Tuesday, February 19, 2013

But what about medical care ON airlines?

My friend and colleague Dr. Melissa Mattison writes in response to my post below comparing airline safety and hospital safety:

Ironically, one area that the airlines could absolutely improve is the care of passengers who become ill and have an inflight medical emergency.

She and BIDMC chief of medicine Mark Zeidel wrote an article about this in JAMA in 2011, entitled "Navigating the Challenges of In-flight Emergencies."  They make some really good points:

Available evidence suggests there is significant room to improve and standardize the care that is provided to patients during in-flight medical emergencies. Even though emergency medical kits are mandated to contain certain medications and equipment, the actual kits vary from airline to airline. The US Federal Aviation Administration (FAA) mandates that flight attendants receive training “to include performance drills, in the proper use of AEDs [automated external defibrillators] and in CPR [cardiopulmonary resuscitation] at least once every 24 months.” However, the FAA “does not require a standard curriculum or standard testing.”

To improve the chances that passengers who become ill during air travel will do well, airlines and their regulators could take steps similar to what they have done to ensure flight safety for all flights under FAA jurisdiction including the following.

First, a standardized recording system for all in-flight medical emergencies should be adopted, with mandatory reporting of each incident to the National Transportation Safety Board, the organization responsible for reviewing safety events and recommending changes to practice. This approach should include a systematic debriefing of anyone directly involved with the in-flight medical emergency. Wherever possible, this debriefing should happen immediately; otherwise, follow-up telephone interviews should be conducted.

Second, based initially on expert recommendations and later on the results of reporting, the optimal content of the first aid kits on airplanes should be determined, with a man-date that a standard kit, with identical elements, in identical locations, be on every flight.

Third, the training of flight attendants in how to deal with medical emergencies should be enhanced and standardized.

Fourth, access of flight crews to ground-to-air medical support should be standardized. If this form of support is deemed to be effective, then it should be available to all passengers, on all flights when on-plane health care professionals are not available.

With standard emergency medical kits and standardized training of flight personnel, it will become possible to provide to physicians and nurses some rudimentary training in in-flight medical emergencies.

Because the airline industry has already developed standardized reporting and responses to many forms of in-flight emergencies, the adoption of these measures by airlines and their regulators should not add a great deal of expense, but such sensible measures have the potential to improve outcomes for airline passengers who become ill.


Edward Wiest said...

My wife (a physician) and I witnessed many of these problems on a Cairo-Brussels flight on a Western Europea carrier in the late 1980's-early 1990's. Over water, an infant on board had breathing problems, and the captain put out a call for assistance. My wife and a German physician responded. While there was a medical kit on board, neither the medications nor the tools were labeled in a manner recognizable to physicians outside the country of registration. Treatment was limited to CP(AED's were some years in the future) R; assistance from the flight attendants was limited to providing space for the physicians to work (even though one would assume flight attendants were CPR-trained). On the recommendation of the physicians, the flight made an emergency stop in Athens where the child (still in need of CPR after over 60 minutes) left the plane with its parents for further treatment (if any treatment would be effective).

What struck my wife and I through the entire incident was the total detachment of both the flight and the cabin crew during the incident. There was little material assistance; indeed, I don't recall that any effort was made to record either physician's name for follow-up (we never heard of the outcome of the case nor anything else from the airline, apart from the apology all connecting passengers got when their baggage was not transferred in Brussels). One would hope that IAEA would not only develop standard training and equipment protocols (and that they would be followed in fact), but such drugs and tools that are placed in the emergency kit are labeled in a manner so they can be used by health care workers of any nationality. That point alone was a major problem in the case in which we participated.

Anonymous said...

The points in the article are very well taken; however, I cannot help but be struck by the irony of two physicians recommending standardization of medical care/reporting/procedures, to be dictated by an oversight agency for care on an airplane; when such standardization is almost completely lacking and, indeed, often highly vilified by physicians, in the provision of medical care in the nation's hospitals.

nonlocal MD

Paul Levy said...

True, but not by these two MDS, who are exemplary adherents to thoughtful process improvement in clinical settings.

Anonymous said...

Right, Paul. I had intended to specifically exempt these two physicians from my comment, but perhaps I did not succeed. My point was that the air travel industry has an oversight agency which can specify standardization to improve performance; would that we could standardize anything at all in health care over the objections of 'cookbook medicine', 'governmental overreach', etc. etc..