Inflight medical emergencies and how to optimize your patients for safe travel

Transcription

1 Inflight medical emergencies and how to optimize your patients for safe travel Dr. Jim Chung Chief Medical Officer April 26, 2018 Travel Health Conference Winnipeg MB

2 Disclosure of Potential Conflict of Interest Financial Disclosure Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: Employee of Air Canada The opinions expressed in this presentation are mine and do not necessarily represent the views of Air Canada 2

3 Introduction Overview of inflight emergencies Emergency medical kits and supplies Airline protocols (ground based medical support) Indemnity Allergies Supplemental oxygen and Portable Oxygen Concentrators (POCs) MEDIF Is my patient safe to travel Use of aviation medical online resources 3

4 Overview 3.8 billion passengers 1 per year Canada = 140 million passengers 2 per year * Emergencies: 1 in 11-20,000 passengers 3 per year 1. (Source: IATA) 2. (STATSCAN) 3. (Chandra et al, In-flight Medical Emergencies, West J Emerg Med Sep; 14(5): ) 4

5 Air travel is on the rise More travellers More vacation travel Older passengers More chronic disease Longer flights Sicker passengers Patients flying to alternative sites for consultation or home for medical care 5

6 Other considerations 6

7 Medical Volunteers Around 30 medical in-flight events per day 69% of events are attended by a medical professional MDs, RNs, Paramedics, first aid responders Flight attendants are trained to St. John s First Aid standard 7

8 Airplane Environment Not ideal environments for dealing with emergencies Cramped conditions Difficult access to the passenger in need Lack of privacy Language barriers Lack of medical equipment and supplies Noise and vibration Exacerbation of pre existing medical problems Newly presenting medical conditions that can manifest themselves in altitude 8

9 Inflight Procedures Since 2000, Air Canada has used telemedicine ground support Stat MD University of Pittsburgh Medical Centre (UPMC) communicates with captain Emergency Medical Kit (EMK) used, STAT MD contacted Medical indemnity form for provider Medical incident form recorded Communication of information through flight deck 9

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12 Air Canada Medical Kit Blood pressure cuff Stethoscope 3 oropharyngeal airways Nitroglycerin 0.4 mg: 10 tab Gloves Diphenhydramine 50 mg: 2 amp 4 syringes & 6 needles D50%: 1 amp 50ml Epinephrine 1:1000 : 6 amp 1 bag-valve device & 3 masks 1 IV set 3 pocket-masks Automated External Defibrillator Glucometer Dressing box Cord clamp Urinary catheter Intravenous Saline Solution Sterile Water ASA 325 mg: 4 tab Naloxone Bronchodilator: 1 inhaler Atropine 0.5 mg: 2 amp Lidocaine 100mg: 2 amp Diphenhydramine 25 mg: 4 tab Acetaminophen 325mg: 4 tab ASA Epinephrine Ativan Atropine Dextrose 5% Dextrose 50% Dimenhydrinate Haldol Lasix Lidocaine Ketorolac Procainamide Solumedrol Valium Ventolin

13 Transport Canada List Blood Pressure cuff Stethoscope Syringes x 4 Needles x 6 D50W 50cc Epinephrine 1:1000 ampoules x 4 Diphenhydramine injectable x 2 doses NTG 10 tabs Latex gloves 2 pairs Bronchodilator 1 ASA 4 tablets CPR mask x 1 IV kit x 1 IV solution NS 500ml x 1 Oral airways x 3 Atropine x 1 Basic instructions for use of the drugs in the kit 13

14 AIR CANADA MEDICAL APP 14

15 LOCATION OF EQUIPMENT 15

16 ALGORITHMS AND INSTRUCTIONS 16

17 Other equipment Most if not all major airlines have AEDs onboard and training for flight attendants on usage Emergency oxygen is also stored and available BVMs are available First aid kits 1/50 pax available consisting of bandages, burn dressings etc. Usually a separate medication pouch is available with common OTC meds such as Gravol, Tylenol etc. 17

