- Email: [email protected]
In-flight medical emergencies – Authors' reply
Correspondence
*Parkinson, Memory & Movement Disorders Center, CHU Notre Dame de Secours, PO Box 3, Byblos, Lebanon (MGJ, B-PWB); Lebanese American University, School of Pharmacy, Byblos, Lebanon (MGJ); Department of Neurology, Hazrate Rasoul Hospital, Tehran, Iran (GAS); and Holy Spirit University of Kaslik, School of Medicine, Kaslik, Lebanon (B-PWB) 1 2
3
4
5
iStock Photo
The printed journal includes an image merely for illustration
Clark HV, King D, Yow R. Carotidynia. Am Fam Physician 1994; 50: 987–90. Kubera M, Kenis G, Bosmans E, et al. Stimulatory effect of antidepressants on the production of IL-6. Int Immunopharmacol 2004; 4: 185–92. Vandezande LM, Lamblin C, Wallaert B. Interstitial lung disease linked to fluoxetine. Rev Mal Respir 1997; 14: 327–29. Medicines and Healthcare Products Regulatory Agency. Yellow card scheme. Drug Analysis Prints. http://www.mhra.gov.uk/Safety information/Reportingsafetyproblems/ Medicines/Reportingsuspectedadversedrug reactions/Healthcareprofessionalreporting/ Druganalysisprints/index.htm (accessed June 11, 2009). Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239–45.
In-flight medical emergencies In their otherwise useful Review of medical issues associated with commercial flights (June 13, p 2067),1 Danielle Silverman and Mark Gendreau state that, “If diagnosis [of chest pain] is uncertain, an antacid could help to confirm dyspepsia.” This is a dangerous recommendation because relief of pain by antacids is neither sensitive nor specific.2 Indeed, in one study, 29% of patients with proven myocardial infarction had relief with antacids.3 Treating epigastric discomfort with antacids is appropriate only if the physician realises the continued potential for myocardial infarction. I declare that I have no conflicts of interest.
Mark Hauswald [email protected] Department of Emergency Medicine, University of New Mexico, School of Medicine, Cancer Center B-30, Albuquerque, NM 87131, USA 1
2
3
1062
Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009; 373: 2067–77. Stewart T, Crawford I, Mackway-Jones K. Antacids and diagnosis in patients with atypical chest pain. Emerg Med J 2003; 20: 170–71. Simpson FG, Kay J, Aber CP. Chest pain— indigestion or impending heart attack? Postgrad Med J 1984; 60: 338–40.
Authors’ reply Assessing undifferentiated chest discomfort within the confines of a commercial aircraft cruising at 42 000 feet can be challenging. Symptoms associated with undifferentiated chest discomfort have poor specificity for ruling in or excluding the possibility of an acute coronary syndrome,1–3 although as few as 10–30% of patients who present with symptoms suggestive of an acute coronary syndrome subsequently prove to have one.1 Nevertheless, clinicians should be mindful of the individual’s overall risk for acute coronary syndrome when assessing chest discomfort or dyspepsia. Chest discomfort radiating into the jaw, arms, or back; indigestion; diaphoresis; nausea; dizziness; palpitations; or severe fatigue in individuals older than 50 years or in those with pre-existing cardiac risk factors (known coronary heart disease or peripheral artery disease, diabetes, hypertension, dyslipidaemia, tobacco use, or family history of premature heart disease) should initially be regarded as potentially cardiac in origin. However, in these individuals, if the symptoms are predominately gastrointestinal and relief with an antacid is complete—and the patient remains symptom-free—it is reasonable to observe the patient and recommend they undergo further assessment after the flight. If symptoms persist or recur, then a cardiac origin to the pain should be entertained and the patient should receive an aspirin and the discomfort treated appropriately with either morphine or nitroglycerine, which are available in the enhanced emergency medical kit aboard the aircraft. Additionally, the volunteering clinician should discuss with the flight crew and telemedical ground support the feasibility of medical diversion of the aircraft as well as reduction of cabin altitude to increase cabin pressure to improve oxygenation. We declare that we have no conflicts of interest.
*Mark Gendreau, Danielle Silverman [email protected]
Lahey Clinic Medical Center, Burlington, MA 01805, USA (MG); and Georgetown University Hospital, Washington, DC, USA (DS) 1
2
3
Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction–2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation. 2002; 106: 1893–900. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features of acute, undifferentiated chest pain? Acad Emerg Med 2002; 9: 203–08. Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F. Signs and symptoms in diagnosing acute myocardial infarction and actute coronary syndrome: a diagnostic metaanalysis. Br J Gen Pract 2008; 58:105–11.
