In-Flight Medical Emergencies: A Review

Oxygen Saturation in Relation to Flying Altitude. A Scoping Review Protocol

BACKGROUND

During air travel, the decrease in air pressure leads to a decrease in oxygen partial pressure causing oxygen desaturation. Every year, several commercial aircraft need to divert and perform unscheduled landings due to hypoxic symptoms or medical emergencies. How individuals are affected depends on their physical and medical conditions, as well as the cabin pressure of the aircraft. The phenomenon is of particular concern for individuals with pre-existing medical conditions, as it may lead to hypoxic symptoms and necessitate unscheduled landings in some cases. The investigators aim to investigate the existing literature to explore how the impact of reduced oxygen partial pressure affects the oxygen saturation as a result of a decrease in cabin pressure due to aircraft altitude, and to assess the frequency of hypoxic symptoms reported during air travel. The purpose of the scoping review is to investigate the relationship between altitude, cabin pressure, and patient oxygenation during air travel. Further, the investigators will report the frequency of the reporting of hypoxic symptoms in the studies conducted.

METHODS AND ANALYSIS

This scoping review will be conducted in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Scoping Reviews. The review question will be formulated using the Population, Intervention, Comparator, Outcome, Study Design, Timeframe (PICOST) framework. Every study design is eligible, apart from reviews, meta-analyses, comments/letters without original data, case reports with less than five cases, animal studies, and in vitro studies. The investigators will include all articles in English or Scandinavian. The investigators will base their conclusions on the findings of the review.

ETHICS AND DISSEMINATION

According to Danish law, scoping reviews are exempt from ethics committee approval. The investigators will publish results from the scoping review in a peer-reviewed journal and present the results at scientific conferences.

Flying to high-altitude destinations

Every year millions of people fly to high-altitude destinations. They thereby expose themselves to specific high-altitude conditions. The hypoxic environment (low ambient oxygen availability) constitutes a major factor affecting health and well-being at high altitude. While the oxygen availability is already moderately reduced inside the aircraft cabin, this reduction becomes aggravated when leaving the plane at high-altitude destinations. Especially if not pre-acclimatized, the risk of suffering from high-altitude illnesses, e.g., acute mountain sickness, high-altitude cerebral or pulmonary edema, increases with the level of altitude. In addition, diminished oxygen availability impairs exercise tolerance, which not only limits physical activity at high altitude but may also provoke symptomatic exacerbation of pre-existing diseases. Moreover, the cold and dry ambient air and increased levels of solar radiation may contribute to adverse health effects at higher altitude. Thus, medical pre-examination and pre-flight advice, and proper preparation (pre-acclimatization, exercise training, and potentially adaptation of pharmacological regimes) are of utmost importance to reduce negative health impacts and frustrating travel experiences.

Exploring the potential of telehealth in-flight medical emergencies

In-flight medical emergencies occur at an average of 127 incidents per one million passengers, without of physicians present at 41.1%. In response, telehealth can play a crucial role in swiftly addressing these emergencies. Adequate internet speed and appropriate latency are necessary for this purpose, alongside the importance of documenting such emergencies to enhance the efficiency of medical services. In-flight telehealth directly benefits passengers, airlines, and volunteered medical professionals. Furthermore, it presents an opportunity for innovative business models, offering new prospects for insurance companies and telecommunications providers.

Characteristics of In-Flight Medical Emergencies on a Commercial Airline in Mainland China: Retrospective Study

Background

In-flight medical emergencies (IMEs) can have severe outcomes, including the deaths of passengers and aircraft diversions. Information is lacking regarding the incidence rate and characteristics of IMEs in most countries, especially in mainland China.

Objective

The objective of this study was to investigate the incidence, patterns, and associated risk factors of IMEs in mainland China and to provide medical suggestions for the evaluation and management of IMEs.

Methods

This population-based retrospective study examined electronic records for all IME reports between January 1, 2018, and December 31, 2022, from a major airline company in mainland China. Outcome variables included the medical category of the IMEs, the outcomes of first aid, and whether or not the IMEs led to a flight diversion. We calculated the incidence rate and death rate of IMEs based on the number of passengers and flights, respectively. A logistic regression model was used to investigate the factors associated with aircraft diversions.

Results

A total of 199 IMEs and 24 deaths occurred among 447.2 million passengers, yielding an incidence rate of 0.44 (95% CI 0.39-0.51) events per million passengers and 66.56 (95% CI 50.55-86.04) events per million flights, and an all-cause mortality rate of 0.05 (95% CI 0.03-0.07) events per million passengers and 7.50 (95% CI 4.81-11.16) events per million flights. From 2018 to 2022, the highest incidence and mortality rates were observed in 2019 and 2020, respectively, while the lowest were in 2020 and 2021, respectively. Additionally, the highest incidence and mortality rates were observed between 6 PM to 6 AM and noon to 6 PM, respectively. There was a higher incidence rate of IMEs in the winter months. Moreover, the highest case-fatality rates were observed in 2019 (12/74, 16.2%), on flights traveling ≥4000 km (9/43, 20.9%), and on wide-body planes (10/52, 19.2%). Seizures (29/199, 14.6%), cardiac symptoms (25/199, 12.6%), and syncope or presyncope (19/199, 9.6%) were the most common medical problems and main reasons for aircraft diversion. The incidence of aircraft diversion was 42.50 (95% CI 37.02-48.12) events per million flights. Narrow-body planes (odds ratio [OR] 5.69, 95% CI 1.05-30.90), flights ≥4000 km (OR 16.40, 95% CI 1.78-151.29), and the months of December to February (OR 12.70, 95% CI 3.09-52.23), as well as the months of March to May (OR 23.21, 95% CI 3.75-143.43), were significantly associated with a higher risk of diversion.

Conclusions

The occurrence of and deaths associated with IMEs are rare in mainland China, but a temporal trend shows higher incidence rates at night and in winter. The leading IMEs are cardiac symptoms, seizures, and syncope. The establishment of a unified reporting system for IMEs and ground-to-air medical support are of great value for reducing IMEs and deaths in the global community.

Exploring the Nature and Challenges Among Physicians in Saudi Arabia Responding to an Inflight Medical Emergency: A Cross-Sectional Survey

Background  Inflight medical emergencies (IMEs) present a challenging situation due to the availability of limited medical resources and a complex cabin environment. The physicians have an ethical responsibility to aid in such situations. This study aims to assess the attitudes of Saudi physicians regarding IMEs. Methods  A cross-sectional survey was conducted among medical interns and postgraduate physicians in Saudi Arabia. Data were collected via a structured online questionnaire distributed through professional networks and social media. The survey evaluated physicians' confidence, preparedness, and barriers to volunteering in an IME.  Results  A total of 368 respondents were included in the study, with a plurality (42.4%, n = 156) in the 30-39 years age group. The proportion of males was 55.2% (n = 203). Among participants, 67.1% (n = 247) had encountered an IME, and 62% (n = 228) had assisted in such a situation. Regarding the nature of IME, 17.9% (n = 66) of the respondents reported respiratory emergency (e.g., bronchospasm). Participants with prior medical emergency experience showed significantly higher scores than those without (54.64 ± 7.81 vs. 49.30 ± 7.10, p < 0.001). Younger physicians (<30 years) displayed the highest confidence scores (54.85 ± 7.03), while those ≥60 years reported the lowest (46.50 ± 4.94, p < 0.01). Physicians with less experience (less than five years) had higher scores compared to their more experienced counterparts (54.69 ± 7.16 vs. 52.25 ± 5.75, p = 0.039). Barriers to volunteering included lack of training (58.6%, n = 215) and legal concerns (61.1%, n = 227), while 67.6% (n = 249) highlighted the need for additional training as a potential motivator.  Conclusion  Overall, the majority of the participants included in our study were willing to aid in an IME. Furthermore, being younger, less experienced, and having prior emergency experience were significant factors in determining the decision to aid in an IME.

