This is a talk I gave in June 2010 on how, as a physician, to deal with a medical emergency while on an airplane.

1. Is There A Doctor On The Plane?
Aaron Neinstein, MD
June 2010

2. What we’ll learn…
• How common are medical emergencies on
planes?
• What are the most common problems?
• What supplies are available on planes?
• Are there laws to protect me?
• Physiologic changes when flying
• In clinic… “Doc, is it safe for me to fly next
week?”

3. Case 1
• 39 year old woman in motorcycle accident on
the way to the airport
• 1 hour into flight…
– Left-sided chest pain
– Dyspnea
– Trachea deviated to right
Is there a doctor on the plane?

5. Most Common Medical Emergencies
Neurologic
Gastrointestinal
Cardiac
Respiratory
Traumatic
Other

6. The Laundry List
• Syncope • Headache • Vaginal bleeding
• Diarrhea • Epileptic seizure • Birth
• Vomiting • Biliary colic • Death
• Fear of flying • Renal colic • Pulmonary
• Generalized pain • Migraine Embolism
• Unruliness • Epistaxis • Aneurysm
• Inebriation • Hyperventilation • GI bleeding
• Cardiac condition • Appendicitis • Cerebral
• Allergy • Pregnancy problems hemorrhage
• Fever • Hypertension • Attempted suicide
• Accident/Trauma • Narcotic abuse
• Hypoglycemia • Meningitis
• Sinus pain • Labor pains

7. How often does this really happen?
• Data is poorly collected, usually just by
individual airlines
• Wide variations in estimates of incidence of
in-flight medical events…1 per 10,000
passengers to 1 per 40,000 passengers
• 30 in-flight medical events per day
• 75% of events are dealt with by cabin
personnel
• Doctor available on the flight in 85% of
medical events

8. Should I tell the pilot to land?
• Cost of medical diversion ranges from $30,000
to $725,000
• Depends on whether fuel needs to be dumped
and whether passengers need overnight
accommodations arranged
• 3-13% of flights with medical events required
emergency diversion
• Most common reason for diversion = cardiac

9. MedAire’s MedLink
• Ground-to-air medical advice service
• Subscribed to by almost every airline
• Should be involved in every diversion decision
• ER-trained providers

10. Case 2
• 22 yo M on Southwest flight from SFO to LAX
• Snacks and drinks were just served
• Patient becomes suddenly short of breath and
breaks out in a full body rash.
Is there a doctor on the plane?

11. Case 2
• 22 yo M on Southwest flight from SFO to LAX
• Snacks and drinks were just served
• Patient becomes suddenly short of breath and breaks out in a full
body rash.
• By the time you get to the patient to
examine him, his heart rate is 135 bpm…
yours feels like 155!
• His lips and tongue are swollen and he
can hardly breathe.

12. Case 2
Doctor, what should we do?
A) Ummm, I’m just an intern. I don’t have my
license yet.
B) IM Epi. Stat.
C) ASA 325 mg chewed. Stat.
D) Get albuterol from any passenger who has it.
Administer as quickly as possible.

13. Case 2
Doctor, what should we do?
A) Ummm, I’m just an intern. I don’t have my
license yet.
B) IM Epi. Stat.
C) ASA 325 mg chewed. Stat.
D) Get albuterol from any passenger who has it.
Administer as quickly as possible.

14. Case 3
• 65 yo F with sudden onset of acute abdominal
pain.
Is there a doctor on the plane?

15. Case 3
• 65 yo F c sudden onset of acute abdominal pain.
• Her husband tells you that she has a history
of chronic back pain.
• She has two Fentanyl patches on her chest.
• She hasn’t had a bowel movement for three
days.
• The plane is an hour from New York, its
destination.

16. Case 3
Doctor, what should we do?
A) Tell the pilot to lower the plane’s altitude from
30,000 feet to 7,000 feet.
B) She’s in so much pain! Ask her husband to put
another Fentanyl patch on her. Stat!
C) Give her 650 mg of Tylenol.
D) “I don’t want to be sued if something goes
wrong. I’m sorry, I can’t help you here.”

17. Case 3
Doctor, what should we do?
A) Tell the pilot to lower the plane’s altitude from
30,000 feet to 7,000 feet.
B) She’s in so much pain! Ask her husband to put
another Fentanyl patch on her. Stat!
C) Give her 650 mg of Tylenol.
D) “I don’t want to be sued if something goes
wrong. I’m sorry, I can’t help you here.”

18. Case 4
• 65 yo M is unresponsive.
Is there a doctor on the plane?
What is your differential
diagnosis as you head over to
the patient?

19. Top Causes of Unresponsive Patient on
Plane
• Vasovagal syncope
• Alcohol-related
• Cardiac/MI
• Hypoglycemia
• Epilepsy

20. Case 4
• 65 yo M is unresponsive.
• His wife tells you he complained of chest pain
before he got diaphoretic and then lost
consciousness.
• He has a history of panic attacks, and also a
heart attack.
• He is, in fact, unresponsive.

21. Case 4
Doctor, what should we do?
A) Tell the flight attendant to bring you the AED so you
can hook it up to the patient.
B) Ask the patient’s wife for his Nitroglycerine spray and
quickly spray some into his mouth.
C) Ask the flight attendant to get the AED and also ask
her to hook it up to the patient.
D) Use one of those cool seat-back phones for $10 a
minute to page the cardiology fellow on call to ask for
help.

