CASE 46
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Incident
You are an ‘off-duty’ pre-hospital and retrieval doctor travelling with your family on an international flight when you notice a commotion in the seat just ahead of you. Two passengers are attending to a fellow passenger.
Shortly afterwards, a request is made over the public announcements system for a doctor.
Questions
46.1 What are the issues associated with offering assistance?
A 56-year-old gentleman in economy class is complaining of central chest pain. He has known ischaemic heart disease and has had a previous myocardial infarction. He is clammy and pale and has vomited once. The aircraft is 9 hours into a 13-hour flight.
Discussion
46.1 Personal
Many doctors feel an obligation to offer assistance in such circumstances but, for most, there is no legal requirement to do so. However, it is widely accepted that physicians do have a humanitarian requirement to offer assistance in an emergency to the best of their ability. As a PHR doctor, the unexpected in the resource poor-environment is not unusual and most are likely to offer assistance. It is important that the doctor offers to help or is invited to help rather than simply ‘taking over’ the situation. As in all aeromedical situations, the pilot is in overall control of aircraft movements and safety.
Legal aspects
Offering assistance in such circumstances is infrequent and industry experts calculate that a doctor may encounter such an emergency only once or twice in a lifetime. In addition, they estimate that the chance of litigation is close to zero. However, this is a complex area and there is no guarantee of indemnity. Legal issues will also vary considerably from country to country. It is best to state at the outset that you are volunteering for this role and that, although you have pre-hospital experience, you do not have any of your equipment with you and that you will do your best for the patient considering the situation, the environment and the equipment.
Alcohol
Having taken an alcoholic beverage does not preclude the doctor from assisting. However, the doctor should take into consideration how much alcohol they have consumed and make this clear to the cabin crew and patient before becoming involved in patient care.
Other doctors
It is possible that other doctors are on the same flight and it is worthwhile for the available clinicians to decide among themselves who is most appropriate to lead the care. Factors such as specialty, alcohol or drug consumption and fatigue should be considered. Other clinicians may be better placed to assist the lead clinician with specific roles or advice.
46.2 ABC
A brief assessment of the patient’s vital signs is required. It should be possible to assess the severity of the situation within a few minutes. Record your findings.
Crew communication
The cabin crew will be looking to you for a plan and you should voice clearly and concisely your concerns. Avoid hesitancy, mumbling and medical jargon. The space constraints in economy class are marked and an immediate request to move the patient is appropriate. More space and an ability to lie the patient flat makes first or business class ideal but there may be better 360 degree access in the galley area. However, it may be easier to move other passengers to make room rather than moving the casualty. If there are other medical personnel (e.g. nurses or paramedics) on board then try to create the ‘two-person team’ with which you are familiar. Alternatively, utilise a member of the cabin crew. Ask for all the medical equipment to be brought to your new location.
46.3 There is a wide variation in medical equipment carried by passenger airlines. The Aerospace Medical Association has a regularly updated list offering guidance in this area. The box below shows the 2007 recommendations for this kit list.
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