As we emerge from our COVID isolation, air travel is beginning to boom again, and many doctors are concerned about what happens when there is an in-flight emergency.

Let’s take a look at that.

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It’s your first real vacation in two years and just as you are finally getting into that huge dragons and snow novel you never had time for before, the cabin loudspeaker comes on. “Is there a doctor on board?”

Now what?

Ethically, if you can help you should help, but ethics is where the matter stops. There is no duty to an ill or injured passenger to compel your involvement and jurisdictions that have duty-to-rescue statutes do not project them into their airspace. In other words, you can say nothing and go back to your book without legal consequences.

However, you actually do want to help but are still concerned about liability. In that regard, though, you can have considerable assurance.

The most common misconception is that there is a trail of liability established as the plane flies so that the doctor who assists during an in-flight emergency can be sued in every place that it passes over during that event as well as where it took off and landed.

However, the law that actually applies to responses to in-flight emergencies is the Aviation Medical Assistance Act, covering all flights in North America, whether or not the carrier is a U.S. company, and to U.S. carriers wherever they fly.

Under this, a “medically qualified” professional who acts in good faith and does not receive financial compensation (meaning payment for providing the care, not unexpected bonus miles from the airline or a bottle of wine from a grateful family) receives the following protection: “An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”

You may recognize that as sounding like a Good Samaritan law and it actually substitutes for such since states do not project their own Good Samaritan laws into their airspace.

If you are flying outside the United States on a non-U.S. carrier the law of the country in which the airline is based will generally control, but these will typically offer Good Samaritan-type protection as well.

There is an important limitation, though:  You must wait to be asked to assist. This is because the members of the cabin crew, who are trained in first aid, are the actual FAA-designated first responders. If they can handle the situation it ends there.  You can certainly identify yourself as a physician and state that you are available to help, but you must be asked to intervene.

Before we leave this section it is also worth noting that while there have been lawsuits over flight crews ignoring the advice of doctors, doctors have actually not been sued for giving in-flight help.

So now, feeling secure that you will not be sued into penury in multiple states, you are ready to volunteer.

Expect to first be asked for your credentials because FAA Advisory Circular 121-33B instructs flight attendants “to check the credentials of passengers holding themselves out as medical specialists.” This is because the flight crew are the first responders and if they are going to give their authority to act in the medical care of a passenger over to you, they need to know that you actually are qualified. This rule would apply to a nurse, a nurse practitioner, a physician’s assistant or an EMT as well. After all, emergencies do not just bring out heroes – they also bring out hucksters and glory-seekers who may misrepresent themselves. Doctors should therefore carry their hospital badge or something else identifying their status as a physician.

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You should also expect to be asked if you have been drinking and, if so, how much.  Again, this is not meant in a deprecating manner. It is actually essential for the flight crew to know that you are sober enough for the task that you will be taking on.

Once you have passed these steps you will be given access to an enhanced medical kit.  The flight crew also has a basic kit for first aid that will be at your disposal and there will also be an AED on the plane.

As per the FAA, the advanced kit will at least contain gloves, a sphygmomanometer, oropharyngeal airways (pediatric, adult. large adult), a self-inflating manual resuscitation device with masks in 3 sizes, CPR masks in 3 sizes, IV tubing with Y connectors, 18-22g needles, alcohol sponges, adhesive tape and scissors, a tourniquet, 500cc normal saline, non-narcotic analgesic, antihistamine (oral and injectable), atropine, aspirin, inhaled bronchodilator, injectable dextrose solution, epinephrine, lidocaine and nitroglycerine tablets. Individual airlines may include other items.

You may note some points on that list that seem odd to you.  Lidocaine for cardiac arrest is still there because the regulation of what should be in the kit has not been updated in two decades, while there is no thermometer or a method to measure blood glucose and no anti-emetics are included even though nausea and vomiting are common in in-flight emergencies. This brings us back to the medicolegal requirement to do only what is reasonable under the limited circumstances. The AMAA encompasses that you will be working under serious constraints, but it is up to you to not exceed those.

When you have entered the case, the situation becomes essentially as when you respond to an emergency in your office or in the street.  Your role in the limited setting of an airplane in flight will typically be to stabilize the ill or injured person until landing, just as it would be to do so until EMS arrives when on the ground. You will not be held to a standard of definitive treatment unless the condition was one that could actually be fully dealt with while on the plane.

The in-flight emergency setting can also parallel that of an emergency in your office or in the street in that it may exceed your training. However, it provides a back-up that you would not have in those situations because the airline will have a contract with an SOS service for emergency medical support by a trained physician on the ground.

What would not be reasonable for you to attempt alone based on a memory from residency can therefore become reasonable when you are working under expert instructions. However, only you can determine whether you can, consistent with the limitations of the AMAA, perform a task adequately even with that help.

Once you have begun treatment your duty to remain in that role continues until either the need ends (the victim recovers adequately, the victim dies, someone qualified takes over) or you are instructed to cease treatment by someone authorized to do so (a competent victim, the legal representative of an incompetent victim, a senior member of the cabin crew, law enforcement.)

Diverting the plane is a separate matter.  That responsibility rests solely with the captain, although he or she will likely ask you for your advice, as well as consulting any involved ground-based physician.  Bear in mind, though, that the captain also has to take non-medical logistics into account, including adequacy of a landing area, weather and fuel reserves.  If your advice to divert is not being followed it may be because there are practical prohibitions. Just state your opinion and the reasons for it and step back to tending the passenger.  Do not get into a confrontation with the crew – the situation is inherently tense and you can go from being an appreciated hero to being arrested by an air marshal very quickly.

The final issue is, as in any medical setting, documentation.

A contemporaneous note for yourself is always prudent even if you have already followed an airline’s own reporting protocols. Do this as soon as possible while the facts are fresh in your mind.

Such a note should include the following:

  • You identified yourself as a physician to the crew.
  • You were asked to intervene by them.
  • You identified yourself as a physician to the victim/their representative and asked the victim/their representative if you could proceed
  • You obtained a relevant medical history, including medications, if possible
  • The victim’s subjective symptoms and objective signs and any statements from witnesses about their condition
  • Your diagnosis
  • You asked for the basic kit, advanced kit or AED as needed
  • If you asked for assistance from the crew, who provided that assistance and what they did
  • If you asked for a ground-based advisor, what they said
  • What interventions you undertook
  • Whether you thought that diversion was necessary; if so, was the plane diverted
  • How the victim responded
  • Who next took charge of the victim

Do this as an e-mail to yourself so that it will have a time and date on it.

…and then go back to your book with the applause of your fellow passengers ringing in your ears.

In summary: The cabin crew are actually the first responders in an in-flight emergency but will seek the assistance of a doctor if necessary. Doctors who respond to in-flight emergencies in North America or on a U.S.  carrier will have Good Samaritan-type protection under federal law and most countries will provide the same. Assistance from a trained physician on the ground will be available. The basic tenet of all emergency care – that it must be reasonable under the limited circumstances – applies to in-flight emergencies. A doctor who has assisted in an in-flight emergency should document the event in a time-stamped note.