A correspondent refers to:

… an article from ABC News on in-flight care by health professionals on airlines.

As pointed out by a number of posters, non doctors professionals ie paramedics/ nurses cannot access on board medical equipment/ medications.

Whilst I would suspect that Good Samaritan legislation would be sufficient coverage for those offering their assistance, and there would be drugs and poisons governance as well, is there actual acts or regulations that prevent non-doctor professionals from accessing on board medical equipment?

Secondly, would an airline, domestic or international be negligent preventing access?

I find it surprising that this may be the case and look forward to your thoughts.

The article that stimulated this question was ‘Is there a doctor on board? What happens during a mid-air medical emergency’ (ABC, Monday 31 July; http://www.abc.net.au/news/health/2017-07-31/is-there-a-doctor-on-the-plane/8650044); but for a string of similar articles, see the list at the end of this post.

Before attempting to answer this question, I sent this question to Damien Toohey, an old school colleague who is both a qualified lawyer and B747 pilot with a major international airline.   His comments are:

Cabin Crew are trained to provide first aid assistance in all cases involving incidents on board aircraft. Each aircraft carry a number of first aid kits and one physicians kit which is accessible by the Customer Services Manager. Any such access must be reported to the Captain and logged. If there is a concern about the passenger’s health the CSM and or the Captain will be notified and contact will be made with ‘MedLink’.

MedLink is a service provided to subscribing airlines by MedAire, a USA based company providing satellite communications between aircrew and an Emergency Room Physician at the Good Samaritan Regional Medical Centre, a Level One Trauma facility in Phoenix, Arizona. MedLink will obtain a history of the patient, ascertain the treatment provided and by whom and generally authorise further treatment/steps and thereafter coordinate additional follow-up support through a database of health professionals in over 45 medical specialties. If a diversion is necessary or an ambulance required and further treatment after landing, MedLink will authorise or arrange such steps to be taken.

It may appear that treatment approval is coming from the crew on board but it is generally being determined by an Emergency Room Doctor who has now taken control of treatment.

An on-board doctor is permitted to be taken to the Captain during flight by the Customer Services Manager to consult with MedLink and to consider the further options.

The Physicians Kit

The kit is sealed and can only be unlocked or have its seal broken by the Customer Services Manager. The CSM or Customer Service Supervisor may access certain equipment without permission from a medical practitioner; including the Stethoscope, Sphygmomanometer, Thermometer, Nebulizer Mask, Spacer and contents list. They may access only Ventolin and Anginine without approval.

Medications which require approval from a medical practitioner include Claratyne, Anapen for Anaphylaxis, Glucose gel, various first aid items and contents contained within various pouches comprising respiratory kit, urinary retention kit, anaphylaxis kit, oral medications kit, IV kit, drugs for injections and a miscellaneous kit. It should be noted that cabin crew cannot dispense even a Panadol but can provide Panadol to passengers whereby they may take the tablet on their own volition.

The important point to understand is that the medical decisions being made are by an Emergency Room doctor and the provision of medications or access to life saving materials carried on board is at their sole discretion or that of a suitably qualified medical practitioner on board the flight. It is, to all intents and purposes, no different than a first aider walking into a hospital and attempting to provide patient care. It would not be possible.

The liability or neglect of the airline is mitigated by their reliance on MedLink for airborne support and decision making. It’s not decided on a whim and adheres to very strict protocols.

The implication of a physician’s kit is indeed that it is only to be opened by a physician or registered medical practitioner rather than a nurse or a paramedic.  If we consider Australian law, medical practitioners are generally authorised to carry and use scheduled drugs. Paramedics do not carry that right by virtue of their profession and training.  Paramedics are authorised to carry drugs supplied by their employer n the course of their employment. As passengers on a commercial aircraft they don’t carry that authority with them and that would also be true for nurses.  Where a ground based doctor has taken a history and considered the patient’s condition he or she might prescribe the use of the scheduled drugs in which case the paramedics or nurses could administer those drugs.   As Damien says, in that case ‘the medical decisions being made are by an Emergency Room doctor and the provision of medications or access to life saving materials carried on board is at their sole discretion’.

