Doctor on Board—good to know

It is estimated that air traffic will continue to increase in the future as well. Over 3 billion people fly on commercial aircraft every year. There is a special physiological environment on board an aircraft that is characterised primarily by decreased ambient pressure and oxygen partial pressure, dry air, time differences and space restrictions. The age of passengers is increasing, and even patients with pre-existing conditions are flying more frequently. Aircraft are increasing in size and flying longer and longer distances. Combined with the stresses associated with travelling, all this leads us to expect a further increase in on-board emergencies. We can thus expect that globally a medical emergency will take place every 12 minutes on board a passenger aircraft. In light of the high passenger numbers, however, the risk is very small (8 – 50: 1 million passengers), the likelihood of an unscheduled landing is 1:1 million passengers, and of a death 1:2 million passengers (J. Siedenburg [2010], Kompendium Flug- und Reisemedizin. BOD, Norderstedt).

Nevertheless, the vast majority of medical emergencies are minor. They are usually caused by cardio-vascular problems, followed by neurological and gastrointestinal disorders. There is an extensive range of equipment for on-board treatment, including a doctor’s kit, AED, several first aid kits, and a plentiful supply of painkillers, nasal sprays, etc., plus an additional medical kit on long-haul flights. The cabin crew are trained in first aid for the usual on-board emergencies, cardiopulmonary resuscitation and use of the AED. They receive annual refresher training and can thus support doctors giving emergency aid to passengers.

Emergencies on board commercial aircraft can seem particularly dramatic – and not only to the layperson – as a result of the circumstances outlined above, lack of space, difficult patient access, lack of privacy from other passengers, language problems and restricted technical and therapeutic options. Emergencies cannot be diagnosed and treated on board in the same way as a in a clinical setting – for example heart, lung and abdomen auscultation and blood-pressure measurement is very difficult due to aircraft noise. The option of telemedicine consultations can be helpful. For these reasons, despite the often dramatic circumstances, a systematic, calm procedure is required (J. Siedenburg [2015], ‘Notfälle an Bord’, in J. Siedenburg and T. Küpper (eds.) ‘Moderne Flugmedizin’, Gentner Verlag, Stuttgart).

Legal problems and issues of liability, which are often feared, are obviated by Lufthansa’s liability cover. However, in an international context, it should be noted that such cover (the “Good Samaritan Principle” in US law) only exists if the assistance is provided free of charge. Indeed, in German and continental European law there is an obligation to provide assistance, which is not provided for in Anglo-Saxon law.

In the recently published standard work on aviation medicine (J. Siedenburg and T. Küpper [eds.] [2015], ‘Moderne Flugmedizin’, Gentner Verlag, Stuttgart) this topic is addressed in greater depth, and all aspects of aviation and aerospace medicine are discussed extensively.


Facts & Figures

Even in the past few months, doctors on board Lufthansa flights have ensured that acutely ill passengers were well cared for
during medical emergencies. Because for every individual concerned a medical emergency on board is and will remain a rare event, we recommend an article from the German Medical Journal which contains relevant facts and figures. To the article

Well-trained cabin crew

Our flight attendants are regularly trained in first aid in accordance with the latest guidelines from the European Resuscitation Council (ERC). You will find details of the information made available by the ERC here.

Fast assistance thanks to the latest technology

Thanks to the Lufthansa fleet’s powerful Wi-Fi networks, the most modern telemedicine tools can be employed if necessary. By transmitting ECG data, for example, it is possible to gather assessments on the further treatment of the patient from centres of excellence on the ground.

General procedure in the event of on-board emergencies:

• introduce yourself to the crew, giving details of your professional background and training

Examination of the patient:

• Ask about the duration and nature of the main symptoms
  
• Ask about any secondary symptoms and risk factors (e.g. chest pains, shortness of breath, nausea or vomiting, weakness or loss of sensation on one side)
• Check vital signs (pulse and blood pressure, if necessary respiratory rate – if blood pressure cannot be taken by auscultation due to loud background noise, estimate systolic pressure by palpating the radial artery)
• Determine the state of consciousness and any focal neurological failures

In the case of cardiac arrest:

• in the event of circulatory arrest, begin cardiopulmonary resuscitation (CPR) immediately
• Request and apply automated external defibrillator (AED). If a pulse can be felt, but a cardiac problem is detected, if necessary use the AED as a monitor if this is technically possible (some airlines require prior contact with a
  team of consultants on the ground)
• Request the doctor’s kit from the cabin crew, and if necessary administer oxygen
• If necessary, make contact with a team of consultants on the ground, if this has not already been done by the cabin crew. Additional measures such as the administration of drugs or intravenous fluids or an unscheduled landing can be discussed with the team as required.
• Document the results of examinations and measures taken. If necessary, give information to the medical personnel responsible for further treatment during handover on the ground

Procedure in the event of syncope:

• is the patient breathing and do they have a pulse?
  
