Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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What use a stethoscope?
- Andrew J Ashworth (15 March 2008)
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What use a stethoscope? correction
- Andrew J Ashworth (15 March 2008)
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What use a coathanger?
- David Menzies (15 March 2008)
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What use a cabin crew?
- Katy Edmonds, Martin John (16 March 2008)
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Re: What use a cabin crew?
- Ajay K Gupta (17 March 2008)
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Practical points
- David N Greig (17 March 2008)
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Personal Experience of Cabin Fever
- Michael E Ward (17 March 2008)
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"Most experts agree"
- Nigel P Dowdall (17 March 2008)
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Flying by the seat of your pants
- Paul A Frisby (17 March 2008)
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capturing the data
- Paul A Frisby (19 March 2008)
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Cabin fever
- Andrew P Jewell (20 March 2008)
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Cabin Fever
- Dr Anand D Deshpande (20 March 2008)
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Claiming an honorarium from the airline
- Dougal Watson (20 March 2008)
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Use a latex glove finger as a non-return valve
- Peter J Flegg (21 March 2008)
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Hot Topic: Time for Mandatory AEDs?
- Daniel A Jones, Neha Chopra (21 March 2008)
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Ground to air medical advice is available from the UK
- James Ferguson (21 March 2008)
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Traveling with Children
- Shan Tang (25 March 2008)
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You may offer help but the airline may not want it.
- Judy Shakespeare (27 March 2008)
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Relapse of Cabin Fever
- Philip D Welsby, Emily Burt, Michael Jones (29 March 2008)
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Andrew J Ashworth, GP Davidson's Mains Medical Centre, 5 Quality St, Edinburgh, EH4 5BP
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The contents recommended (1) for an airline medical bag appear extensive but, as reported by Wallace (2) have required improvisation. The Royal Navy carried (and presumably continues to carry) in its warships non -return Heimlich chest drain valves that are not only portable, but independent of gravitational force. Had our orthopaedic professorial colleague had a Heimlich Valve on his flight in 1995 (or the presence of mind to find among his fellow passengers’ hand luggage a condom, which can be cut through the teat to provide an equally effective non-return valve) his jacket might have been better cared for by retaining its hanger and any dehydration addressed by drinking the water (even though the brandy had been sacrificed for medical need). It would be of interest to identify the value of a stethoscope in an aeroplane as anything more than a badge of rank: BP can be assessed using the pulse method, murmurs, bruits and bowel sounds are likely to be both inaudible and irrelevant to the short term management and anyone who can confidently assess the absence of breath or bowel sounds through an unfamiliar stethoscope using barotraumatised ears in a noisy environment is a braver doctor than me! Perhaps the aviation industry should consider substituting the stethoscope for a Heimlich valve (or a condom!) in its recommended equipment list. 1. Thibeault C, Evans A, Air Transport Medicine Committee, Aerospace Medical Association. Emergency medical kit for commercial airlines: an update. Aviat Space Environ Med 2007;78:1170-1. 2. Wallace WA. Managing in flight medical emergencies. BMJ 1995;311:374-5 Competing interests: None declared |
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Andrew J Ashworth, GP Davidson's Mains Medical Centre, 5 Quality St, Edinburgh, EH4 5BP
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Many appologies - he used the coathanger as an introducer! I wonder if you would edit out the bit about the jacket, though drinking the water can be retained. Thank you Andy Ashworth Competing interests: None declared |
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David Menzies, SpR Emergency Medicine St Vincent's University Hospital, Dublin 4, Ireland
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Of course, the plane could have descended (or pressurized) to 2000ft in the time it took to improvise this chest drain. The pneumothorax would have decreased in size and the element of tension may have disappeared. Competing interests: None declared |
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Katy Edmonds, SHO ENT surgery Guys' Hospital, London, Martin John