One can see the difficulties for international crews.  The concept of a doctor is probably reasonably universal but who is a paramedic or a nurse and what they are allowed to do may be quite different across countries and in an emergency, cabin crew have little opportunity to make an assessment as to whether or not the person who says ‘I’m a paramedic’, or ‘I’m a nurse’ or even ‘I’m a doctor’ really is what they say they are and what their level of competence is. The question is further complicated by trying to decide what law applies.  It may be the law of the country that the aircraft has departed from, the law of the country where they arrive or the law of the country where the aircraft is registered.  (People often say ‘it’s the law of the country that the aircraft is registered in’ but try committing an offence on an aircraft and you’ll get arrested by police at the airport where you arrive and tried under their laws for various offences).

There are also rules. In Australia, civil aviation is regulated by the Civil Aviation Safety Authority (CASA).  Under the Civil Aviation Safety Regulations 1988 (Cth) there is no standard for medical or first aid kits.  According to the CASA website it is proposed to introduce a new part 121 to the Regulations. One of the key proposals is ‘re-introduction of the requirement for first aid kits and a new requirement for emergency medical kits and universal precaution kits on specified flights’ (https://www.casa.gov.au/standard-page/casr-part-121-commercial-air-transport-operations-aeroplanes (accessed 8 August 2017)).

International air standards are set by the International Civil Aviation Safety Organisation (ICAO).   ICAO recommends that aircraft carry ‘accessible and adequate medical supplies’. There is no standard of what that means but they do recommend ‘one or more first-aid kits for the use of cabin crew in managing incidents of ill health’ and ‘for aeroplanes authorized to carry more than 100 passengers, on a sector length of more than two hours, a medical kit, for the use of medical doctors or other qualified persons in treating in-flight medical emergencies’ (see https://www.icao.int/MID/Documents/2013/capsca-mid3/ICAOHealthRelatedSARPsandguidelines.pdf ).    The recommended medical kit contains:

Equipment

List of Contents — Stethoscope — Sphygmomanometer (electronic preferred) — Airways, oropharyngeal (three sizes) — Syringes (appropriate range of sizes ) — Needles (appropriate range of sizes) — Intravenous catheters (appropriate range of sizes) — Antiseptic wipes — Gloves (disposable) — Needle disposal box — Urinary catheter — System for delivering intravenous fluids — Venous tourniquet — Sponge gauze — Tape – adhesive — Surgical mask — Emergency tracheal catheter (or large gauge intravenous cannula) — Umbilical cord clamp — Thermometers (non-mercury) — Basic life support cards — Bag-valve mask — Flashlight and batteries

Medication

Epinephrine 1:1 000 — Antihistamine – injectable — Dextrose 50% (or equivalent) – injectable: 50 ml — Nitroglycerin tablets, or spray — Major analgesic — Sedative anticonvulsant – injectable — Antiemetic – injectable — Bronchial dilator – inhaler — Atropine – injectable — Adrenocortical steroid – injectable — Diuretic – injectable — Medication for postpartum bleeding — Sodium chloride 0.9% (minimum 250 ml) — Acetyl salicylic acid (aspirin) for oral use — Oral beta blocker -5- If a cardiac monitor is available (with or without an AED) add to the above list: — Epinephrine 1:10 000 (can be a dilution of epinephrine 1:1 000)

The International Air Transport Association, a trade association of the world’s airlines, says this about first aid and medical kits (https://www.iata.org/whatwedo/safety/health/Documents/medical-manual-2013.pdf )

This need for first aid and medical response kits was well recognised shortly after the inauguration of regular scheduled flights by the airline industry, and is now regulated by the licensing authorities.

Airline first aid and medical kits vary in scope and complexity. Several factors must be taken into consideration in deciding what items and the number of each item should be included in an aircraft medical first response kit. The need should be based on audit of the inflight incidents. Although injuries, abrasions, contusions, burns, syncope, asthma, neurologic seizures, and cardiac events are high prevalence medical events based on several studies, the first step in any airline‘s medical kit design is to first survey and determine what medical events are occurring on board in that unique air carrier. Also, the airline medical expert should determine the frequency that medical providers travel on the airline, to determine whether or not the kit should be first aid based, more based on advanced medical expertise, or some combination of both. Also, the air carrier must consider whether groundbased physician expertise is available to provide direction to cabin attendants, or on-board travelling medical personnel…

It is the opinion of many airlines that narcotics should not be included, however some airlines believe they should. Likewise, the inclusion of surgical instruments is also controversial.

