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Medical News & Perspectives
June 27, 2018

“Is There a Doctor on the Plane?”

JAMA. Published online June 27, 2018. doi:10.1001/jama.2018.6654

It might seem like an odd thing to pack in a travel bag, but Rachel Zang, MD, never boards a flight without a supply of ondansetron. On a flight from the United Kingdom back to the United States, Zang stepped up to help a 2-year-old who was vomiting. To her surprise, the medical kit on board had no antiemetics.

iStock.com/Mutlu Kurtbas

“The standard [kits] do not require them,” says Zang, a fourth-year emergency medicine resident at the Hospital of the University of Pennsylvania in Philadelphia. “You have no ability to give a medication to stop vomiting.”

As a frequent traveler—she has been to 30 countries, including medical missions to Tanzania and Rwanda—Zang wanted to be better prepared when the next in-flight medical emergency crops up. She researched domestic and international laws and learned what those airline medical kits are supposed to contain and what they lack.

In fact, Zang amassed so much material that she shared it with her colleagues during a grand rounds on in-flight medicine. “Lots of people were interested,” she says. “[I]t’s something everyone’s a little uncomfortable with … so they want to know as much information as they can about it.”

With summer travel in full swing, Zang spent some on-the-ground time talking with JAMA about the ins and outs of responding to in-flight medical emergencies. The following is an edited version of that conversation.

JAMA:How often have you encountered medical emergencies on flights?

Dr Zang:In the last 4 years, I've had 2 medical emergencies that I responded to, and then my husband has had 2 as well. He’s also a physician.

JAMA:The common conditions that usually occur in flight are lightheadedness, loss of consciousness, nausea, vomiting, and cardiac or respiratory symptoms. Have these been the conditions that you, your husband, or other physicians you know have encountered during flights?

Dr Zang:Yes, definitely. My husband has responded to 2 syncopal episodes and many of my colleagues have responded to lightheadedness or vomiting. In the literature, the most common condition is syncope or near syncope. That accounts for about 37% of in-flight medical emergencies. The next most common is respiratory distress. That's about 12%, followed by vomiting and then chest pain.

JAMA:Are those conditions related to circumstances inside the plane, either cabin pressure or other factors?

Dr Zang:The airplane causes a lot of unique changes in the body that we're not really aware of. Being on a flight is the equivalent to being at 6000 to 8000 feet of altitude. At sea level, oxygen saturation in all of us healthy people is 99% to 100%, but when we go up into the air, most of us would be about 92% to 95%. So you can see how anyone who had underlying respiratory or cardiac issues, if their oxygen saturation drops lower, it's going to exacerbate angina or make their COPD [chronic obstructive pulmonary disease] or asthma worse. In turn, the very low humidity in the airplane has been shown to exacerbate asthma and COPD because of the increased dehydration and the increased mucosal dryness.

JAMA:Were the medical supplies on the plane adequate for the emergencies you dealt with?

Dr Zang:The emergencies that I handled were minor. One person had a headache and wanted Tylenol, which is in the medical kit. For the young child who was vomiting and very dehydrated, I had to mix my own oral rehydration solution, which is very easy. It's 6 teaspoons of sugar and half a teaspoon of salt in a liter of water. And you have syringes. So for very little kids, you can mix that up, and mom can give it to the child. Or you could use an IV [intravenous route] in a dehydrated child, which I think would be very challenging in the air.

JAMA:Are there standard supplies that airlines are required to keep on board, either by federal law or their company policies?

Dr Zang:In the United States, federal law mandates that all airlines have a first aid kit, an oxygen tank with enough oxygen for 2% of the passengers for the duration of the flight, and an AED [automated external defibrillator]. In the standard medical kit you get a stethoscope, blood pressure cuff, and gloves. You get an array of oral airways and bag valve masks and CPR [cardiopulmonary resuscitation] masks. You get a few needles, a few syringes, and a 500-cc bag of saline solution, and then you get a short list of medications: Tylenol and Benadryl in oral and IV form, aspirin, atropine, albuterol, and 1 A of D50 [50% dextrose]. You also have epinephrine in both IO [intraosseus] dose and anaphylactic dose, lidocaine, and nitroglycerin tablets.

JAMA:Despite the US minimum requirements, do any airlines go beyond the minimum?

Dr Zang:The only airlines I found that went beyond the minimum were international airlines. That's not to say US airlines don't; I just couldn't find any documentation. Some that go above and beyond are ANA [All Nippon Airways], a Japanese airline, and Lufthansa. Both of them have very extensive medical kits, and they have a program called Doctor on Board that allows you to designate yourself as a physician when you book your ticket so they don't have to page overhead. They provide some access to their medical supply kits and information when you sign up so you know what's on their plane. Turkish Airlines has a similar program.

JAMA:Would it be helpful to have a universal program like that for all airlines worldwide?

Dr Zang:Yes. We don't even have a national reporting database to figure out how often these in-flight medical emergencies happen. We think the numbers we have are grossly underestimated and it is well known in the airline industry that in-flight medical emergencies are expected to increase. People are flying more often and more elderly and people with preexisting medical conditions are flying. It's expected that by 2023, half of airline passengers will be over the age of 50. Doctors could be better equipped if there was a standard medical kit on every flight so you knew the medication and equipment you had access to.