18 Common issues and complaints Pulse oximeter on ground 98-99% normal in the air 90-94% normal Blood pressure (BP) cuff and stethoscope Due ambient cabin noise, often difficult to hear with stethoscope. Can do systolic BP by palpation of radial artery Glucometer Take the time to read the instructions and ensure strips are right side up Tempa-dot thermometers Follow the instructions to apply and record the reading 18

19 Indemnity and Liability Air Canada has formal indemnification policy and form medical provider receives a copy of this Most countries have Good Samaritan provisions U.S. Aviation Medical Assistance Act CMPA will provide assistance Note: accepting monetary compensation can potentially cause issues with volunteer status Ethical and moral obligation in common law jurisdictions In civil law countries may be legal obligation 19

20 Allergies Animal allergies can request buffer zone Peanut allergies no peanut products are offered onboard Should carry own food, cannot guarantee peanut free food Must carry onboard own epipen and other medications ie. Ventolin Bring wipes, hand sanitizer Will be allowed to board early to clean surrounding area Passengers around your patient will be advised not to consume or bring out any peanuts due to passenger with allergy Most airlines have similar policies in place 20

21 Oxygen and POCs Generally most airlines do not provide oxygen WestJet allows passengers to bring own oxygen Air Canada provides oxygen on request for a fee U.S. carriers only allow POCs (portable oxygen concentrators) 21

22 The cabin is a relatively hypobaric environment Jet airplanes cruise at 30 40,000 feet ASL Cabin pressurized to 6,000 8,000 feet Normal healthy individuals will not notice any effects Those at risk of hypoxia may see symptoms and exacerbation of their condition 22

23 Oxygen requirements Need more supplemental oxygen at altitude Rule of 2s High Altitude Simulation Test (HAST) 100 m walk test (mild physical exertion) POCs should be used on ground first to ensure familiarity and ability to manage device i.e. Change batteries POCs cannot plug in to outlets onboard low voltage and won t work, need enough batteries to complete flight 23

24 Oxygen You want to figure out what the patient s O 2 needs will be at altitude. Altitude Oxygen Requirement Equation FiO 2 ground x P ground = FiO 2 alt P alt

25 Oxygen cylinder at home 1lpm = 24% 2lpm = 28% 3lpm = 32% 4lpm = 36% 5lpm = 40% 6lpm = 44%

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27 Calculating Oxygen Need FiO 2 ground x P ground = FiO 2 alt P alt 0.30 x 760mmHg = FiO 2 alt = FiO 2 alt 40% oxygen

28 Conditions aggravated by hypoxia Anemia can cause multiple issues Sickle cell anemia Chronic Obstructive Pulmonary Disease (COPD) Pleural effusion Pulmonary fibrosis Atrioventricular shunts, congenital heart disease Coronary Artery Disease (CAD) Cerebral Vascular Accident (CVA) 28

29 Pressure/Volume relationship Boyle s Law Inverse relationship between pressure and volume of a gas Barotrauma risk Middle ear, sinuses in winter Upper Respiratory Tract Infection (URI) season Bowels laparoscopic, laparotomy procedures, diverticulitis Eyes retinal pneumoplexy Catheters replace air with saline Pneumothorax Acute fractures in circumferential casts 29

30 Typical presentations of inflight events Chest Pain Shortness of Breath Dizziness/Loss of Consciousness (LOC) Abdominal Pain Ear/sinus pain 30

31 MEDIF (passenger clearance form) On most airline websites will find MEDIF form to provide medical information Airline will work with health provider to ensure a safe and unremarkable flight Stretcher passenger are generally not accepted by most airlines with some exceptions Range of medical services available inflight vary with the airline, please check with the intended airline to confirm 31

32 Lufthansa PTC 32

33 Online Medical Resources IATA Medical Manual Feb Aerospace Medical Association Various airline websites i.e. Air New Zealand, Qantas, Cathay Pacific 33

34 CMAJ 34

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38 Summary The relatively hypobaric and hypoxic environment of an airplane cabin can be an issue in those with some compromise There are lots of resources out there to assist you in determining whether your patient is safe to travel including calling the airline s medical department directly Medical care overseas can be costly and diversion and dropping off a patient in a country they weren t intending on travelling to can be stressful as well as language issues, local laws etc 38

39 Thank you Merci aircanada.com