Many airlines also have first aid kits for ground personnel, tropical first aid kits, and travel first aid kits.

The air carrier should conduct a careful study of state, country and international laws governing first aid kits, and/or the practice of medicine within certain locations, before designing an airline Emergency Response medical program. As an example, the kit recommended by the Aerospace Medical Association is shown in Appendix „B‟.

See also Aerospace Medical Association Air Transport Medicine Committee, Medical Emergencies: Managing In-flight Medical Events (Guidance material for health professionals) (https://www.asma.org/asma/media/AsMA/Travel-Publications/Medical%20Guidelines/In-flight-medical-events-guidance-document-revised-July-2016.pdf ).

Damien mentioned MedAire.  They sell first aid and medical kits designed for use on an aircraft including an emergency medical kit (http://www.medaire.com/business-general-aviation/services-solutions/medical-kits-equipment ).    They say:

… Designed with long-haul flights in mind, it [the Emergency Medical Kit Rx] includes items to begin treatment of common in-flight ailments, stabilize potentially serious medical events, and aid in a survival situation.

Contents Include:

  • Prescription medications that address chest pain, nausea and vomiting, bacterial infections, trouble breathing, and allergic reactions.
  • Survival supplies including an LED flashlight, emergency blanket, moleskin, insect repellent etc.
  • Non-prescriptions medications that address aches and pains, dehydration, motion sickness, coughs, and diarrhea.
  • First-aid supplies to including wound and burn dressings, antibiotic ointment, antiseptic scrubs, bandages, splint, etc.

Due to the prescriptive contents, the Emergency Medical Kit Rx can only be used at the express instruction of a physician at MedAire’s MedLink Global Response Center.

Conclusion

It would appear that like many things the issue is risk management.  It is up to airlines to assess the risk of a medical emergency which must take into account the nature of their operations.  They will then carry appropriate medical and first aid supplies.  As with everything the high reliability organisations do, their procedures will be documented and thought out.   Actions are ‘not decided on a whim and adheres to very strict protocols’.

If an airline has determined that it’s going to carry a kit particularly one with scheduled drugs they may also have determined that they won’t allow anyone to access it without approval from a medical practitioner.  But as Damien said, it may be the airlines ground based practitioner, rather than the doctor or other health professional on the plane, that is actually authorising the use of the kit.  No doubt those advisers may approve that if they are satisfied that the person who has come forward to help is actually competent to use the equipment in the kit.

So one can infer that both airline practices and of course the law with respect to access to scheduled drugs would prevent non-doctor professionals from accessing on board medical equipment but the large airlines have procedures in plans to grant approval to access the kit on the direction of the doctor who must make decisions both about the patient’s condition and the competence of the person planning to administer any treatment.

There is no chance an airline would be negligent for not allowing a person who claimed to be a paramedic or a nurse or even a doctor from accessing the kit given all the risks and the complexity of resolving the issues in flight.  The pilot in command has the option to land to seek medical aid and for the larger airlines there are procedures in place that will be based on a risk assessment, the essential issue for a ‘reasonable’ response.

Other airborne medical emergency articles

Is there a doctor on board? What really happens during a medical …

http://www.telegraph.co.uk › Travel › Travel Truths

What happens when there’s a medical emergency on a flight?

www.news.com.au/…goes-on…medical-emergency…flight/…/1ae85065d213a9f038b45…

What happens when there’s a medical emergency on a flight?

http://www.traveller.com.au › Travel Planning › Tips & Advice

Doctors Share What Really Happens When There’s an Emergency …

http://www.cntraveler.com/…/doctors-share-what-really-happens-when-theres-an-emergenc…

What Happens If you Have a Medical Emergency on an Airplane …

http://www.menshealth.com/health/medical-emergency-on-airplane

What really happens during a medical emergency on planes | OverSixty

http://www.oversixty.com.au › Travel Tips

Medical emergencies in the sky: What happens if you get ill on a plane …

http://www.today.com/…/what-happens-if-you-get-ill-plane-medical-emergencies-sky-t246…