среда, 27. јул 2016.

New challenges in resuscitation medicine

New challenges in resuscitation medicine

You're seated in an aircraft, flying at 30,000 feet across the country to attend an EMS conference. Unexpectedly, you hear a chime, and the flight attendant makes the announcement made popular by episodes of "Rescue 911" and other medical drama shows: "Is there a medical professional on board this aircraft?" Will you volunteer your knowledge and skills on this flight? Do you know what supplies and resources are available to you?
Every year, more than 500 million Americans travel by air in the U.S. (1) Medical emergencies aboard aircrafts are inevitable, and an estimated one per 10–40,000 passengers will experience one. (2) With commercial air traffic increasing, these emergencies are expected to become more frequent as the percentage of older people increases. (3) Although flight attendants are required to undergo initial and recurrent training on aviation medicine, first aid, CPR and automated external defibrillator (AED) usage every 12–24 months, EMTs, paramedics and other medical professionals can still provide valuable assessment and treatment to passengers who become ill in flight. (4,5) EMS providers should be aware of the legal protections afforded to them as Good Samaritans of the sky, along with equipment and technologies aboard aircrafts that will assist in providing patient care.
All EMS providers know that state Good Samaritan laws protect them legally while providing assistance off duty and in good faith. In 1998, these protections were expanded to medical professionals in the sky providing in-flight emergency care, with the enactment of the Aviation Medical Assistance Act by Congress. The act specifically protects state-qualified EMTs and paramedics, along with physicians, nurses and physician assistants. (6) It states, "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."
Despite these generous protections, EMS providers must continue to follow the standards expected of Good Samaritans. EMTs and paramedics who choose to volunteer in an in-flight emergency may be required to show identification to the cabin crew indicating their level of training at the time of the emergency. Air carriers may choose to refuse assistance if identification isn't provided.
EMS providers should only work within their scope of practice and not perform interventions or treatments they haven't been trained to do. Whenever possible, an attempt should be made to contact the ground-based physician services the airline may utilize on a regular basis. (7) MedLink is one of the most popular telemedicine services, and is used by many U.S. air carriers. This service permits an aircraft to contact emergency department physicians at a dispatching center in Phoenix via aircraft VHF radio or satellite phone.
A ground-based physician may help guide patient treatment and request that the EMS provider administer medications. More importantly, the ground physician typically will take responsibility for deciding if a flight diversion is appropriate. Although medical volunteers may offer a recommendation to divert the aircraft in an emergency while on board, the final diversion decision is made by the pilot in command because landing weight, fuel, weather, appropriate airport facilities and geographical terrain must be considered. One European study found that on transcontinental flights, the most common causes of aircraft diversion included suspected myocardial infarction, stroke and seizures. (2)
The Aviation Medical Assistance Act also mandates U.S. commercial air carriers that have at least one flight attendant be equipped with an AED, along with an emergency medical kit (EMK). (8,9,10) Other national aviation regulators, such as the European Aviation Safety Agency (EASA), still don't mandate that European commercial aircraft be equipped with AEDs. (11,12,13,14) (Pending amendments to the EASA regulations that are currently in the rulemaking process are expected to change this.)
Fortunately, a significant number of airlines exceed national regulatory requirements. For example, the U.K.-based carrier Virgin Atlantic equipped their aircrafts with AEDs as early as 1990, despite no law requiring AEDs be carried on British aircraft. (15) American Airlines had the distinction of being the first airline in the U.S. to equip its fleet with AEDs in 1997, along with the first documented domestic in-flight cardiac arrest save in 1998. (16)
EMS providers may be surprised at what medical equipment is available to them on a commercial aircraft. Providers on commercial flights with at least one flight attendant can expect to find a first aid kit, portable oxygen bottles, an AED and an EMK on board. The contents and quantity of equipment is regulated carefully by the Federal Aviation Administration. As such, the equipment carried by different air carriers is fairly universal.