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On a long haul charter flight with a well-known company, the request for the attendance of a doctor was put out. Although initially reluctant to respond due to our inexperience, we did so when it became apparent that there were no other medics on board. We were called forward to see a passenger with chest pain who had recently suffered a myocardial infarction. We were shocked at both the disorganisation and the apparent lack of training of the crew. Tonks states that medical volunteers rarely work alone, though unfortunately that was the case in this situation. The medical kit carried on the flight was also in a poor state. There was neither aspirin nor a sphygmomanometer, and the crew were unable to work the defibrillator. Not only were we trying to assess and treat the patient with these inadequate facilities but the crew were also putting pressure on us to make a decision regarding diversion of the flight. These points were raised with the airline in question on return but we did not even receive a response. It was certainly an unpleasant experience and we would both think twice before volunteering in such situations in the future. Competing interests: None declared |
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Ajay K Gupta, Clinical Research Fellow St Mary's Hospital, W2 1PG
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I can identify with that as well. I've also had a misfortune of being left on my own, caring for a sick passenger for duration of few hours, while, the cabin staff went on to do their own work. Most distressing aspect for me was that after spending those few hours--siting with that passenger-- away from my family and food!, the cabin staff (or the airline) didn't have courtesy to say thanks at the end of it. It was as if, being a doctor, this is my job, and least of their concern. However,my reward was the thanks and gratefulness in the eyes of that patient, but, the point here is responsiblities of the airline and it's crew towards paying passenger. And what about my rights as a paying passenger, reimbursing or helping these profit making airline at no cost to them! Competing interests: None declared |
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David N Greig, Retired GP Taunton TA2
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On three occasions I have been asked to attend another passenger or a crew member on a longhaul flight. An elderly man collapsed. He spoke no English. I did not realise how anaemic he was until we came in to land as curtains were drawn and it was anyway dark outside. Once he was in daylight the diagnosis was obvious. The cabin staff had been reluctant to draw the curtains as it was still early morning. I suggest that where possible the curtains are drawn when you are making an assessment. The cabin staff wanted this passenger strapped upright in his seat for landing but I managed to persuade them to lie him on floor against a bulkhead. Even sitting him upright in his seat had caused him to faint. The stethoscope in the kit is useless because the background noise from the aircaft's engines drowns out any other sound. On two of the occasions when I have asked to see a passenger the captain of the aircraft discussed the option of diverting the flight but both times I did not think it would help. I have always found the cabin staff were well trained and helpful. One purser told me that on average they thought that they had at least one medical problem that they dealt with themselves every ten flights. Competing interests: None declared |
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Michael E Ward, Retired Consultant Anaesthetist Nuffield Department of Anaesthetics, Oxford
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Your Feature article 'Cabin Fever' and the Personal View by Osman Dar on the subject of emergencies during flight and the travelling doctors' and crews' responses bought back all too vividly my own experiences of less than one year ago. My wife and I had been in Australia for three weeks on holiday and to attend a wedding in Sydney. For the last couple of days in Sydney I had been feverish and unwell, but still participated in the wedding festivities, and prided myself on my attempts to dance every dance until midnight. The next afternoon we made our way to the airport to commence our return to the UK with a planned two night stop in Hing Kong en route. At check-in I was feeling quite unwell. My temperature was up at 39.4C but I was very keen to board and to get home so popped another couple of paracetemol and got on to the plane and slumped down in my seat in an effort to sleep the afternoon away. About an hour after take off I awoke with a sever pain in my right knee and thigh. The area was exquisitely tender too. I examined the tv display of our route and could see we were still over central Australia. I turned to my wife and told her I was feeling unwell and my leg was in pain and that I thought I might have a DVT. I was told to not be so silly, and go back to sleep. I tried but it was just too painful. As I tried to doze off I could not help but imagine the consequences of a big DVT leading to a big Pulmonary Embolus (PE) whilst in the air. I reckoned my chances