In-flight Medical Emergencies

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In-flight Medical Emergencies

28 Oct, 3:30 PM

[Music] uh good evening everyone and welcome aboard flight netflix i'm dr niveda and today we shall be addressing uh some of the medical emergencies encountered midair in slides so for this session we have with us uh dr madev desai he's a senior consultant physician with fcg hospital and we also have with us a very special guest um colonel dr nageshwara he is the chief medical officer uh with indigo airlines over to you so do you want me to start the quiz first yeah please good evening everyone welcome everyone welcome especially to dr colonel rao because he is the one who is going to help us a lot in the aviation medicine person answer sessions so welcome sir he's not only coming but he's coming everyone is his entire team he's here with his entire team and many aviation experts also are joining so yes yeah please just to get the idea that what do we expect and how is our general knowledge about the when we are traveling in the air we should know what at what level we are traveling and what is the change in the pressure and also please go ahead yes uh so this is the first question uh you all can use the comment section to uh jot down your answers y'all can just put in as one two three four and uh we'll take it from there i'll wait for a few seconds on this slide and then proceed to the next slide [Music] so the first question says or what is the average altitude of airplanes so we'll move on to the next uh question it is uh what is the standard atmospheric pressure at sea level so once again y'all can put in your answers in the comment section all right um okay let's move to the third question what is the pressure maintained inside the cabin and it's equivalent to an atmospheric pressure of a lot of mixed answers um this is an interesting question because this will form the basis for their understanding yeah all right uh moving to the next question this is the last one what is the pao2 inside the cabin all right so that was the end of the quiz so do you want to run over the answers or we'll just uh start with the presentation then i think we'll discuss during the presentation only with the justification of why we have put these questions and what is the answer and why the answer is this particular one surely so hang on and you will get the answers to the questions in the presentation itself good evening everyone welcome everyone aboard and especially special thanks to dr nagesh rao and his team and what we are going to discuss in the next 40 minutes then you will have all questions answered and we will also give chance to you to experience give your experience while you had it anytime during the flight in your experience so in flight medical emergencies as we can see in this very first picture can occur at the time of takeoff it can occur in mid-air it can occur at the time of landing so that's what we are going to discuss and whenever there is a question or a public announcement in the address system that is there a doctrine board well it may give her a sign of some thumb or some excitement or anxiety should we tell should we come forwards will not come forward what should we do and if we say yes we should know what are we prepared for that so all that questions will be answering see first thing that i am going to talk about is the physics and the physiology of the high altitude because that's very very important to understand to understand many of the common problems that occur that can be encountered easily and the common medical problems in the flight what should we do as a doctor what are our duties what are our obligations what are our privileges and is are we supposed to attend a particular call or we can refuse to attend the call and what are the kids available in the flight and again some of the few suggestions that come from dr rao so first let us have some introduction about why we get more and more in-flight medical events here now considered as events and not emergencies because not everything that occurs is an emergency so in-flight medical events are definitely on a rise because the number of travelers are more we know that so many people are traveling so many people of different age group are travelling the people with chronic diseases are traveling and now we have got the number of people traveling for medical reasons and in fact we want we have many institutions which have the medical tourism department itself but attending a medical event in flight is not so easy for the very simple reason that the atmosphere is unfamiliar and uncomfortable think of so you need to do some cpr in the mid air and then all the whole plane is overbooked that it's very very difficult to attend that emergence in ideal situations and there may not be help there equipments and infrastructure may not help us to deliver the good and as against that the patients and the passengers expect some miracles because they always feel that the moment the doctor judges the patient a patient has to be all right and they start expecting so much that it becomes very difficult to deliver each and every time and on the our side also there is a fear of failure as well as the litigations then there is always a dilemma of morality and legality we as i said to do or not whether to come forward or not that always remains a dilemma and we'll see in the course of time that i for one believe that we must come forward we must try to help the person in emergency come what may see the magnitude problem is the number of air travelers i have increased to 4 billions before copied i just read now before few minutes that in the kobe time it has dropped by 60 percent the air traffic has dropped by 60 to around 1.8 billions but otherwise 4 billion passengers are traveling annually and the in-flight medical events occur at a rate of about 1 or 604 flights or we can say 24 to 130 uh events occur per million passengers if we just calculate these two how many events might be occurring daily then about 260 to 4 14 120 events occur daily right and we can say that at any given time in the air there are about five lakh people in the air and the death rate fortunately is very very low it comes around 0.1 per million passengers so that's a good part heartening part but if something goes wrong in mid-air there is always an anxiety and fear and panic situations and that is where we need to know how to pacify the panic people see the common medical problems that are reported to the crew members are the figures here it involves most of the systems like neurological system respiratory system gastrointestinal system cardiac also trauma right if there is just and somebody is just trying to put the luggage overhead and if it drops and is a sustained injury then musculoskeletal because of a long travel and there is a small increased risk of venous thrombus embolisms but it's a very small list and that between a predisposed people that will be talking later but as just mentioned here practically we have many system involved but the commonest is the neurological ones across the papers we have seen the commonest emergency that is reported it's in copy or pre-sync that comes to around 35 to 40 percent of the total reported events and we know how to handle it we'll see that later dizziness headache may be because of the neurological problems or maybe because of simple sinusitis or air in the sinuses then respiratory breathlessness definitely because of the difference in the air pressure that we talked again asthma exacerbation patients were known asthmatics then abdominal pain nausea vomiting the flatulence are all important com common complaints then the main serious complaints are the chest pain the brahman in discomfort palpitations these are the complaints that we commonly see in the app but first