Although the first aid kit contains only basic equipment, such as bandages and splints, the EMK, which was envisioned by the FAA to be more of a doctor's kit, provides a considerable range of emergency pharmaceuticals and devices that most EMT-Intermediates and paramedics would be familiar with. These items include a stethoscope; blood pressure cuff; bag-mask resuscitator (one required, child/infant optional); oral airways (three sizes required); nitroglycerin (at least 10 tablets); aspirin (at least four tablets); albuterol (one metered-dose inhaler required); dextrose 50% (at least 25 grams); injectable 1:1000 epinephrine for an allergic reaction (at least 2 mg); oral antihistamines (at least four tables); IV antihistamines (at least two ampoules) and cardiac resuscitation drugs, including IV 1:10,000 epinephrine (at least 2 mg total), atropine (at least 1 mg total) and lidocaine (at least 200mg total). Five-hundred milliliters of normal saline, an IV drip set and a variety of needles and syringes are also to be equipped. (17,18,19)
Although not required by regulatory requirements, airlines may also elect to equip their aircraft with additional drugs and equipment, such as the antiemetic ondansetron (Zofran), glucagon, nalbuphine (an opiate for pain relief) and naloxone. (20, 21, 22) A small number of airlines have chosen to equip their long-haul aircraft with the Tempus IC, a state-of-the-art telemedicine monitor that includes an automated blood pressure cuff, glucometer, thermometer, capnometer, 12-lead ECG and pulse oximeter that can transmit information (including digital pictures and video) to a ground-based physician. (23) The device provides on-screen, step-by-step instructions on how to use the diagnostic features, much like AED prompts, enabling even the cabin crew to provide essential medical monitoring. Investments in these medications and technologies, while expensive, may still be cost-effective, considering diversions can cost from $15,000 to well more than $500,000 depending on the aircraft's travel route. (7)
However, much of these advanced devices and drugs not required to be in the EMK are reserved for air carriers travelling on intercontinental flights. The EMS provider in most aircraft medical emergencies may quickly realize the limitations of the medical equipment provided on board.
Limitations of Equipment & Alterations to Care
The biggest challenge is the tight space in which a patient may be located, particularly in such areas as coach or lavatories. Aircraft in the U.S. with 60 or more seats are required to carry an on-board wheelchair, which is designed to allow access into the aisles and lavatory. (24) Some airlines carry mobility aids, such as transfer slings for short moves, but this equipment isn't mandated aboard aircrafts.
Should a patient need to be placed supine, such as in a cardiac arrest situation, flight attendants are typically trained to use able-bodied passengers to assist in manually moving the patient into the aisle or the galley area where the patient can be more easily managed. Flight attendants are also specially trained on how to open a locked lavatory door if a passenger becomes unconscious inside.
Here are some equipment challenges that EMS providers may face, some of which are the result of peculiarities with Federal Aviation Regulations:
  • During patient assessment and evaluation, auscultation in an aircraft using a stethoscope can be difficult due to ambient engine noise and instead require that systolic blood pressure be palpated.
  • Aviation portable oxygen bottles (POBs) generally have only one of two fixed settings: "low flow" (2 lpm) and "high flow" (4 lpm) for first aid purposes and decompression emergencies, which is far lower than what is normally used in EMS settings. Even more unusual, oxygen tubing for the bag-valve mask resuscitations aren't required to be compatible with these on-board oxygen bottles.
  • The AEDs on board aren't required to have ECG screen even though ACLS medications are provided; without an ECG screen, it may be more difficult for the EMS provider to determine which cardiac resuscitation algorithm and drug to use during a prolonged cardiac arrest. If an AED does have an ECG screen, it's typically limited to a leads II/paddles view.
  • Glucometers aren't mandated in EMKs, despite the requirement to have dextrose 50%, which may make it difficult to identify hypoglycemic emergencies.
These limitations may require creative thinking by the EMS provider, such as consulting the ground-based physician for ACLS medication orders, or, for example, using the public announcement system to ask if any passenger on board the aircraft would be willing to share their personal glucometer for the medical emergency.