of survival were nearly nil. I turned to my wife and explained that if I reported my condition now then the plane could land at Darwin and I could be off loaded and admitted, and that way I could survive the journey. With a sigh my wife reported my anxieties to the stewardess. She listened patiently then went away to discuss me with her superior the Cabin Crew Manager. This efficient lady then took a history, filled in a form and told me to rest quietly whilst she reported the matter to the Pilot. After some time the Cabin Crew Manager returned to say the Pilot was going to discuss me with MedLink and they would then act on the advice received. I repeated my concerns about a fatal PE in the air. My wife now tells me that by this time I was very hot and she thinks I may have been on the verge of delirium! The Senior Stewardess also asked my wife if she would like the Crew to put out a call to see if there was a Doctor on the flight - apart from myself that is. This was then done and I listened with some detachment to the call go out. Five doctors responded and my wife was put into the somewhat surreal position of interviewing to find the appropriate specialist from a short list of a retired physician, two psychiatrists a general surgeon and an SPR in Accident and Emergency. She chose the trainee in A&E, a decision I believe to be the correct one. My Samaritan came and took a history and then asked the crew if there was anywhere on board she could examine me. I was helped to the Galley and the curtains drawn around us. On examination there was nothing to see at all. No calf tenderness, but still exquisitely tender popliteal fossa and inner thigh. I returned to my seat and the doctor consulted with the Pilot and the clinical findings relayed to Medlink in Phoenix, Az, half way round the world. The Pilot soon came to talk with my wife, I think perhaps the crew had decided I was too unwell to be rational. He reassured her that the advice received from MedLink had been to proceed to Hong Kong but that contingency plans had been made in the event I became worse to land at Brunei. I should take aspirin, pleny of fluids and lie flat with my leg elevated. However, there was no room in first class so I was downgraded to economy and made to lie across five seats in the middle of the plane with my leg elevated and strapped onto a pillow. I remember little else of the next six hours, apart from asking for water from time to time, until just before landing at Hong Kong when I was told I had to be strapped in for landing, and that as I was a special case I could be strapped in a lying position. This was rigged up with seat belt extensions. After a safe landing the other passengers disembarked, a Chinese immigration officer came on board and briefly interviewed my wife and myself, before a paramedic crew, wearing masks, came on with a special carry chair. I was unceremoniously off loaded via the baggage door and hoist onto a standard ambulance gurney and then taken directly to the Princes Margaret Hospital, Hong Kong Accident and Emergency Department. On examination there a red line was visible up my leg from my calf to my groin, lymphadenopathy was evident in my inguinal region and I was diagnosed with lymphangitis and septicaemia. IV antibiotics were started, I was admitted for four days before I was fit to travel home to the UK. It was presumed my infection had started follwing an insect bite around the ankle region of which I have no recollection My experience with my 'Cabin Fever' was a positive one. The crew and the respondants to the "is there a doctor on board" all acted calmly and professionally. Both my wife and myself were treated calmly and with tact and kindness. I am gratful to Virgin Atlantic's crew and the staff of the Princes Margaret Hospital Hong Kong for their care. It has taken a year before my wife has allowed me to travel longhaul again. Dr Michael Ward Competing interests: None declared |
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Nigel P Dowdall, Head of Health Services, British Airways Waterside (HMAG), P.O. Box 365, Harmondsworth UB7 0GB
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Despite the emergence of evidence based medicine, so-called 'expert consensus' continues to be used to perpetuate myths, in this case that the frequency of inflight medical emergencies is rising. Data from airline cabin crew reports show wide variation because of differing reporting processes and thresholds. Passenger demographics may be changing such that the average age of passengers is increasing, but I know of no robust evidence that this is associated with more inflight medical problems - it may well be that the current generation is fitter and more able to travel than previous generations. If in-flight medical incidents were becoming more frequent, we would expect to see increasing trends for medical diversions and for deaths. We have examined the data for our airline, a global international carrier. Although medical diversions are increasing as a percentage of the total, this reflects a reduction in other causes and there has been no increase in the frequency of medical diversions. Similarly there has been no change in frequency of the (small) number of deaths which occur during flight each year. Clearly if the total number of passengers continues to rise and the average journey duration increases, the total number of cases is likely to rise. However, other than in the context of the total number of passengers on the aircraft, this 'expert' would argue that the chances of encountering an inflight medical incident is low and there is no evidence that it is increasing. Competing interests: None declared |