Perception, confidence, and willingness to respond to in-flight medical emergencies among medical students: a cross sectional study

BACKGROUND

In-flight medical emergencies (IMEs) are expected to increase as air travel normalized in the post-COVID-19 era. However, few studies have examined health professions students' preparedness to respond to such emergencies. Therefore, this study aimed to investigate medical students' knowledge, confidence, and willingness to assist during an IME in their internship program.

METHODS

This cross-sectional survey utilized an online, self-administered questionnaire-based survey targeted at medical students at two medical colleges in Saudi Arabia. The questionnaire comprised three parts: sociodemographic characteristics, knowledge about aviation medicine (10 items), and confidence (7 items)/willingness (4 items) to assist during an IME. Odds Ratios (OR) and 95% Confidence Intervals (95%CI) were computed to detect potential associations between the knowledge levels and the other independent variables. Responses to confidence and willingness questions were scored on a 5-point Likert scale.

RESULTS

Overall, 61.4% of participants had inadequate knowledge scores for providing care during an IME, and the proportion of participants did not differ between those who had or had not attended life support courses (60.4% vs. 66.7%, p > 0.99). Only frequency of air travel ≥ two times per year was associated with higher odds of adequate knowledge score [OR = 1.89 (95%CI 1.14-3.17), p = 0.02]. In addition, 93.3% of the participants had low, 6.3% had moderate, and 0.8% had high willingness scores, while 86.3% had low, 12.2% had moderate, and 1.5% had high confidence scores. There were no differences in the proportion of participants with low, moderate, and high willingness or confidence scores by attendance in life support courses.

CONCLUSION

Even though over 8 in 10 students in our study had previously attended life support courses, the overwhelming majority lacked the knowledge, confidence, and willingness to assist. Our study underscores the importance of teaching medical students about IMEs and their unique challenges before entering their 7th-year mandatory general internship.

Hearts in the sky: understanding the cardiovascular implications of air travel

Air travel is widely regarded as the safest mode of transportation, with the United States leading in airline passengers. However, travelers with pre-existing heart conditions face acute cardiovascular risks. Flight pilots and cabin crew are particularly vulnerable to air travel's physiological changes, which can significantly impair their health and performance. Cabin pressure differences and reduced oxygen levels at cruising altitudes of 5000-8000 feet make air travel challenging for individuals with underlying cardiac and pulmonary problems. This, along with dry air, sleep deprivation, missed medication and prolonged sitting, can lead to physiological changes. In-flight and pre-flight stressors contribute to increased health issues, and studies show a rise in medical emergencies during flights. Prolonged exposure to the airplane environment can lead to various health issues for pilots and cabin crew. These changes include impaired judgment, cognitive function and discomfort in the sinuses and ears due to pressure differentials. Therefore, thorough medical screening, skilled instrument use and compliance with safety measures are essential to mitigate these risks. This article reviews the cardiac implications of air travel, discussing the underlying pathophysiology, associated risks and preventive measures to ensure safer flights for individuals with cardiovascular diseases.

Effects of moderate alcohol consumption and hypobaric hypoxia: implications for passengers' sleep, oxygen saturation and heart rate on long-haul flights

BACKGROUND

Passengers on long-haul flights frequently consume alcohol. Inflight sleep exacerbates the fall in blood oxygen saturation (SpO2) caused by the decreased oxygen partial pressure in the cabin. We investigated the combined influence of alcohol and hypobaric hypoxia on sleep, SpO2 and heart rate.

METHODS

Two groups of healthy individuals spent either two nights with a 4-hour sleep opportunity (00:00-04:00 hours) in the sleep laboratory (n=23; 53 m above sea level) or in the altitude chamber (n=17; 753 hPa corresponding to 2438 m above sea level, hypobaric condition). Participants consumed alcohol before one of the nights (mean±SE blood alcohol concentration 0.043±0.003%). The order of the nights was counterbalanced. Two 8-hour recovery nights (23:00-07:00 hours) were scheduled between conditions. Polysomnography, SpO2 and heart rate were recorded.

RESULTS

The combined exposure to alcohol and hypobaric condition decreased SpO2 to a median (25th/75th percentile) of 85.32% (82.86/85.93) and increased heart rate to a median (25th/75th percentile) of 87.73 bpm (85.89/93.86) during sleep compared with 88.07% (86.50/88.49) and 72.90 bpm (70.90/78.17), respectively, in the non-alcohol hypobaric condition, 94.97% (94.59/95.33) and 76.97 bpm (65.17/79.52), respectively, in the alcohol condition and 95.88% (95.72/96.36) and 63.74 bpm (55.55/70.98), respectively, in the non-alcohol condition of the sleep laboratory group (all p<0.0001). Under the combined exposure SpO2 was 201.18 min (188.08/214.42) below the clinical hypoxia threshold of 90% SpO2 compared with 173.28 min (133.25/199.03) in the hypobaric condition and 0 min (0/0) in both sleep laboratory conditions. Deep sleep (N3) was reduced to 46.50 min (39.00/57.00) under the combined exposure compared with both sleep laboratory conditions (alcohol: 84.00 min (62.25/92.75); non-alcohol: 67.50 min (58.50/87.75); both p<0.003).

CONCLUSIONS

The combination of alcohol and inflight hypobaric hypoxia reduced sleep quality, challenged the cardiovascular system and led to extended duration of hypoxaemia (SpO2 <90%).

Willingness and self-confidence of healthcare workers in Bahrain in assisting with in-flight emergencies

BACKGROUND

In-flight medical emergency (IFE) impose considerable challenges on healthcare workers (HCWs) because of limited resources, constrained environment, and medico-legal issues. This study assessed HCWs knowledge, willingness, and confidence in addressing in-flight medical emergencies.

MATERIALS AND METHODS

A cross-sectional study was conducted between June and August 2023 among nurses and physicians working in primary healthcare centers and governmental hospitals in Bahrain. Subjects were selected using stratified random sampling; a self-administered online questionnaire of high reliability (Cronbach alpha = 0.914) was used to collect the data. Logistic regression analysis were performed to determine association of knowledge, willingness, and confidence in dealing with in-flight emergencies with various characteristics of HCWs.

RESULTS

The study included 805 HCWs with mean age of 35.5 years (SD=9.2). The findings indicated deficiency in training, with <10% of participants trained on IFE. A considerable proportion of participants exhibited low levels of knowledge (88.3%) and confidence (75.9%) with IFE. Nonetheless, more than half of the participants expressed the willingness to assist in IFE (59.1%). Non-Bahraini healthcare professionals (odds ratio [OR] = 2.901, P < 0.001) had higher knowledge of IFE. Nurses (OR = 1.642, P = 0.047) and participants with longer work experience had higher willingness to assist in IFE. In addition, professionals who were non-Bahraini (OR = 3.249, P < 0.001), working in secondary care (OR = 1.619, 95% confidence interval P = 0.021), had had training on IFE (OR = 2.247, P = 0.004), and had encountered IFE before (OR = 1.974, P = 0.006) had greater self-confidence levels.

