Doctor on Board: good to know

It is estimated that air traffic will continue to increase in the future, with over 3 billion people currently flying on commercial aircraft every year. There is a special physiological environment on board an aircraft that is characterised primarily by decreased ambient pressure and oxygen partial pressure, dry air, time differences and space restrictions. Passenger age is increasing, and even patients with pre-existing conditions fly more frequently. Aircraft are increasing in size and flying longer and longer distances. Combined with the stresses associated with travelling, all this leads us to expect a further increase in on-board emergencies. We can therefore expect that, around the world, there will be a medical emergency on board a passenger aircraft every 12 minutes. Given the high passenger numbers, however, the risk is very small (8–50 : 1 million passengers); the likelihood of an unscheduled landing is 1 : 1 million passengers, and that of a death is 1 : 2 million passengers (J. Siedenburg [2010], Kompendium Flug- und Reisemedizin. BOD, Norderstedt).

Nevertheless, the vast majority of medical emergencies are minor. They are usually caused by cardiovascular problems, followed by neurological and gastrointestinal disorders. There is an extensive range of equipment for on-board treatment, including a doctor’s kit, AED, several first aid kits and a plentiful supply of painkillers, nasal sprays, etc., plus an additional medical kit on long-haul flights. The cabin crew are trained in first aid for the usual on-board emergencies, including cardiopulmonary resuscitation and use of the AED. They receive annual refresher training and can therefore support doctors providing emergency aid to passengers.

Emergencies on board commercial aircraft can seem particularly dramatic – and not only to the layperson – as a result of the circumstances outlined above, lack of space, difficult patient access, lack of privacy from other passengers, language problems and restricted technical and therapeutic options. Emergencies cannot be diagnosed and treated on board in the same way as in a clinical setting; for example, heart, lung and abdomen auscultation and blood pressure measurement are almost impossible due to the noise of the aircraft. The option of telemedical advice can be helpful. For these reasons, despite the frequent drama of events, it is essential to proceed systematically and calmly (J. Siedenburg [2015], ‘Notfälle an Bord’, in J. Siedenburg and T. Küpper (eds.) ‘Moderne Flugmedizin’, Gentner Verlag, Stuttgart).

Legal problems and issues of liability, which are often feared, are obviated by Lufthansa’s liability cover. However, in an international context, it should be noted that such cover (the ‘Good Samaritan Principle’ in US law) only exists if the assistance is provided free of charge. Indeed, in German and continental European law, there is an obligation to provide assistance, which isn’t included in Anglo-Saxon law.

In the recently published standard work on aviation medicine (J. Siedenburg and T. Küpper [eds.] [2015], ‘Moderne Flugmedizin’, Gentner Verlag, Stuttgart) these topics are addressed in greater depth, and all further aspects of aviation and aerospace medicine are discussed extensively.


Facts and figures

Even in the past few months, doctors on board Lufthansa flights have ensured that acutely ill passengers were well cared for
during medical emergencies. Because for every individual concerned, a medical emergency on board is and will remain a rare event, we recommend reading an article from the Deutsches Ärzteblatt (German Medical Journal) that contains relevant facts and figures. Read the article

Well-trained cabin crew

Our flight attendants are regularly trained in first aid in accordance with the latest guidelines from the European Resuscitation Council (ERC). You can find details of the information provided by the ERC here.

Fast assistance thanks to the latest technology

Thanks to the Lufthansa fleet’s powerful wi-fi networks, state-of-the-art telemedicine tools can be employed if necessary. By transmitting ECG data, it is possible, for example, to obtain assessments on further treatment of the patient from centres of competence on the ground.
The airRX app gives doctors on board an insight into a wide range of scenarios and provides an overview of medical equipment. Go to the app

General procedure in the event of on-board emergencies:

• Introduce yourself to the crew, giving details of your professional background and training.

Examination of the patient:

• Ask about the duration and nature of the main symptoms.
  
• Ask about any secondary symptoms and risk factors (e.g. chest pains, shortness of breath, nausea or vomiting, weakness or loss of sensation on one side).
• Check vital signs (pulse and blood pressure and, if necessary, respiratory rate; if blood pressure cannot be taken by auscultation due to loud background noise, estimate systolic pressure by palpating the radial artery).
• Determine the state of consciousness and any focal neurological failures.

