s a medical student, I used to worry about hearing those words while flying between interviews and trips home from school. Thankfully I managed to make it through my training without my services being requested on an airplane. Since leaving residency and entering private practice, however, I have been involved with two such incidents. The most recent occurred as the plane was being pushed back from the gate in Sitka, Alaska. Someone on the other side of the aisle started yelling that one of the passengers was not moving. I looked over to see an elderly gentleman slumped over in his seat. I found that he was not breathing and had no pulse. The flight attendants asked if I needed the plane’s emergency kit. Another man who identified himself as an E.R. resident also offered to help. We managed to drag the man to the center aisle floor of the plane so that we could perform cardiopulmonary resuscitation (CPR). Much to my amazement, I was handed an Ambu bag to provide positive pressure ventilation. The E.R. resident physician began doing chest compressions. An automatic external defibrillator (AED) also appeared. Once I attached it to the patient, we could see that he was in a very slow bradycardia.

The flight crew handed me an amazingly well-stocked medication kit containing atropine, epinephrine and a variety of other medications. Once an I.V. was started, we gave the patient atropine followed by epinephrine without any significant improvement in his cardiovascular status. We continued CPR until the local emergency medical technicians (EMTs) arrived. We moved the patient to the front of the plane and onto the waiting gurney in the jetway. I told the EMTs that I was an anesthesiologist and offered to intubate the patient’s trachea if they had the necessary equipment. After placing the tube, we moved out through the airport to the waiting ambulance. By the time the EMTs were ready to depart for the hospital, the patient’s pulse had returned, and he was breathing with some assistance. I telephoned the hospital the following morning. The nurse taking care of the patient said the man was now extubated and sitting up in bed.

A few years prior to that, on a flight to Hawaii, I was summoned to see a passenger in first class who was complaining of chest pain. (Due to managed care, I was, of course, seated in coach.) On speaking with him, I decided he was having heartburn, which he told me had experienced many times before. This was confirmed after he consumed some antacid, which caused his symptoms to rapidly dissipate.

My having been involved with both of these incidents made me curious as to the entire process surrounding in-flight medical emergencies. I wanted to know about the preparations that airlines make for such emergencies, how the process was regulated, how frequently these emergencies occur and the legal implications of practicing outside of the state where the physician is licensed. I thought it would be valuable for physicians to know what sort of preparations have been made should they face an in-flight medical emergency.

Having sophisticated medical kits and defibrillators on all commercial airlines is a relatively new phenomenon. It was not until April 12, 2004, that the Federal Aviation Administration (FAA) implemented a regulation (FAR 121.803) that all U.S.-based commercial airlines must carry a defibrillator and an enhanced (containing an I.V. along with injectable medications) emergency medical kit.¹

Today the vast majority of commercial airlines, instead of using their own medical departments, outsource the emergency preparations to a company known as MedAire located in Tempe, Arizona <www.medaire.com>. In addition to providing the medical equipment and medications, the company provides 24/7 support to commercial airliners (as well as to ocean-going ships and private jets). If there is an in-flight emergency, the pilot contacts MedAire either by telephone, telex or radio. MedAire/MedLink has a group of board-certified emergency physicians available to provide assistance and guidance. MedAire currently provides this support for almost 90 of the world’s commercial airlines² (listed at <www.medaire.com/comm_clients.html>). Most of the private jets produced by Gulfstream, Boeing and other manufacturers also include these emergency kits and come with a subscription to the MedAire service.

I spoke with Jill Drake, one the firm’s representatives, who told me that her organization handles between 90 to 100 medical calls per day. The company statistics for the year 2005 as to the leading causes of calls are listed below³ in Table 1:

The firm does not report statistics for survival/morbidity rates. Ms. Drake stated that according to their records in 2005, of all of the cases handled by MedLink (MedAire’s inflight medical advisory service), a medical professional volunteered to assist in only 20 percent of the cases. She did not have any information as to whether this was due to lack of medical personnel being present or due to unwillingness to volunteer.