22. Case 4
Doctor, what should we do?
A) Tell the flight attendant to bring you the AED so you
can hook it up to the patient.
B) Ask the patient’s wife for his Nitroglycerine spray and
quickly spray some into his mouth.
C) Ask the flight attendant to get the AED and also ask
her to hook it up to the patient.
D) Use one of those cool seat-back phones for $10 a
minute to page the cardiology fellow on call to ask for
help.
Once he is shocked and awake… Give ASA 325mg, Oxygen via nasal cannula, and
ask the pilot to fly at a lower altitude and then land the plane as quickly as possible.

23. Case 5
• 65 yo M is unresponsive.
Is there a doctor on the plane?

24. Case 5
• 65 yo M is unresponsive.
• He is traveling alone.
• Nobody witnessed anything strange before
he became unconscious.

25. Case 5
Doctor, what should we do?
A) Ask the flight attendant to hook up the AED.
B) Place an IV and give an amp of D50.
C) Place oxygen via nasal cannula.
D) Give Narcan.
E) All of the above.

26. Case 5
Doctor, what should we do?
A) Ask the flight attendant to hook up the AED.
B) Place an IV and give an amp of D50.
C) Place oxygen via nasal cannula.
D) Give Narcan.
E) All of the above.

27. What is available for use on planes?
Required by FAA • Normal saline
• ASA 325 mg
• Stethoscope • Albuterol inhaler
• BP Cuff • Lidocaine
• Oropharyngeal airway
• Syringes and needles Other often-available items
• Gloves
• Nitroglycerine • Narcan
• Diphenydramine (Benadryl) • Metoclopramide (Reglan)
• D50 • Diazepam (Valium)
• Epinephrine • Foley catheter
• Automatic External Defibrillator • Atropine
(AED)
• IV infusion kit

28. Don’t forget to…
• … ask for medications from other passengers
– Benzodiazepenes
– Albuterol inhalers

29. AEDs (Automatic External Defibrillators)
• Survival 25-40% when AEDs used in-flight
• Several airlines allow ONLY flight attendants to
operate the AEDs since the physician on board
may be unfamiliar with the equipment
• Required on US-registered airplanes with >12
passengers on board or >1 flight attendant

30. Will I get sued?
Do I have any legal protection?

31. Aviation Medical Assistance Act (1998)
• “An individual shall not be liable for damages
in any action brought in a Federal or State
court arising out of the acts or omissions of
the individual in providing or attempting to
provide assistance in the case of an in-flight
medical emergency unless the
individual, while rendering such assistance, is
guilty of gross negligence or willful
misconduct.”

32. Aviation Medical Assistance Act
• Protects medically qualified passenger who
provides medical assistance on an airplane.
• Must be:
– Volunteer
– Render care in good faith
– Receive no monetary compensation
• Travel vouchers, wine, or seat upgrades ok.
• Must render medical care similar to the care that
others with similar training would provide under
similar circumstances.

33. Medicolegal Recommendations
1) Properly identify yourself and state your medical
qualifications. Some airlines require proof of
your medical qualifications.
2) Obtain a history, inform passenger and/or family
of your impression, and obtain consent before
initiating exam or treatment. Assume implied
consent if passenger is incapacitated.
3) If consent given, examine the patient.
4) Inform flight crew of your clinical impression.
5) Establish communication with on-ground
medical support staff. Respect their expertise
and experience.

34. Medicolegal Recommendations
6) If condition is serious, request diversion of
flight.
7) Request the in-flight medical kit.
8) Document in writing your
findings, impression, treatment, and
communications with flight crew and on-
ground medical support.
9) Do not use any treatment you do not feel
confident administering.
10) Never officially pronounce a patient
dead, especially on international flights.
11) Do not fear litigation.

35. The bottom line…
• If asked, volunteer
• Do not fear litigation
• Communicate with ground-based support

36. Challenges on a plane
• Noisy
• Bad lighting
• Low humidity = dried mucous membranes
• Low air pressure (equiv. to 8,000 feet altitude)
– Expands all air-filled spaces by 30%
– Drops oxygen saturations
• Cramped spaces
• No privacy

37. Other potential dangers of air travel
• Jet lag
• Transmittal of infectious diseases– increased
risk within 2 rows of infected passenger and
on flights longer than 8 hours duration
• Cosmic radiation exposure

38. Doctor… Is it safe for me to fly?
• Normal person has decreased O2 sat 3-4% in flight…
rec. supplemental O2 if resting sat is <92%
• Wait 2 weeks after major surgery– expanded spaces
with air could theoretically rupture
• Wait 12-24 hrs after a scuba dive
• Gas expansion affects tubing eg foley catheter, cuffed
tracheostomy… can fill these with water instead
• DVT…
– Low-mod risk– stay hydrated, get up and walk around and
do calf stretches
– High risk (eg prior DVT) and long flight– Enox SQ prior to
flight if not on coumadin

40. What we learned…
• Incidence of medical emergencies: 1 in 10,000 to 1 in
30,000 passengers.
• Most common problems are vasovagal syncope, GI
problems, cardiac problems
• Supplies on board
• You are not legally obligated to help, but you are very
legally protected (at minimal risk of suit), and
ethically, you should help.
• Physiologic changes stemming from cabin pressure and
low humidity
• How to advise an outpatient considering air travel

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