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Paul A Frisby, General Practitioner Eastbourne BN21 1DH
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I was interested to read Alison's article about clinicians giving assistance in the air. My own personal experience and anecdotal evidence from colleagues leads me to believe that these events are greatly underreported by the airlines. I have given assistance on 5 occasions over the last 15 years. I am not a frequent flier, but I do fly to Canada once a year and the 3 most significant episodes have occurred on these long-haul flights. The call for assistance goes out frequently enough that I have stopped drinking alcohol before or during flights, fearing that I will need to make important decisions whilst in the air. These events may not result in litigation but they certainly ruin your flight and can impact upon the enjoyment of your holiday. On one occasion, when I was helping an ill passenger, she fainted profoundly and repeatedly. I have learnt that listening to heart sounds and checking blood pressure on the floor in the galley over the noise of the engine, with stuffy ears and with the toy stethoscope in the medical kit. We were a couple of hours out from the US and the purser was sent to ask me whether the captain should divert the flight and land at Halifax Nova Scotia. With two large gins inside me and 90% oxygen saturation to my brain (according to the article), and wanting to get home to Heathrow as I had to work the next day, I sent word to the captain to "press on" though I made sure to state that I had been drinking both before and after giving assistance and could not therefore be confident in my judgements. I did a good job that day and, had I not been on board, the plane may well have had to land and all the passengers transferred from Halifax to New York to await flights home. The crew were most grateful and transferred me to first class for the rest of the flight. On another occasion flying across the Atlantic, I had to look after someone who had been taken ill (she had fainted and I wasn't surprised as the air conditioning wasn't working properly and everyone had sweltered on the plane for 90 minutes before take -off). I was rewarded with two bottles of cheap wine from the trolley but my wife was left to look after our toddler on her own for the best part of an hour, while worrying what might be happening to me at the back of the plane. I was away from my family as the plane landed. As a General Practitioner, on every occasion that I have gone to help I have been the most suitable and experienced clinician present and the paediatricians, dermatolgists, midwives and nurses who have also come forward have been happy for me to get on with it. Although I have offered identification I cannot remember anyone ever checking my credentials. The crew have usually required me to fill in an incident report, which I have done, to complete a record of what has happened, though I have never yet received any written thanks from either the airline or the patient. I have also kept my own contemporaneous notes as protection against complaint or litigation. If British Airways only called for a passenger to help 375 times last year as your article states (about once a day then), surely it wouldn't hurt them to give those good samaritans a free flight or even just write to say thankyou! A better way to measure the frequency of such events would be to ask doctors and nurses about their experiences. Many of my friends and colleagues can tell similar stories. Indeed I had spoken to a plastic surgeon only a year before my Chicago flight who had told me never to divert to Halifax, as he claimed that although the runway is long enough for a jumbo to land it is sometimes impossible to take off again if the weather is bad. He had ordered such a diversion and been 3 days late getting home as a result. Perhaps I have just been unlucky so far and can look forward to a less eventful future. Paul Frisby, GP Eastbourne Competing interests: None declared |
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Paul A Frisby, GP Eastbourne BN21 1DH
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Nigel Dowdall challenges the anecdotal evidence of the frequency of in-flight emergencies and highlights the difficulty capturing the data. I suggest a scheme whereby doctors and nurses coming forward to assist when requested could claim an honorarium from the airline of, say, a free flight or $1000 US. My experience with the QOF tells me that we would soon have some accurate prevalence data. 1. Dowdall "Most experts agree" Rapid responses. Competing interests: None declared |
