Medical safety in airline—personal experience

Case history: no1

10 September, 2018.

Qatar Airbus 011 was cruising smoothly at 30000 feet above with packed passengers in mid sky after leaving Hamad International Airport at 4 AM Bangladesh time. The sun has risen now, showing start of a good day, just 15 minutes before we have been served with Arabian breakfast. Many people by this time finished it and were watching movies in the screen in front of them. Suddenly the microphone became active. The voice of the pilot came in the air:

 Ladies and gentlemen,

Is there any doctor or medical personnel on board? Please contact our crew. A passenger is sick.

Immediately I got up from my seat taking my stethoscope and blood pressure instrument which I was carrying with me and rushed to the rear of the plane where crews were standing. I was received by an air hostess. She asked my nationality and specialty, then quickly took me down stair where a middle aged white man was sitting in his seat with a vacant look holding half eaten morning bread in his hand. He was motionless, speechless, not answering any question. His blood pressure, pulse and respiration were within normal range. A suspicion of heart attack was made and a suggestion of hospitalization was given. By the time a white doctor came and took over the case. Some emergency treatment was given. The crews thanked me and I returned to the seat. After 10 minutes an announcement came from the microphone that due to emergency situation the plane is being diverted to Athens. We were Heathrow bound and not supposed to have a transit in Athens. But the captain was wise enough to take the decision for saving a life. At 11-34 Bangladesh time the plane landed in Athens. The patient was handed over to hospital. The plane waited for 2 hours hoping his return but he didn't. It left the airport at 1-21 PM BD time.

After reaching London when my friend Dr. Abu Bakar working with NHS heard it became very annoyed with me. He asked me why I handled the patient. If any untoward happened in the plane I had to face charges as I was not registered in UK nor in Qatar or in the country of the patient. All I could say that as a doctor I could not sit idle when somebody is dying. I hope airlines should give immunity to such doctors (licensed in their own country) ignoring caste, creed, colour, country who come forward to save life in the sky.

Case history no.2

In 1992 I was accompanying surgeon of a cancer (middle ear) patient Mr. Asab who was a professor of Dhaka College. I was travelling by Bangladesh Biman from Dhaka to Calcutta for better treatment at Thakur Pukur Cancer Research Hospital. At normal flying altitude he started feeling severe pain in the ear and  discharge started from it.

Case history no.3

On 30 January, 2008 I met a road traffic accident and had a pertrochanteric fracture of left femur which was fixed internally. When it barely united I wanted to travel to Sylhet by air. But the GMG Airline refused to carry my supporting stick in the passenger's cabin without which I even could not stand at that time. After much argument when they agreed they kept it in the cockpit with the pilot despite my need at hand. I think airline can't snatch away medical support from a passenger in the name of security which is against medical safety.

Case history no.4

I myself became sick in a plane journey. I was travelling from Dhaka to Karachi PIA en route to Tripoli. I had colds but I ignored it. I knew I can't wait and delay my flight any longer as my entry visa will be expiring after two days and in that case I will not be allowed to enter Libya in any circumstances resulting in losing of my job. All Arab airports are extremely rigid about 'Khoruj' and "Awdah', i.e. exit and entry dates of visas of expatriate workers. I was feeling discomfort when the plane took the altitude and it was terrible when it started flying at 30000 feet above the sea level. I felt intense pain as if covering of my brain was tearing. After sometime I started bleeding from the nose. As a doctor myself I felt ashamed to seek any medical advice or telling air hostess about the matter. I thought I was dying and afraid if there was cerebral haemorrhage. I fervently prayed to Allah so that the flight ends and the plane reaches its next destination in no time. At the time of landing when the plane lowered my discomfort disappeared. After one day rest at Karachi Airport Hotel I started my journey to Tripoli again.

Case history no.5

I had another experience in 1978.I was working as a Surgical Specialist of Ghadames Central Hospital, Libya at that time. I had to accompany a Burst Abdomen patient by Libyan Arab Airline from Ghadames to Tripoli (700 k.m. approx). The patient started feeling discomfort in the middle air. The pilot was very co-operative. At times he put the plane on Auto-Pilot and came in the cabin to talk to me and inquire about the condition of the patient. He personally informed the ground staff of Tripoli airport and Central Hospital, Tripoli. On arrival I found the ambulance ready and the patient was immediately shifted to the hospital

Medcal safety:

Medical safety is in fact a wide term. It includes Hospital Safety, Medical Device Safety, Drug Safety, Medical Personnel Safety of the patients, Medical safety of the travellers etc.