we must understand why these problems occur and how we can sort about it that is why we have put certain questions like the what is the physics of high altitude we know that we at the sea level we don't appreciate the atmospheric pressure but there are 300 miles of atmospheric pressure over earth and at sea level the there is a maximum pressure and as we go up there pressure is reducing the air becomes thinner the air molecules are less and less so at sea level our oxygen concentration the air is around 21 and the pressure at the sea level is 760 millimeters or we can say 14.5 14.7 pounds and as we go up the partial pressure the atmospheric pressure reduces the oxygen levels in the our arteries also reduces and in the side inside the cabin see the fun of the first question that was asked was at what height the most of the planes fly whether it's a domestic or interference all flights are usually kept at the height of 30 to 40 000 and the reason is at that point it is fluent fuel efficient and that is the reason that it is kept the jet engines are designed in such a way that they have a better fuel efficiency the faster speed at that level at that level the air is very thin the temperature outside the plane is around minus 50 to minus 60 degree centigrade and the atmospheric pressure is around 141 as again 760 in the at the sea level but what is done at that level the air pressure inside the cabin is maintained around six to eight thousand that is a compromise between the sea level and the uh highest altitude the reason is we can't have the pressure maintained at the sea level to make the comfort because that will add to the cost and add to the other logistics so the inside cabin the atmospheric pressure is maintained around 560 millimeters of mercury and the oxygen partial pressure oxygen which is at sea level is around 100 is 65 to 69 millimeters so the answer was probably 60 70 then humidity is also minus around 20 degrees it's not minus it's around 20 degrees the jet airplanes all the planes which are definitely the four things they don't like they all call h one is the weight right the second part is the height the third is the hot or heat and fourth is the humidity so all these factors are very important in the economics or the fuel efficiency so if the humidity is more normally at sea level our humidity we are comfortable in around 40 humidity if the humidity is less there are problems if the humidity is less inside the cabin so many people complains of dryness itchy itchy eyes itchy nose throat and there may be exacerbation of asthma that's because of the low humidity and the oxygen saturation is also false by around three to four percent so if per oxygen saturation around 97 98 percent at sea level inside the cabin it would come to around 93 94 which may be comfortable to most of the people because we compensate by view of tachycardia and little increase in the respiratory rate but that may not be the case with the people who already have some breathing difficulty or asthmatic or copd so that's very important to keep in mind then very important thing is this fl as i said the flight altitude is around 30 to 40 000 feet and the cabin altitude is maintained around six to eight thousand feet the it's contained it is controlled automatically by way of the different walls and because of that the person feels comfortable and there is also fuel efficiency maintained very important thing is as we go up and up and the air becomes thinner the pressure in decreases so if you recall our physiology days of boyle's law the boyle's law says that pressure and volume are inversely related if the pressure is less the volume will be more so at the new pressure the pressure at the sea level is different pressure in the cabin is different pressure outside the cabin is different so inside cabin also the pressure is less around 560 millimeters of mercury so that is why the volume has to go up and that volume is of air so wherever is the air whether it is in our stomach or in the intestines or in our sinus or in the ear or in the tooth or if they undergo any procedures right and there is a leakage of the wound or if you apply the plasters everywhere the air will expand by around 30 percent if the height of the cabin pressure of 8 000 so this is very very important and many of the complaints are because of the this volume expense of the gas inside our body so that is that leads to the commonest complaint we have seen when the flight suddenly take off or when the flight is landing so many people have sudden pain in the sudden earring or there is tinnitus or vertigo and that is uh very rarely you get a tympanic membrane rupture but otherwise most of the people have a very transient tiny torso severe earring and it goes with the person some people get it every time they travel the simplest way is to perform a mild while silver manufacture what is valsalla maneuver we just try to blow okay just blow out and that will probably or another way is that we keep chewing with the chewing gums or we may do swallowing or we do yawning and that will definitely help in case of children they may we may put them a pacifier bottle in their mouth and that will definitely help and trying to establish maintaining the balance inside and outside the body so this is a very very important simple manual then that changes in the barometric pressure in the sinus and teeth can lead to severe headache and ideally persons with sinus sinusitis i this should refrain or they should take extra precautions and they make sure that they before entering they should have the steam inhalations and they keep the sinuses clean otherwise they can have problems and they can have analysis with them then the expansion of gas in the stomach and intestines can lead to nausea abdominal pain and distension this is very very important particularly in the long distance travels when we do consume the carbonated beverages that will produce more gas and that's very important that refrain from using too much of carbonated beverages because that will create more problems then these are the minor problems which can be managed but there can be serious problems because of the expansion of the gas even if the person has patience with copd and astha they might a small amphisometers bully and if god forbid it ruptures the expansion of the gas will produce serious pneumothorax similarly if the person was undergone right triangle surgery many of the retinal surgery they instill gas and ideally this would not travel because of the as recent surgery they say that up to six weeks person undergoing the injection of the gas should not travel if the gas expands it will produce increased intracranial pressure will headache vomiting and it might produce the further complications so persons who had recent surgery surgery and gas institution should refrain then if the person is traveling with any of these tubes like urinary catheter or feeding tubes or pneumatic spleens or an air-filled tracheostomy tube in that case we may sure that feeding tubes at least we must cap it so that the air doesn't go in and produce more expansions and pneumatic explains also if it is there we must make sure that the person has had just had a fracture they call this fracture and they put and splint and the gas between the splint and the skin it may be little one but because of this difference in the pressure the volume of the gas increases and that might produce compression swelling and compromise the circulation so we have to keep that in mind and whenever the person travels with a plaster they must put a vertical sleeve so that the gas doesn't remain between the skin and the plaster which is close one so it's very very important but keep this simple measures but it will help a lot then well this is always a questions that the air commercial air flight conditioning system is such