CONCLUSION

Considering the low levels of knowledge and confidence healthcare professionals in Bahrain had with regard to IFE, targeted training initiatives and educational programs are necessary to improve HCW's confidence and preparedness to deal with such emergencies.

Worldwide Regulation of the Medical Emergency Kit and First Aid Kit

INTRODUCTION: On-board medical emergencies are increasing. Different geographies have different legislation and requirements for medical emergency kits and first aid kits. A comprehensive review to compare the contents of both kits was conducted, including the International Air Transport Association, European Union Aviation Safety Agency, and Federal Aviation Administration, as well as some from other geographical areas of the globe to cover continents and regions with the highest air traffic, such as Brazil, Kenya, Australia, and Taiwan.METHODS: On June 10, 2023, a search was conducted using standardized medical terms (medical subject headings) within the PubMed® database. The relevant terms identified were "Aircraft" and "Medical Emergencies"; articles published within the last 10 yr were filtered. Subsequently, even articles published before 2013 were consulted if cited by the initial ones. The main regulatory entities' documentation was found using the Google search engine and consulted.CONCLUSIONS: It is impossible to be prepared for every emergency on board. Still, as doctors, we have a moral and ethical obligation to try to improve the outcomes of those emergencies. Getting a standardized report of every on-board emergency is crucial. That would make optimizing the items to include in the emergency and first aid kits easier. There are many similarities among the compared entities, but essential differences have been found. There is room for improvement, especially for pediatric travelers.Oliveira ATB. Worldwide regulation of the medical emergency kit and first aid kit. Aerosp Med Hum Perform. 2024; 95(6):321-326.

Approaches to Medical Emergencies on Commercial Flights

In-flight medical incidents are becoming increasingly critical as passengers with diverse health profiles increase in the skies. In this paper, we reviewed how airlines, aviation authorities, and healthcare professionals respond to such emergencies. The analysis was focused on the strategies developed by the top ten airlines in the world by examining training in basic first aid, collaboration with ground-based medical support, and use of onboard medical equipment. Appropriate training of crew members, availability of adequate medical resources on board airplanes, and improved capabilities of dialogue between a flying plane and medical doctors on the ground will contribute to a positive outcome of the majority of medical issues on board airlines. In this respect, the adoption of advanced telemedicine solutions and the improvement of real-time teleconsultations between aircraft and ground-based professionals can represent the future of aviation medicine, offering more safety and peace of mind to passengers in case of medical problems during a flight.

Identifying the Causes of Unexplained Dyspnea at High Altitude Using Normobaric Hypoxia with Echocardiography

Exposure to high altitude results in hypobaric hypoxia, leading to physiological changes in the cardiovascular system that may result in limiting symptoms, including dyspnea, fatigue, and exercise intolerance. However, it is still unclear why some patients are more susceptible to high-altitude symptoms than others. Hypoxic simulation testing (HST) simulates changes in physiology that occur at a specific altitude by asking the patients to breathe a mixture of gases with decreased oxygen content. This study aimed to determine whether the use of transthoracic echocardiography (TTE) during HST can detect the rise in right-sided pressures and the impact of hypoxia on right ventricle (RV) hemodynamics and right to left shunts, thus revealing the underlying causes of high-altitude signs and symptoms. A retrospective study was performed including consecutive patients with unexplained dyspnea at high altitude. HSTs were performed by administrating reduced FiO2 to simulate altitude levels specific to patients' history. Echocardiography images were obtained at baseline and during hypoxia. The study included 27 patients, with a mean age of 65 years, 14 patients (51.9%) were female. RV systolic pressure increased at peak hypoxia, while RV systolic function declined as shown by a significant decrease in the tricuspid annular plane systolic excursion (TAPSE), the maximum velocity achieved by the lateral tricuspid annulus during systole (S' wave), and the RV free wall longitudinal strain. Additionally, right-to-left shunt was present in 19 (70.4%) patients as identified by bubble contrast injections. Among these, the severity of the shunt increased at peak hypoxia in eight cases (42.1%), and the shunt was only evident during hypoxia in seven patients (36.8%). In conclusion, the use of TTE during HST provides valuable information by revealing the presence of symptomatic, sustained shunts and confirming the decline in RV hemodynamics, thus potentially explaining dyspnea at high altitude. Further studies are needed to establish the optimal clinical role of this physiologic method.

Injuries and medical emergencies among international travellers

BACKGROUND

Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings.

METHODS

We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled).

RESULTS

All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur.

CONCLUSIONS

Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.

Assessing Family Medicine Residents' Knowledge, Attitudes, and Confidence in Managing In-Flight Medical Emergencies in Riyadh, Saudi Arabia

The global increase in air travel has led to a rise in in-flight medical emergencies (IMEs), posing significant challenges to global public health. In a significant number of instances, physicians are often called upon to respond to IMEs during flights. These emergencies are unique due to the cabin environment's constraints, including confined space, ambient noise, and reduced atmospheric pressure. Various proactive measures have been introduced to mitigate IME occurrences, but many healthcare professionals, including family medicine (FM) residents, feel inadequately prepared to respond effectively. This cross-sectional study was conducted among all family medicine (FM) residents in Riyadh, Saudi Arabia, in January 2023. A self-reported questionnaire was used, including questions aimed at evaluating the sociodemographics, travel profiles, knowledge, confidence, and attitudes of FM residents toward IMEs and their ability to respond to such emergencies. A total of 189 FM residents participated in the study, revealing a young and diverse group of participants. Most were male (97 (51.3%)), averaging 27 years old. Nearly all held life support credentials (185 (97.9%)), particularly basic life support (BLS) and advanced cardiovascular life support (ACLS). Despite frequent travel, the majority lacked in-flight emergency training and experience. Allergic reactions (28%), cardiovascular (24%), and respiratory emergencies (24%) were the most common IMEs encountered. While 109 (57.7%) would assist during an IME, 87 (46%) were unsure of their competence, and 109 (57.7%) had medico-legal concerns. Most, i.e., 176 (93.2%) agreed with the need for more IME training, but 138 (73%) lacked clarity about in-flight medical supplies. In conclusion, this research underscores the importance of preparing FM residents and healthcare professionals for IMEs, advocating for specialized training programs that enhance their readiness to respond competently to an IME.

Application of SHEL Model in the Management of Respiratory Tract Exposure in Fangcang Shelter Hospitals for COVID-19

Objective

To explore the application effect of the (software factors, hardware factors, environmental factors, parties and other factors, SHEL) model in respiratory tract exposure protection of staff in temporary COVID-19 hospitals.

Methods

207 Staff members working in the isolation units of Fangcang shelter hospitals between 20 May 2022 and 5 June 2022 were selected as research subjects. The SHEL model was used to protect and manage the respiratory exposure of the isolation unit staff to the novel coronavirus. The incidence of respiratory exposure among the staff in the isolation units was compared before the SHEL model's implementation (20 May 2022-28 May 2022) and afterwards the SHEL model's implementation (29 May 2022-5 June 2022).

