Tiago Villanueva: What have I learnt from dealing with an in-flight medical emergency?

Tiago_VillanuevaRecently I was confronted with a medical emergency on board a short haul to Europe. The problem was a case of syncope, which is the most common in-flight medical emergency.

It was the first time I heard the phrase “Is there a doctor on board?” and I was apparently the only doctor on that flight. I learnt quite a lot from the experience, and it has made me think about what I should do now to be as prepared as possible in case this happens again, considering that I fly very often.

So, what I have learned exactly from this experience?

It reminded me that I should book a refresher course on immediate life support, since the last one I did was about four years ago. Fortunately, I didn’t have to carry out cardiopulmonary resuscitation (CPR) this time. But under conditions where resources are limited and working conditions are suboptimal, having sharp, fine tuned resuscitation skills may be vital if the worse comes to worst, particularly on long haul flights or flights that fly across long barren areas (like deserts or mountain ranges) or long stretches of sea, when it may take a long time to reach the nearest suitable airport. I’ve also been on flights over countries where it may not be safe to land.  As a GP it’s easy to overlook the need to remain able to manage life threatening emergencies as they are rare in primary care and it is easy to become deskilled even with regular refresher training. Even carrying out relatively simple technical procedures can become a challenge. There was a point when I thought I’d have to introduce an intravenous cannula, which is something I did for the last time many years ago when I was still working in hospital.

Nevertheless, I still think GPs and other generalist physicians like specialists in internal or emergency medicine are ideally placed to stand forward when situations like this happen. I’ve had a chance to discuss this incident with friends of mine who are doctors in other specialties like medical genetics, psychiatry, and ophtalmology, and many told me they would feel out of their depth if faced with such a situation. Moreover, a GP or any other doctor is never really offduty. I think the public expect a generalist physician (if not any physician) to be an adequate first responder to a medical emergency happening outside a healthcare facility before fully fledged pre-hospital support is available.

I found it extremely challenging to examine a patient during the flight and was wondering in what ways a lower oxygen environment such as a pressurised cabin changes the way we deliver care compared with our normal work on the ground. For example, how does the rate of the oxygen therapy administered during the flight differ from that administered on the ground? The turbulence, vibration, noise, and the plane’s changes of direction make it very difficult or to carry out certain technical procedures, for example auscultating a patient. Doctors will also need to continue to provide care until the patient is handed over to the on ground paramedical and medical teams, which will clearly include the descent and landing periods, when the plane is not in a horizontal position. I also think there was a conflict between what the flight crew considered was best for the patient’s safety (to have the patient seated), and what I thought was best for the patient’s health (to remain supine in the back of the plane).

Finally, I was expecting that airplanes used for short haul flights in Europe be better equipped for medical emergencies on board. There was a medical bag, which included some basic equipment and some drugs. However, there was no defibrillator available (making it impossible to monitor the heart rhythm), and there was no oximeter when I asked for one. Airlines in Europe should review their policies on medical equipment available on short haul flights.

In my case, even though the outcome was good and the patient recovered and was successfully handed over to the ground paramedical team, I faced a few dilemmas and I wish I had had specific training to attend to in-flight medical emergencies. I now believe this is something that cannot be overlooked in both undergraduate and postgraduate medical training curriculums as people (including both doctors and patients) travel increasingly more. When I was in medical school during the 90s, flying was still a privilege and low cost airlines were still in their infancy, but now flying is accessible to most people. The number of passengers going through Europe’s 20 busiest airports increased in 16 out of 20 airports from 2011 to 2012.

A non-medic friend of mine suggested there should be a doctor on board every flight, just like there are armed guards on board all the flights of certain airlines. I’m not sure we need to go that far, but this was my wake-up call to the importance of being prepared to assist a patient in the air as competently as I would do with a patient on the ground.

Tiago Villanueva is the BMJ editorial registrar.

See also: Emergency medicine—Cabin fever