they use hepa filters high efficiency particulate air filters so that will prevent the sterile atmosphere that will maintain the external atmospheres but what about the fellow passengers there may be passengers who independently come with in spite of knowing that they have suffering from viral infections they enter and they might be the source of the infections so there are infections recorded tuberculosis influenza missile smallpox and sars these are the infections which have been reported following the air travel very very important point that we need to know is what are the contraindications to air travel of course this is no fixed uh hard and fast rules in the every air carriers they have their own rules and regulations but as a medical person's what we advise it any of these patients fall in then ask for us our advice whether we should go if the person has pneumothorax at the time of flight if the as i already said if there is an intraventral betrayal gas injections recently up to eight weeks they should not be allowed to travel if the person has recent severe stroke up to one month is no travel patients having unstable medical conditions right unstable diabetes there might be fear of hypoglycemia or hyperglycemia unstable coronary artery disease the asthma which is not under control they should refrain from traveling sickle cell anemia we know that the at the height the sickle cell anemia might requires the more oxygens right and that might produce sickle cell crisis then uncontrolled seizures in the last one month soon also not uh the person should not be allowed to travel and severe asthma or recent hospitals in the previous six weeks should also not allow and it is an active communicable disease then these are relative contractions not that they cannot travel but they have to travel with precautions or with new prescriptions and the treatment from their doctors if the person's has sinus infections and especially the estation tube is blocked this would refrain or be very careful then if they had history of decompression sickness after diving if that history is available they should be very careful sickle cell anemia we already said but if the person is due to any cause of anemia if the hemoglobin level is less than 8.5 they might require supplemental oxygen in during the travel and psychotic illness right if something goes wrong and because of so many situations which are unfavorable a person with psycho illness might become violent or agitated and create more problem more than medically another problems right so it's important that their psychotic illness is perfectly under control when they take the flight then especially if the woman patient at what level of pregnancy they should be allowed to travel see there is most of the airflow carriers they said that if the there is a single pregnancy single feeders then after 36 bucks they are not allowed if that is about the domestic flights in the intestinal flights many of the error flight carriers they do not allow even after 28 weeks of the pregnancy but 36 weeks is definitely allowed up to in the domestic flights then if there is a twin pregnancy or multiple pregnancy then after the end of 32 after completion of 32 weeks the women are generally not allowed to travel but again there are different rules for different uh companies and one should victor check this before until buying their tickets and they may prefer a particular flights because of their relaxations it's very important that they carry their obstetricians full prescription and their status and they might want to know about the period of gestations and on return so it's very important they carry all these documents with them infants less than 48 hours are also not allowed to take this flight very interesting questions probably we'll need dr nagasa rao's input in this that there are so many rules applicable because of the different situations that occur this one of the specialist aviation specialist dr nikolas said that which rules supply which countries will apply they say that if the aircraft is with the doors open at the local country's rules applies but if the aircraft doors are closed that means it is in the flight mode then the law of the country of the registration applies despite related to the most of these situations but again if the plane is in the mid air what rules would be applicable right the may be that flight belongs to singapore we are flying over the germany the patient is an english person with a british passport holder and you as a indian doctor is trying to uh save him so what will supply there are so many ifs and buts i so we need dr rao opinion about this sir please a very good evening to everyone and thank you for making me a part of this some of the slides i did want to speak and i will start with this in the sense that this is a very gray area and let me tell you there is no clear cut guideline on this this is ballpark what is followed and in the aircraft the aircraft is said to be in motion the moment the doors close so that's why the law of the country of registration applies so whatever if it is a british registered aircraft it will be from british but if the challenge comes if he goes into a diversion if he goes on diversion and lands in a different country then the moment the doors open the lower law of the land applies but having said that a doctor under the good samaritan law is absorbed from all legal complications that may arise at any point of time having helped so we can go ahead and take care and help everybody in the air without any fear of any legal issue cropping up so as and when the the patient is handed over the local law of the land applies so that is something which i wanted to clarify here in the previous slide dr desha aisara talked about the pregnancies so generally all the countries whether it is diseases or whether it is any particular medical ailment there is an international air transport association ayata which publishes the guidelines for all airlines to follow and create their own list of do's and don'ts with respect to allowing the medical ailments as such so in pregnancy the the challenge that we face is that no customer service executive can ask a passenger whether she is pregnant so we know as medical professional we know a nine-month pregnancy can look like a three-month pregnancy or a four-month pregnancy and vice versa so no customer service it is the self declaration of the passenger which applies here anybody who declares pregnancy is up to 36 weeks in case of single pregnancy the doctor's certificate the gynecologist's obstetrician certificate that they need to carry has to be within the last 72 hours we as indigo have had the dubious distinction of having two in-flight deliveries in the last one and a half year luckily for us two senior gynecologists or situations on board who could conduct successful deliveries but this is a very challenging area but i'll come to how we actually handle it once uh sir goes through his uh presentation so as far as this slide is concerned as doctors it is irrespective of which countries will apply we are safe we are protected by uh by this good samaritan law which is internationally accepted thank you very much thank you your comments are really very very important and comes from authentic presence so your legal duty to render assistance as doctor raw is rightly said it differs and there is no clear-cut uniform rules but it depends on across the globe it depends on which country your medical persons you belong to the rules are different for france germany and other europa nations that there the doctor if you are a registered doctor of any of these countries you are obligated to provide the services when it is requested by the crew you have to get if you don't give it your answerable but that's not the case with usa canada and great britain here the