Results

Before the implementation of the SHEL model, a total of nine cases (4.35%) from 207 workers had respiratory exposure. Occurrence location: six cases in the isolation room (one-out room, level-one protection zone) and three cases in the drop-off area for patients outside the ward. After implementation, a total of two cases (0.97%) of respiratory tract exposure occurred among the 207 staff members; both occurred in the unprotected zone (two-out room, level-two protection zone), and the difference was statistically significant before and after the implementation (P < 0.05).

Conclusion

New coronary pneumonia Fangcang shelter hospitals should use the SHEL model to manage the respiratory exposure of their isolation unit staff to reduce the respiratory exposure risk to staff in isolation units.

Impact of simulated flight conditions on supraventricular and ventricular ectopy

Though billions of passengers and crew travel by air each year and are exposed to altitude equivalents of 7000-8000 feet, the health impact of cabin oxygenation levels has not been well studied. The hypoxic environment may produce ectopic heartbeats that may increase the risk of acute in-flight cardiac events. We enrolled forty older and at-risk participants under a block-randomized crossover design in a hypobaric chamber study to examine associations between flight oxygenation and both ventricular (VE) and supraventricular ectopy (SVE). We monitored participant VE and SVE every 5 min under both flight and control conditions to investigate the presence and rate of VE and SVE. While the presence of VE did not differ according to condition, the presence of SVE was higher during flight conditions (e.g. OR ratio = 1.77, 95% CI: 1.21, 2.59 for SVE couplets). Rates of VE and SVE were higher during flight conditions (e.g. RR ratio = 1.25, 95% CI: 1.03, 1.52 for VE couplets, RR ratio = 1.76, 95% CI: 1.39, 2.22 for SVE couplets). The observed higher presence and rate of ectopy tended to increase with duration of the flight condition. Further study of susceptible passengers and crew may elucidate the specific associations between intermittent or sustained ectopic heartbeats and hypoxic pathways.

The frequency and characteristics of epinephrine use during in-flight allergic events

BACKGROUND

Allergic reactions account for 2% to 4% of medical events in-flight and 5.5% of all medical events in passengers 18 years and under.

OBJECTIVE

To evaluate the incidence of in-flight allergic events including availability, use of epinephrine, and final patient outcome.

METHODS

We conducted a retrospective study of the ground-based medical service (GBMS) database from January 2017 to December 2019 for all allergic events and epinephrine utilization.

RESULTS

A total of 140,579 in-flight medical events (IFMEs) were initially retrieved from the period between January, 2017 and December, 2019, of which 4230 (3.0%) unique cases were identified as allergic events. Epinephrine administration was recommended in 398 passengers by GBMS. Of those, 328 (82.4%) ultimately received at least 1 dose of epinephrine. In multivariate analysis, there was a significant difference in the involvement of volunteers (odds ratio [OR], 3.19; P value < .001; 95% confidence interval [CI], 2.43-4.16), availability of autoinjectors (OR, 2; P value < .001; 95% CI, 1.55-2.58), flight diversion (OR, 11.21; P value < .001; 95% CI, 3.60-34.89), and hospital transport (OR, 6.58; P value < .001; 95% CI, 4.62-9.38) between the 2 groups. Passengers older than 12 years of age were at a higher risk for epinephrine administration. In the secondary analysis of 51 airlines that consistently use GBMS for all IFMEs, the incidence of allergic events was found to be 0.91 cases per million passengers. The incidence of severe in-flight allergic emergencies requiring epinephrine administration was 0.08 cases per million passengers or 12.5 million passengers for 1 event.

CONCLUSION

IFME requiring epinephrine administration is rare with an incidence rate of 1 event in 12.5 million passengers. The risk for epinephrine administration is higher in passengers more than 12 years of age and is associated with significantly higher flight diversion, hospital transport, and involvement of medical volunteers.

Effects of sequential aeromedical evacuations following traumatic brain injury in swine

INTRODUCTION

Traumatic brain injuries (TBI) represent a significant percentage of critical injuries in military conflicts. Following injury, wounded warfighters are often subjected to multiple aeromedical evacuations (AE) and associated hypobaria, yet the impact in TBI patients remains to be characterized. This study evaluated the impact of two consecutive simulated AEs in a fluid-percussion TBI model in swine to characterize these effects.

METHODS

Following instrumentation, anesthetized Yorkshire swine underwent a frontal TBI via fluid-percussion. A hypobaric chamber was then used to simulate AE at simulated cabin pressure equivalent to 8000ft (hypobaria) in a 6 h initial flight on day 3, followed by a 9 h flight on day 6, and were monitored for 14 days. Animals in the normobaria group were subjected to the same steps at sea level while Sham animals in both groups were instrumented but not injured. Parameters measured included physiologic response, intracranial pressure (ICP), hematology, chemistry, and serum cytokines. Histopathology of brain, lung, intestine, and kidney was performed, as well as fluorojade staining to evaluate neurodegeneration. All animals were divided into sub-groups by block randomization utilizing a 2-way ANOVA to analyze independent variables.

RESULTS

Survival was 100% in all groups. Physiologic parameters were largely similar across groups as well during both 6 and 9 h AE. Animals exposed to hypobaria in both the TBI and Sham groups had elevated heart rate (HR) during the 6 h flight (p<0.05). Three animals in the TBI hypo group demonstrated leukocytosis with histologic evidence of meningeal inflammatory response. Expression of serum cytokines was low across all groups. No significant neuronal degeneration was identified in areas away from the site of injury.

CONCLUSION

Aeromedical evacuation in swine was not associated with significant differences in physiologic measures, cytokine expression or levels of neuronal degeneration. Histological examination revealed higher risk of meningeal inflammatory response and leucocytosis in swine exposed to hypobaria.

The Intersection of Telemedicine and Wilderness Care: Past, Present, and Future

Wilderness medicine and telemedicine seemingly exist at opposite ends of the clinical continuum. However, these 2 specialties share a common history and the literature abounds with examples of successful deployment of telemedicine to resource limited settings. The recent widespread adoption of telemedicine has important ramifications for wilderness providers. Telemedicine is inherently reliant on some sort of technology. There is a wide spectrum of complexity involved, but in general these systems rely on a hardware component, a software component, and a network system to transmit information from place to place. Today, connectivity is nearly ubiquitous through access to cellular networks, Wi-Fi, or communication satellites. However, bandwidth, defined as the amount of data which can be transmitted through a given connection over time, remains a limiting factor for many austere settings. Telemedicine services are typically organized into 4 categories: 1) live/interactive; 2) store and forward; 3) remote patient monitoring; and 4) mHealth. Each of these categories has an applicable wilderness medicine use case which will be reviewed in this paper. Though the regulatory environment remains complex, there is enormous potential for telemedicine to enhance the practice of wilderness medicine. Drones are likely to transform wilderness medicine supply chains by facilitating delivery of food, shelter, and medicines and are able to enhance search and rescue efforts. Remote consultations can be paired with remote patient monitoring technology to deliver highly specialized care to austere environments. Early feasibility studies are promising, but further prospective data will be required to define future best practices for wilderness telemedicine.