American Airlines was the first U.S. airline to place AED units on all of its aircraft. It also was the first to include enhanced emergency kits, beginning in 1997, seven years before the FAA regulations were changed to require them.⁴ The contents of the enhanced emergency kit required by the FAA are shown in Table 2. While certainly not on par with a hospital emergency department, the list of medications and equipment seems thorough. Medaire also provides additional equipment or medications if requested by the individual airline.² I think it might be wise if the required list was re-evaluated by physicians to determine if there are other items that might be helpful to be included such as naloxone, glucagon and perhaps a beta-blocker. Both of the airlines I flew on had more medications available than are required by the FAA regulation. For instance the oral antacid that I gave the man in my second incident was not required to be included in the kit.

As I indicated, I was pleasantly surprised at how well-prepared the flight crew was on my Alaska Airlines flight on which I helped perform CPR. I received more information from Scott Strickland, flight attendant instructor for Alaska Airlines, who outlined for me how the flight crews on his airline are trained. All Alaska Airline flight attendants are certified in CPR, AED use and first aid before they begin flying. They receive periodic printed updates on equipment use and procedures. They also must attend yearly classes that review new procedures and determine CPR proficiency. The airline utilizes the Medaire service to provide for additional assistance.⁶

Legal Issues
Many physicians are concerned about legal liability when called to assist someone in an environment outside of their office/hospital setting. The “good samaritan” laws were created to protect those rendering aid in an emergency situation. The California legislature passed the first statute that would eventually be labeled a good samaritan law in 1959. All of the remaining states ultimately passed similar laws.⁷ In addition, if an onboard medical professional acts on the advice of the MedAire physician on the ground, MedAire covers him or her for legal liability. If physicians act on their own, they are covered by their malpractice insurance as if they rendered care in a local shopping mall, etc.^{1, 7}

Four requirements must be met for the good samaritan statutes to be in effect. First, the situation must be a true emergency. Second, the care must be rendered free of charge. If a physician renders aid, then bills for the care, he/she is no longer under the good samaritan legal umbrella. Third, the care must be provided in good faith; in other words, not doing anything intentional to harm the patient. Most states exclude protection for gross negligence (willful or intentional harm inflicted on another that results from a substantial deviation from the general standard of care). Finally, once a physician offers emergency assistance, he or she has a legal duty to remain with the patient until the victim is stabilized or until another provider with equivalent or higher training takes over.⁷

Since the patient’s chances for survival go down rapidly the longer it takes for the heart to be defibrillated, having a life-saving device such as the AED, along with the appropriate medications, readily available is clearly beneficial. Also having skilled individuals available for assistance is clearly helpful in saving lives. It is important for health care professionals traveling on commercial airlines to know that should an emergency occur with one of the passengers, there is a good system for assistance as well as a well-stocked emergency kit available to assist them in caring for the patient. Similarly it is vital that all physicians remain current on their advanced cardiac life support (ACLS) and basic life support certifications so that they will feel comfortable in such a situation where someone requires immediate assistance in a remote location such as an airplane over the ocean.

Perhaps someday in the future we will see the airlines offer to upgrade a doctor (and hopefully his/her spouse) to first class if he/she identifies him/herself while boarding as an ACLS-certified physician who would be willing to help in the event of an emergency. Such a policy would eliminate the need to make an overhead page in the event of an emergency and also would serve as an incentive for all physicians to keep up their basic life-saving skills.


References:
1. FAA regulations, section 121.803. and appendix to section 121.803. 2006. <www.airweb.faa.gov/Regulatory_and_Guidance_Library/zrgFAR.nsf/0/129DB265D2422DEE86256A65006505A2?OpenDocument&Highlight=121.803>.
2. Personal communication with Jill Drake, Medaire marketing representative. May 2006. <www.medaire.com>.
3. Unpublished data. Personal communication with Jill Drake, Medaire marketing representative. June 2006.
4. McKenas, DK. American Airlines was the first domestic air carrier to place automatic external defibrillators on its fleet, commencing July 1st, 1977. American Airlines Corporate Medical Department. <www.house.gov/transportation/aviation/hearing/06-20-00/mckenas.html>.
6. Strickland, S. Flight Attendant Instructor, Alaska Airlines. Personal communication. May 2006.
7. DeGuerre C. Good Samaritan Statutes: Are Medical Volunteers Protected? American Medical Association (Virtual Mentor) Case in Health Law. April 2004. <www.ama-assn.org/ama/pub/category/print/12191.html>.

Richard O’Leary, Jr., M.D., is an anesthesiologist with Associated Anesthesiologists Medical Group, San Jose, California, and Medical Director, Forest Surgery Center, San Jose.