience
“When a physician participated in the decision to divert the hospital admission rate
was 49% versus 15% with no physician input”

37. Medically Qualified Volunteers (MQVs)
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Process:
Cabin crew alerted to medical emergency
Document Voyage report – history, obs
Request Captain to contact MedAire for advice
– ground to air 24/7 service
May ask for medically qualified pax to assist for
medication or procedure
MedAire will direct onboard physician,
indemnify
Decision to divert
discussed with MedAire, MQV
Captain has ultimate responsibility
Recommendations:
 Pre-embarkation: refer to ground med
services
 In-flight: only intervene if
 Competent in practice
 Full capacity to act i.e. not under influence
of medications or alcohol
 Requested by cabin crew &/or MedAire
 Carry evidence of medical qualification
 Document assessment & mgt
 Consider informing personal insurance on
return
 US: Aviation Medical Assistance Act 1998 –
airlines & individuals not liable unless gross
negligence or wilful misconduct

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Recognition of MQVs
Recognition of MQVs based on analysis of reported events
Categorised by:
• Type of event (seriousness, time, risk)
• Value to airline / sick passenger
• Disruption to MQV journey
Type of recognition:
• Immediate onboard
• Post-flight
• Points, rewards, upgrades, refunds
Documentation important

39. Physician’s kit Design & contents – Qantas Group
Meets or exceeds relevant standards and recommendations (ICAO, CASA, AsMA)
Continuous improvement
• advisory panel with Qantas Doctors, Pharmacists + external specialist Emergency Physician
• Usage, contents and protocols reviewed quarterly at passenger health meeting
• tracking of all batches and expiries plus data collection, grading and evaluation of all onboard
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medical incidents

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Physician’s kit

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43. Automatic External Defibrillator (AED)
Defibrillator used in-flight approximately 5-10
times per year.
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Shock indicated in 20-30%
‘Save rate’ from Ventricular Fibrillation is
approximately 25-30% in the air
Higher for the airport terminal (more witnessed)
Current transition to new AED: Phillips FR3
Paediatric mode
ECG trace

44. Current issues under consideration
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 Medical Kits
Post partum haemorrhage (Misoprostol)
Use of wafers and intranasal administration
IV fluid
Pulse oximetry
 Travel clearances
Travellers with Halo brace
Tracheostomy pax and decompression
Clearance post radioactive iodide treatment
Gas issues: Craniotomies, eye surgery, bullae
 In-flight treatment
Oxygen in MIs
Sedation in the agitated passenger
Management of narcotic overdose
Management of chest pain *

45. Improving the management of in-flight chest pain
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44 Diversions or air turn-backs due medical cause
18 A380/747
7 of 18 transpacific
HNL commonest diversion port (5)
QF Diversions/BRPK 0.34 (IATA bench 0.39)
QF deaths/BRPK 0.05 (IATA bench 0.08)
Cardiac conditions including chest pain are the
predominant cause of diversions
Some of the diverted cases are retrospectively
determined to have been unnecessary
3 diversions related to crew illness (incl PVG, HKG)

46. Cardiac cases: potential impact with access to ECG
Analysis of 20 QF cardiological cases
Assessed each case for potential impact of on board ECG
15 physician, 1 nurse
17 International / 3 Domestic
14 cases with B747 / A380
Evaluation criteria:
0 – ECG not indicated
1 – ECG useful / no change expected
2 – ECG useful / change expected
Conclusions:
In 50% of cases an ECG may have made a difference to the outcome
Differences included:
 Improved diagnosis
 Potential diversion avoidance
 Potential earlier diversion with improved operational and clinical
outcomes for confirmed cardiac cases
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Medical telemetry options
Non-expert user devices for improved diagnosis
Can be interpreted by on-board medically qualified volunteer
With comms can be relayed to MedAire for cardiology interpretation to augment voice calls
Spaulding ECG Machine +
Glove + iPad combination
Tempus IC
Telemetry device
MedAire telemedicine Service

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Summary
Serious IFMEs occur uncommonly, diversions are rare and deaths exceedingly rare
Screening of passengers medical conditions pre-flight with appropriate controls
appears effective in reducing serious IFMEs
When needed, medical care onboard is effective and generally improves outcomes
when crew are trained appropriately
Improved diagnostic accuracy can be achieved via the use of ground based
telemedicine support and appropriately qualified medical volunteers
Medical volunteers do not appear to be at medicolegal risk and are generally
indemnified for actions taken in good faith.
Recognition is important to encourage ongoing support
Continuous review of medicines and medical equipment is required to ensure
currency and meet medicolegal requirements
The use of data telemetry is promising and there is evidence that onboard ECG may
improve medical and operational outcomes

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The End