COPD patients’ pre-flight check: A narrative review

 For most of the people with stable and well-controlled chronic obstructive pulmonary disease (COPD), air travel is safe and comfortable, but the flight environment may pose clinical challenges. This narrative review aims to update the requirements for allowance to fly of people with COPD without chronic respiratory failure.  A literature review was performed on platforms: Pubmed, Scopus and Ovid, for citations in English from 2000 to 2021. The following key words were used: COPD AND: air-travel, in-flight hypoxemia, fitness to air travel.  Official regulatory documents and guidelines were also examined. Current air travel statements recommend supplemental oxygen when in flight arterial oxygen tension (PaO2) is expected to fall below 6.6 or 7.3 kPa. Several lung function variables, prediction equations and algorithms have been proposed to estimate in-flight PaO2, the need for in-flight supplemental oxygen, and to select individuals needing more advanced pre-flight testing, such as the hypoxia-altitude simulation test. Exercise induced desaturation and aerobic capacity correlate significantly with in-flight PaO2. COPD patients with late intensification of disease, new changes in medications, recent acute exacerbation/ hospitalization or anticipated emotional and physical stress during the proposed air-travel should be carefully evaluated by the caring family or specialist physician.

In-flight medical emergencies during commercial travel

BACKGROUND

Growing number of passengers travelling by air is associated with increased in-flight emergency medical events (IEMEs). However, there are scarce data regarding IEMEs during commercial travels. In this study, analysis of IEMEs occurring among adult and paediatric passengers during commercial international and domestic flights of a major airline company was targeted.

METHODS

Data regarding IEMEs recorded in all international and domestic flights of a major airline company between 1 January 2018 and 31 December 2020 were collected. Demographics, adult and paediatric IEMEs, in-flight deaths and aircraft diversions (ADs) were analysed.

RESULTS

Total number of passengers was 177 400 748 and a number of 22 541 (0.012%) IEMEs occurred. The frequency of IEMEs per 1 million passengers was 127. The number of male patients suffering from IEMEs was 8387 (37.2%), while the number female patients was 10 853 (48.1%). Median age of adult and paediatric patients were 43, [32-57], 4, [2-10], respectively. The most common cause of IEMEs in adult patients was headache (3424 IEMEs, 15.1%) and it was fever in paediatric patients (688 IEMEs, 3.05%). Multiple symptoms were present in 8449 IEMEs (37.4%). On-board doctors managed events in more than half of IEMEs (13 295 IEMEs, 58.9%). AD was required in 255 (1.13%) IEMEs. The most common reason for AD was chest pain (45 IEMEs, 17.6%) in adult patients. The most common reason for AD in paediatric patients was epileptic seizures (nine IEMEs, 3.5%). A total of 46 (0.2%) patients, including 2 (0.008%) paediatric patients, died.

CONCLUSIONS

Majority of IEMEs are not life-threatening conditions, which can be easily managed by cabin crew or on-board doctors without AD. Multiple symptoms can be present in a patient suffering from IEME. Ground-to-air medical assistance may help optimization of diagnosis and decision for AD.

Training Family Medicine Residents to Prevent and Respond to In-flight Emergencies

In-flight emergencies (IFE) reportedly occur globally in about 1 in 604 flights¹. During training, family medicine (FM) residents acquire the skills necessary to counsel patients who are at risk, provide comprehensive management, and respond in emergent situations. The purpose of this study was to assess FM resident's knowledge about IFE, counseling, and attitudes towards responding to IFEs. A 15-question survey was sent to FM residents in the Dallas-Fort Worth area. IFE training options were also reviewed. Survey results revealed gaps in knowledge, yet a willingness to assist if necessary. A didactic IFE training format was found to be more achievable.

A Comparison of In-flight and Ground-Based Emergency Medical Events on the Clinical Demand for Outreach Medical Services at Taoyuan International Airport, Taiwan

Background: Limited information is available covering all medical events managed by the airport-based outreach medical service. This study explores the clinical demand for emergency medical outreach services at Taoyuan International Airport (TIA), Taiwan.

Methods: Electronic medical records collected from TIA medical outreach services from 2017 to 2018, included passengers' profiles, flight information, events location, chief complaints, diagnosis (using ICD-9 -CM codes), and management outcomes. Medical events distribution was stratified by location and ages, and were compared statistically.

Results: Among 1,501 eligible records, there were 81.8% ground-based emergency medical events (GBME), 16.9% in-flight medical events (IFME) managed after scheduled landing, and 1.3% IFME leading to unscheduled diversion or re-entry to TIA. The top three GBME diagnoses were associated with neurological (23.3%), gastrointestinal (21.2%), and trauma-related (19.3%) conditions. The top three IFME diagnosis that prompted unscheduled landings via flight diversion or re-entry were neurological (47.4%), psychological (15.8%), and cardiovascular (10.5%). The chief complaints that prompted unscheduled landings were mostly related to neurological (42.1%), cardiovascular (26.3%), and out-of-hospital cardiac arrest (OHCA) (10.5%) symptoms. A higher frequency of IFME events due to dermatologic causes in patients aged ≤ 18 years compared with adults and older adults (19 vs. 1.5% and 0, respectively); and a higher frequency of IFME due to cardiovascular causes in adults ≥ 65 years compared with patients aged ≤ 65 (15.1 vs. 9%). Among all IFME patients, six out-of-hospital deaths occurred among passengers from scheduled landings and two deaths occurred among 18 IFME passengers who were transferred to local hospitals from flight diversion or re-entry. A statistically significant difference in outcomes and short-term follow-up status was found between patients with IFME and those with GBME (p < 0.001).

Conclusion: Ground-based emergency medical events exceeded in-flight medical events at TIA. The most frequent events were related to neurological, gastrointestinal symptoms, or trauma. Results of this study may provide useful information for training medical outreach staff and preparing medical supplies to meet the clinical demand for airport medical outreach services.

Emergency drug usage during flight and airline safety management for passengers

During flight, passengers may experience aviation-related symptoms such as headache, nausea, respiratory failure, and panic disorders. To treat patients with these symptoms, emergency drugs are prepared in the cabin and crews treat patients according taking into account usage and dose guidelines described on the drug containers. However, certain types of drugs are limited and not adequately prepared in the cabin. The aim of this study was to examine (1) emergency drugs used during flight and frequency of symptoms experienced in passengers and (2) cognizance of drug usage among crews was also determined in low-cost carriers. Most frequent symptoms recorded were headache (74.1%), abdominal pain (72.3%), nausea (70.5%), and ear pain (60.7%). Panic disorder (50.9%) is the fifth frequent syndrome in passengers, but emergency drugs are not available for this condition in the cabin. The cognizance survey showed that 21% of crews out of 112 who responded were not interested in usage guidelines of emergency drugs or simply ignored. Thirty-seven percent of crews failed to pay attention to drug expiration dates. Our findings suggest that crews need to be better trained for preparation and usage of emergency drugs in the cabin for passengers suffering from various symptoms. Further, it is recommended that airline companies need to consider to improve the emergency drug management system by requesting training from pharmacists and doctors for safe drug usage.

