Correspondence

Medical Events during Airline Flights

N Engl J Med 2002; 347:535-537August 15, 2002

Article

To the Editor:

In their review article on medical events during commercial airline flights (April 4 issue),1 Gendreau and DeJohn underplay the threat of lawsuits and report that “no litigation has been brought to date against a physician who has rendered assistance during an in-flight medical event.”

At the conclusion of my first year of surgical residency, as a licensed physician, I provided care to a woman during a transatlantic flight. This unfortunate woman had severe asthma and had a mid-flight attack that was fatal. I, along with a physician and a nurse from England and members of the flight crew, performed cardiopulmonary resuscitation for nearly two hours. I was later summoned to appear in both federal and state courts because of lawsuits. Only after I recruited the assistance of my surgical department would my residency hospital provide me with legal support. After I had several sessions with a lawyer, reviewed documents, and provided a deposition, I was dismissed from the lawsuits on the basis of good Samaritan protection.

Even if ultimately dismissed, defendants in such cases suffer emotional and financial losses as well as loss of time. I am not recommending that we abandon our fellow passengers, but physicians should be aware of these personal risks before intervening.

Audra A. Noel, M.D.
Mayo Clinic, Rochester, MN 55905

1 References

1
Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med 2002;346:1067-1073
Full Text | Web of Science | Medline

To the Editor:

Gendreau and DeJohn mention that “vasovagal episodes (fainting, near-fainting, dizziness, and hyperventilation) are the most common events” during commercial flights. According to my own experience and interviews of people afraid of flying,1 “panic attack”2 is a better, more descriptive diagnosis for many of these cases of sudden, intense discomfort accompanied by multiple bodily symptoms. Hyperventilation is often but not always present. Subjective dyspnea may prompt the administration of oxygen, but that approach is much less likely to be helpful than getting the passenger to breathe slowly and shallowly. Dizziness or lightheadedness may be reported but is rarely accompanied by the slow pulse and low blood pressure that are characteristic of a true vasovagal reaction.

Reassuring the passenger that he or she is not having a heart attack, stroke, or asthma attack can be very helpful, since people with panic attacks tend to think the worst is happening. The distraction of a conversation with a physician can hasten recovery from such episodes, which usually decrease in intensity after 20 minutes or so. Emergency medical kits may contain diazepam, which can be given if simpler measures do not suffice.

Walton T. Roth, M.D.
Stanford University School of Medicine, Stanford, CA 94305
wtroth@stanford.edu

2 References

1
Wilhelm FH, Roth WT. Clinical characteristics of flight phobia. J Anxiety Disord 1997;11:241-261
CrossRef | Web of Science | Medline

2
Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994.

To the Editor:

Physicians should keep in mind that in addition to the medications that may (or may not) be available in the airplane's first-aid kit, passengers themselves make up a virtual in-flight pharmacy with the personal prescriptions that they possess. A simple announcement by the flight crew can yield all sorts of potentially beneficial drugs, including narcotics, benzodiazepines, beta-blockers, beta-agonists, antihypertensive agents, antiemetic agents, antibiotics, and diuretics, to name just a few. Physicians who use this approach should be familiar with the appearance of a given product and must confirm the identity of what is being offered.

Robert Baevsky, M.D.
Baystate Medical Center, Springfield, MA 01199
robert.baevsky@bhs.org

To the Editor:

Gendreau and DeJohn state that patients who have recently undergone a surgical procedure “are at increased risk for wound dehiscence in conditions that cause gas expansion.” I believe that this idea has no scientific basis, especially with regard to commercial flights, and that such a presumption can be misleading. Surgeons may even feel liable for sending patients home soon after surgery, if their destination is accessible only by air.

The authors cite an article by Skjenna et al.1 to support their statement, but that article only offers guidelines to help physicians advise patients who are planning to travel by air; it includes no scientific data. Wound dehiscence is usually a technical problem and should not be blamed on air travel.

Homero Rivas, M.D.
University of Louisville, Louisville, KY 40202
homerorivas@hotmail.com

1 References

1
Skjenna OW, Evans JF, Moore MS, Thibeault C, Tucker G. Helping patients travel by air. CMAJ 1991;144:287-293
Web of Science | Medline

To the Editor:

Gendreau and DeJohn do not list venous thromboembolism among the medical events that commonly occur aboard commercial aircraft. The association between symptomatic venous thromboembolism and air travel may be weak.1 However, in persons at high risk, the incidence of deep-vein thrombosis during prolonged air travel (the “economy-class syndrome”) may be in the range of 4 to 6 percent.2 Life-threatening pulmonary embolism is rare, but the topic has received extensive publicity in the media. The administration of an antithrombotic drug for the management of deep-vein thrombosis during a flight should be possible. Therefore, we propose that low-molecular-weight heparin be included in the on-board emergency medical kit.

