飞机上的急症患者半数得到医生乘客的救治

根据对2008年1月~2010年10月期间从5条国内、国际航线上打给医疗通信中心的11,920次求助电话的分析，在客机上发生的医疗紧急情况接近一半是由乘客中的医生首先处置的(N. Engl. J. Med. 2013;368:2075-83)。

飞行途中发生的医疗紧急情况很少导致飞机改变航向或患者死亡。多数事件与晕厥(37%)、呼吸系统症状(12%)或胃肠疼痛(9.5%)有关。

在这近3年的时间内，这5条航线共运送了约7亿4千万名乘客，约占全球航空乘客的10%。据此推算，全球每年发生约44,000次此类事件。

有24例心脏骤停患者接受了自动体外除颤器(AED)治疗，其中5例接受了电击。91.6%的患者事后接受了随访。共有36例患者死亡(其中30例在飞行途中死亡)，其平均年龄为59岁。

有31% 的医疗紧急情况在飞机着陆前已被完全解决而不需要紧急医疗服务(EMS)人员的救助。在其余患者中，37%被转运至医院急诊室，后者中有54%不必住院；32%的患者被收住院或违反医嘱离院；13%失访；0.6%死亡。

48%的患者在飞机上获得了来自医生的帮助，其次为护士(20%)，少数患者获得了EMS人员(4.4%)或其他医务人员(3.7%)的帮助。相关客机在7.3%的情况下改变了航向，与改变航向关联最强的因素是使用AED和有EMS人员在机上提供帮助。收住院与可能为卒中[比值比(OR)，3.36；置信区间(CI)，1.88~6.03]、呼吸系统症状(OR，2.12；CI，1.48~3.06)及心脏症状(OR，1.95；CI，1.37~2.77)有关。

1998年《航空安全医疗救助法案》包含了“心地善良者”条款，规定乘客可免除严重过失或故意处理不当的责任。作者认为，医生和其他医务人员尽管并无救助患病乘客的法律义务，但确实有道义上和职业上的责任去成为“心地善良者”。

Peterson 博士指出：“联邦航空管理局规定所有商业航班上都必须配备急救箱，而这些急救箱通常足够用于启动对严重问题的处理。在有丰富经验的乘务员的协助下，症状常常能够得到控制。”

作者建议医务人员在机上发生医疗紧急情况时做到以下几点：表明自己的身份，并向机组人员说明自己的专业水平；评估确认患者的主要问题、持续时间以及相关高危症状(例如胸痛、气促、恶心或呕吐、单侧无力或麻木)；评估生命征；要求机组人员提供急救箱，必要时给予氧供；假如机组人员尚未征求地面医疗专家的意见，就自己与地面专家沟通。

“根据上述发现，我们认为飞机乘客中的医务人员应当清楚，当飞行途中发生医疗紧急情况时，自己应该主动给予救助。我们还建议对所有的飞行途中医疗紧急情况进行追踪，包括了解结局，从而更好地指导对此类事件的干预。”

作者报告称无相关利益冲突。

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By: MARK S. LESNEY, Cardiology News Digital Network

In nearly half of all in-flight medical emergencies, an on-board physician volunteer is the first medical responder, based on a retrospective analysis of nearly 12,000 medical emergency calls over a 3-year period from five domestic and international airlines to a physician-directed medical communications center.

Few in-flight emergencies resulted in diversion of the aircraft or death. Most events were related to syncope (37%), respiratory symptoms (12%), or gastrointestinal distress (9.5%).

The 11,920 in-flight emergencies occurred among an estimated 744 million airline passengers, representing approximately 10% of the global passenger flight volume from Jan, 1, 2008, through Oct. 31, 2010, for an estimated 44,000 such emergencies worldwide each year, according to Dr. Drew C. Peterson of the department of emergency medicine at the University of Pittsburgh, and his colleagues.

An AED was applied in 24 cases of cardiac arrest; with shock delivery in 5 cases. Post flight follow-up was available for 91.6% of patients. The mean age of the 36 passengers who died (30 died in-flight) was 59 years (N. Engl. J. Med. 2013;368:2075-83).

For 31% of patients, the medical situation resolved sufficiently before landing and EMS personnel were not requested. Of the remaining patients, 37% were transported to a hospital emergency department. Of these, 54% were discharged; 32% were admitted or left against medical advice; 13% were lost to follow-up; and 0.6% died.

On-board assistance was provided by physicians (48%), nurses (20%), emergency medical service providers (4.4%), or other health care professionals (3.7%). Aircraft diversions occurred in 7.3% of cases, and the factors most strongly associated with diversion were AED use (applied to 1.3% of patients) and on-board assistance by an EMS provider as the highest level of provider. Hospital admission was associated with possible stroke (odds ratio, 3.36; confidence interval, 1.88-6.03), respiratory symptoms (OR, 2.12; CI, 1.48-3.06), and cardiac symptoms (OR, 1.95; CI, 1.37-2.77).

The 1998 Aviation Safety Medical Assistance Act includes a Good Samaritan provision, protecting passengers from liability other than liability for gross negligence or willful misconduct, therefore: "Although there is no legal obligation to intervene, we believe that physicians and other health care providers have a moral and professional obligation to act as Good Samaritans," the authors stated.

"The emergency medical kit available on every commercial airline regulated by the Federal Aviation Administration is usually sufficient to initiate treatment of serious problems," according to Dr. Peterson and his colleagues. "Symptoms can often be managed in collaboration with the flight attendants, who are well versed in the equipment the airplanes carry and in operational procedures."

The authors recommended that health care providers identify themselves during in-flight medical emergencies and specify their level of expertise to the flight crew; assess the patient by identifying the chief problem and duration as well as associated and high-risk symptoms (such as chest pain, shortness of breath, nausea or vomiting, or unilateral weakness or numbness); assess vital signs; ask for the emergency medical kit, administer oxygen as needed, and initiate consultation with a ground-based consultant if the flight crew has not already done so.

"On the basis of our findings, we believe that airline passengers who are health care professionals should be aware of their potential role as volunteer responders to in-flight medical emergencies. We also advocate for systematic tracking of all in-flight medical emergencies, including outcomes, to better guide interventions in this sequestered population," the researchers concluded.

The authors reported no potential conflicts of interest relevant to the article.