Inflight medical emergencies and how to optimize your patients for safe travel
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Inflight medical emergencies and how to optimize your patients for safe travel Dr. Jim Chung Chief Medical Officer April 26, 2018 Travel Health Conference Winnipeg MB
Disclosure of Potential Conflict of Interest
Financial Disclosure
• Grants/Research Support: None
• Speakers Bureau/Honoraria: None
• Consulting Fees: None
• Other: Employee of Air Canada
The opinions expressed in this
presentation are mine and do not
“ necessarily represent the views of
Air Canada
2
Introduction
• Overview of inflight emergencies
• Emergency medical kits and supplies
• Airline protocols (ground based medical support)
• Indemnity
• Allergies
• Supplemental oxygen and Portable Oxygen Concentrators
(POCs)
• MEDIF – Is my patient safe to travel
• Use of aviation medical online resources
3
Overview
3.8 billion passengers 1 per year
• Canada = 140 million
passengers 2 per year
Emergencies:
* 1 in 11-20,000 passengers 3
per year
1. (Source: IATA)
2. (STATSCAN)
3. (Chandra et al, In-flight Medical Emergencies,
West J Emerg Med. 2013 Sep; 14(5): 499–504.)
4
Air travel is on the rise
• More travellers
• More vacation travel
• Older passengers
• More chronic disease
• Longer flights
• Sicker passengers
• Patients flying to alternative
sites for consultation or home
for medical care
5
Other considerations
6
Medical Volunteers
• Around 30 medical in-flight
events per day
• 69% of events are attended by
a medical professional
• MDs, RNs, Paramedics, first aid
responders
• Flight attendants are trained to
St. John’s First Aid standard
7
Airplane Environment
• Not ideal environments for dealing
with emergencies
– Cramped conditions
– Difficult access to the passenger in need
– Lack of privacy
– Language barriers
– Lack of medical equipment and supplies
– Noise and vibration
• Exacerbation of pre existing medical
problems
• Newly presenting medical conditions
that can manifest themselves in
altitude
8
Inflight Procedures
• Since 2000, Air Canada has used
telemedicine ground support
• Stat MD – University of
Pittsburgh Medical Centre
(UPMC) communicates with
captain
• Emergency Medical Kit (EMK)
used, STAT MD contacted
• Medical indemnity form for
provider
• Medical incident form recorded
• Communication of information
through flight deck
9
Air Canada Medical Kit • Blood pressure cuff • Bronchodilator: 1 inhaler • Stethoscope • Atropine 0.5 mg: 2 amp • 3 oropharyngeal airways • Lidocaine 100mg: 2 amp • Nitroglycerin 0.4 mg: 10 tab • Diphenhydramine 25 mg: 4 tab • Gloves • Acetaminophen 325mg: 4 tab • Diphenhydramine 50 mg: 2 amp • ASA • 4 syringes & 6 needles • Epinephrine • D50%: 1 amp 50ml • Ativan • Epinephrine 1:1000 : 6 amp • Atropine • 1 bag-valve device & 3 masks • Dextrose 5% • 1 IV set • Dextrose 50% • 3 pocket-masks • Dimenhydrinate • Automated External Defibrillator • Haldol • Glucometer • Lasix • Dressing box • Lidocaine • Cord clamp • Ketorolac • Urinary catheter • Procainamide • Intravenous Saline Solution • Solumedrol • Sterile Water • Valium • ASA 325 mg: 4 tab • Ventolin • Naloxone
Transport Canada List
• Blood Pressure cuff
• Stethoscope
• Syringes x 4
• Needles x 6
• D50W 50cc
• Epinephrine 1:1000 ampoules x 4
• Diphenhydramine injectable x 2
doses
• NTG 10 tabs
• Latex gloves 2 pairs
• Bronchodilator 1
• ASA 4 tablets
• CPR mask x 1
• IV kit x 1
• IV solution NS 500ml x 1
• Oral airways x 3
• Atropine x 1
• Basic instructions for use of the
drugs in the kit
13AIR CANADA MEDICAL APP
14LOCATION OF EQUIPMENT
15ALGORITHMS AND INSTRUCTIONS
16Other equipment
• Most if not all major airlines
have AEDs onboard and
training for flight attendants on
usage
• Emergency oxygen is also
stored and available
• BVMs are available
• First aid kits – 1/50 pax
available consisting of
bandages, burn dressings etc.
• Usually a separate medication
pouch is available with common
OTC meds such as Gravol,
Tylenol etc.
17Common issues and complaints
Pulse oximeter – on ground 98-99% normal
• in the air – 90-94% normal
Blood pressure (BP) cuff and stethoscope
• Due ambient cabin noise, often difficult to hear with stethoscope.
