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Patient Safety Perils at 36,000 Feet

Physician pulling suitcase

There are more than 50 in-flight medical emergencies a day on commercial airlines — or one for every 604 flights, according to a study published in 2013.

What are the odds that two emergencies would occur on the exact same flight, above the Atlantic Ocean and hours from the nearest airport?

My colleague Mark, a critical care physician with whom I'd worked as an ICU nurse, and I were travelling to the Middle East for a patient safety conference. We were comfortably tucked into our seats, as he snored next to me.

It must have been about 3 a.m. when I was awakened by an overhead announcement asking for a medical doctor. I nudged Mark, asking him to press his call light.

As the flight attendant approached, I told her that Mark was a doctor.

"And she's an ICU nurse, and we work together," he said, gesturing toward me.

We were led to a galley where a young woman was lying on the floor near a restroom. She was excessively sweaty, cold and clammy. We began to assess her just as we had done as a team in the ICU.

This was an uncontrolled, austere environment, very unlike the hospital units where we had everything we needed at our fingertips. After assessing her, we realized that she likely had a virus, and I requested a drug box from the flight attendant. After about three to four minutes, she returned with a box that looked like it hadn't been opened in a long time. Rather than containing supplies and drugs for emergency situations, such as epinephrine, it was more like the first aid kit kept in a home medicine cabinet. Yet none of the labels were in English.

We needed an anti-nausea medication to give to the "patient." Desperate to communicate with the flight attendant, who spoke rudimentary English, I feigned vomiting in hopes she would point out the medication that I needed. My miming efforts failed, but I managed to identify Pepto-Bismol-like pills by their color and the letters "bisma" on the foreign label.

Our relief that her problems did not appear serious was short-lived. As I kneeled next to her, a heavy weight fell on me. An elderly gentleman had collapsed while walking to the restroom. (At that point, I was sure that the entire plane was sick and thought to myself: What did they serve for dinner?)

Once Mark rolled this man onto his back, we realized that we had a much different situation. The man couldn't speak, but rather grunted and groaned. His eyes rolled in the back of his head. He looked a shade of green-gray that reminded us of ICU patients with heart attack or stroke symptoms. We could not feel a pulse in his wrist, and the pulse on his neck was faint.

I asked for another box with emergency medications in it, mimicking the action of injecting myself. But no new medical kit was ever brought out to us.

Fortunately, the man snapped back to consciousness after Mark gave him a few chest compressions.

As we began to assess this new patient, I called out the supplies that I needed to the flight staff, despite the language barriers. The attendant would disappear and then reappear with items. It took several minutes to bring out a blood pressure cuff — an electronic version that wraps around the wrist. After I fiddled with this contraption for a couple moments, the batteries died. A more traditional cuff was later brought out, but it was upside-down and backward, making it harder to read the gauge. It took several minutes to get an accurate reading. I asked for an automated external defibrillator, or "shocker," only to be met with blank stares. Luckily we did not need one.

Attendants were able to locate an oxygen tank and mask. When the gas began to flow, the man started to come around.

After what seemed like hours but was really about 50 minutes, we safely returned both passengers to their seats, and Mark and I collapsed in ours. We reflected on the experience, sharing our mutual relief that we hadn't faced the crisis alone. We also agreed that we might not have been able to save the man’s life if he had experienced complete cardiac and respiratory arrest, given the haphazard supplies and communication barriers.

Much of our nonclinical work has focused on designing safer systems for health care in hospitals. After this event, we talked about system changes that might have made this one go more smoothly.

  • Standardization of medications, supplies and equipment. If I were to walk into most U.S. hospitals, I could find a crash cart with all of the supplies needed to resuscitate a patient, and these supplies would be arranged in similar ways. This should be true of any airline. There are standards for what must be carried in emergency medical kits on U.S. airlines, including catheters, needles, syringes, airways and emergency medications. However, a 2010 study found wide variation in the contents of emergency medical kits on 12 European airlines. None met international standards, and two were deemed insufficient to handle acute care situations. Mark and I should not have had to ask what supplies and medications were available but should have received the entire kit, stocked with everything we might reasonably need.
  • Managing language barriers. Are there interpretation services — perhaps based on the ground — that an airline can tap to bridge any communication gaps? If not, perhaps the airline can request passengers to help fill this role.
  • Requesting medical assistance. Asking: "Is there a medical doctor on board?" may not be the best question to ask passengers. If I were in cardiac arrest on a plane, I would prefer that a paramedic or ICU nurse try to resuscitate me than, say, a dermatologist. Physicians in many specialties, and many types of nurses, do not conduct advanced life support on a regular basis. A more appropriate question might be: "Is there a health care professional on board?" Anyone who responds can work as a team to decide who is best to attend to the patient based on their skill sets and scope of practice.
  • Early preparation of health care professionals. Before every flight, attendants make sure that people sitting near an emergency exit know what to do in case of a crash or water landing. Yet those events are much rarer than medical emergencies. Would it help to pre-identify health care professionals and perhaps provide them with a pamphlet explaining what to expect should they be asked to assist a sick passenger? Some airlines contract with land-based medical services staffed by emergency department physicians to provide guidance during in-flight medical issues. If that were an option for Mark and me, we would have benefited from that knowledge. It would also be helpful to explain the legal protections provided to good Samaritans who help in these situations.

The event we experienced was one of thousands that happen every year. Hopefully our case is an outlier — the result of one poorly stocked aircraft, bad timing and an unfortunate set of circumstances. A recent Washington Post article painted a picture of more orderly responses to sick passengers on U.S. carriers.