Medical Legal Implications When Providing Emergency Care on a Commercial Flight

INTRODUCTION: U.S. airlines often request a healthcare professional to volunteer to assist an ill passenger. Litigation from a Good Samaritans care of an in-flight medical emergency (IME) is considered improbable. The 1998 Aviation Medical Assistance Act (AMAA) encourages health care professionals to volunteer with indemnity for standard and good medical care. It does not offer legal or financial assistance. Our review explored the legal support malpractice companies and U.S. airlines provide if litigation is initiated for IME care. Malpractice insurance policies can differ on IME coverage. We found most private practice physicians policies include IME. Medical institutions may have policies restricting their physicians coverage to the institutions location. Those without malpractice coverage will need to retain and pay for a legal defense to demonstrate no gross negligence and no willful misconduct. The physicians, airline crews, and on-ground IME documentation support should be retained by the Good Samaritan especially for a pediatric or adolescent ill passenger. U.S. airlines consider a Good Samaritan medical volunteer as a passenger and do not extend legal assistance. This contrasts with some foreign airlines that do provide liability protection. Knowledge of the malpractice policy IME coverage is essential prior to traveling by air. After completing care for an ill passenger, physicians should generate their medical documentation and request the IME documentation generated by the airline and on-ground medical expert. We also believe U.S. airlines should assume responsibility to provide legal assistance to a Good Samaritan physician in the event of IME litigation.de Caprariis PJ, Di Maio A. Medical legal implications when providing emergency care on a commercial flight. Aerosp Med Hum Perform. 2021; 92(7):588592.

Is there a doctor on the plane? A review of in-flight emergencies for the on-board radiologist

In-flight medical emergencies (IFME) are the acute on-service events involving illness or injury to a passenger with the potential for long-term health compromise. With the continuously rising number of flights available, both domestically and internationally, it is conceivable that the number of IFMEs will similarly continue to rise. Although most of these instances are relatively self-limited, the rare instance of a severe occurrence justifies preparation, both from in-flight staff and healthcare providers traveling on these flights. Given these events' sporadic nature and the variable availability of medical support, all physicians need to understand their in-flight ethical and legal capabilities, the available medical supplies, and the most likely etiologies to manage such situations successfully. Most radiologists rarely utilize the hands-on, clinical skills developed in medical school or internship for emergencies beyond allergic contrast reactions. Therefore, they may not be adept in caring for patients during an IFME. As such, we present a thorough overview and literature review for the radiologist regarding the management of various acute IFMEs, with consideration for ethical and legal precedence and a review of medical equipment available on-board.

"Is there a doctor on board?": willingness and confidence of physicians in the Kingdom of Saudi Arabia in assisting with in-flight medical emergencies

Background

In-flight medical emergencies (IMEs) are common, and for a traveling physician, it is very likely to encounter such a condition. Data discussing this issue are limited. Thus, this study aimed to evaluate the willingness and confidence of physicians in the Kingdom of Saudi Arabia (KSA) in responding to IMEs. As well as, to assess the associated sociodemographic, occupational, and travel-related factors, and their previous experience with such events.

Methods

This cross-sectional, online-based, study was conducted among all physicians in KSA during January 2021. The self-administered questionnaire included questions on sociodemographic, occupational, travel profiles, willingness and confidence towards IMEs. Chi-Squared or Fisher’s Exact test were used for bivariate analysis followed by the multivariable binary logistic regression analysis.

Results

A total of 4558 physicians participated in the study. About one-third of participants reported one or more IME incidents, and the vast majority of them provided assistance. Cardiovascular diseases were the most common IMEs. About half of the participating physicians are concerned about the medico-legal consequences of providing assistance with such a condition. Among all specialties, emergency physicians reported the highest willingness and confidence toward IMEs. Predictors for a physician’s willingness to assist in IMEs were being male, having been involved in a previous IME situation, attended life support and IME courses, frequent traveling, and practicing medicine in the Central region of Saudi Arabia.

Conclusion

Findings from the current study stressed the need for establishing standardized guidelines about the roles of healthcare workers and the legal consequences of providing medical assessment in IMEs. Moreover, training programs on IMEs to all physicians, especially those who deal with a variety of cases during their practice such as internal medicine and family medicine are also suggested.

The global incidence of in-flight medical emergencies: A systematic review and meta-analysis of approximately 1.5 billion airline passengers

BACKGROUND

Medical emergencies during short- or long-haul commercial airline flights have become more commonplace due to the aviation industry's contemporary growth, the popularization of commercial flights, and an increased aging of air travelers with significant comorbidities. However, the precise incidence of onboard medical events on commercial airlines and the most common medical conditions is unclear.

METHODS

In this systematic review and meta-analysis, we explored the incidence of in-flight medical emergencies among airline passengers and estimated the incidence rate by physiological body system, or organ class/syndrome for emergencies that may be associated with different body systems. We limited our search to cohort studies published between 1945 to October 31, 2020 in MEDLINE, Embase, Cochrane Library and official reports from the Federal Aviation Administration/International Air Transport Association, regardless of the language of publication. Only studies that evaluated the overall frequency of onboard medical events on commercial air carriers (in which they also presented the total number of annual revenue passengers) and the frequency of events by physiological body systems or organ class/syndrome were included. We excluded case reports and case series, systematic or narrative reviews, and studies addressing specific health-related conditions. Two independent investigators performed first- and second-phase study screening, abstracted data, and appraised risk of bias. We rated the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Using a quality effect model, we meta-analyzed data associated with the incidence of in-flight medical emergencies, all-cause fatality, incidence of medical events by medical condition category, frequency of en-route diversion, presence of medical personnel on board, and the use of an automatic external defibrillator. We also extracted data regarding the cost of flight diversion.

RESULTS

Of 18 individual studies with approximately 1.5 billion passengers, 11 reported the overall incidence of in-flight medical emergencies. Low certainty of evidence suggested that the global incidence of in-flight medical emergencies was 18.2 events per million passengers (95% CI 0.5 to 53.4 per million; I² = 100%, P < 0.001, very low certainty), and an all-cause mortality rate was 0.21 per million passengers (95% CI 0 to 0.76 per million; I² = 99%, P < 0.001, low certainty). The four most common categories of medical conditions or syndromes during flight were syncope, gastrointestinal events, respiratory and neurological diagnostic groups. The diversion rate was 11.1 per 100,000 flights (95% CI 5.9 to17.6 per 100,000 flights; I² = 97%, P < 0.001), with an average cost ranging from $15,000 to $893,000 per unplanned emergency landing across studies which examined this outcome.

CONCLUSIONS

In-flight medical events on commercial travels are extremely low with a corresponding very low in-flight mortality rate. Associated costs derived from en-route diversion might significantly influence airlines' budgetary equilibrium. Novel and modern standardized reporting systems or platforms should be internationally provided and enforced by health and aviation authorities to obtain higher quality patient-passengers datasets. Onboard volunteer medical providers must be aware of everyday life-threatening events during commercial flights and should consider the establishment of a connection between the aircraft and ground-based medical advisory services while assisting in-flight medical events.

Moral Dilemmas of Nurses and Paramedics During In-Flight Medical Emergencies on Commercial Airlines

During commercial flights, in-flight medical emergencies may lead the cabin crew to request assistance from qualified health care professionals among the passengers. Although a physician's function and role are well known and virtually universal globally, the role, education, and scope of practice of nurses and paramedics varies significantly. This article analyzes the possible dilemmas that medical professionals other than physicians who assist during in-flight medical emergencies may face and presents recommendations for aviation authorities. There is an identified need for universal cross-border regulations and an awareness of legal and ethical boundaries for medical responders other than physicians on board commercial international aircraft.

