Doctor on Board – Good to know

It’s assumed is that air travel will also continue to grow in the future. Over 3 billion people travel by air every year. There is a distinct physiological environment on board characterised by reduced ambient pressure and partial oxygen pressure, dry air, time differences and restricted personal space. The age of passengers is increasing, and even passengers with existing health conditions are taking more trips by air. Aircraft are becoming bigger and bigger and covering ever longer routes. Combined with travel stress, all this is likely to lead to a further increase in emergencies on board. It’s assumed that a medical emergency will occur on board a passenger aircraft somewhere in the world every 12 minutes. But compared to actual passenger numbers this risk is still very low (8–50:1 million passengers), while the probability of an unscheduled landing is 1:1 million passengers and that of a fatality approx. 1:2 million passengers (Siedenburg J (2010): Kompendium Flug- und Reisemedizin [Compendium of Flight and Travel Medicine]. BOD, Norderstedt).

The overwhelming number of medical emergencies are nevertheless of a harmless nature. They are mainly caused by cardiovascular symptoms, followed by neurological and gastrointestinal disorders. There is an extensive range of equipment to treat such conditions on board, consisting of a Doctor’s Kit, AED, several first aid kits and a general supply of painkillers, nasal sprays, etc., as well as an additional medical kit on long-haul flights. Cabin crew are trained in first aid for potential emergencies on board right through to cardiopulmonary resuscitation and the use of an AED, they receive follow-on training every year and can therefore assist the emergency aid provided by doctors amongst the passengers.

Emergencies on board airliners are seen as particularly dramatic events, and not just by lay people, due to the conditions described, limited space, more difficult access to the patient, the lack of screening from fellow passengers, possible language problems and restrictions to the technical and therapeutic options available. Emergencies on board cannot be diagnosed and treated in the same way as in a clinical setting – for example auscultation of the heart, lungs and abdomen and blood pressure measurements is almost impossible due to aircraft noise. The option of telehealth consultation can be helpful. Despite the often dramatic nature of the event, a systematic and calm approach is therefore required (Siedenburg J (2015): Notfälle an Bord [Emergencies on board]. In: Siedenburg J, Küpper T (Publ.): Moderne Flugmedizin [Modern Aviation Medicine]. Gentner Verlag, Stuttgart).

The often feared legal and liability problems do not exist due to liability protection taken out by Lufthansa. However, it should be noted that such protection only exists internationally (known in U.S. law as the “Good Samaritan Principle”) if assistance is provided without payment. There is even an obligation to provide assistance under German and continental European law that is not provided for in the same way in Anglo-Saxon law.

These subjects are considered in greater depth in the recently published standard work on aviation medicine (Siedenburg J, Küpper T (Publ.) (2015): Moderne Flugmedizin. Gentner Verlag, Stuttgart), and all the further aspects of aviation and space medicine are handled in some detail.


Figures, data and facts

Just in the past few months, doctors treating medical emergencies on board Lufthansa aircraft have ensured that acutely sick passengers have been provided with good
medical care. Because a medical emergency on board is and will remain a rare event for any individual passenger affected, we recommend an article from the German medical journal “Deutsches Ärzteblatt” that has all the relevant figures, data and facts. To the article

Ideally trained air crew

Our cabin crew members are given regular first aid training based on the guidelines of the European Resuscitation Council (ERC). You can view the results provided by the ERC ​here.

Rapid assistance thanks to the latest technology

The latest telehealth assistance can be used thanks to high-performance wi-fi networks in the Lufthansa fleet. For example, it is possible to obtain assessments about the patient’s further treatment from centres of excellence on the ground via the transmission of ECG data.
The “airRX” app allows doctors on board to look at a wide variety of scenarios and gives an overview of the medical equipment available. To the app

General procedures in the event of emergencies on board:

• Make yourself known to the crew stating your professional background and qualifications

Examination of the patient:

• Enquire about the duration and nature of the main symptoms
  
• Ask about the accompanying symptoms and risk factors (e.g. chest pain, shortness of breath, nausea or vomiting, weakness or loss of sensation on one side)
• Check vital signs (pulse and blood pressure, possibly the rate of breathing, and if blood pressure cannot be measured through auscultation due to loud background noise, determine the systolic pressure through palpation of the arteria radialis)
• Determine the level of consciousness and any focal neurological deficit