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Andrew P Jewell, Professor St George's University of London, SW17 0RE
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The article by Alison Tonks on Health emergencies on aeroplanes suggests that "most doctors will encounter a medical emergency once or twice in a lifetime of travelling". I found this unusual as my recent experience is having been on several recent flights where help has been called for. The "recent best guess" quoted in the article is that serious events occur somewhere between 10,000 and 40,000 passengers. However the risk of being called on a plane is the risk per trip and not per passenger, and making some crude assumptions can make the figures look different. A Boeing 747 carries approximately 500 passengers and crew depending on the seat configuration. Although not all flights carry this many passengers, most medical emergencies will occur on long-haul flights so this is not too misleading. Again, assuming most people by return tickets, a typical long haul flight exposes the doctor to approximatley 1000 passengers. This equates to the risk of a serious medical event occuring on a trip to approximately between 1 in 10 and 1 in 40, which is an entirley different prospect Competing interests: None declared |
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Dr Anand D Deshpande, physician Westhoughton, Lancashire BL5 2QE,UK
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A few years ago I attended a day course in London airport to learn the management of in-flight emergencies. This was conducted by an Airline and was quite useful at least to make us aware what happens and how these emergencies are dealt with by the crew. I believe we were about twenty doctors doing that course. During the lunch break, while we were talking with each other, one thing came loud and clear. Almost all of the doctors said they would not volunteer to treat an ill patient in the flight if that passenger was an American. Everyone was afraid (rightly or wrongly but the Americans are perceived that way by the world) that Americans are litigants by nature and why get involved with a court case. The article says the litigation risk is very small. But it doesn't actually say it is nil or doctors in such situation are given immunity. Just because no one has sued any doctor so far doesn't mean an ungrateful man or woman wouldn't do it in the future. This is the point which has to be assured firmly. The article hasn't said that. I have heard anecdotes from a few friends involved with emergency treatments and also a few responses this week have shown that the airline crew fail to thank the doctor. What these doctors should realise is that the species of an ungrateful man or woman is not walking just on the land but they can be flying high in the clouds as well. Some doctors have suggested a free flight or some other gift. That is quite a dangerous proposition. A samaritan work should not be expected to be rewarded. Doctors should positively refuse to take free champagne (if offered by the crew) or upgrading their seat etc. Because accepting such silly offers can be construed as the doctor has been payed for the work. Litigation may be possible in such situation! (Lawyers can enlighten on this point.) Please show that you are a doctor and above all the petty behaving cabin crew. Using a stethoscope in that noise is a waste of time, I have tested it sometime. By the way, the tension pneumothorax quoted in the article made me wonder if a wide bore needle was sufficient to pierce the chest and release the air instead of untangling the coat hanger and using the catheter etc. Competing interests: None declared |
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Dougal Watson, Principal Medical Officer CAA Petone 5014 New Zealand
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Paul Frisby postulates that a medical practitioner claiming an honorarium from the airline after assisting in the event of an in-flight medical emergency might assist in data gathering. Having responded to many such calls in the past I would be far more comfortable acting as a gratis good samaritan than with any expectation of honorarium of any sort from the airline or any other party. I am no international aviation lawyer but I do believe I would be far more exposed to the risk of litigation if I were accepting or expecting any sort of recompense (other than thanks) for providing such emergency assistance. I am aware of one major international airline that has a program whereby participating medical practitioners consent to be called in the event of in-flight emergencies are are provided with non-financial benefits in recognition of their involvement. I am not aware of this approach being embraced by other airlines. Competing interests: None declared |
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Peter J Flegg, Consultant Physician Blackpool FY3 8NR