We entirely agree with Danielle Silverman and Mark Gendreau1 that data on medical in-flight emergencies are scarce. In our study, we asked 32 European airlines to provide anonymous data on in-flight medical emergencies; 28 were unable to provide the required data backed by adequate medical flight reports.2 An international database documenting in-flight medical emergencies in a standardised manner could improve preventive strategies by assisting preflight medical assessment.3 Further, it would promote standardisation of the contents of medical flight kits, which currently vary extensively. In Europe, the regulations applicable to commercial air transportation are published by the Joint Aviation Authorities (JAA). The specifications for the typical contents of emergency medical kits seems very precise according to Silverman and Gendreau’s panel 3, but unfortunately this does not reflect the recommendations published in the joint aviation requirements by the JAA.4 These recommendations are rather loosely formulated in terms of equipment and medication, giving airlines broad leeway in assembling their medical flight kits while fulfilling the letter of the law. In our study, we also compared the medical flight kit of a large national www.thelancet.com Vol 374 September 26, 2009
*Parkinson, Memory & Movement Disorders Center, CHU Notre Dame de Secours, PO Box 3, Byblos, Lebanon (MGJ, B-PWB); Lebanese American University, School of Pharmacy, Byblos, Lebanon (MGJ); Department of Neurology, Hazrate Rasoul Hospital, Tehran, Iran (GAS); and Holy Spirit University of Kaslik, School of Medicine, Kaslik, Lebanon (B-PWB) 1 2
3
4
5
iStock Photo
The printed journal includes an image merely for illustration
Clark HV, King D, Yow R. Carotidynia. Am Fam Physician 1994; 50: 987–90. Kubera M, Kenis G, Bosmans E, et al. Stimulatory effect of antidepressants on the production of IL-6. Int Immunopharmacol 2004; 4: 185–92. Vandezande LM, Lamblin C, Wallaert B. Interstitial lung disease linked to fluoxetine. Rev Mal Respir 1997; 14: 327–29. Medicines and Healthcare Products Regulatory Agency. Yellow card scheme. Drug Analysis Prints. http://www.mhra.gov.uk/Safety information/Reportingsafetyproblems/ Medicines/Reportingsuspectedadversedrug reactions/Healthcareprofessionalreporting/ Druganalysisprints/index.htm (accessed June 11, 2009). Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239–45.
In-flight medical emergencies In their otherwise useful Review of medical issues associated with commercial flights (June 13, p 2067),1 Danielle Silverman and Mark Gendreau state that, “If diagnosis [of chest pain] is uncertain, an antacid could help to confirm dyspepsia.” This is a dangerous recommendation because relief of pain by antacids is neither sensitive nor specific.2 Indeed, in one study, 29% of patients with proven myocardial infarction had relief with antacids.3 Treating epigastric discomfort with antacids is appropriate only if the physician realises the continued potential for myocardial infarction. I declare that I have no conflicts of interest.
Mark Hauswald [email protected] Department of Emergency Medicine, University of New Mexico, School of Medicine, Cancer Center B-30, Albuquerque, NM 87131, USA 1
2
3
1062
Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009; 373: 2067–77. Stewart T, Crawford I, Mackway-Jones K. Antacids and diagnosis in patients with atypical chest pain. Emerg Med J 2003; 20: 170–71. Simpson FG, Kay J, Aber CP. Chest pain— indigestion or impending heart attack? Postgrad Med J 1984; 60: 338–40.
Authors’ reply Assessing undifferentiated chest discomfort within the confines of a commercial aircraft cruising at 42 000 feet can be challenging. Symptoms associated with undifferentiated chest discomfort have poor specificity for ruling in or excluding the possibility of an acute coronary syndrome,1–3 although as few as 10–30% of patients who present with symptoms suggestive of an acute coronary syndrome subsequently prove to have one.1 Nevertheless, clinicians should be mindful of the individual’s overall risk for acute coronary syndrome when assessing chest discomfort or dyspepsia. Chest discomfort radiating into the jaw, arms, or back; indigestion; diaphoresis; nausea; dizziness; palpitations; or severe fatigue in individuals older than 50 years or in those with pre-existing cardiac risk factors (known coronary heart disease or peripheral artery disease, diabetes, hypertension, dyslipidaemia, tobacco use, or family history of premature heart disease) should initially be regarded as potentially cardiac in origin. However, in these individuals, if the symptoms are predominately gastrointestinal and relief with an antacid is complete—and the patient remains symptom-free—it is reasonable to observe the patient and recommend they undergo further assessment after the flight. If symptoms persist or recur, then a cardiac origin to the pain should be entertained and the patient should receive an aspirin and the discomfort treated appropriately with either morphine or nitroglycerine, which are available in the enhanced emergency medical kit aboard the aircraft. Additionally, the volunteering clinician should discuss with the flight crew and telemedical ground support the feasibility of medical diversion of the aircraft as well as reduction of cabin altitude to increase cabin pressure to improve oxygenation. We declare that we have no conflicts of interest.
*Mark Gendreau, Danielle Silverman [email protected]
Lahey Clinic Medical Center, Burlington, MA 01805, USA (MG); and Georgetown University Hospital, Washington, DC, USA (DS) 1
2
3
Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction–2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation. 2002; 106: 1893–900. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features of acute, undifferentiated chest pain? Acad Emerg Med 2002; 9: 203–08. Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F. Signs and symptoms in diagnosing acute myocardial infarction and actute coronary syndrome: a diagnostic metaanalysis. Br J Gen Pract 2008; 58:105–11.
We entirely agree with Danielle Silverman and Mark Gendreau1 that data on medical in-flight emergencies are scarce. In our study, we asked 32 European airlines to provide anonymous data on in-flight medical emergencies; 28 were unable to provide the required data backed by adequate medical flight reports.2 An international database documenting in-flight medical emergencies in a standardised manner could improve preventive strategies by assisting preflight medical assessment.3 Further, it would promote standardisation of the contents of medical flight kits, which currently vary extensively. In Europe, the regulations applicable to commercial air transportation are published by the Joint Aviation Authorities (JAA). The specifications for the typical contents of emergency medical kits seems very precise according to Silverman and Gendreau’s panel 3, but unfortunately this does not reflect the recommendations published in the joint aviation requirements by the JAA.4 These recommendations are rather loosely formulated in terms of equipment and medication, giving airlines broad leeway in assembling their medical flight kits while fulfilling the letter of the law. In our study, we also compared the medical flight kit of a large national www.thelancet.com Vol 374 September 26, 2009