clinicians can come forward voluntarily and if they help they as dr has rightly said they are protected by good samaritan legislation so what is good samaritan legislation is that if you are a medically qualified person now the definition says who are the good i mean qualified medical persons physicians they are licensed and certified right they have to be licensed and certified if you are physicians nurse practitioners physician assistants nurse paramedic or emergency medical technicians they all can come forward needless to say that if a physician is available nurse practitioner would not come forward as fast or the physician would take the lead but in that hierarchy you can definitely volunteer and again to repeat that you are not obligated means you there is no compulsion or your part if you are a us uh if you belong to us system but if you come forward at least you have an indemnity for any malpractice litigations provided you fulfill certain uh requirements so what is the good samaritan law that if you are protected from the malpractice litigations if you follow particular conditions that is you are medically qualified so it's very important that you don't cross your limit or what is said that if you if i'm a physicians i would not venture to do a delivery fee i just don't know how to do it right that's very important but definitely i can come forward and give a medical treatment for the areas where it's area of my competence then we must give a volunteer that means there is no contract of patient doctor relations in the sense that we don't ask for any specifically monetary gain when we come forward then we do it in good faith obviously and we will not do any cross negligence or willful misconduct what we mean by gross negligence or willful misconduct is this is more likely when we are in the international flight for a long distance somebody might have consumed alcohol right and in the effect of alcohol if you do something and something was wrong it's a willful misconduct or it's a negligence so then the aviation law will not help so any intoxicated person's right medical provider at the risk of being categorized as engage in cross negligence and willful misconduct and you lose your indemnity because the aviation medical assistant act would not help you if you falter on this part so it's very very important that you have to be very careful or you have to very clear whether you are in a position to give your discharge your duty as a doctor then what how do we go ahead if there is a call and if you happen to come forward first and foremost thing it is good idea to carry some kind of photo identity with you right so of course they are they may or may not check for it but we have to have some identity so that it becomes easier for them and we don't waste time otherwise they might need some crosstalk but it's better that we carry some kind of photo identity of about our speciality then we have to introduce ourselves we have to ask the patient or the relatives if the patient is unconscious that whether we can provide the assistance or we get a verbal consent then if there is a problem of long language we might need an interpreter or a translator then we must keep not at the time of doing the treatment but later on we must keep a record because the record speak later on so it's very very important that we must keep a record of whatever we have done it whatever findings that we had it and whatever treatment we have given then we should ask for an emergency medical kit there are different types of kits available that would be the next slide and if the passenger is critical we may ask for the ground-based medical system support or diversion so it's a very very important decision of diversion as dr ravis rightly said it's not easy right just to tell diversion it's not easy because we don't know what is the status of the fuel how much distance that and or whether there is a any flight which is going to land at a particular plate whether the host country is going to receive you and whether there are enough medical facilities and what are the relations of that country with the carrier and there are so many things so many logistics so usually it is the captain captain is the commander-in-chief as far as any flight is concerned as a medical person we suggest but it is the captain's call and he will take he may need the help of the ground-based medical support systems now many of the aircrafts have provided the facilities of video transmission of the ecg or even the records or the patients and the doctors can also communicate through the specialized arrangement and then things become easier but as far as the medical negligence in carson in usa there has been only one case that has i mean one person has been challenged or there was a litigations but even that case was also totally uh rejected without hearing so that is the u.s law that they will not just entertain any negligent small suit so that much as doctor also said that even in our indian laws we have seen that the law always in the side of the persons who is going to help in good faith so we should not have that kind of hesitations or the fear of uh litigation to prevent us from going forward for any help now next is the what are the resources available board this is again not that every flight or carrier would carry all this of course they have to have the basic facilities in the form of because the international civil association organizations called icao they are the it's an even agency and they definitely give the recommendations and most of the aircrafts would follow these recommendations there are three types of medical kits available one is called first aid kit another is called emergency medical kit and the third is universal precaution kit the first aid kit is very very basic it's more for a uh kind of some incidental injury right so it's required in each and every plane with a capacity of more at least hundred seats so we need one first aid kit 400 and it contains mainly the dressings materials and it can some of the flats also include the non prescription and prescription drugs but that is optional basically for first aid kit is more for dressing this is the most important kit and that is going to help us and help somebody saving their life this is called emergency medical kit the important part is the emergency medical kit cannot be opened without the presence of a doctor qualified doctor so at least for this sake also we should come forward right so that the medical kit can be open and many of the crew members are already trained for many of the say whether it's a cpr one person cannot continue cpr beyond few minutes that we know if you want to give the correct effective cpr we need help and there we need so many even the mask and which is available that can be opened only if the medical person is available the pilot cannot open the emergency medical kit however he wishes if there is no doctor so that is why it is important that we come forward and allow the emergency medical kit to open the medical kit contains so many instruments drugs big momentometer pulse oximeter and in the list of drugs the injectables all the emergency drugs like adrenaline or maybe the dextrose for the hypoglycemia then we have got the lid okay nitroglycerin and so many drugs aligns iv sets then instruments now most of the international carriers they keep automated external defibrillator because we know that out of the hospital cardiac arrest one of the commonest reason is ventricular fibrillation and inventive fibrillation if one thing that can save life is the aed automated external defibrillator and the most of the crew members also they have the training of using it only thing is they cannot open it without our help so that is why aed needs to be opened and it's an interactive voice recorder system the ad will guide you the moment you