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I would endore what Dr Ashworth says about the improvisation of a chest drain in situations as he describes. There is no need for gravity- dependent water seal systems as used by Wallace. A non-return valve is all that is required, and can be fashioned simply from the finger of a latex glove with the ends snipped off, without the need to embarrass anyone by asking for a condom! We used a similar method during the guerrilla war in Rhodesia (Zimbabwe) during the 1970s, when cases of traumatic haemo/pneumothorax could be treated in the field with a simple valve system designed for field use by a local cardiothoracic surgeon, Mr Thompson. My only experience of assisting as a doctor came just after disembarkation from a flight, when a girl developed an acute asthmatic attack. My offer of assistance was accepted unquestioningly with no request to provide any confirmation of my identity. For all anyone knew or cared, I could have been Fred West. The organisation on the ground left a lot to be desired, and the "hand over" from air crew to ground crew was nonexistent. I eventually was able to board a much later connecting flight to my destination after a significant delay. I gave my details, was promised that I would be contacted and receive an offer of some recompense for my efforts in terms of vouchers, but heard nothing. Competing interests: None declared |
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Daniel A Jones, SHO Cardiology Basildon and Thurrock NHS Trust, Neha Chopra
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To Editor We read with interest the article on emergency medicine and air travel1 which highlights important issues with regard to attending and treating passengers. The American Heart Association estimates that as many as 1000 lives are lost annually from cardiac arrests in commercial aircraft, although this statistic is almost impossible to verify as airlines are not obliged to record medical emergencies2. These statistics are only likely to increase with older, sicker people flying more and further. The issue of debrillators and aircraft is one that is hotly debated and has received much media attention in recent years e.g. Paul Keetch the MP who was successfully resuscitated by AED earlier this year. At the moment, European airlines do not have to carry defibrillators, although most long-haul carriers do. In the US, the Federal Aviation Authority says all international flights must carry defibrillators. I personally have attended to a passenger suffering from cardiac arrhythmia on a plane and the lack of defibrillator or basic monitoring equipment was both concerning and frustrating to say the least. Reports from Air France, Quantus and US airlines have shown benefit with AEDs on board3 AEDS prove beneficial to airline operations as well as passengers, with their cardiac monitoring facilities providing information as to whether to divert or not. E.g. diverting with patient in asystole is likely to be futile. We audited a selection of 40 european airlines to assess whether they carried AEDs. 27/40 (68%) carried AEDs on all aircraft. All airlines that traveled long haul carried AEDs. Those airlines that did not carry defibrillators flew both medium and short haul distances. The majority of these airlines were ‘low-cost’ or budget airlines. Without defibrillator on board, cardiac arrest/ventricular tachycardia are likely to be fatal with facilities too far away to be of use. BMJ article estimates 10 arrests/year per airline and with the Federal Aviation Administration current valuation of $2.7 million for each human life, only one or two lives over the next 5 years need to be saved to justify the cost of installing and maintaining AEDs and providing the expanded medical kits4. Part of the NHS service framework of CHD is to be within <8 mins of a defibrillator, almost 10 years on and in the 21st century is it acceptable for an individual to be >30 mins from defibrillation facilities when required? AEDs should be part of all aircrafts medical kits. References 1). Tonks A. Cabin fever BMJ 2008; 336: 584-586 2). O'Rourke MS, Donaldson E, Geddes JS. An airline cardiac arrest program. Circulation. 1997;96:2849-2853 3). Page R, Joglar J. Kowal R et al. Use of Automated External Defibrillators by a U.S. Airline. N. Engl. J. Med., October 26, 2000; 343(17): 1210 - 1216. 4). O'Rourke R. Saving Lives in the Sky. Circulation. 1997;96:2775-2777 Competing interests: None declared |
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James Ferguson, Emergency Medicine Consultant Emergency Department, Aberdeen Royal Infirmary,Foresterhill, Aberdeen AB25 2ZN
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I read with interest your article on In-flight emergencies amd the comments from the representative of Medaire. I was surprised that a British Journal did not approach a British supplier of Ground to Air Medical advice for comment. You may not be aware that there are companies doing this in the UK. You may wish to peruse our website at www.thefirstcall.com We are about to publish a 5 year review of our activity in the Journal of Telemedicine and Telecare which was presented at Telemed 2007 at the RSM in London. If you wish further information, do not hesitate to contact me. James Ferguson Consultant in Emergency Medicine, Aberdeen Royal Infirmary. Clinical Lead, The First Call Competing interests: Unpaid Clinical Lead for The First Call. Contract to supply emergency telemedical advice is with NHS Grampian who i am employed by. |
