Responding to an in-flight emergency - Curbside Consultation

American Family Physician,  Sept 1, 2003  by Robert Dachs

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Case Scenario

While we were flying home from a vacation, my husband abruptly woke me from a deep sleep by saying, "Wake up, they're calling for a doctor." One of the passengers had lost consciousness. When I got to the back of the cabin, another physician, who had already responded, asked me about my medical specialty. I told him I am a family physician. He then asked me to take over, stating that this was "out of his field."

The patient was seizing. Somewhat terrified, I followed the ABCs of emergency care. It took numerous attempts to get an intravenous (IV) line inserted, and there was blood everywhere. The airline emergency kit had lorazepam, so while I was trying to insert the IV, I administered the medication intramuscularly to control the seizures. The pilot asked whether he should plan to reroute the plane for an earlier landing. I said yes because at the time the patient was still seizing. Eventually, the seizures stopped.

Meanwhile, we learned that the patient was an alcoholic and that these were withdrawal seizures. By the time the patient became stable, however, it was impossible to land at our scheduled airport. Later, on the ground at the airport to which we had been diverted, emergency personnel seemed to suggest that I was incompetent for delivering the lorazepam intramuscularly. Overall, it was an exhausting, scary experience, and my husband and I didn't get home until the next day. The airline did put us up in a hotel in the city to which our flight had been diverted.

Was I obliged to provide assistance in this case? Am I protected legally? What do you think about the first physician who handed over the care? Do the airlines typically compensate physicians who help out in these circumstances?

Commentary

Although usually it's just the in-flight movie and food we get to fret about, unfortunately, in-flight emergencies are a frequent occurrence. In fact, approximately 1,000 cardiac arrests occur each year on airplanes, which is more than the total number of people who die in plane crashes each year. (1) The clinical scenario described here is all too common.

Is a physician obliged to give assistance in this situation? In a previous Curbside Consultation in American Family Physician (2) involving a wreck on the highway, I noted that many medical societies state that physicians have a moral and ethical responsibility to act in these cases. In some states, there is also a legal requirement to assist those in emergency care.

But what about the legal risk to a physician who gets involved in such a situation? In today's medicolegal environment, concern about legal protection for performing a "Good Samaritan act" is certainly understandable. Currently, all 50 states have some form of Good Samaritan legislation. But what legislation covers a physician who is flying? The Aviation Medical Assistance Act, which was passed by Congress in 1998, "... limits non-employee passenger liability for providing assistance during an in-flight medical event unless the assistance is grossly negligent, or is willful misconduct." (3) To date, no physician has been sued successfully for rendering assistance in this situation.

As for the actions of the other physician in this case, I can only speculate that he did not feel comfortable managing this patient. If more than one health care worker is present in such a circumstance, the person with the most experience or expertise should manage the care of the patient. The family physician in this scenario should be proud of the fact that she was willing and able to save this patient's life.

And, indeed, this case scenario involved a potentially life-threatening condition. Even though managing patients with alcohol-related illness may not be many physicians' favorite pastime, severe withdrawal and delirium tremens remain potentially life-threatening conditions. Up to 5 percent of patients with "the dts" die, and this rate increases if there are underlying medical problems. At 30,000 feet in the air, there is no way to know anything about the patient's medical history or to perform diagnostic testing. The decision to land the plane, whether the patient continued to seize or not, was absolutely correct.

Benzodiazepines remain the mainstay of therapy in patients with acute seizures, whether the latter are induced by alcohol or not. In particular, lorazepam (Ativan) has recently been shown to be somewhat more effective than diazepam (Valium) in the treatment of out-of-hospital status epilepticus, (4) and it was the correct choice in this case. Ideally, it would have been best to titrate the benzodiazepine intravenously, but as described in this emergency situation, this is not always possible (see accompanying table). How many of us can say with any certainty that we could insert an IV line in a patient who is thrashing about? This situation demonstrates the probable reason that we have come up with so many alternative routes to deliver these agents. Benzodiazepines can be given intravenously or intramuscularly, or by intra-nasal, buccal, or rectal application, alternative routes that can come in handy in emergency situations.