open the led that how to give the shock some of the leds have got the monitor and they can give the see the arrhythmias but most of the time the machine itself uh recognize and say that it's a sockable rhythm so give the shock then pigmonometers ethoscope laryngoscope all these instruments syringes needles are available in an emergency kit and there are different types of ambu bag or different types of the cpr mass are also available so emergency medical kit is something which is very very important and that needs to be used in presence of medical persons only the universal precaution kit is more for the communicable diseases and where we have to have the personal protection equipment kits which are there for the doctors the paramedic volunteers who come forward for this now when to suggest diversion of flight this is again very very important decisions and with lot of repercussions on the part of the patient the fellow passengers so it's very important that we should know when we should at least insist medically insist for the if the person is cardiac arrest right if the person is microlight infections right the history suggests of course we do may not have ecg but history suggests that is in acute colon syndrome or micro infections or heart failure arrhythmia or severe stroke or status epileptics pneumothorax may be treated in emergency if we know how to insert a needle right and still the patient continues to be breathless then if the patient sustained serious head injury or leave injury or pregnancy related complications we should suggest the diversions ultimately it is the captain's call that he has to decide at what which particular airport he can let then at least last two slides and then we go for the questions answer sessions that this is my list of medical drugs which should carry because of the frequent traveling i have come to know that these are the drugs which are as such as i said the medical kit may not be open so that easily but if we have and there is a provision that if the fellow passengers have any medicines and if the doctor is available he can suggest and take use of those medicines like glucometer this they can carry glucometer if you have doubt of hypoglycemia we can give glucose or we can get the glucometer and the glucose tested and give it like that if we carry drugs like the protein from inhibitors or anti-semitic drugs decongestant drugs then benzodiazepines particularly the mouth dissolving ones like clonazepam are available analgesic drugs then steroids glucose tablets or oral solutions then the diarrhea is another problem patients have just had some food and before joining or entering and there is a diary an on-board diary it's a very very tricky situation so we may carry drugs like refuge metrosil are anti biotics and loperamide if there is a clear-cut loose water oceans we should also carry for our own sake if you have a problem of the earache the chewing gums then i glasses if somebody is using the glasses then contact lessons and sunscreen and sterilium so these are the thing that we can carry and one of the last ones what should we advise to our patient passengers if the patients come to us before taking a flight we should tell them that they should carry all the last prescriptions all these medicines would be in their original level containers that's very important they should know their correct dosages it's better that they have it on their mobile phones also and they have to have at least medical alert bracelets or the car that they say that they are allergy to a particular drugs or they should have the recent ecg if the patients are cardiac patients and in international travels it is very important we have to keep in mind the times on flights are for 18 hours 24 hours and the time zones are different and there are few medicines like insulin warfarin anti-epileptic medicines anti-hypertensive medicines or even parkinson's drugs they need to be taken at time to time so it is better that person carries or change his wristwatch in such a way or he has two different types of monitors so that he knows when he should take the medicines in the air or at the time of landing so these are all very very important precautions we should be keeping and i think we must try to keep our air safe with the help of our friends and we'll request dr nagesh rao and then questions and comments from the audience and we will also have many experts i'm sure many of our members have their own experience and they can raise their hands and come forward and share their experience and what they need but first doctor ralph please ah thank you sir and uh let me compliment you sir for one of the most comprehensive lectures on in-flight medical emergencies i have been in this field for the last 20 plus years but this is one of the most comprehensive expectations that i have seen and well researched i'll go over a few things and then we can take the questions if you permit so i i i don't have any uh slides as such but i'll take from whatever you've spoken and maybe add on some things to this as doctors we are we are called upon at various times to come on and help out in terms of need and aviation is one place where the anxiety levels are high where the there is a element of uncertainty which compounds everything with respect to a medical emergency so starting with the first slide that you shared in flight medical emergencies the number one increase of why they are increasing off late is one is kovid has actually forced people to travel by air if i have an option of traveling from bangalore to delhi by a train in say spending 48 hours in a closed train and i reached the same place by two hours i would rather prefer a well-researched cabin ventilated environment where it has been proven that it is as it is more uh safer than an operation theater working room where the cabin air is actually completely exchanged every two to three minutes and pass through the high energy particulate air filters that is one reason why people are moving more people are flying at this point of time second is why are the medical emergencies increasing ovate has imposed upon us a very heightened level of anxiety so any small issue coming in i am relating this to covid because we are living in these times any small issue coming in is getting magnified and people are panicking very very fast so some data from our airline which i can share is we we have approximately about 40 000 departures per month and we have about 400 medical incidents on board every month and out of which 80 would qualify as a medical emergency and diversions are very very minimal maybe because we have smaller sectors but in international flights as you brought out diversion if i if i am flying in airbus a380 the largest aircraft or 747 if i just take off now from say delhi to go to new york and i have to there is a medical emergency over karachi or or dubai i cannot land because the amount of fuel will not permit me to land the pilot has to dump fuel and then he has to land it and there are many other considerations whether the medical facilities on ground at that divergent site are available i would rather land in dubai and prolong flight and land in dubai rather than in karachi so those decisions prompt the pilot to ask again and again so as far as the challenges between equipment on board is concerned and environmental challenges are concerned let's come to the environmental challenges as you brought out hypoxia hypothermia hypobaria reduce pressure dehydration people forget dehydration you are brought out very nicely dehydration is one of the biggest bug bears which is the cause of the syncope on on board and the communist in indian skies we have seen the communists are bronchial asthma which is also a fallout of dehydration which can be exacerbated by dehydration then comes hypoglycemia and various other things