It's almost cliché to talk about how health care is adapting tactics from the aviation industry to improve teamwork and reduce preventable harm. Here's a case where that learning might go in the other direction.


Rhonda Wyskiel

Rhonda Wyskiel served as a patient safety innovation coordinator for the Armstrong Institute, seeking to engage all members of the care team in creating safer, more patient-centered processes.

7 thoughts on “Patient Safety Perils at 36,000 Feet”

  1. Thank you for sharing this article. I have had similar bad experiences on airline flights. I was aboard a continental flight in the U.S. Jet setting for my honeymoon.I has just dozed off and startled awake to hear the daunting call for any healthcare professionals. I am healthcare professional- a physical therapist- and of course healthcare provider CPR certified- but have never provided CPR. I immediately was hoping that someone else would quickly comes forward. Luckily a physician and an EMT did. The lady in acute cardiac distress is now being attended to by the 3 of us. We ask the airline for the crash kit. Blank stares ensue. First aide kit? Uhhhh, is the response. She had told the stewardess she needed her overhead bag for her Nitro. The stewardess was frantically searching for gloves to put on before getting her bag. I quickly retrieved the pills and Was able to help her. Once the person, was stable and recovering, I was livid and embarrassed for the airlines and their ill-preparedness for this situation.

    Your list of improvements and requirements that should be mandatory is great! Spot on! One thing I think the airline should also do- is ask for each person's emergency contact information upon purchase of the ticket. I was able to converse with person and figure out who to contact in case she became unconscious.

    My very next flight. We are taxing on the runway. And ding - any healthcare providers on board? Oh no, not again! Hypoglycemia -quickly resolved with a snack. Yikes!
    Hoping for improvement on this!

  2. Wow, thanks for sharing your experience. I believe that this problem is more ubiquitous than we think. You highlight some important points that reveal the need to be proactive versus reactive. Knowing who is available to provide skilled medical care on a flight seems like a must do. Having supplies ready and available at the start of the emergency is a fundamental necessity.
    I like your suggestion regarding emergency contact information upon purchase of ticket, and availability of that in flight.
    Imagine if we were able to brainstorm solutions among all users of this system, including flight crew members, passengers who have had an emergency in flight, and passengers who have not, medical staff who have been requested to provide care, and family members of those individuals. Wisdom of the crowds tells me that we could land upon many ideas for solutions to this problem.

  3. Sooner or latter airlines will have to provide definitive healthcare solutions on board. Making announcements requesting for any health care personnel to come forward is not the solution.
    The over all health status of the passengers is never known clearly. The most common medical/surgical emergencies that occur in land can occur in air with equal or higher frequency. Sitting in a chair for hours together greatly increases the risk of deep venous thrombosis. Many passengers don't carry their full stock of medicines when traveling and may miss a vital dose. Anyone can get a bolus of food stuck in his airway. Emergencies like appendicitis, myocardial infarction,stroke, ruptured ectopic pregnancy etc can occur in air and no doctor can do anything bare handed. These emergencies need a patient to be treated in a hospital setting. Diverting and grounding a flight poses lot of costs and inconvenience to other passengers. Finally imagine pilots getting sick themselves. What options are left. The auto pilot can keep the flight going on, but fuel is going run out and landing needs a pilot.
    I think the aviation industry has to link itself with healthcare facilities on the ground. An air ambulance may be a future possibly but till then a rational plan should exist to handle complicated situations. Watching a fellow passenger suffer in agony or even approach death is the last thing to happen on a flight.

  4. As I travel to visit my old country I have used different airlines. On several occasions I had to help w a passengers who got sick on the plane. I always carry aspirin and nitrostat blood pressure cuff and stethoscope with me. Two of the "fainting" cases were because of too much drinking of the free alcohol offered by the airlines consumed by patients with previous heart problems. The last case was most challenging because patient knew only Albanian. Never the least I attempted to take his blood pressure and checked his pulse only to be pushed away by the patient still vomiting violently, because I was a women (5'3"tall). I remembered from old med school that a women is not to touch a male Muslim unless it is her father or brother or husband! The airline assistant frantically brought me gloves and Luckilly a young Albanian that knew English came to my rescue as translated. After I ruled heart attack or stroke I asked the attendant for their medication box. There were only herbal tablets in the box and written in Austrian/languich I don't know except recognizing herbal. There were even not Latin names for the herbs. O asked to give the patient O2 by the ceiling oxygen mask and the attendant say, "We use this only in emergency!!!" I ask if the pilot can ask any of the passengers may have Compazine or Maalox or Pepto Bismol. The answer was "we are not allowed to disturb the passengers! On about twenty mins attendant brought me a portable oxygen mask that had less than one litter of oxygen. It did made the patient feel better." So I let the patient in the bathroom to vomit and have bowel movement and calmed his stomach with sips of ginger ale that Luckily they had aboard. And we were not near any airport to land. Beside me there was a mt from NY just bear hands. Via translator we found out the man ate 10 hamburgers before boarding plus the steak dinner on the plane as per his wife. After he felt better anytime I went to use the bathroom the man made several bows to me to thank me. Not to mention that the chief attendant questioned if I am physician.
    I just told him Google my name! Obviously he did because as I was getting off the plane him and the young English speaking Albanian came to help me w my luggage. I am a retired GP from Pennsylvania!Next time I will carry my own med kit to save lives for this has been my calling for 45 years of my life, Yes the airlines must have at least a nurse trained in CPR and emergency well equipped box and defibrillator.

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