Medical safety of the travellers in airline is very important topic. All these above incidents will tell you in flight medical emergency can occur at any time in any aircraft. It is more common nowadays because the longevity has increased all over the world and more elderly persons are taking long distance travels and some of them are apparently healthy but potentially disabled. The anxiety of travel, stress of getting to and through various formalities for long time in a modern airport can make them exhausted and quite sick before boarding the plane. Besides this air travel can precipitate or can create medical problems even for some normal persons.

Reason and remedy:

The cabin pressure is usually kept equivalent of 6000-8000 feet. In the air gas expands 30/: and oxygen deficiency occurs. At this height there is 3/: desaturation arterial blood .The human body is very adaptable with fall of pressure of atmosphere and reduction in amount of oxygen available for breathing even up 10000 feet due to sigmoid shape of oxy- haemoglobin dissociation curve.

Pain in the middle ear or Paranasal air sinuses blocked by catarrh especially during descent is common. Decongestants, analgesics or drinking a sip of water i.e. swallowing can give relief. Reduced partial pressure of oxygen with hypoxia even at 6000 feet can cause problems especially in sick persons having CABG(open heart surgery) status, cardiac failure, myocardial ischaemia, severe anaemia, blood disorder, cerebral insufficiency, respiratory diseases e.g. chronic bronchitis, emphysema, bronchiectasis, cor-pulmonale etc. Cases of Tension Pneumothorax also reported. Shortness of breath can be relieved by breathing into paper bags readily available in the craft. Dry cabin atmosphere in long journey can irritate mucous membrane and drinking juices and water but not alcohol is helpful. Sitting long time can cause Deep Vein Thrombosis. To avoid it passengers should walk up to toilet in the narrow passage after sitting for considerable period of time and move their extremities. Personal medications should be always in the cabin bag and not in the accompanied luggage otherwise those who are patients of epilepsy, diabetes, parkinsonism,  respiratory diseases, heart patients etc may face sudden problem due to lack of medicine and altitude.

Recent surgery:

Recently operated(before 10 days especially open surgery of the hollow viscus of abdomen) should not undertake air travel as gases expansion can cause rupture of the newly stitched organ as stitches can give away. For medical safety patients after heart surgery should fly after 4-6 weeks, Angioplasty after 3-5 days, Tonsillectomy after 10 days, Appendisectomy and laparoscopy after 4 days Penetrating eye injury after 7 days. In case of plastered fracture limb air can remain trapped in the plaster cast which will expand during flying causing compression ischaemia endangering blood circulation, i.e vitality of limb.

Other causes:

Accidental scalds can occur by falling hot water or tea etc from moving trolley of a busy air hostess in a crowded area or in kitchen. Sometimes female passengers in advanced stage of pregnancy (most airline allow flying at 36 weeks) may feel extreme uncomfortable and deliver in the air or some person who is having stomach upset etc can any time  face problem. Head injury can occur by falling of heavy luggage on the head of seated passenger from overhead holder. Passengers with uncontrolled high blood pressure and heart disease can have sudden stroke or heart attack and even death. A diabetic patient taking usual big dose of insulin like home but taking less quantity of food of airline may have hypoglycaemia leading to confusion and even coma.

 At times severe allergic reactions can occur to sensitive person from contents of food item. Rarely engine oil of plane leaks causing toxic fumes in the passenger cabin and may create breathing problem. Cabin crews should keep an eye over elderly persons and pregnant women if they are having

some medical distress and immediately report it to the authority (Captain).

Health care training of the crews:

Keeping all these and other possibilities in mind health training of all crews is a must. They should be trained how to tackle emergency medical, surgical and obstetrical situation. The training can be given on a simulator as to how to put an oro-pharyngeal airway tube, how to deliver a pregnant passenger on board and take care of the pre-term baby, how to put an intravenous drip, or give intramuscular injection, how to support a broken limb by a splint (instantly made of any hard matter) due to accidental fall or how to catheterise an elderly person in case of retention of urine in long flight etc. Also they should know taking of arterial pulse and blood pressure. Besides CPR (Cardio-pulmonary resuscitation) is compulsory for every crew including the pilot. However many standard airlines give the training but not all.

 After flight all planes should not only be cleaned but disinfected.