JAMA:If you had a wish list of onboard improvements, what would they be?

Dr Zang:I would start small. Since 2001, when regulations for the emergency medical kit and the AED onboard went into effect, the FAA [Federal Aviation Administration] has not reexamined the medications in the kit. For example, lidocaine is still in the kit because it used to be recommended for cardiac arrest. It no longer is, but it's still in the kit, as opposed other medications. At the very least, it would be nice if the FAA would reevaluate what's in the mandated medical kit and add some basic things like Zofran for an antiemetic. On a broader scale, airlines are governed by so many different bodies, not just in the United States, but internationally.

So my wish would be that one person could create an international governing body of airlines and have it mandate medical equipment. The AED is necessary; a few more in the kit would be helpful. Now, if you want to put in an IV, you have 2 tries, and that's it. If you miss, you're done. Some more fluid in the kit would be helpful; 500 cc is not very much if you're dealing with a significantly dehydrated person on a long flight. Definitely, the medications need to be updated. If I had all of my dreams, pediatric and obstetric equipment would be included. There is no obstetric medication in any of the kits and there is no pediatric dosing or, aside from a CPR mask, anything pediatric related. There's not even a glucometer.

JAMA:Do you think physicians sometimes are hesitant to come forward when there's a medical emergency on their flight?

Dr Zang:Yes, for a variety of reasons. You don't know why they're asking for a physician or if you're equipped to handle what they're asking for. Maybe you're really exhausted from a long trip. Maybe you had a beer with your dinner and you're not sure if you should step in. I think a lot of physicians aren't sure what their liability is if something goes wrong. So there's a whole host of reasons why physicians would feel uncomfortable.

JAMA:What are the potential legal liabilities?

Dr Zang:It depends on where you are. The US has the Aviation Medical Assistance Act of 1998 that says individuals shall not be liable for damages in federal or state court for any reason when they provide in-flight medical care unless they were grossly negligent or had willful misconduct. This covers physicians, nurses, nursing assistants, paramedics, and EMTs (emergency medical technicians). What that says is you will not be penalized if you attempt to help in good faith. The only reason that you could be liable is if you were grossly negligent because you were so fatigued you couldn't think straight, or you had taken medication because you were planning to sleep, or you were intoxicated because you drank a lot on the plane. The Act goes even further and says you can't be held liable if your recommendation is to divert the plane and they don't and something goes wrong. You can't be held liable if the equipment fails or if the patient collapses in front of you and you jump in to help even though nobody asked.

What’s less clear is when you're on international flights. For example, the United Kingdom does not have national law on this, and their airlines decide individually how they will cover physicians’ legal protections. British Airways, Virgin Atlantic, and other carriers provide indemnity for medical professionals, but unless you're looking up every flight, you might not know how you're covered. Then it becomes unclear what airspace you're in. If you’re on a French flight to the US in US airspace, are you covered under US law or French law? It can get complicated.

JAMA:Have you ever had to ask the pilot to divert the flight?

Dr Zang:I have never been in that situation. But diverting a flight is not as simple as it may seem because it involves a lot of other things besides the issue of that 1 patient. How far are you from the next possible airport and what is the emergency they're having? If somebody's going into labor, the next closest airport might not have medical capabilities to deal with obstetric issues. Ultimately, it's the pilot's decision.

JAMA:This issue was in the news recently after a lawsuit was filed in a case from 2016. A young woman died after a physician on the plane said she needed immediate care on the ground. An airline physician on the ground advised to continue on for 90 minutes and the pilot didn’t divert the flight. The woman died 3 days later; the cause reportedly was a pulmonary embolism. Is there anything else a physician could do in a circumstance like that?

Dr Zang:No. All you can do is speak with the ground doctor and the pilot and offer your recommendations. If the patient worsens or something changes, it's important to relay that to the ground doctor because it might change his or her decision. Statistically, the pilot will side with the doctor on the ground simply because they tend to have more experience in in-flight medical emergencies.

JAMA:During your grand grounds on in-flight medical emergencies, what were the most important things you felt your colleagues should know, especially those who had never encountered an in-flight emergency?

Dr Zang:The most important things for them to know were what equipment they can expect to have on board, the most common chief complaints, and what other resources they have. Flight attendants are all certified in CPR and AED use. Having access to a medical command doctor who deals with in-flight medical emergencies every day was something I didn’t know, and I think it's helpful to realize that you're not entirely alone up in the air.

I've received a lot of questions about credentials. The Aviation Medical Assistance Act of 1998 says that in good faith, the flight attendants believe the passenger offering assistance is a medical-qualified individual. So technically, you do not have to show credentials. But the FAA has come out with other regulatory letters, most recently in 2006, that said it’s preferable for flight attendants to check credentials of people holding themselves out as medical specialists. So I wouldn't be surprised or offended if somebody asks for credentials. I always fly with my medical credentials now.

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