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Shan Tang, Paediatric Registrar Newham University Hospital E13
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On a recent long haul flight, I volunteered my medical services. It emerged that a baby with diarrhoea and vomiting needed attention - as a general paediatric registrar, this was right up my street. The baby was dehydrated and not tolerating fluids. I asked to look at the medical kit and was led to a suitcase full of neatly labelled drugs and equipment - but strikingly for a paediatrician; none was suitable for small children. There were no child sized cannulas, catheters, face mask or endotracheal tubes. Fortunately with gentle syringing of small amounts of fluid into the baby's mouth, we were slowly able to rehydrate the baby. Almost every flight has a young child onboard. Small children and babies need specific medical equipment for resuscitation. This should be taken into consideration when packing a medical kit. Competing interests: None declared |
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Judy Shakespeare, GP Summertown Health Centre OX2 7BS
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I was recently travelling on a QATAR airlines flight from Sri Lanka when the request for a doctor came over the tannoy. After a minute of waiting to see if anyone else volunteered I "made myself known to a member of the cabin crew". I was surprised when I was asked if I could prove I was a doctor. I said that I was on holiday and had not intended to work so was not carrying any proof. At this stage she said that she could not accept my offer of help as I might be impersonating a doctor. I don't know if this has ever actually happened but having volunteered and done my duty I was made to feel like a criminal. Competing interests: None declared |
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Philip D Welsby, Post retirement teaching Fellow Western Gernal Hospital, Edinburgh EH4, Emily Burt, Michael Jones
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RELAPSE OF CABIN FEVER We wish to provide additional comment on your 15th March article.(1) Worldwide, there are 30-33 IPMIs each day (2). The numbers of passengers on long haul flights are increasing (in 2010, it is predicted that there will be 2.2 billion passengers - 80% more than in 1995), and it is anticipated that more older people will travel. In 2005 we conducted a retrospective study of 100 doctors (42 GPs, 58 hospital staff) who had assisted at a total of 107 in-plane medical incidents (IPMI). Fifty-six IPMIs occurred on flights of length eight hours or less, 46 in flights of over eight hours, and on five diverted flights (the planned duration of which was not relevant). The commonest cause of IPMI were cardiac, gastrointestinal and vasovagal. Five (4.7%) of the IPMIs resulted in diversions. Two were caused by cardiac episodes, one by a vascular event (deep venous thrombosis), one by a gastrointestinal event, and one by haematemesis following a gunshot wound sustained before flying. Diversions are expensive, a suitable diversion destination must be rapidly identified, facilities for unanticipated arrivals at diversion destinations need to be organized, passengers and crew will arrive at their intended destinations hours if not days later than planned, and connecting flights or meetings may be missed. Nevertheless a doctor’s responsibility is to the patient, and not to other passengers. As your article stated, there will be a greater risk of IPMIs (1), and inevitably diversions, with ultra long haul planes such as the Airbus A380 with ranges of 9,700 miles and passenger capacities of 550 – 800), and also the duration of in-flight care will increase, because relatively few airports possess runways long enough to land such large aircraft. In such circumstances, the presence of on board doctors should not be left to chance. IPMIs should be more rigorously monitored with standardized international reporting correlating associations between in-flight diagnoses, post-flight diagnoses, hospital admissions, and final outcomes. Finally, as discovered by MJ, stethoscopes are well-nigh useless because engine noise makes auscultation very difficult - their main use is as a badge of authority and, during apparent use, allow thought as to what should be done next. Emily Burt MBChB, FY2 Philip D Welsby FRCP(Edin) Post-retirement Teaching Physician Michael Jones FRCP(Edin) FFTM RCPS (Glasg) Consultant Physician Potential conflict of interest. British Airways paid an air fare for EM to discuss her student project with a British Airways’Physician. Regional Infectious Diseases Unit, Western General Hospital, Edinburgh EH4 2XU Corresponding author PDW Philipwelsby@aol.com REFERENCES 1. Tonks A. Cabin Fever. BMJ 2008;336:585-6. 2. Gendreau M, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med 2002;346:1067-73 Competing interests: One of the authors, Emily Burt, had her air fare paid to discuss her student project with a British Airways Physician |
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