Cockpit should have sterile environment.

Emergency cup board:

Some emergency medicines and medical equipments should be kept in the cupboard of plane (should within expiry date). A probable list is as follows:

Stethoscope

2. Blood pressure instrument (manual and electronic).

3. Oropharyngeal airway tube

4. Pocket ECG machine

5. Defibrillator: At least one flight attendant should know how to use it.

6. B.P. Handle and blade.

7. Plain and toothed dissecting forceps and reasonable quantity of straight and curved mosquito and medium artery forceps and 2 small retractors

8. Absorbable and non absorbable sutures with round and cutting needles-- a few.

9. Dressing materials, bandages, splint, absorbent cotton, Micropore, Foley's catheter (various sizes).

10. Sterile gloves of various sizes, Sterile sheet, Tourniquet, Disposable syringes of various sizes, masks.

11. Injections: Epinephrine 1:1000, Antihistamine, Hydrocortisone, Oxytocine, Atropine, Diuretic, Antiemetic, Sedative anticonvulsant, Major analgesic/oral, Aminophyline, 5/: Dextrose in aqua- 500 c.c, 5/: Dextrose in normal saline, Normal saline Dextrose 50/: 50 ml etc.

12. Oral Medications: Acetylsalicylic acid, Beta blocker, Antihistamine, Antiemetic, Bronchodilator Tab/ Inhaler, Nitroglycerine Tab/Spray,

13. Solutions/Ointments: lignocaine 2/:, Povidone iodine 10/: solution, Physohex cream, Fucidine ointment.

Conclusion:

Medical safety in the airline should be of high standard.

If for any reason the passenger is unconscious the trained crews should do preliminary assessment based on ABC of First Aid as follows:

* Airway: Does the passenger have open airway?

*Breathing: Is the person breathing?

* Circulation: Is there detectable heart beat i.e pulse?

A trained crew can deal with limited emergency situation, but they can't deal with potential hazards. In the absence of above signs they should inform it to Captain who will seek help from doctor or qualified medical professional (Nurse/Paramedics) travelling in the plane. In their absence he can contact medical service providers (Med link/Med air) via satellite phone or VHR or Aircraft communication. He should also take decision whether to continue flying to destination or to divert to nearest suitable aerodrome.

