Friday, December 21, 2018

Should seats be fixed for doctors in airplanes and trains?

“Is there a doctor on board?” This is a very familiar announcement to us all. In-flight medical emergencies are becoming very common as more and more people are now opting for air travel, especially with the advent of many low-cost airlines.

In 2013, the New England Journal of Medicine reported that around 44,000 in-flight medical emergencies occur worldwide every year. Around one in-flight medical emergency will occur in every 604 flights. The top five causes of medical emergencies were found to be syncope (37.4%), respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%) and seizures (5.8%). Data from the Lufthansa registry published in 2012 also showed that one medical incident will occur for  every 10,000 to 40,000 passengers on commercial aircraft will have a medical incident while on board (Dtsch Arztebl Int. 2012 Sep;109(37):591-601). 

Research has shown physicians to be the primary responder in 40-50% of inflight emergencies, nurses and paramedics in 5-25% of events and flight attendants alone in 45% of incidents. Air Canada data showed that between 2014 and 2016, about 49-53% of in-flight medical emergencies were managed by a physician, nurse or paramedic, with the remainder managed by flight attendants alone (unpublished observations) (CMAJ. 2018 Feb 26;190(8):E217-E222).

Around 1000 deaths reportedly occur each year in-flight. This number excludes ill patients being transported from one destination to the other. Instead, this number represents unexpected deaths in people who otherwise are either healthy or a known-disease patient but fairly well controlled on medicines.

Similar is the case with train travel. All these medical emergencies may also occur when traveling by trains.

All airlines by law are required to have automatic electric defibrillators (AEDs) on board besides a first aid kit, which can be administered only by a doctor. All flight crew should be trained to recognize common medical emergencies and certified in first aid for medical emergencies.  They should also be trained in hands-only CPR, which can be life-saving, if the cardiac arrest is due to ventricular tachycardia or ventricular fibrillation and, also the use of AED. 

According to the Ministry of Railways, “all passenger trains also carry First Aid Boxes containing essential drugs and dressing materials, which are provided with the guards. Augmented First Aid Boxes with wide range of medicines, disposable medical material, etc. have been provided with the Train Superintendents/ Guards of Rajdhani/Shatabdi Express trains and some nominated trains. Front line staffs deployed on trains are also trained in rendering First Aid. The Station Masters of all stations have details of doctors, clinics and hospitals, both Government and Private, in the vicinity of the station, so that their services could also be availed, in emergencies…” (Press Information Bureau, April 4, 2018)

Cardiac arrest is the major cause of death in such situations. A victim of cardiac arrest needs to be revived immediately. Any delay in starting cardiopulmonary resuscitation (CPR) and in using a defibrillator to deliver a shock when needed will reduce the person’s chance of survival. With each minute delay in defibrillation from the onset of cardiac arrest, the probability of survival decreases by 10% (Ont Health Technol Assess Ser. 2005;5(19):1-29).

CPR has to start promptly, if the patient is to have a chance at a life. Immediate first-aid can save the lives of many.

All exit seats (or any other) in airplanes should be earmarked or reserved for doctors or any other health care provider who is trained in first-aid training course, including CPR and is well-versed with an AED. Similarly, few seats in a train or a coach should be reserved for doctors or health care providers, so that they can be identified immediately and be the “first responders” even in out-of-hospital cardiac arrests.

They should be given first preference for these seats.

A pilot project of deployment of doctors in Duronto Trains was undertaken for a period of two years. During the Pilot Project, it was noted that serious patient could not be treated on board and had to be de-trained for medical treatment at a hospital only because the medical equipments such as ECG machines etc. do not function properly on the trains due to noise/ vibration etc. (Press Information Bureau, April 4, 2018). The Ministry then decided to discontinue deployment of doctors and para-medical staff in Duronto trains having a run of less than six hours, but railways decided to deploy a para-medic trained in Emergency Medical Response with all essential life-saving medicines and equipment in place of a doctor in Duronto trains having a run of more than six hours… (Hindu Business Line, August 22, 2013).

Currently, it is not mandatory to have a doctor on board during air travel or travel by train.

Having a doctor on board does not automatically ensure survival; but, it does give the person a fighting chance.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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