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.

Patient Transport Compartment – Intensive care transport on long-haul flights

In principle there is a range of different medical and organisational options for assistance available on scheduled air services. The options include: additional oxygen (Wenoll system), extra seats to elevate a passenger’s legs, transport lying down on a stretcher (always with professional assistance from a nurse, paramedic or doctor) or – uniquely worldwide but limited to the long-haul fleet – intensive care transport using a Patient Transport Compartment (PTC).

Irrespective of the medical or organisational challenges, a safe flight or appropriate patient transport is feasible in most cases. Critical factors are infectious diseases and resistant bacteria: these must not be carried on board airliners according to the rules of the International Air Transport Association (IATA).

You can contact the Medical Operation Centre at ​medicaloperation@dlh.de or at +49 69 696 55077, every day from 06:00 to 22:30 h Frankfurt local time.

Holiday season, travel periods and peak season at the Lufthansa Medical Operation Centre

Summer months are the main travel season for many people, to help them recuperate from their stressful everyday lives. Holiday destinations can be anywhere in the world and often cannot be exotic or far away enough. But what if the unexpected suddenly happens? A swimming accident in Florida, stroke in Thailand or a motor accident in South Africa – what are intended to be most enjoyable moments of the year can easily turn into a nightmare in minutes, thousands of miles away from home.

It was exactly for instances like this that Lufthansa set up its “Medical Operation Centre” in 2009. The MOC is unique in the world in this form in the field of commercial airlines. The MOC can be contacted by telephone by any passenger from 06:00 – 22:30 h (CET). But most of their customers are professional companies arranging the repatriation of sick or injured holidaymakers back home.

Diagnosis & Treatment

That’s also the case with 49-year old Peter Seifert*, who was seriously injured in a motor accident in Argentina. This German holidaymaker was on a tour with his family when the accident happened. The following injuries were found according to initial examinations at a primary care centre: polytrauma, traumatic brain injury II°, front basal contusions with described small haematomas, unstable open fracture of the right lower thigh, right acetabulum fracture, fracture of the pelvis with symphysis dislocation of 4 cm, I-II° burns covering 3% of the BSA (body surface area), bilateral fracture of the AC joint, bilateral lung contusion, respiratory failure and pneumonia with no evidence of bacterial infection. The patient was ventilated and the fractures were partially treated on the ground, but the doctors from Mr Seifert’s foreign travel insurance company presumed inadequate medical care.

Arrangements made via the insurance company and the Medical Operation Centre

The assistance service employed by the insurer enquired about the progress of the injuries and the patient’s current condition by telephone, arranged for translations of the preliminary doctor’s report where required and then asked the Lufthansa Medical Operation Centre (MOC) for suitable patient transport. The MOC was brought up to speed on the case with all the available information.

Finally, the Lufthansa aviation physician on duty specified the appropriate mode of transport for an injured passenger. The options were to carry the patient as a “normal” passenger in one of the travel classes available, in this case possibly accompanied by medically trained staff. For patients who cannot sit upright there is the option of transport on a stretcher (carried lying down). This service is available at 48 hours’ notice on all aircraft models operated by Lufthansa AG and the patient must be accompanied by a doctor, paramedic or nurse provided by the insurance company. One further option is the Patient Transport Compartment (PTC). This is a closed cabin that can be installed on intercontinental flights with equipment equivalent to that in an intensive care unit. In this case a specially trained Lufthansa PTC crew member travelled with the patient with a doctor provided by the insurance company. This team was then responsible for the patient’s medical care throughout the up to 14-hour flight.

From South America to Frankfurt

In Mr Seifert’s case the PTC offered the only suitable option for repatriation to Germany due to the injuries present. An experienced intensive care doctor and a PTC crew member therefore took off from Frankfurt to collect the patient from South America. Just 24 hours after the team’s arrival they returned with Mr Seifert to Frankfurt. He was flown by air ambulance to Sao Paulo and handed over at the airport. The inadequate medical care suspected by the doctors in Germany was confirmed when they took over the patient. Mr Seifert’s condition increasingly stabilised on the 12-hour flight to Frankfurt. He was also now under adequate care, including a CVC and arterial blood pressure measurement, and connected to a controlled ventilator. An intensive care transport team was already waiting on landing in Frankfurt to take the patient on the ground to a maximum care facility.

Conclusion

The case of Mr Seifert described here is just one of the approx. 8,000 patient transports carried out every year on board a Lufthansa aircraft. The number of patient transports is increasing every year. That’s why Lufthansa is now also investing in new developments to meet market demand.