Peter Schuff-Werner, M.D.
Peter Kohlschein, M.D.
Michael Steiner, M.D.
University of Rostock, D-18055 Rostock, Germany

2 References

1
Bagshaw M. Traveller's thrombosis: a review of deep vein thrombosis associated with travel: the Air Transport Medicine Committee, Aerospace Medical Association. Aviat Space Environ Med 2001;72:848-851
Web of Science | Medline

2
Belcaro G, Geroulakos G, Nicolaides AN, Myers KA, Winford M. Venous thromboembolism from air travel: the LONFLIT study. Angiology 2001;52:369-374
CrossRef | Web of Science | Medline

To the Editor:

On a commercial flight from England to the United States in August 1999, a 64-year-old woman had a syncopal episode and became ashen and disoriented. I responded to the request for a physician, only to find that there was no medical equipment on board. I was without a stethoscope or sphygmomanometer. I had to use a finger blood-pressure device provided by another passenger. The only medication available was aspirin. Luckily, the woman responded to placement in a supine position and the administration of supplemental oxygen. According to Gendreau and DeJohn, commercial aircraft with more than 30 passengers have been required since 1986 to carry an emergency medical kit. Obviously, there was no such kit on this flight, or no one knew where to find it.

Stephen C. Ross, M.D.
UCLA School of Medicine, Santa Monica, CA 90404

Author/Editor Response

The authors reply:

To the Editor: Good Samaritan statutes do not prevent a plaintiff from initiating legal action. The dismissal in Dr. Noel's case underscores the fact that the statutes work. Other resources are also available to protect a physician. Some airlines carry an umbrella liability policy and extend coverage to health care providers who provide assistance during in-flight medical events. Ground-based medical-support companies may also extend liability coverage to medical personnel who provide assistance.

A significant proportion of air travelers experience some form of situational anxiety1; however, Dr. Roth's anecdotal experience and his assertion that panic attacks are the most common in-flight medical event are not supported by the current literature. According to a recent Federal Aviation Administration (FAA) report, vasovagal episodes account for 22 percent of in-flight medical events, whereas anxiety and psychological complaints account for only 3.4 percent of such events.2 The FAA study compared common causes of in-flight medical events with those reported in six other studies. None of the studies reported that anxiety is the most frequent cause of in-flight medical events.

We agree with Dr. Baevsky. Additional items that will be required in medical kits by 2004 were selected because they are items frequently obtained from passengers and are not available in current FAA-mandated medical kits. Many air carriers now use commercial medical kits that contain many items not required by the FAA.

Of relevance to Dr. Rivas's concerns is the report by Skjenna and associates of a case of incisional dehiscence that occurred in a passenger who had undergone a cholecystectomy three days earlier; the dehiscence occurred once the aircraft had reached cruising altitude.3 The position of the Aerospace Medical Association is that passengers who have undergone abdominal surgery are at risk for torn suture lines, perforation, and bleeding because of gas expansion with increased altitude, which occurs during routine air travel; therefore, air travel should be delayed for 7 to 14 days after surgery. Laparoscopic procedures are less associated with ileus than are open surgical procedures, since the residual carbon dioxide after laparoscopic procedures rapidly diffuses into the tissues. Air travel in such cases can occur the day after surgery if bloating is absent.4

No definitive conclusions can be drawn from the available data on air travel and the risk of venous thromboembolism.5 The World Health Organization has announced the launch of a comprehensive research program to investigate this problem. Until the question has been answered and evidence provided, it seems reasonable to recommend only simple preventive measures such as adequate hydration and physical activity, including isometric muscle contractions, based on individual risk factors, as suggested by Dr. Schuff-Werner and associates.

Mark Gendreau, M.D.
Lahey Clinic, Burlington, MA 01805
mark.a.gendreau@lahey.org

Charles DeJohn, D.O., M.P.H.
Civil Aerospace Medical Institute, Oklahoma City, OK 73169

5 References

1
McIntosh IB, Swanson V, Power KG, Raeside F, Dempster C. Anxiety and health problems related to air travel. J Travel Med 1998;5:198-204
CrossRef | Web of Science | Medline

2
DeJohn CA, Veronneau S, Wolbrink AM, et al. The evaluation of in-flight medical care aboard selected U.S. air carriers: 1996 to 1997. Washington, D.C.: Federal Aviation Administration, Office of Aviation Medicine, 2000. (Technical report no. DOT/FAA/AM-0013.)

3
Skjenna OW, Evans JF, Moore MS, Thibeault C, Tucker AG. Helping patients travel by air. Can Med Assoc J 1991;144:287-293
Web of Science | Medline

4
Medical guidelines for airline travel. Alexandria, Va.: Aerospace Medical Association, 1997.

5
Hirsh J, O'Donnell MJ. Venous thromboembolism after long flights: are airlines to blame? Lancet 2001;357:1461-1462
CrossRef | Web of Science | Medline

Citing Articles (1)