• check vital signs (most patients present low RR values)
  
• move patient to aisle or preferably the galley, place in a recumbent position with legs raised, and administer oxygen
  
• if patient is known to be diabetic, measure blood sugar (device in doctor’s kit, if necessary from patient’s or another passenger’s baggage)
  
• most patients recover after a few minutes, if necessary administer fluids orally if possible
  
• the administration of intravenous fluids is usually only necessary if RR drops further and oral administration is not possible

Procedure in the case of chest pains or palpitations:

• check vital signs
  
• give oxygen
  
• if chest pains are thought to be cardiac-related, if necessary give aspirin, or heparin if available
  
• depending on systolic pressure, administer nitroglycerin sublingually every 5 minutes (check RR after every dose)
  
• if the AED has a monitor, use it to monitor heart rhythm if required, and examine limbs as a rough indicator of possible ST segment depression, if necessary
  
• if the symptoms abate after the treatment mentioned above, a diversion can be avoided if possible. Discuss with team of consultants on the ground if necessary

Medical incidents on board the Lufthansa fleet

In the last few years, an overall increase in on-board medical incidents has been recorded in global aviation traffic (source: IATA Medical Advisory Group). And this applies to Lufthansa too: with around 1,700 flights every day, between 10 and 15 medical incidents take place. These range from minor illnesses such as headaches via fever and vomiting to asthma attacks, colic, strokes and suspected heart attacks.

Medical care using the doctor’s kit

In most cases, adequate medical care is possible on board through the cooperation of the crew with doctors, such as yourself, supported by the on-board doctor’s kit and first aid kit.

While it may seem improbable to us, on many routes the equipment of the doctor’s kit on board the Lufthansa fleet is at least equivalent to medical options on the ground. And also often the quickest way for the patient to receive the necessary medical care is to continue on to the destination.

Round-the-clock advice from MedAire

In this context, do not forget the option of medical advice via satellite phone on long-haul aircraft (A330/340, A380, Boeing 747): with their suitably qualified flight and emergency physicians, the service provider MedAire is available round the clock to advise our crews and also the doctors assisting on board. The support provided by MedAire in the handling of an on-board emergency cannot be overestimated as their medical colleagues offer expertise in such cases with their knowledge of aviation medicine, emergency medicine and the operational specifics of aviation (length of time until next-possible landing, infrastructure of the nearest hospital).

A practical example

In the following article, an actual example is used to demonstrate how an emergency situation can arise on board. To the article

Assessing fitness to fly

Acute or chronic illnesses, as well as disabilities, can sometimes lead to the person concerned being restricted in their so-called ‘fitness to fly’. This can bring a loss of comfort, affecting health, but it can also put the safe operation of the flight at risk for all concerned.
Issues which are often regarded as trivial, such as the carrying of prescription drugs or insulin syringes, the ability to sit upright during take-off and landing, possible cardio-vascular or pulmonary risk on exposure to the cabin atmosphere (mild hypoxia), previous interventions or operations sometimes require assessment by an aviation doctor.

Support from Lufthansa’s Medical Operation Centre

A reliable answer to all these questions can be provided by Lufthansa’s Medical Operation Centre (MOC), part of the Medical Service. Every day between 06.00 and 22.30 hours, the MOC offers advice about and plans air travel for acute or chronically ill passengers, often on behalf of insurance or assistance companies, in the case of repatriation due to illnesses or accidents abroad. However, it is also happy to deal with direct enquiries from hospitals, doctors or patients.

Patient Transport Compartment – intensive transport on long-haul flights

In principle, scheduled air services offer various options for medical and organisational support. What is available: extra oxygen (Wenoll system), additional seats to raise legs, transportation lying on a stretcher (always accompanied by a qualified nurse, paramedic or doctor) or intensive-care transportation via the Patient Transport Compartment (PTC), which is globally unique but limited to Lufthansa’s long-haul fleet.

