How Common Are In-Flight Emergencies? • Occur on one in every 600 flights • 44,000 of 2.75B airline passengers / year What Are Most Common Emergencies • Lightheadedness or fainting ~37% • Respiratory problems ~12% • Nausea or vomiting ~10% • Cardiac symptoms ~8% • Seizures ~6% • Other Emergencies • Laceration ~0.3% • Cardiac arrest ~0.3% • Ear pain ~0.4% • Obstetrical or gynecological symptoms ~0.5% • Headache ~1% Who Responds to the Call? • Physician passenger responds in ~48% • Nurse passenger responds in ~20% • EMT passenger responds in ~5% Minimum first aid kits on commercial airliners 16 Adhesive bandage compressors, 1 in 20 Antiseptic Swabs 10 Ammonia Inhalants 8 Bandage compressors, 4 in 5 Triangular bandage compressors, 40 in 1 Arm splint, non inflatable 1 Leg splint, non inflatable 4 Roller bandage, 4 in 2 Adhesive tape, 1 in standard roll 1 Bandage Scissors 2 Protective latex gloves pair 2 Insect sting relief pad 2 Triple antibiotic ointment 2 First Aid/burn cream, 9 gm. 2 Povidone iodine infection control wipes 2 Alcohol cleansing pads 2 Gauze dressing pad 2" x 2" in 2 Motion Sickness Tab 4 Ibuprofen tablets 4 Non Aspirin Tablets 2 Sunscreen lotion towelette 2 Trauma pads 5 x 9 in (12,7 x 22,8 cm) 1 Survival rescue blanket 1 Pelican case 1170 waterproof 1 Emergency first aid guide (American Red Cross) Required medications on flights • Antihistamine – tablets and injectable • Atropine 0.5 mg injectable • Aspirin tablets 325mg • Bronchodilator MDI • Dextrose 50% injectable • Epinephrine 1:1000 and 1:10,000 • Nitroglycerin tablets • Lidocaine injectable • IV needle • 500ml Saline injectable All crew members are trained for common emergencies. For each flight attendant ¥ Instruction to include performance drills in the proper use of automated external defibrillators ¥ Instruction to include performance drills in cardiopulmonary resuscitation ¥ Recurrent training … at least once every 24 months

1. Is There a Doctor
on the Plane?
Joe Lex, MD, FACEP, MAAEM
Professor of Emergency Medicine
Department of Emergency Medicine
Temple University School of Medicine
Philadelphia PA USA
joe@joelex.net @JoeLex5

3. Physician is
traveling on ~85%
of US domestic air
flights
Hordinsky JR, George MH.
Utilization of Emergency Kits by
Air Carriers. Oklahoma City:
Federal Aviation Administration,
Civil Aeromedical Institute,
1991/DOT/FAA report AM-91/2

23. For each flight attendant
• Instruction to include performance drills in the proper
use of automated external defibrillators
• Instruction to include performance drills in
cardiopulmonary resuscitation
• Recurrent training … at least once every 24 months

29. At least one approved automated external defibrillator,
legally marketed in the United States in accordance
with Food and Drug Administration requirements.

31. How Common?
• ~ 1/600 flights
• 44,000 of 2.75B passengers / year
• Federal Aviation Administration (2000): 13%
of in-flight medical incidents aboard domestic
aircraft result in emergency diversion
Peterson DC, et al. Outcomes of medical
emergencies on commercial airline flights. N Engl J
Med. 2013 May 30;368(22):2075-83.

32. Emergency landing of domestic
flight: $30,000
International flight: $70,000 to
$230,000

33. Most Common Emergencies

36. Most Common Emergencies
• Lightheadedness or fainting ~37%
• Respiratory problems ~12%
• Nausea or vomiting ~10%
• Cardiac symptoms ~8%
• Seizures ~6%
• Most common diverting conditions: cardiac,
neurological, respiratory

38. Other Emergencies
• Laceration ~0.3%
• Cardiac arrest ~0.3%
• Ear pain ~0.4%
• Obstetrical or gynecological symptoms ~0.5%
• Headache ~1%
• Snakes <<<0.1%

39. Ground Back-Up
• Phone with MedAire – Tempe, Arizona
– 480 333 3700
• Mostly ER Docs - >50 of them
• Level I Trauma Center

43. Births and Deaths
• 5 years
• 2 airlines in Europe
• 613B revenue passenger kilometers
• 20% continental / 80% intercontinental
• 10,189 in-flight emergencies
• 279 diversions
• 2 births, 52 deaths

44. Who Responds to the Call?
• Physician passenger responds in ~48%
– But available in up to 85%
• Nurse passenger responds in ~20%
• EMT passenger responds in ~5%

45. Fitness to Fly
Can someone walk 50 yards (46 m) or
climb a single flight of stairs without
become severely dyspneic?
Medical Guidelines for Airline Travel, 2nd ed. Aerospace
Medical Association Medical Guidelines Task Force
Aviat Space Environ Med. 2003 May; 74(5 Suppl):A1-19.

46. Pressure / Oxygen
• Low available oxygen level drops healthy
adult’s pO2 to ~90%
• Cabin pressure roughly equivalent to same
altitude as Aspen, Colorado (~2400m)
• Low air pressure in cabin expands all air filled
spaces by ~30%
– Bowel, sinuses, middle ears, pneumothoraces

47. Managing in flight emergencies. Wallace TW, Wong
T, O'Bichere A, Ellis BW BMJ. 1995 Aug 5;
311(7001):374-6.

48. Procedure Note from Dr Wallace
I advised the patient that she had a serious
condition and that an operation was required,
but she was too ill to give written consent.
With the patient seated in her aircraft seat…
the insertion of a chest drain under local
anaesthetic was performed…insert chest drain
(i.e. 14F catheter with a wire coat hanger
trocar) into the left second intercostal space in
the mid-clavicular line.

49. Procedure Note from Dr Wallace
As soon as the drain was connected (Evian
bottle with two holes in the cap), air was
released from the pleural cavity and within five
minutes the patient had almost fully recovered.
The patient was left sitting in her passenger
seat and settled down to enjoy her meal and
the inflight entertainment.
Note: the author used a “five star brandy” as
disinfectant for the introducer.

51. US 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.”

52. Countries other than USA??
• Generally under jurisdiction of country where
aircraft is registered
• No known cases of lawsuits for responding

53. 1. Incidents rare, diversions rarer
2. Births and deaths REALLY rare
3. Cabin crew well trained
4. AED may save a life
5. First aid kit dinky but adequate
6. Good Samaritan’s got you covered
… unless you REALLY screw it up
7. Hey, you’re an ER doc – you got it
covered