burns is something very very common these are the things which we can handle but when it comes to anything cardiac people panic and then the diversion sets in one of the other common very common things which happens on board is seizures and at this point of time i would like to say make a mention about the training that the cabin crew undergo as doctors we must understand that the strongest aid available to us on board and a flight is the cabin crew a pilot cannot come out of the cockpit and help you out correct cabin crew is very very well trained they are one of the experts in first aid they they have a syllabus which they have to clear mandatory they have simulator based cpr training they have extensive training in first aid and cpr so they are qualified people they may not be able to give you an intravenous injection but short of that they will be able to follow every instruction that is given like a trained paramedic so that is one thing we must bear in mind and utilize as in when it comes in when we are asked to certify certain people not only on board certify a certain people we must see that things like anemia may be a challenge in aircraft which you have brought out because of the reduced oxygen contents and talking about the first first aid kits and medical kits one of the questions which was on the comment box i saw is that is it available on domestic flights also yes any aircraft which has got more than 100 passengers capacity is mandated to carry a medical kit there is a scale which is governed by the director general of civil aviation and they have to carry less than 100 seats first aid kit more than 100 seats first aid kit medical aid kit and a universal precaution kit which is extensively used in this ovate circumstances are available on board so you have the basic infrastructure available having said that the aircraft environment is very different from a hospital environment you can't even make the patient lie down properly except for the front and the aft aisles or the middle eyes which is there so uh training of the cabin crew is something which we must carry with us in the sense that in our memory that yes i have these people who help me out to an extent that they are also trained to conduct a normal delivery they cannot conduct a delivery which can get into complications but they are trying to conduct a normal delivery also there was one mention of the connectivity to ground is concerned there is a bit of a difference between india and the other countries in this particular aspect in india we still do not have wi-fi on board so telemetry is not possible i mean passing ecg is passing parameters life parameters may not be possible we do have certain airlines have got the system where the cabin crew conveys to the pilot the pilot conveys to the flight dispatcher on ground the flight dispatcher connects with the doctors on ground and the message is relayed back so the ground medical team are connected to satellite phones or vhs radio sets as we call them so whichever is the nearest airport where their staff is available they can always communicate this is very different from the western world where every aircraft is equipped with wi-fi so you have agencies like mid-air who get real-time data and give real-time advice so we are slowly moving towards that there is a lot of work going on in this in our regulatory area also consideration of wi-fi on board which will help us connect with the onboard cabin crew directly and help out in helping them attend to these these medical emergencies now as regards the medical emergency how to handle i would request all the doctors on this forum if there's a free free download available from the ayata international air transport association medical manual that gives you a very crisp understanding of how things are to be handled and how airline medical departments handle the the in-flight medical emergencies there is a ready reckoner which almost all the airlines follow very few airlines differ from that there is an ayat ready reckoner available on in the ayat medical manual i would request iata a medical manual is something which you need to follow a word about infectious diseases when you when you get on board so you have the upk universal precaution which has got an apron glass i mean face shield and goggles and mask everything that you you take it on board so wear that get into that and as regards the spread of the disease because the airline aircraft is engineered beautifully in such a way the spread of the disease is not beyond three seat front and three c driver that is something which will give you an idea about the air flow and there is no documented case unless the person has been repeatedly walking up and down in the aircraft where an infectious disease can spread three rows a front or three rows back there was a mention of diving please be very careful about diving again we go to atmospheric physics every 10 feet under water the atmospheric pressure doubles from 760 it doubles to i mean one four eight zero if mathematics is correct for one five to zero so two zero so the amount of nitrogen dissolved is much more so he if he within next 24 hours if he flies there is a real chance of case ons or bends or decompression sickness as we call it so we must prevent these people to travel especially flights originating out of these diving heavens like old blair or goa if the patient is having chokes then you must ask for this history that is something we must keep in mind so these were some of the points that i wanted to add not that they've been missed but i i felt that maybe we as doctors flying very frequently with number of people flying more it is important for us to know that yes we have a set of regulations which helps us attend to that people we have a set of equipment which is useful in terms of addressing medical emergencies and we have trained manpower in terms of the cabin crew available on board so that we can do the best that we do and thereafter i mean thereafter it's as good in the hospital we do our best and then after uh take it forward from there thank you sir right sir very very very important very important way to put your inputs you have given and there was one question that asked by one of the out of curiosity that if there is a delivery on board which citizen saved the person i believe that it is the carrier wherever it is registered ideally they are supposed because it is said that the every airplane or every company that flies have citizenship so that particular carrier is supposed to give the citizenship wherever it is registered but i need your comments so this is again a very gray area so right now air india i i don't know if dr vivekananda is on on the call is if dr vivekananda is there because india is right now having one such case where they landed in one of the european countries and the citizenship still has to be decided upon the general understanding is yes the registry of the aircraft matters second nationality of the individual also matters okay right and third if the if the delivery has been complicated and there is a diversion and the delivery has actually occurred in the in the diversion hospital and that all that state also comes into play so there is no uh yes and no answer on this there is no clear cut answer on this but there has to be some citizens it cannot be stateless so yes so one is the origin the citizenship of the parents that is the first deciding factor second is the origin of the aircraft these are the two major determinants in that right very interesting now are there any persons who have raised their hands and they would like to uh i'll just get them on stage yeah please please okay uh we have dr abhilasha the question has already been answered it was regarding delivery and if there is a serious condition like ectopic pregnancy because most of the airlines