In-flight automated external defibrillator use and consultation patterns.
AM Brown, et al. Prehosp Emerg Care, 2010.
This 2010 article speaks to the issue of in-flight emergencies on commercial aircrafts, but also raises two broader themes: AED use and availability in public, and lack of uniform standards in many narrow subsets of emergency care.
The study is a retrospective descriptive look upon in-flight AED use, as reported by three major airlines during various periods between 2004 and 2009 to an airline consultation service ran in connection with University of Pittsburgh. 169 cases of AED use, including 40 cases of cardiac arrest were reported and examined. Mean patient age was 58 and 63, respectively, 64% male.
Out of 40 arrest cases, 10 presented with V-fib/Vtach (7+3), and 9 were defibrillated. 5 additional patients were shocked after initial PEA or asystole converted to a shockable rhythm. There were 2 human failures to shock when advised by the AED: 1 initial Vfib and 1 PEA conversion (1 shock out of 3 advised given, an MD present). 6 patients had survived to hospital admission: 5 out of 9 with initial Vfib/Vtach who were shocked, and 1 person with ROSC after 7 min CPR without a shockable rhythm.
An AED was applied for monitoring in an additional 129 patients with various complaints but not in cardiac arrest. There were no inappropriate shocks given.
Survival was 100% to the hospital, with only 2 deaths prior to discharge. Sinus rhythm or tachycardia was seen in 89%, as well as Afib/flutter, SVT and complete heart block.
The authors report that available ground medical consultation was obtained in only 40% of the 129 patients above, and for only 35% of the cardiac arrests. Diversion was recommended twice, zero times for cardiac arrest cases. The service was accessed for only half non-sinus rhythms, including only 2 out of 4 complete heart blocks. The study presents no information regarding number and type of medical personnel from among the passengers who gave assistance, except in 1 CPR case. All flight crew were BLS and AED certified.
The study supports prior literature indicating poor to no survival in cases of out-of-hospital cardiac arrest who do not present nor develop shockable rhythms, or are not shocked early in such rhythms. Only one person out of 40 survived to the hospital after no shock, with ROSC after an initial junctional rhythm and CPR alone. However, 5 out of 9 shocked Vfib/Vtach cases surviving is important to note, while no statistical significance can be derived from the study.
Bigger picture items are as follows:
There is poor awareness among medical professionals regarding equipment available on board commercial aircraft and flight crew training. Reliance on passenger expertise is both historic and accidental, subject to luck of the draw
There is no standard of care for in-flight emergencies. On-line control or ground consultation services, when available, are poorly utilized
While any aircraft diversion decisions are complex, and pose real and unique risks to the rest of the passengers and crew, little exists regarding streamlining such decision processes. Any medical professionals present on board are likely to lack training to be able to interact with the pilots and ground control concisely and effectively
There is a lack of mandatory reporting of in-flight medical events
Overall, medical care on board domestic and international flights represents a medical frontier that is only beginning to resurface in EM and EMS literature, with ample opportunities for study and intervention
Anthony Rodigin, MD, FAAEM, FACEP