Medical safety in airline—personal experience

Case history: no1 10 September, 2018. Qatar Airbus 011 was cruising smoothly at 30000 feet above with packed passengers in mid sky after leaving Hamad International Airport at 4 AM Bangladesh time. The sun has risen now, showing start of a good day, just 15 minutes before we have been served with Arabian breakfast. Many people by this time finished it and were watching movies in the screen in front of them. Suddenly the microphone became active. The voice of the pilot came in the air: Ladies and gentlemen, Is there any doctor or medical personnel on board? Please contact our crew. A passenger is sick. Immediately I got up from my seat taking my stethoscope and blood pressure instrument which I was carrying with me and rushed to the rear of the plane where crews were standing. I was received by an air hostess. She asked my nationality and specialty, then quickly took me down stair where a middle aged white man was sitting in his seat with a vacant look holding half eaten morning bread in his hand. He was motionless, speechless, not answering any question. His blood pressure, pulse and respiration were within normal range. A suspicion of heart attack was made and a suggestion of hospitalization was given. By the time a white doctor came and took over the case. Some emergency treatment was given. The crews thanked me and I returned to the seat. After 10 minutes an announcement came from the microphone that due to emergency situation the plane is being diverted to Athens. We were Heathrow bound and not supposed to have a transit in Athens. But the captain was wise enough to take the decision for saving a life. At 11-34 Bangladesh time the plane landed in Athens. The patient was handed over to hospital. The plane waited for 2 hours hoping his return but he didnt. It left the airport at 1-21 PM BD time. After reaching London when my friend Dr. Abu Bakar working with NHS heard it became very annoyed with me. He asked me why I handled the patient. If any untoward happened in the plane I had to face charges as I was not registered in UK nor in Qatar or in the country of the patient. All I could say that as a doctor I could not sit idle when somebody is dying. I hope airlines should give immunity to such doctors (licensed in their own country) ignoring caste, creed, colour, country who come forward to save life in the sky. Case history no.2 In 1992 I was accompanying surgeon of a cancer (middle ear) patient Mr. Asab who was a professor of Dhaka College. I was travelling by Bangladesh Biman from Dhaka to Calcutta for better treatment at Thakur Pukur Cancer Research Hospital. At normal flying altitude he started feeling severe pain in the ear and discharge started from it. Case history no.3 On 30 January, 2008 I met a road traffic accident and had a pertrochanteric fracture of left femur which was fixed internally. When it barely united I wanted to travel to Sylhet by air. But the GMG Airline refused to carry my supporting stick in the passengers cabin without which I even could not stand at that time. After much argument when they agreed they kept it in the cockpit with the pilot despite my need at hand. I think airline cant snatch away medical support from a passenger in the name of security which is against medical safety. Case history no.4 I myself became sick in a plane journey. I was travelling from Dhaka to Karachi PIA en route to Tripoli. I had colds but I ignored it. I knew I cant wait and delay my flight any longer as my entry visa will be expiring after two days and in that case I will not be allowed to enter Libya in any circumstances resulting in losing of my job. All Arab airports are extremely rigid about Khoruj and Awdah, i.e. exit and entry dates of visas of expatriate workers. I was feeling discomfort when the plane took the altitude and it was terrible when it started flying at 30000 feet above the sea level. I felt intense pain as if covering of my brain was tearing. After sometime I started bleeding from the nose. As a doctor myself I felt ashamed to seek any medical advice or telling air hostess about the matter. I thought I was dying and afraid if there was cerebral haemorrhage. I fervently prayed to Allah so that the flight ends and the plane reaches its next destination in no time. At the time of landing when the plane lowered my discomfort disappeared. After one day rest at Karachi Airport Hotel I started my journey to Tripoli again. Case history no.5 I had another experience in 1978.I was working as a Surgical Specialist of Ghadames Central Hospital, Libya at that time. I had to accompany a Burst Abdomen patient by Libyan Arab Airline from Ghadames to Tripoli (700 k.m. approx). The patient started feeling discomfort in the middle air. The pilot was very co-operative. At times he put the plane on Auto-Pilot and came in the cabin to talk to me and inquire about the condition of the patient. He personally informed the ground staff of Tripoli airport and Central Hospital, Tripoli. On arrival I found the ambulance ready and the patient was immediately shifted to the hospital Medcal safety: Medical safety is in fact a wide term. It includes Hospital Safety, Medical Device Safety, Drug Safety, Medical Personnel Safety of the patients, Medical safety of the travellers etc. Medical safety of the travellers in airline is very important topic. All these above incidents will tell you in flight medical emergency can occur at any time in any aircraft. It is more common nowadays because the longevity has increased all over the world and more elderly persons are taking long distance travels and some of them are apparently healthy but potentially disabled. The anxiety of travel, stress of getting to and through various formalities for long time in a modern airport can make them exhausted and quite sick before boarding the plane. Besides this air travel can precipitate or can create medical problems even for some normal persons. Reason and remedy: The cabin pressure is usually kept equivalent of 6000-8000 feet. In the air gas expands 30/: and oxygen deficiency occurs. At this height there is 3/: desaturation arterial blood .The human body is very adaptable with fall of pressure of atmosphere and reduction in amount of oxygen available for