don't allow full-time pregnancies to pregnant patients to fly but if it is early pregnancy like ectopic what will we do because as a doctor i am attending a passenger and i am suspecting ectopic pregnancy what will i do i will take that question we do not find it it's as simple if we come to know most of these problems occur only in undeclared patients they don't declare their pregnancy status but if it is a declared ectopic pregnancy complicated we will not delivered nobody will fly herself if it is emergency ectopic declared declared if they have not declared we don't know if they have declared it we will not permit them to fly will never fly yeah no they are not permitted yeah they won't fly themselves but if i if it is a if i suspect a serious patient on board to be ectopic what will i do you have to ask for diabetes and i am sure thank you thank you very much with the risk of hemorrhage thank you thank you very much hello sir hello sir i have a question to dr how and also doctor they said suppose say some flights might be there do not have a ready-made emergency kit and i as a doctor usually carry my kit am i allowed legally to give my samples to the patient is my question number one question number two is again coming to the legality in cases like strata supply because where iv access is required uh getting an iv line is very tough because i was once treating a patient on london flight 2010 i could not so are we allowed to do cut down win a section or cut down or we do allowed because patient is not in a status to give consent so if something has an implied consent be taken wherein we can go go ahead to do those procedures as a good summation practice so first part is that yes definitely our samples and whatever medicines we have we can definitely allow because we are the qualified persons and if it is not there in the emergency simulation kit definitely we can give it and we can prescribe on board also because we are a medical person there is no question why we cannot give it as even that simple one the second part is about dr narada would be in a better position to answer about the very section answer to both the sections is yes now whether you are able to do it on board but it is within limits of what dr desai had brought out in the slide that you are a licensed personal you are authorized to do it on ground then you are authorized to do it in the air also question is whether you have the infrastructure available to do right you have the ib sets available but any section performance is a unless you are carrying uh the further equipment required it may be a challenge but as as far as the legality is concerned yeah there is no challenge right and in the consumer protection act also they what they call it the bolom test reasonable competence is whatever treatment he is giving if you give that one to that standard that is fair absolutely fine you should not be below that part so if an average doctor whatever he does and if you do it even in emergency that's more than it is so that is called a test okay i can answer the question that is asked one of the questions asked is whether the non-allopathic doctors can also come forward and attend as i understand as far as the domestic flights in india are concerned our indian law said that all ice doctors can also prescribe now that the supreme court has allowed so whatever medicines that they know of how to use it if they are very confident of using it definitely they can come forward but i am not saying about the international flights uh on the international flights whether they would be permitted but in india definitely theirs what is your take sir in india we have had very limited experience because if doctors have been permitted uh relatively recently right and the onboard kids are not catered to their requirements right so we have not had such experience but having said that what you say is by legal uh provisions the ios doctors are permitted within the indian skies but outside indian skies we will have to check and get back ah thank you i have another question here can uh medical students help in uh any medical event in air since they aren't certified but have basic idea of what to do so this i think a lot of our doctors want to know about it yeah so there have been a paper yeah yeah please please no there was one incidence where the medical student came forward and luckily the patient survived but then there were questions of the ethics game and it's if nobody's available if you volunteer yourself as a medical student maybe you try just as any other person who is helping but i am not sure whether uh they have a legal backing doctor rao will be in a better position too so legally no but uh as a help to the cabin yes they cannot open the medical kit because uh that was one point which i i wanted to add i forgot that the procedure that the cabin crew follow the moment they announce for a doctor they check your credentials they are uh they are trained to check your registration number and credentials only then they will take it forward if you don't carry your credentials then it becomes a challenge because these drugs are such that they can also kill somebody right yes if we cannot use adrenaline or those drugs just like that we have to be very confident of prescribing or once we open it then it becomes very difficult not to use these medicines by anybody so it's better that only the qualified persons would allow that emk to be open and at this juncture i would also like to add that all doctors if you can visit the site of director of general civil aviation there is a rule civil aviation regulations if i can share it with the organizers it's an open source place yeah which lays down which lays down what equipment is carried on board it's a good uh it's a in a tabular form it gives what all medicines are available on board and on board also the the cabin crew will come with you uh with the list these are the medicines which are available in medical kit right only issues the drugs would must be in a limited quantity if there is a more than one or few people just have the problem then there may be a problem so so that also is catered to over a period of time they know how many kids to carry suppose the the number of passengers is more more than 200 the number of medical kids and first aid kits also increase so there will be two or first aid kits or four first eight kids or two medical kids four medical kids so it is catered to that right good yeah this question is doctors can orthopedic surgeons open their definitely yes he is a qualified person then all basic for mbbs degree is good enough to for the kid to be open was the event with me i was the only doctor on the little flight and being an orthopedic surgeon uh there was an emergency suffered so i was waiting for some other doctor to raise the head because being an orthopedic surgeon i was a bit scared okay if i will i be able to handle the emergency or not and if the patient dies or something bad happens to her so what in that case will be medical legally held in that case so already i got the answer from you sir but then nobody raised the hand so on then uh my conscience told me being an amphibious doctor being an mpps degree just go and do whatever you can so i just went i did what can i do and i saved that person's life but the first question which arose in my mind was you did the right thing and you came forward and it was good and now you'll have the satisfaction right when you say that if you leave right once is enough that's it yeah so as as dr desha had brought out in his presentation unless there is direct cause for medical negligence no no no doctor will be challenged for his assistance on board that is number one number two your mbbs is enough for your uh opening the medical kit you don't have to be a specialist also [Music] we can give it otherwise we have