On-board emergency medical equipment of European airlines

BACKGROUND

Medical emergencies frequently occur in commercial airline flights, but valid data on causes and consequences are rare. Therefore, optimal extent of onboard emergency medical equipment remains largely unknown. Whereas a minimum standard is defined in regulations, additional material is not standardized and may vary significantly between airlines.

METHODS

European airlines operating aircrafts with at least 30 seats were selected and interviewed with a 5-page written questionnaire including 81 items. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted up to three times by email and/or phone. Descriptive analysis was used for data interpretation.

RESULTS

From a total of 305 European airlines, 253 were excluded from analysis (e.g., no passenger transport). 52 airlines were contacted and data of 22 airlines were available for analysis (one airline was excluded due to insufficient data). A first aid kit is available on all airlines. 82% of airlines (18/22) reported to have a "doctor's kit" (DK) or an "Emergency Medical Kit" (EMK) onboard. 86% of airlines (19/22) provide identical equipment in all aircraft of the fleet, and 65% (14/22) airlines provide an automated external defibrillator.

CONCLUSIONS

Whereas minimal required material according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in availability of the additional material. The equipment of most airlines is not sufficient for treatment of specific emergencies according to published in-flight medical guidelines (e.g., for CPR or acute myocardial infarction).

Data-Driven Estimation of the Impact of Diversions Due to In-Flight Medical Emergencies on Flight Delay and Aircraft Operating Costs

INTRODUCTION: In-flight medical emergencies (IFMEs) average 1 of every 604 flights and are expected to increase as the population ages and air travel increases. Flight diversions, or the rerouting of a flight to an alternate destination, occur in 2 to 13% of IFME cases, but may or may not be necessary as determined after the fact. Estimating the effect of IFME diversions compared to nonmedical diversions can be expected to improve our understanding of their impact and allow for more appropriate decision making during IFMEs.METHODS: The current study matched multiple disparate datasets, including medical data, flight plan and track data, passenger statistics, and financial data. Chi-squared analysis and independent samples t-tests compared diversion delays and costs metrics between flights diverted for medical vs. nonmedical reasons. Data were restricted to domestic flights between 1/1/2018 and 6/30/2019.RESULTS: Over 70% of diverted flights recover (continue on to their intended destination after diverting); however, flights diverted due to IFMEs recover more often and more quickly than do flights diverted for nonmedical reasons. IFME diversions introduce less delay overall and cost less in terms of direct operating costs and passenger value of time (averaging around 38,000) than do flights diverted for nonmedical reasons.DISCUSSION: Flights diverted due to IFMEs appear to have less impact overall than do flights diverted for nonmedical reasons. However, the lack of information related to costs for nonrecovered flights and the decision factors involved during nonmedical diversions hinders our ability to offer further insights.Lewis BA, Gawron VJ, Esmaeilzadeh E, Mayer RH, Moreno-Hines F, Nerwich N, Alves PM. Data-driven estimation of the impact of diversions due to in-flight medical emergencies on flight delay and aircraft operating costs. Aerosp Med Hum Perform. 2021; 92(2):99105.

Are patients with cognitive impairment fit to fly? Current evidence and practical recommendations

BACKGROUND

The worldwide prevalence of dementia is increasing and represents a major public health concern. In the last decades, air travel services have undergone an impressive expansion and one of ten passengers is aged 65 years and older. While air travel can be stressful at all ages and health conditions, older individuals with cognitive impairment carry a greater risk for air-travel-related complications. Consequently, demands to general practitioners for assessing their older patient's fitness to fly are increasing.

METHODS

We conducted a search of the literature in PubMed on the impact of in-flight environmental changes on passengers with cognitive impairment and possible resulting complications. This set the base for a discussion on pharmacological and non-pharmacological interventions aimed at preventing in-flight complications in this vulnerable population.

RESULTS

While our research strategy identified a total of 11 articles related to older age and air travel, only three focused on passengers with cognitive impairment. Our literature review showed that the airplane environment may lead to a large spectrum of symptoms in passengers of all age groups. However, passengers with cognitive impairment due to neurodegenerative diseases are at increased risk for experiencing the most extreme symptoms such as acute confusional state. Non-pharmacological and pharmacological interventions at different stages of the travel process (before, during and after) can help prevent complications in this vulnerable population.

CONCLUSION

The decision to let a patient with cognitive impairment fly requires a solid understanding of the in-flight environmental changes and their impact on older patients with cognitive impairment. Moreover, a sound weighing of the risks and benefits while considering different aspects of the patient's history is demanded. In this regard, the role of the treating physicians and caregivers is essential along with the support of the medical department of the airline.

In-Flight Medical Events and Cabin Crew First Aid Response

INTRODUCTION: In-flight medical events (IMEs), although rare, are challenging due to the limited onboard resources and the time needed to reach an airport. Cabin crewmembers (CCMs) are trained to provide first aid, but their effectiveness has not been appropriately studied.METHODS: IMEs occurring in the biggest airline of Greece were prospectively recorded during a 5-yr period (20142018) and categorized according to a symptom-based taxonomy.RESULTS: During the study period 990 IMEs were recorded corresponding to 16 IMEs for each million passengers or 1.8 IMEs for every thousand flights. The most frequent events were loss of consciousness (38.4%) followed by injuries (8.6%), gastrointestinal problems (8.3%), respiratory symptoms (7.3%), anxiety (5.7%), and burns (5.9%). Diversion was decided in 3% of the cases while death on board was rare (0.3% of events). CCMs responded in 33.5% of IMEs without assistance by a volunteer health professional, achieving a 97% success rate.DISCUSSION: IMEs are rare events and the majority can be treated with simple first aid measures. CCMs acting according to a simplified algorithm were very efficient in providing first aid. A standardized symptom-based IME form will assist in creating a reliable registry for further studies.Paxinos O, Savourdos P, Alexelis V, Anastasopoulos A, Karantoni E, Grigoropoulos P, Konstantinou X. In-flight medical events and cabin crew first aid response. Aerosp Med Hum Perform. 2021; 92(1):3238.

Commercial Air Travel for Passengers With Cardiovascular Disease: Stressors of Flight and Aeromedical Impact

The exponential growth of commercial flights has resulted in a sharp rise of air travellers over the last 2 decades, including passengers with a wide range of cardiovascular conditions. Notwithstanding the ongoing COVID-19 pandemic that had set back the aviation industry for the next 1 to 2 years, air travel is expected to rebound fully by 2023-2024. Guidelines and evidence-based recommendations for safe air travel in this group vary, and physicians often encounter situations where opinions and assessments on fitness for flights are sought. This article aims to provide an overview of the stressors of commercial passenger flights with an impact on cardiovascular health for the general cardiologist and family practitioner, when assessing the suitability of such patients for flying fitness.