Can do systolic BP by palpation of radial artery
Glucometer
• Take the time to read the instructions and ensure strips are right
side up
Tempa-dot thermometers
• Follow the instructions to apply and record the reading
18Indemnity and Liability
• Air Canada has formal indemnification policy and form – medical
provider receives a copy of this
• Most countries have Good Samaritan provisions
• U.S. – Aviation Medical Assistance Act
• CMPA will provide assistance
• Note: accepting monetary compensation can potentially cause issues
with “volunteer” status
• Ethical and moral obligation in common law jurisdictions
• In civil law countries may be legal obligation
19Allergies
• Animal allergies – can request
buffer zone
• Peanut allergies – no peanut
products are offered onboard
– Should carry own food, cannot
guarantee peanut free food
– Must carry onboard own epipen
and other medications ie. Ventolin
– Bring wipes, hand sanitizer
– Will be allowed to board early to
clean surrounding area
– Passengers around your patient
will be advised not to consume or
bring out any peanuts due to
passenger with allergy
• Most airlines have similar policies in
place
20Oxygen and POCs
• Generally most airlines do not
provide oxygen
• WestJet allows passengers to bring
own oxygen
• Air Canada provides oxygen on
request for a fee
• U.S. carriers only allow POCs
(portable oxygen concentrators)
21The cabin is a relatively hypobaric
environment
• Jet airplanes cruise at
30 – 40,000 feet ASL
• Cabin pressurized to
6,000 – 8,000 feet
• Normal healthy individuals will
not notice any effects
• Those at risk of hypoxia may
see symptoms and
exacerbation of their condition
22Oxygen requirements
• Need more supplemental oxygen
at altitude
• Rule of 2s
• High Altitude Simulation Test
(HAST)
• 100 m walk test (mild physical
exertion)
• POCs should be used on ground
first to ensure familiarity and
ability to manage device i.e.
Change batteries
• POCs cannot plug in to outlets
onboard – low voltage and won’t
work, need enough batteries to
complete flight
23Oxygen
You want to figure out what the patient’s O 2 needs will be at
altitude.
Altitude Oxygen Requirement
Equation
FiO2ground x Pground = FiO2alt
PaltOxygen cylinder at home 1lpm = 24% 2lpm = 28% 3lpm = 32% 4lpm = 36% 5lpm = 40% 6lpm = 44%
Calculating Oxygen Need
FiO2ground x Pground = FiO2alt
Palt
0.30 x 760mmHg = FiO2alt
565 .40 = FiO2alt
40% oxygenConditions aggravated by hypoxia
• Anemia – can cause multiple
issues
• Sickle cell anemia
• Chronic Obstructive Pulmonary
Disease (COPD)
• Pleural effusion
• Pulmonary fibrosis
• Atrioventricular shunts,
congenital heart disease
• Coronary Artery Disease (CAD)
• Cerebral Vascular Accident
(CVA)
28Pressure/Volume relationship
Boyle’s Law
• Inverse relationship between
pressure and volume of a gas
• Barotrauma risk
• Middle ear, sinuses in winter Upper
Respiratory Tract Infection (URI)
season
• Bowels – laparoscopic, laparotomy
procedures, diverticulitis
• Eyes – retinal pneumoplexy
• Catheters – replace air with saline
• Pneumothorax
• Acute fractures in circumferential
casts
29Typical presentations of inflight events
• Chest Pain
• Shortness of Breath
• Dizziness/Loss of
Consciousness (LOC)
• Abdominal Pain
• Ear/sinus pain
30MEDIF (passenger clearance form)
• On most airline websites will
find MEDIF form to provide
medical information
• Airline will work with health
provider to ensure a safe and
unremarkable flight
• Stretcher passenger are
generally not accepted by most
airlines with some exceptions
• Range of medical services
available inflight vary with the
airline, please check with the
intended airline to confirm
31Lufthansa PTC
32Online Medical Resources
IATA – Medical Manual Feb 2018
– http://www.iata.org/publications/Pages/medical-manual.aspx
Aerospace Medical Association
– https://www.asma.org/publications/medical-publications-for-
airline-travel
Various airline websites i.e. Air New Zealand, Qantas, Cathay Pacific
33CMAJ
3436
37
Summary
The relatively hypobaric and hypoxic environment of an airplane
cabin can be an issue in those with some compromise
There are lots of resources out there to assist you in determining
whether your patient is safe to travel including calling the airline’s
medical department directly
Medical care overseas can be costly and diversion and dropping off a
patient in a country they weren’t intending on travelling to can be
stressful as well as language issues, local laws etc…
38Thank you Merci aircanada.com
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