to ask for the diversions these are the emergencies where we just cannot treat on board without the facilities of investigations and the further management so we have to ask if you have a strong suspicion conviction that it is a medical emergency like a stroke or am i we have to ask for the diverse dental surgeons can uh attend yes they are there is a subject of medicine in the third video so they know medicine and they are qualified persons only they think they should know their limitations and what level they can help definitely they can help in opening the kid and dr rao can uh give his impact so as a as a rule uh they we do not permit dental surgeons to a medical kit but they can attend to the patient they can assist the patients whichever way they can okay but they are not allowed to open the medical kit yeah i mean i have been worked for air india for last three years in 2015. uh i found that after having the car clamp inside the medical kit i don't see any i'm little caught scissors inside it as well as i can see on and centron uh syrup in into in in inside that but not a parasitic syrup for a pediatric uh pediatric uh as well as there is a date yes surgeries are done over in ophthalmology also so patients have done a retinal surgeries uh vitrectomy as well as filling the gas also they are not mentioned in the performer of flying also and after that after flying of long distance and coming back to ophthalmologist we find that it has been clocked inside the lens also [Music] so they are not mentioning in the paper what type of surgeries they have done undergone also so we the medical offices find difficult if it is a long time surgeries only they have been enrolled in the paper so in the tickets but not for day surgeries but patients are losing their visions also so uh doctor i'll answer both the questions first is regarding the online citron syrup and parasite it's an internal call for the airline to take which setups to put on board generally generally the utility of a paracetamol syrup on board is very very less actually so it's it's for the airline to take a call we can always put it across to the airline medical department we will do that i'll tell my counterparts in india you are also that the second part is unless we need to create awareness among the if you have identified a hospital from which they are coming what happens is these are these are the parts the challenges of medical tourism you uh there are certain hospitals or for reducing the stay in the hospital they discharge them and after discharge the cost of living in a city goes up so they immediately want to take the next flight so you must tell the air the hospital and create awareness among the passengers that if they had a recent surgery they should not be flying so we have identified certain hot spots like that so a flight taking off from say bhagtogra to chennai or to hyderabad we know a lot of them are medical uh most likely with uh liver or retinal problems so we have in the checklist of the of the staff attending to them while boarding we have this as a part of their checklist asking the question whether they have undergone a recent procedure but if the passenger hides it we really can't help there is no way for us to know about it so it's a catch-22 situation right about right trying our surgery in gas we already mentioned and insisted more than once for the same reason that that is something the passenger himself should have been informant he should have taken care of that part yes refrain from we must reach out to that hospital and tell them in their discharge sleep they must write it thank you sir talk like give a little brief about what aviation medicine is uh there were a couple of or people from the audience who wanted to know about it trying to find that in three minutes aviation medicine is a science which deals with medical problems having engineering solutions in one line i'm answering your question for example if you are flying in an aircraft which is flying at 30 000 to 40 000 feet okay there are certain environmental challenges imposed upon you how to prevent that is not a medical answer we advise the engineers what cabin pressurization to be maintained what is the oxygen percentage what is the humidity to be done so the solutions are engineering solutions so in essence aviation medicine unlike a clinical medicine where an unfit patient goes to a fit doctor i mean onto goes to a doctor and to become fit in aviation medicine generally the people of it they go to a doctor and they they are exposed to a hazardous environment and the doctor features in trying to keep that milieu interior as it is without uh i mean decompensating in this hazardous environment so it takes about three years to learn that basically it's a it's an altered physiology uh if you are in the early part of your uh medical career please there is a small chapter underwater and deep sea diving in guyton read that extra i mean every word in that you expand it into i mean a textbook that becomes aviation but we'll need you sir on our platform for the full at least one hour discussion on aviation medicine if not glad to share whatever we can [Music] uh yeah so there's another i think one for dr rao again how does one become a medical officer with an airlines okay so the vacancies are do keep coming on the on the website of the airlines or the hr recruiting agency it's a regular process and each airline have got very fixed sort of i mean the basic qualification is mbbs there are very few aviation medicine people who have done the post graduation aviation medicine i mean i can count only three of us in in all these airlines that are available in india there are three of us who are in different airlines or aviation medicine postgraduates but uh having said that the basic qualification is mbbs there's something more about dr rao your military training and medicine training if you can share i'm a graduate of the armed forces medical college and i i joined the army immediately on completion of the of my mbbs and then been with the army for about 22 years had the honor of serving the country in every place that they sent us right from seattle malaysia to karnikov to arunachal pradesh wherever they sent us but did what i was expected to do in and then thereafter during the course of this time i did my post graduation in aerospace medicine at the institute of aerospace medicine bangalore which is the only institute which gives in southeast asia and thereafter we i continued with army aviation squadrons and retired in 2016. in 2016 i have been with indigo airlines and trying to play a part in civil airlines though the covet situation was a was a real challenge which we feel we have successfully thank you so much sir for attending this session it was a real pleasure and it was an honor to have you on our platform and i'm pretty sure that everybody on here has learned a lot about the medical emergencies and are better equipped now to handle them when they are flying themselves um we hope to have you back on our platform and [Music] dr desai thank you so much for this coming up with this topic it was really needed and we hope to see you all back on our session soon and thank you so much and uh good night everyone thank you once again dr rao it's pleasure having you yes thanks it's my honor sir singular honour thank you so much for choosing this talk thank you [Music]


In-flight medical emergencies (IMEs) are common, with one occurring every 604 flights. These emergencies occur in a complex environment with limited medical resources. Health care personnel are frequently asked to assist affected passengers and the flight crew, and many have limited experience in this environment. Join us with Dr. Mahadev Desai as he discusses the line of management for these emergencies.


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