In the event of cardiac arrest:

• Start cardiopulmonary resuscitation (CPR) immediately in the event of circulatory arrest
• Request and attach automated external defibrillator AED. If the pulse is palpable but a cardiac problem is suspected, attach the AED as necessary for monitoring where technically feasible (some airlines require prior contact with a
  ground-based consultation facility)
• Request the Doctor’s Kit from the cabin crew and give oxygen as required
• Possibly make contact with a ground-based consultation facility, if not already initiated by the cabin crew. The latter may be consulted about any further measures to be taken, such as the administration of medication, intravenous fluids or an unscheduled landing
• Document the results of the examination and measures. Pass on any information on handover to the medical staff providing further treatment on the ground as necessary

Procedure in the event of syncope:

• Is the patient breathing and do they have a pulse?
  
• Check vital signs (most patients will show low RR figures)
  
• Move the patient into the aisle or preferably the galley, place in a horizontal position with their legs raised and give oxygen
  
• Measure blood sugar if diabetes is known (device from the Doctor’s Kit or possibly from the patient’s or other passengers’ baggage)
  
• Most patients recover after a few minutes, give fluids by mouth when indicated if possible
  
• Intravenous fluids are generally only necessary if the RR is further reduced and oral administration is impossible

Procedure in the event of chest pain or palpitations:

• Check vital signs
  
• Provide oxygen
  
• Give aspirin as necessary if cardiac-related chest pain is suspected, or heparin if available
  
• Sublingual nitroglycerin every 5 minutes depending on the systolic pressure (check RR after each dose)
  
• If AED has a monitor use as necessary to monitor heart rhythm and check extremities as a rough indication of any ST reductions
  
• If symptoms subside after taking the measures described above, it is possible that a diversion is unnecessary. Consult ground-based advisory facility as necessary

Medical incidents on board the Lufthansa fleet

There has been an increase in medical incidents overall in the last few years on board global air traffic (Source: IATA Medical Advisory Group). This is also true for Lufthansa: between ten and 15 medical incidents occur over approx. 1,700 flights per day. These range from minor illnesses such as headaches or fever and vomiting, to asthma attacks, colic, strokes and suspected heart attack.

Medical care using the Doctor’s Kit

Adequate medical care is generally possible through collaboration between the crew and doctors on board – such as yourself – and assisted by the resources on board such as the Doctor’s Kit and First Aid Kit.

Even if this seems hardly conceivable from our perspective, 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 continuing the flight to its destination is also often the quickest way to get the patient the medical care they require.

Round-the-clock advice via MedAire

Not to be forgotten in this context is the option of obtaining medical advice via satellite telephone on long-haul aircraft (A330/340, A380 and Boeing 747): The service provider MedAire is available round the clock with suitably qualified aviation and emergency physicians to advise our crew and the assisting doctors on board. The support provided by MedAire in handling an emergency on board cannot be overestimated, because the medical colleagues applying their knowledge here are familiar with aviation and emergency medicine and the specific features of flight operations (time to the next possible landing, infrastructure at the nearest hospital).

A practical example

You will learn how an emergency on board may play out in the following article based on a specific example.

Fitness to fly assessment

Acute or chronic diseases, as well as disabilities, can sometimes lead to a restriction to what is known as “fitness to fly” for those affected. This may involve a loss of comfort and impair the passenger’s health as well as the safe operation of the flight for all concerned.
Although questions about factors such as the carriage of medication or insulin injections and the passenger’s ability to sit up straight on take-off and landing are often seen as trivial, the cardiovascular or pulmonary risk assessment through exposure to the cabin atmosphere (mild hypoxia), previous interventions or surgery sometimes require the judgment of an aviation physician.

Support from the Lufthansa Medical Operation Centre

The Lufthansa Medical Operation Centre (MOC) is integrated into the Medical Service and can provide an authoritative answer to all these questions. The MOC advises on and plans air travel for acute or chronically sick passengers every day from 06:00 to 22:30 h, often on behalf of insurance companies or assistance services for the repatriation of patients who are taken ill or suffer accidents abroad, but it is also happy to handle direct enquiries from hospitals, doctors or patients.