Despite being in a pressurized metal container at 30,000 feet, U.S. commercial aircraft have well-trained crews with considerable equipment the EMT and paramedic can utilize in a medical emergency. EMS providers are well suited to being first responders of in-flight emergencies because the creativity and innovation they use every day at work will assist in providing appropriate patient care.

1. United States Federal Aviation Administration. Moving America safely: 2005 annual performance report. FAA, 2005. http://www.faa.gov/air_traffic/publications/media/APR_year2.pdf.
2. Sand M, Bechara FG, San D, et al. Surgical and medical emergencies on board European aircraft: a retrospective study of 10189 cases. http://ccforum.com/content/13/1/R3.
3. Goodwin T. In-flight medical emergencies: an overview. Brit Med J. 321:1338–1341.
4. U.S. Department of Transportation. FAA. Advisory circular: Air Carrier First Aid Programs. FAA, 1995. http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%20120-44A/$FILE/ac120-44a.pdf
5. FAA. Advisory circular: Emergency medical equipment training.
6. Aviation Medical Assistance Act of 1998.
7. Ruskin KJ, Hernandez KA, Barash PG. Management of in-flight medical emergencies. Anesthesiology. 108:749–755, 2008. http://journals.lww.com/anesthesiology/Fulltext/2008/04000/Management_of_In_flight_Medical_Emergencies.27.aspx.
8. FAA. Appendix A: First-aid kits and emergency medical kits. Code of Federal Regulations A121.1.
9. FAA. Subpart M: Airman and crewmember requirements. Code of Federal Regulations Sec. 121.391. http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgFar.nsf/FARSBySectLookup/121.391!OpenDocument&ExpandSection=2.
10. FSF Editorial Staff. Enhanced emergency medical kits increase in-flight options. Cabin Crew Safety 36.6 (2001): 1–6. www.flightsafety.org/ccs/ccs_nov-dec01.pdf.
11. Civil Aviation Authority. Defibrillators. Is it compulsory for airlines to carry a defibrillator on an aircraft? FAQ Details. www.caa.co.uk/default.aspx?catid=923&pagetype=70&gid=924&faqid=929.
12. Joint Aviation Authorities. JAR-OPS 1: Commercial Air Transportation (Aeroplanes). www.jaa.nl/publications/jars/jar-ops-1.pdf.
13. European Aviation Safety Agency. Notice of proposed amendment (NPA) no 2009-02B. www.easa.europa.eu/ws_prod/r/doc/NPA/NPA%202009-02B.pdf.
14. Bentley D. “Is there a doctor onboard?” International Travel Insurance Journal. www.medaire.com/doctor3.pdf.
15. Virgin Atlantic. Virgin Atlantic's Special Assistance. www.virgin-atlantic.com/tridion/images/factsheet_specialassistance_tcm4-426062.pdf.
16. Chiu Alexis. Man becomes first person to be saved by in-flight defibrillator. www.cjonline.com/stories/112698/new_flightsave.shtml.
17. FAA. Subpart K: Instrument and equipment requirements. Code of Federal Regulations Sec. 121.333. http://rgl.faa.gov/REGULATORY_AND_GUIDANCE_LIBRARY/RGFAR.NSF/0/5a99c617262ef7ab862570d70078ae87!OpenDocument&ExpandSection=-3.
18. Federal Aviation Administration. Appendix A to Part 121: First Aid Kits and Emergency Medical Kits. 2005. http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=85f4200801c3d7eeab7b83c94d88c21c&rgn=div9&view=text&node=14:
19. FAA. Advisory circular: Emergency medical equipment
training. http://rgl.faa.gov/REGULATORY_AND_GUIDANCE_LIBRARY/RGADVISORYCIRCULAR.NSF/0/cf4757674272a38a8625710700523ad6/$FILE/AC121-34B.pdf.
20. Air Canada. Air Canada aircraft medical kit 2008.
21. MedAire. Enhanced emergency medical kit contents. MedAire, 2007.
22. MedAire. MedAire strategically adds/deletes kit items.
23. Alcock C. Tempus adds video link to medical emergency kit. www.ainonline.com/news/single-news-page/article/tempus-adds-video-link-to-medical-emergency-kit/
24. Code of Federal Regulations. § 382.65 What are the requirements concerning
on-board wheelchairs?