Regardless of the medical or organisational challenges, a safe flight or suitable patient transportation is possible in almost all cases. Infectious illnesses and resistant germs are critical, and may not be transported on board scheduled aircraft according to the regulations of the International Air Transport Association (IATA).


You can contact the Medical Operation Centre by email: medicaloperation@dlh.de or by phone: +49 69 696 55077. The Centre is open daily from 06.00 to 22.30 hours Frankfurt local time.

Holiday time, the tourist season and the high season in Lufthansa’s Medical Operation Centre

For many people, the summer months are quite simply the time to get away and recover from everyday stresses. Their chosen holiday destinations are spread across the globe and often can’t be exotic enough or far enough away. But what if the unexpected suddenly happens? A swimming accident in Florida, a stroke in Thailand or a car accident in South Africa – within minutes what was meant to be the best time of the year can turn into a nightmare, thousands of miles away from home.

It was for exactly such events that in 2009 Lufthansa established its Medical Operation Centre (MOC), which is unique in this form among the world’s commercial airlines. The MOC can be telephoned by any passenger seven days a week, between 06.00 and 22.30 hours (CET). However, the majority of its customers are professional companies that are organising the medical repatriation of sick or injured holidaymakers.

Diagnosis & treatment

Take, for example, the case of 49-year-old Peter Seifert* who was seriously injured in a road accident in Argentina. The German national was taking a round-the-world trip with his family when the accident occurred. After an initial examination at a primary care clinic, the following injuries were identified: polytrauma, 2nd-degree TBI, front basal contusions with delineated small haematomas, unstable open fracture to the lower right leg, fracture of the right acetabulum, pelvic fracture with symphysis displacement of 4 cm, 1st to 2nd degree burns 3% BSA, AC joint fractured on both sides, lung contusion on both sides, pulmonary insufficiency and non-bacterial pneumonia. The patient was ventilated and the fractures were partly treated on site. However, the doctors at Mr Seifert’s travel insurance company in Germany feared the medical treatment was inadequate.

Organisation via insurance company and Medical Operation Centre

The assistance service appointed by the insurer will request the medical prognosis and current status of the patient by phone, arrange for translations of the preliminary doctor’s report if necessary and subsequently request suitable patient transportation from Lufthansa’s Medical Operation Centre (MOC). The MOC will be given all the available information about the case.

Ultimately, the Lufthansa aviation doctor on duty decides on the mode of transport suitable for a sick passenger. There is an option of transporting a patient as a “normal” passenger in one of the available travel classes, if necessary in this case accompanied by medically trained personnel. For patients who cannot sit upright, there is the option of transportation using a stretcher (stretcher transportation). This service is possible on all types of aircraft in the Lufthansa fleet at 48 hours notice. The patient must be accompanied by one of the doctors appointed by the insurance company, by paramedics or by a nurse. Another option is Lufthansa’s Patient Transport Compartment (PTC). This is an enclosed cabin which can be installed on intercontinental flights and which is equipped as an intensive-care unit. A specially trained Lufthansa PTC crew member flies with the patient, alongside a doctor appointed by the insurance company. This team is then responsible for the patient’s medical care during flights of up to 14 hours.

From South America to Frankfurt

In Mr Seifert’s case, because of the extent of his injuries, the PTC offered the only suitable option for transporting him back to Germany. An experienced intensive-care doctor and a PTC crew member took off from Frankfurt to collect the patient in South America. Within 24 hours of the crew’s arrival, they were on their way back to Frankfurt with Mr Seifert. He was flown by air ambulance to Sao Paulo and from there was transferred to the airport. The suspicions of the doctors in Germany regarding insufficient medical treatment were confirmed when they received the patient. Mr Seifert’s condition stabilised increasingly on the 12-hour flight to Frankfurt. During this time he was also appropriately cared for, including the insertion of a CVC, arterial blood pressure monitoring, and he was attached to a ventilator. When the aircraft landed in Frankfurt, an intensive-care transport team was already waiting to take Mr Seifert to a hospital intensive-care unit on the ground.

Summary

The case of Mr Seifert described here is only one of approximately 8,000 patient transportations each year on board Lufthansa aircraft. The number of patient transportations is increasing year on year and so now Lufthansa is also investing in new developments in order to meet market demand.