BMJ  2008;336:616 (15 March), doi:10.1136/bmj.39514.477917.59

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A wing and a prayer: the tale of an in-flight emergency

Two weeks in Africa: fishing, hunting, snorkelling, fresh papaya, and daily barbeques. Oh, and visits to all my relatives. The flight out to the continent of my birth started well enough. Snack, nap, snack, nap. But I awoke several hours into the flight to find three members of the cabin crew huddling around the passenger in front of me. When I heard one of them say, "It might be a good idea to bring some oxygen," I found myself rousing from my slumber, inexorably and possibly quite against my will. I heard myself whisper, with some trepidation, "I’m a doctor, can I be of any help?" The relief on their faces was immediately evident.

An elderly man had had chest pain for some 20 minutes. I thought it strange that no announcement had been made asking whether a doctor was on board. Neither I nor the crew spoke the man’s language. With a series of hand gestures the man communicated that he had a crushing chest pain. He was sweating and breathing rapidly. I tilted his seat back as far as I could and called for the oxygen. I asked what drugs and medical equipment were available: one stethoscope, a sphygmomanometer, chewable antacid tablets, paracetamol, glyceryl trinitrate (GTN) spray. No aspirin.

I put the oxygen on at full strength from the portable tank. The chest pain continued. Antacid didn’t relieve it; GTN spray eased it; his blood pressure and pulse were within normal limits. Ten minutes passed and the pain returned—GTN again.

After an hour I was still standing in the aisle, with the chief steward holding the oxygen tank. With 10 minutes to go before landing he apologetically told me that he had to go and sit down (airline regulations). He promptly thrust the oxygen tank into my arms and left—it was every man for himself. I had earlier asked for the pilot to radio ahead and inform the ground staff to have an ambulance ready to transfer the passenger to a hospital, as he may have been having a heart attack.

We landed. The crew did not announce that an ill patient was on board who needed priority evacuation from the plane; thus, inevitably, 300 people got up to disembark at the same time. Fifteen minutes later, after everyone had finally trudged off the plane, I was politely informed that no ambulance was available and that a porter with a wheelchair would arrive shortly. The passenger would have his move through immigration expedited but would have to arrange his own transport to hospital. This is where I gave up the proverbial ghost. I watched him being wheeled away and said a little prayer for him.

What I experienced can only be described as a catalogue of failures by a reputable airline. It prompted me to look up the latest (2004) International Air Transport Association guidelines on in-flight medical emergencies and to consider how doctors should act in such circumstances. A recurring theme in much of the literature on the subject is to uphold the Good Samaritan principle and help where possible (Emergency Medicine Australasia 2007;19:1-8). The medicolegal liability risk is extremely small, we are assured.

With the advent of telemedicine and the availability of automated external defibrillators (AEDs), passenger safety protocols should be upgraded and optimised on all major airlines. No reason exists now why a suitably trained doctor on the ground cannot at least communicate basic life support management to aircraft crew or even advise the captain to request an emergency landing.

IATA guidelines say: "The airport operator has direct responsibility to ensure emergency services are provided or have unimpeded access. The airline medical department may elect to provide basic accident and emergency services for staff and passengers particularly if remote from hospital care." However, in places where airport emergency services cannot routinely be provided the onus should be on the airline to at least ensure that an emergency ambulatory service is provided on the ground for anyone who needs it as a result of an acute event during the flight.

Although cost implications are an issue for airlines around the world, a proactive policy rather that a reactive one seems the sensible option in countries that can afford the additional cost. The United States, for example, has mandated AEDs on all airlines since 2004. Airlines that carry AEDs on their aircraft should ensure that they have clear policies with respect to maintenance, quality, and training standards. Airplane medical kits are another area of concern. Airlines are currently advised to audit in-flight medical incidents to determine which types of medical events are most common. What may help is to have basic minimal standards for medical kits on all planes on all routes and then to encourage the use of audit to improve the kits and individualise them.

As a gesture of goodwill the airlines could, perhaps, start by providing more leg space and stockings for everyone, which might at least allay passengers’ concerns about that old favourite of the media, deep vein thrombosis among the economy class on long haul flights.

He promptly thrust the oxygen tank into my arms and left—it was every man for himself

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See Feature doi: 10.1136/bmj.39511.444618.AD.

From the archive: "A painful experience" by BMJ columnist Liam Farrell, BMJ 2002;324:857 doi: 10.1136/bmj.324.7341.857/a.

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