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Training Physicians to Respond to Vulnerable Patients – At 30,000 Feet

Drs. Lara Phillips and Wendy Ross are creating a Continuing Medical Education program that addresses in-flight emergencies & the myths and theoretical concerns healthcare providers have that may prevent people with medical training from volunteering in the event of an inflight medical emergency.

The thought undoubtedly crosses the mind of any physician accustomed to traveling by plane. Is this the flight that the call goes out – “Is there a doctor on the plane?”

In-flight medical emergencies (IMEs) are surprisingly common. A 2013 study in the New England Journal of Medicine (NEJM) found that there is one medical emergency for every 604 flights, though the actual number is likely higher, as not all incidents are reported. Worldwide, about 160 flights a day have an urgent medical matter. And as the U.S. population gets older with more chronic medical illnesses like diabetes and heart disease, most physicians can expect to encounter an emergency in the air at some point.

Dr. Lara Phillips (left) and her mother Kathy Hershcovitch.

“If you consider how many flights there are, daily, in-flight emergencies are not uncommon,” says Dr. Lara Phillips, an emergency medicine physician and faculty advisor of the Wilderness and Disaster Medicine Interest Group at the Sidney Kimmel Medical College at Thomas Jefferson University. Dr. Phillips, who regularly presents lectures to medical students and residents on in-flight medical emergencies, says it’s a topic on the minds of many learners. There are myths and theoretical concerns, she says, that cloud the issue and prevent people with medical training from volunteering during IMEs. “Anyone with medical training should feel confident to volunteer. For doctors to be able to have that confidence to help out someone as a Good Samaritan is important.”

In the U.S., medical professionals who volunteer in IMEs are protected from liability by the Good Samaritan provision of the Aviation Medical Assistance Act except in cases of gross negligence or willful misconduct (such as intoxication, willfully harmful behavior, etc.). While airlines can get sued for conduct during IMEs, there has only been one reported case in the U.S. of a medical professional being sued for volunteering to assist – and the case was dismissed without a hearing.

In the U.S. (as well as in Canada, England, and Singapore), physicians have no legal obligation to assist in an IME. However, in Australia, some European countries, and the Quebec province of Canada, they do. If a physician decides to volunteer, they are usually not required to have proof of their credentials on U.S. flight, but that may differ based on the airline.

During her lectures, Dr. Phillips recreates IMEs as best she can, moving chairs close together to simulate the cabin of a plane and running through a series of scenarios she wrote for responding to different emergencies within the constraints of a commercial airliner. “It’s always been a fun and popular lecture,” Dr. Phillips says. “I always thought it would be neat if we could do these on an actual plane.” She worked with SKMC student, Jennifer Kim, to create a proposal to film on an aircraft.

With a proposal in hand, Dr. Phillips connected with her mentor, Dr. Judd Hollander, who put her in touch with Dr. Wendy Ross, a developmental and behavioral health pediatrician and director of Jefferson Health’s Center for Autism and Neurodiversity. In 2009, Dr. Ross founded a nonprofit organization called Autism Inclusion Resources (AIR), as a vehicle for preparing families with autistic children for community experiences, and preparing communities for experiences with those affected by autism. She’s worked extensively with clinicians and airlines to develop an air-travel program at Philadelphia International Airport that lets families affected by autism practice everything from check-in and security screening to boarding a mock flight. United Airlines worked with AIR to roll the program out nationally.

The two physicians met and discussed developing a Continuing Medical Education (CME) program that addresses in-flight emergencies, as well as working with special populations and people with autism who might experience different types of behavioral emergencies onboard a plane. The In-Flight Medical Emergency Project was born.

“I was so impressed with what Dr. Phillips was doing,” Dr. Ross says. “When I talked to her about the possibility of including an autism case, she was cool with it.”

