A couple of months ago I was somewhere over the Atlantic, heading back to the US on the 15 ￂﾽ hour non-stop flight from Johannesburg to Atlanta. At 3.30am, I had given up trying to doze off, upright, in seat 30A. Through the semi-dark I was aware that the fellow traveler in row 28A was struggling to breathe. I was trying to decide whether this was just a case of bad snoring (sleep apnea) or something worse. Moments later, when the passenger stopped breathing, I became embroiled in a full-scale resuscitation.
It turns out this drama at 30,000 feet happens more often than you may think. A study published this week in the New England Journal of Medicine found that there was a medical emergency on one of every 600 flights; that translates to an estimated 44,000 inflight emergencies each year across the world. About 10 percent of the time, these incidents result in flight diversions. It turns out you have about a 50/50 chance of a doctor being on board, and often there are other health personnel amongst the passengers.
On my flight, there were a number of medical personnel who happened to be on board. Apart from me, a pediatric lung specialist, there were two emergency room nurses, a surgeon and an infectious diseases doctor -- a full team that tried to make the most of the emergency "kit" that appeared within moments. We made a make-shift bed across three seats, the flight attendant performed energetic and effective cardiac massage, and we placed a plastic tube in the mouth of the "patient" to keep open his airway and pump air into his chest with the bag and mask provided.
The pads connected to the automated external defibrillator were slapped on his chest, showing on the small screen that there was no sign of a heartbeat. The automated voice told us to stand clear and press the button that unleashed the electric current. After another round of cardiac massage and assisted breathing, his heartbeat returned and he started breathing on his own.
The question is; are we as safe as we could be if we unexpectedly run into medical trouble while in the air? On my flight, with the passenger unconscious and no access to information about his past medical history, we were "flying blind", guided only by what we observed. An ER nurse swiftly placed an intravenous tube into his hand, and we were able to give him fluids and glucose, ready to administer the drugs available in the kit to speed up or regulate his heart. We administered an Aspirin that was volunteered by a passenger, a precaution in case he'd had a heart attack.
Following discussion with the captain, the plane diverted to Miami, the closest port of call, and two and a half hours later, with our "patient" still unconscious but with a strong pulse and breathing well, we landed with the medical team standing and sitting around him, before he was hauled off the plane by the emergency medical services to an unknown outcome.
The paper published in the NEJM gave a good account of who runs into what sort of trouble; the average age of the acutely unwell passenger was 48 years and most common conditions were syncope (passing out) and breathing difficulties. Our patient was at the most severe end of the spectrum since fewer than one percent in the NEJM study had a cardiac arrest. However, this study suggests that, worldwide, about 400 passengers die from medical causes on planes each year.
While airlines cannot be expected to provide emergency room care for its passengers, is it possible that the industry, together with medical safety experts, could come up with a better response to the inevitable medical emergencies that occur while flying? Many airlines contract with medical experts on the ground who can provide expert guidance on the management of different conditions. But how well can you expect to be treated if you have a serious emergency that requires support of your breathing or cardiac system? How well prepared are flight attendants and the available medical personnel -- who may just happen to be on board -- to deal with seriously ill passengers? While skilled advice from the ground and rapid diversions can address many in-flight emergencies, that option is not possible for transoceanic or transpolar flights where the nearest port of safe medical care may be several hours away. The travel conditions on these long flights (prolonged immobility, dehydration, disruption of sleep, interference with medication routine, lower oxygen concentration in the plane) are precisely what may provoke a medical incident in a predisposed traveler.
What can be done? The NEMJ authors propose a set of guidelines for medical personnel who are called to assist a passenger. That will likely help to orient and guide medics who happen to be on board - but is that enough? The majority of doctors and nurses called to assist just don't deal with this type of emergency in their daily practice. They face a daunting obstacle in trying to manage a seriously unwell passenger: no knowledge of the patient, unfamiliarity with resuscitation routines, an unfamiliar set of medical tools, working in a cramped physical environment, managing anxious onlookers hovering over their efforts.
The irony is that the health industry has looked for years to the airline industry for lessons on how to improve safety of their patients. So here's the question: has the airline industry taken the same rigorous approach to mid-flight medical emergencies as it takes to other mid-flight crises? The airlines, more than any other industry, taught us concepts of reliability and gave us tools such as checklists that have made flying extremely safe. These perfections of the system of flying have propelled airlines to a remarkable achievement; in the last four years there have been of no airline passenger deaths due to crashes of U.S. airliners, despite the approximately 30 million flights undertaken during this time.
Why not bring together aviation and health safety experts to apply to mid-flight emergencies, the same systems principles that were applied to airline safety? Here are some ideas that could be considered...
• Make sure that at least one flight attendant has Emergency Medical Technician training on every flight where easy diversion is not possible -- someone who is trained to use the basic tool kit that the medical team on my flight used effectively to save this patient's life. There is a precedent for this type of action: the U.S. government provides an estimated 4,000 air marshals for our safety for a danger that is arguably less common.
• Identify a safe place to which a sick passenger can be moved. On my flight, we spent three hours actively managing a critically ill patient across three seats in row 28, without knowing that there was an "aisle" wheelchair that could be used to cart the heavy patient to a galley or other flat area.
• Make sure the emergency kit is better designed; in my case AmbuBag (mechanical ventilation bag) could not connect to the oxygen tank.
• Insist on an effective handoff from the ad hoc on board medical team on the plane to the EMT staff members who take the passenger off the plane. In my case, the EMT staff showed no interest and some irritation at my efforts to tell them what had transpired, and what drugs and electric shock we had delivered.
• Use the suggested NEJM guidelines to provide better directions for medical personnel called to deal with onboard emergencies.
A better plan is needed for caring for those who become seriously ill on long flights. The aviation and health care industries should work together to design, test and implement it.
The author is Senior Vice President of the Institute for Healthcare Improvement (www.ihi.org) and Clinical Professor of Pediatrics at the University of North Carolina at Chapel Hill.