breathing even up 10000 feet due to sigmoid shape of oxy- haemoglobin dissociation curve. Pain in the middle ear or Paranasal air sinuses blocked by catarrh especially during descent is common. Decongestants, analgesics or drinking a sip of water i.e. swallowing can give relief. Reduced partial pressure of oxygen with hypoxia even at 6000 feet can cause problems especially in sick persons having CABG(open heart surgery) status, cardiac failure, myocardial ischaemia, severe anaemia, blood disorder, cerebral insufficiency, respiratory diseases e.g. chronic bronchitis, emphysema, bronchiectasis, cor-pulmonale etc. Cases of Tension Pneumothorax also reported. Shortness of breath can be relieved by breathing into paper bags readily available in the craft. Dry cabin atmosphere in long journey can irritate mucous membrane and drinking juices and water but not alcohol is helpful. Sitting long time can cause Deep Vein Thrombosis. To avoid it passengers should walk up to toilet in the narrow passage after sitting for considerable period of time and move their extremities. Personal medications should be always in the cabin bag and not in the accompanied luggage otherwise those who are patients of epilepsy, diabetes, parkinsonism, respiratory diseases, heart patients etc may face sudden problem due to lack of medicine and altitude. Recent surgery: Recently operated(before 10 days especially open surgery of the hollow viscus of abdomen) should not undertake air travel as gases expansion can cause rupture of the newly stitched organ as stitches can give away. For medical safety patients after heart surgery should fly after 4-6 weeks, Angioplasty after 3-5 days, Tonsillectomy after 10 days, Appendisectomy and laparoscopy after 4 days Penetrating eye injury after 7 days. In case of plastered fracture limb air can remain trapped in the plaster cast which will expand during flying causing compression ischaemia endangering blood circulation, i.e vitality of limb. Other causes: Accidental scalds can occur by falling hot water or tea etc from moving trolley of a busy air hostess in a crowded area or in kitchen. Sometimes female passengers in advanced stage of pregnancy (most airline allow flying at 36 weeks) may feel extreme uncomfortable and deliver in the air or some person who is having stomach upset etc can any time face problem. Head injury can occur by falling of heavy luggage on the head of seated passenger from overhead holder. Passengers with uncontrolled high blood pressure and heart disease can have sudden stroke or heart attack and even death. A diabetic patient taking usual big dose of insulin like home but taking less quantity of food of airline may have hypoglycaemia leading to confusion and even coma. At times severe allergic reactions can occur to sensitive person from contents of food item. Rarely engine oil of plane leaks causing toxic fumes in the passenger cabin and may create breathing problem. Cabin crews should keep an eye over elderly persons and pregnant women if they are having some medical distress and immediately report it to the authority (Captain). Health care training of the crews: Keeping all these and other possibilities in mind health training of all crews is a must. They should be trained how to tackle emergency medical, surgical and obstetrical situation. The training can be given on a simulator as to how to put an oro-pharyngeal airway tube, how to deliver a pregnant passenger on board and take care of the pre-term baby, how to put an intravenous drip, or give intramuscular injection, how to support a broken limb by a splint (instantly made of any hard matter) due to accidental fall or how to catheterise an elderly person in case of retention of urine in long flight etc. Also they should know taking of arterial pulse and blood pressure. Besides CPR (Cardio-pulmonary resuscitation) is compulsory for every crew including the pilot. However many standard airlines give the training but not all. After flight all planes should not only be cleaned but disinfected. Cockpit should have sterile environment. Emergency cup board: Some emergency medicines and medical equipments should be kept in the cupboard of plane (should within expiry date). A probable list is as follows: Stethoscope 2. Blood pressure instrument (manual and electronic). 3. Oropharyngeal airway tube 4. Pocket ECG machine 5. Defibrillator: At least one flight attendant should know how to use it. 6. B.P. Handle and blade. 7. Plain and toothed dissecting forceps and reasonable quantity of straight and curved mosquito and medium artery forceps and 2 small retractors 8. Absorbable and non absorbable sutures with round and cutting needles-- a few. 9. Dressing materials, bandages, splint, absorbent cotton, Micropore, Foleys catheter (various sizes). 10. Sterile gloves of various sizes, Sterile sheet, Tourniquet, Disposable syringes of various sizes, masks. 11. Injections: Epinephrine 1:1000, Antihistamine, Hydrocortisone, Oxytocine, Atropine, Diuretic, Antiemetic, Sedative anticonvulsant, Major analgesic/oral, Aminophyline, 5/: Dextrose in aqua- 500 c.c, 5/: Dextrose in normal saline, Normal saline Dextrose 50/: 50 ml etc. 12. Oral Medications: Acetylsalicylic acid, Beta blocker, Antihistamine, Antiemetic, Bronchodilator Tab/ Inhaler, Nitroglycerine Tab/Spray, 13. Solutions/Ointments: lignocaine 2/:, Povidone iodine 10/: solution, Physohex cream, Fucidine ointment. Conclusion: Medical safety in the airline should be of high standard. If for any reason the passenger is unconscious the trained crews should do preliminary assessment based on ABC of First Aid as follows: * Airway: Does the passenger have open airway? *Breathing: Is the person breathing? * Circulation: Is there detectable heart beat i.e pulse? A trained crew can deal with limited emergency situation, but they cant deal with potential hazards. In the absence of above signs they should inform it to Captain who will seek help from doctor or qualified medical professional (Nurse/Paramedics) travelling in the plane. In their absence he can contact medical service providers (Med link/Med air) via satellite phone or VHR or Aircraft communication. He should also take decision whether to continue flying to destination or to divert to nearest suitable aerodrome.