It can be a tough call to service for doctors who find themselves thousands of feet up in the air, providing medical care in a contained space with little equipment.

A recent article in the New England Journal of Medicine gives doctors instructions on how best to respond to in-flight scenarios of cardiac arrest, acute coronary symptoms, and strokes, as well as other, less serious symptoms.

“You don’t have the room to sometimes even put the patient in a supine position to examine them,” says William Brady, a professor of emergency medicine at theUniversity of Virginia, Charlottesville and senior author of the article. “If you did have a stethoscope, the ambient noise in the cabin is usually so loud that you can’t hear anything. You don’t have many medications and the people that are present to help you can range from none to several.”

One 2013 study, also in the NEJM, estimates that one in every 600 flights involves a medical event, though some experts believe the numbers are higher. And while some doctors voice concerns about liability, experts note that federal law protects providers who respond to most emergencies on domestic flights and most international flights.

Airline staff must be trained in cardiopulmonary resuscitation, or CPR, and must know how to use the automated external defibrillator required on all planes.

During a flight, they can also expect support from on-the-ground medical experts. The University of Pittsburgh Medical Center’s communications center provides about 11,000 in-flight emergency consultations a year. MedAire, a Phoenix-based service, is the other major source of this kind of on-the-ground medical guidance. It helps over 130 commercial airlines.

The Federal Aviation Administration also requires airlines to carry a medical kit with certain equipment and medications.

But experts say the emergency kits vary widely in quality. More standardization is needed, says Melissa Mattison, chief of the hospital medicine unit at Massachusetts General Hospital.

Dr. Mattison co-wrote an editorial in Journal of the American Medical Association in 2011 calling for greater standardization of medical kits and protocol, better training and mandatory external reporting of incidents.

She was motivated to write the editorial after she and two fellow doctors were flying from Boston to Houston for a conference and a diabetic woman had a seizure and lost consciousness.

“We had to assist her breathing,” she says. The first kit they were given had only bandages. The second included equipment to help the woman breathe, but the tubing included in the kit didn’t fit with it. “It was a real mess in terms of attending to this woman.”

“Fortunately, it’s rare for terrible things to happen in flight,” she says. “But there are a lot of elderly people flying these days, and as our population ages and lives longer, it’s only going to get worse in terms of the likelihood of in-flight medical emergencies.”

Richard Gilroy, a professor of medicine at the University of Kansas in Kansas City, Kansas, found himself sitting near a man who went into cardiac arrest over the Pacific Ocean.

Dr. Gilroy says he was wearing scrubs for comfort, so he was immediately identified as a doctor.

With the assistance of an airline crew member and another passenger, Dr. Gilroy moved the man to the galley, where food is prepared, put an IV in him and started performing CPR. A medical intern joined them, and the group tried CPR for 45 minutes. “Ultimately, we were not able to get him back,” Dr. Gilroy says.

Dr. Gilroy says the airline staff was well-trained, but the medical equipment was rudimentary. “My greatest fear was getting him back and then not being able to do much,” he says.

Available IV tubes were outdated, he says. Had the CPR worked, the group would have had trouble protecting the man’s airway without endotracheal tubes, which weren’t included in the medical kit.

wsjhealth.com

September 14, 2015