Fangcang shelter hospitals are a One Health approach for responding to the COVID-19 outbreak in Wuhan, China

In February 2020, the exponential growth of COVID-19 cases in Wuhan city posed a huge economic burden to local medical systems. Consequently, Wuhan established Fangcang Shelter hospitals as a One Health approach for responding to and containing the COVID-19 outbreak by isolating and caring for mild-to-moderate cases. However, it is unclear to what degree the hospitals contained COVID-19. This study performed an interrupted time series analysis to compare the number of new confirmed cases of COVID-19 before and after the operation of Fangcang Shelter hospitals. The initial number of confirmed cases in Wuhan increased significantly by 68.54 cases per day prior to February 4, 2020. Compared with the number of cases noted 20 days before the use of Fangcang Shelter hospitals, a sustained reduction in the number of confirmed cases (trend change, -125.57; P < 0.0001) was noted 41 days after the use of the hospitals. Immediate-level changes were observed for confirmed cases (level change, 725.97; P = 0.025). These changes led to an estimated 5148 fewer confirmed cases (P < 0.0001). According to the mean confirmed cases of 395.71 per day before the intervention, we estimated that Wuhan had advanced the terminal phase of COVID-19 by 13 days. Furthermore, immediately after introduction of Fangcang Shelter Hospitals on February 5, the reproduction number dropped rapidly, from a pre-introduction rate of 4.0 to 2.0. The Fangcang Shelter hospitals most likely to reversed the epidemic trend of COVID-19 while a containment strategy was implemented in Wuhan. In a One Health perspective, Fangcang Shelter hospitals, with their functions of isolation and treatment of confirmed COVID-19 patients, engaging professionals from many disciplines, such as medicine, engineering, architecture, psychology, environmental health, and social sciences. The results of this study provide a valuable reference for health policy makers in other countries.

In-Flight Emergency: A Simulation Case for Emergency Medicine Residents

INTRODUCTION

In-flight medical emergencies are common occurrences that require medical professionals to manage patients in an unfamiliar setting with limited resources. Emergency medicine (EM) residents should be well prepared to care for patients in unusual environments such as on an aircraft.

METHODS

We developed a simulation case for EM residents featuring a 55-year-old male passenger who suffers a cardiac arrest secondary to a tension pneumothorax. We conducted this case eight times during a 5-hour block of scheduled simulation time. Participants included EM residents of all training levels from one residency program. We arranged the simulation lab as an airplane cabin, with rows of chairs representing airplane seats and a mannequin in a window seat as the patient. Residents were expected to manage cardiac arrest and perform needle thoracostomy on the patient. Residents also evaluated and treated a flight attendant with a near syncopal episode. Throughout the case, residents were expected to practice teamwork skills, including leadership, communication, situational awareness, and resource utilization. Participants were debriefed and completed voluntary anonymous evaluations of the session.

RESULTS

Seventeen EM residents participated in the simulation. Overall, all 17 found the simulation to be a valuable educational experience. In addition, all agreed or strongly agreed that they felt more prepared to respond to an in-flight emergency after participating in the simulation.

DISCUSSION

This simulation was determined to be a valuable part of EM resident education. The challenges presented and skills practiced in this in-flight medical emergency simulation case are transferable to other resource-limited environments.

Medical Flight Emergencies and Bias: #thatisbias #whatadoctorlookslike #ILookLikeaDoctor

One in 604 flights will have a medical emergency. With 87,000 flights per day in the United States alone, that is ∼144 medical emergencies per day. When a passenger has a medical emergency in-flight, do staff respond with equity to persons who offer assistance? Unfortunately, several news stories have highlighted race and gender bias against woman physicians of color who come to the aid of a person in distress while in-flight. Three separate stories have ignited a national conversation about what it means to “look like a doctor.” In this article, we profile three vignettes of women physicians of non-white race that challenges the notion that all doctors are treated equally when trying to assist passengers who are experiencing a medical in-flight emergency. We share stories of how bias has affected other health care providers in similar situations. Some physicians have not been asked anything but their name, whereas others are questioned for their credentials before they can assist. In other vignettes, even with valid credentials, these offers of assistance from physicians are rebuked. We will challenge the aviation industry to put passengers first by training flight crews to see and address implicit and explicit biases, standardize protocols to remove barriers for assistance, challenging the notion of paperwork superseding care, and changing a very broken process that is inconsistent at best.

Stranded abroad: a travel medicine approach to psychiatric repatriation

BACKGROUND

The incurred mental alteration of a traveler abroad should be an alarming signal for patient, for family and for the local healthcare professionals alike. It is estimated that 11.3% of travelers experience some kind of psychiatric problem, with 2.5% suffering from severe psychosis and 1.2% requiring more than 2 months of therapy upon return from a trip abroad. Acute psychotic episode represents approximately one-fifth of travel-related psychiatric events. Yet, the travel-related mental problems have been a neglected topic till today. Now a good selection of literature is available to help further researches.

METHODS

Besides describing the most relevant literature of travel-related mental disturbances, authors present two key issues of dealing with psychiatric problems of travelers abroad: to identify the origin of the mental alteration and the process of the patient with psychiatric problems.

RESULTS

Identifying the origin and the nature of the mental symptoms of travelers is often difficult because of the language barrier, among extraordinary circumstances. A simple two-step three-branch algorithm could make the decision easier for the attending physician. Some of the brief psychotic disorder and organic origin of mental disturbance can be and often are treated in place.

CONCLUSIONS

Some mental problems probably originated from or triggered by the travel or a foreign environment itself. In these cases the full recovery will be expected if the triggering factor is eliminated. The solution is early repatriation. The repatriation for psychiatric reasons is highly different from repatriation for other medical emergencies. The authors describe a proposal of a step-by-step action of repatriation of a psychotic patient. By the help of this suggested protocol, the patient may successfully be taken home.

Characterization of In-Flight Medical Events Involving Children on Commercial Airline Flights

STUDY OBJECTIVE

More than 4 billion passengers travel on commercial airline flights yearly. Although in-flight medical events involving adult passengers have been well characterized, data describing those affecting children are lacking. This study seeks to characterize pediatric in-flight medical events and their immediate outcomes, using a worldwide sample.

METHODS

We reviewed the records of all in-flight medical events from January 1, 2015, to October 31, 2016, involving children younger than 19 years treated in consultation with a ground-based medical support center providing medical support to 77 commercial airlines worldwide. We characterized these in-flight medical events and determined factors associated with the need for additional care at destination or aircraft diversion.

RESULTS

From a total of 75,587 in-flight medical events, we identified 11,719 (15.5%) involving children. Most in-flight medical events occurred on long-haul flights (76.1%), and 14% involved lap infants. In-flight care was generally provided by crew members only (88.6%), and physician (8.7%) or nurse (2.1%) passenger volunteers. Most in-flight medical events were resolved in flight (82.9%), whereas 16.5% required additional care on landing, and 0.5% led to aircraft diversion. The most common diagnostic categories were nausea or vomiting (33.9%), fever or chills (22.2%), and acute allergic reaction (5.5%). Events involving lap infants, syncope, seizures, burns, dyspnea, blunt trauma, lacerations, or congenital heart disease; those requiring the assistance of a volunteer medical provider; or those requiring the use of oxygen were positively correlated with the need for additional care after disembarkment.

CONCLUSION

Most pediatric in-flight medical events are resolved in flight, and very few lead to aircraft diversion, yet 1 in 6 cases requires additional care.