The project was a perfect fit for Dr. Ross’s mission with the Center for Autism and Neurodiversity. While the Americans with Disabilities Act (ADA) has changed the lives of people with physical disabilities since its passage 29 years ago, it has fallen short in addressing invisible conditions like autism spectrum disorder, ADHD and Tourette syndrome. Her goal is to create a model, measure outcomes and create best practices as to how the ADA applies to neurodiverse individuals. “We then hope to apply it across the healthcare system and community settings everywhere,” Dr. Ross says.

Recently, Drs. Ross and Phillips, along with a film crew, spent an evening at the airport onboard a United Airlines jet, filming two in-flight emergency simulations: A passenger experiencing supraventricular tachycardia (faster than normal heart rate) and a teenager with autism who becomes agitated during a flight. Depending on personality, where they are on the autism spectrum, and how their particular disability manifests, autistic travelers will have different needs and challenges. Many behaviors, such as diverting the eyes, avoiding touch, and repeating movements or phrases, can be misinterpreted or misunderstood by airline crew or security agents.

The filming took some seven hours; two autistic volunteers who support Dr. Ross with programs at the Center for Autism and Neurodiversity, served as consultants during the filming. Dr. Phillips’s parents were on set as well, serving as extras on the “flight.”

Dr. Wendy Ross with an autistic volunteer during filming onboard the aircraft

Dr. Wendy Ross (right) with an autistic volunteer during filming onboard the aircraft.

“The idea is to turn this into a CME course,” Dr. Phillips says, “showing these scenarios and the steps that one takes as a bystander/Good Samaritan.” Currently at Jefferson, there is no formal IME curriculum requirement in graduate or undergraduate medical education. Ideally, Dr. Phillips says, this project would result in a CME activity that can be targeted to healthcare personnel interested in learning how to respond in the event of an IME. The objective is to show how such scenarios differ from medical emergencies that physicians typically treat in a hospital setting, the legal implications involved with volunteering, how best to communicate with the flight crew, and what resources are available within in-flight medical kits.

U.S. flights carry oxygen, an automated emergency defibrillator (AED) to re-start a heart in cardiac arrest, and an emergency medical kit. These kits are required by the Federal Aviation Administration (FAA) to contain a variety of equipment for assessment, airway and IV access as well as medications. The minimum level of content includes equipment such as a stethoscope, a manual blood pressure monitor, bag valve masks, syringes, IV fluid, and mediations such as dextrose, aspirin, antihistamines, epinephrine and nitroglycerin, among other items. Depending on the airline and size of the aircraft, kits may include more extensive supplies beyond the minimum requirements.

Flight attendants are trained in CPR and the use of the AED, so healthcare providers aren’t on their own. More important, all U.S. airlines have an emergency consulting agency standing by to assist from the ground.

Drs. Wendy Ross and Lara Phillips in the cockpit of the airplane.

Drs. Wendy Ross (left) and Lara Phillips in the cockpit of the airplane.

Doctors should allow their anxiety to resolve — and their training to kick in — before they volunteer, Dr. Phillips says, keeping in mind that most emergencies turn out to be minor ones. Only about 7% of medical problems in the air result in diversion, according to the NEJM study.

The study found that the most common in-flight medical emergencies are fainting (37%), respiratory difficulties (12%), and nausea and vomiting (9.5%), followed by cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4%). But doctors also see their share of complaints like allergies, anxiety, ear pain and headaches. Cardiac arrest accounts for just 0.3% of in-flight emergencies.

Dr. Ross says the project represents how Jefferson is bringing medicine to the community. “Not everyone who requires care gets it, or needs it, in our offices or our emergency rooms,” she says. “That’s one common denominator between what Dr. Phillips and I are both doing and it shows how Philadelphia needs a Jefferson – a place that provides the most care to the most vulnerable people.

While the difficult work of filming onboard the plane is complete, there are still instructive portions of the CME program to be filmed. Drs. Phillips and Ross plan on continuing their collaboration until it is complete.

“It’s been a really fun, cool experience,” Dr. Ross says. “It shows how Jefferson provides opportunities for care that are very unique and interdisciplinary.”

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