In the case of cardiac arrest:

• In the event of circulatory arrest, begin cardiopulmonary resuscitation (CPR) immediately.
• Request and apply automated external defibrillator (AED). If a pulse can be felt but a cardiac problem is presumed, use the AED as a monitor if necessary and if technically possible (some airlines require prior contact with a
  team of consultants on the ground).
• Request the doctor’s kit from the cabin crew, and administer oxygen if necessary.
• If necessary, make contact with a team of consultants on the ground, if this hasn’t already been done by the cabin crew. Additional measures such as the administration of drugs or intravenous fluids or an unscheduled landing can be discussed with the team as required.
• Document the results of examinations and measures taken. If necessary, give information to the medical personnel responsible for further treatment during handover on the ground.

Procedure in the event of syncope:

• Is the patient breathing, and do they have a pulse?
  
• Check vital signs (most patients present low RR values).
  
• Move patient to aisle or preferably the galley, place in a recumbent position with legs raised, and administer oxygen.
  
• If patient is known to be diabetic, measure blood sugar (device in doctor’s kit, or use device from patient’s or another passenger’s luggage if necessary).
  
• Most patients recover after a few minutes; administer fluids orally if necessary and if possible.
  
• The administration of intravenous fluids is usually only necessary if RR drops further and oral administration isn’t possible.

Procedure in the case of chest pains or palpitations:

• Check vital signs.
  
• Give oxygen.
  
• If chest pains are thought to be cardiac-related, give aspirin if necessary or heparin if available.
  
• Depending on systolic pressure, administer nitroglycerin sublingually every five minutes (check RR after every dose).
  
• If the AED has a monitor, use it to monitor heart rhythm if required, and examine limbs as a rough indicator of possible ST segment depression if necessary.
  
• If the symptoms abate after the treatment mentioned above, it may be possible to avoid a diversion. Discuss with team of consultants on the ground if applicable.

Medical incidents on board the Lufthansa fleet

In the last few years, an overall increase in on-board medical incidents has been recorded in global aviation traffic (source: IATA Medical Advisory Group). This is also the case for Lufthansa: out of the approximately 1,700 daily flights, there are between ten and 15 medical incidents every day. These range from minor illnesses, such as headaches, fever and vomiting, to asthma attacks, colic, strokes and suspected heart attacks.

Medical care using the doctor’s kit

In most cases, it is possible to provide adequate medical care on board through cooperation between the crew and doctors—like you—supported by the on-board doctor’s kit and first aid kit.

While it might be hard for us to imagine, on many routes the equipment in the doctor’s kit on board the Lufthansa fleet is at least equivalent to medical options on the ground. And often the quickest way for the patient to receive the necessary medical care is to continue on to their destination.

Round-the-clock advice from MedAire

In this context, we mustn’t forget the option of receiving medical advice via satellite phone on long-haul aircraft (A330/340, A380, Boeing 747): with their suitably qualified flight and emergency physicians, the service provider MedAire is available around the clock to advise our crews and the doctors assisting on board. The support provided by MedAire in the handling of an on-board emergency cannot be overestimated. Should an emergency arise, the MedAire medical professionals can offer their knowledge and expertise in aviation medicine, emergency medicine and the operational specifics (length of time until next-possible landing, infrastructure of the nearest hospital).

A practical example

In the following article, an actual example is used to demonstrate how an emergency situation can arise on board.

Assessing fitness to fly

Acute or chronic illnesses, as well as disabilities, can sometimes restrict a person in their so-called ‘fitness to fly’. This can involve a loss of comfort, affect the person’s health and also put the safe operation of the flight at risk for all parties.
Issues which are often regarded as trivial, but sometimes require assessment by an aviation doctor, include carrying prescription drugs or insulin syringes, the ability to sit upright during take-off and landing, cardiovascular or pulmonary risk assessment upon exposure to the cabin atmosphere (mild hypoxia) and previous interventions or operations.

Support from Lufthansa’s Medical Operation Centre

A reliable answer to all these questions can be provided by Lufthansa’s Medical Operation Centre (MOC), part of the Medical Service. Every day between 06:00 a.m. and 10:30 p.m., the MOC plans and offers advice about air travel for passengers with an acute or chronic illness, often on behalf of insurance or assistance companies with respect to repatriation due to illnesses or accidents abroad. However, it is also happy to deal with direct enquiries from hospitals, doctors or patients.