Many anaesthetists — indeed many doctors of any specialty — have found themselves in the position of providing care in unusual circumstances. This can range from helping someone falling in the street to major medical emergencies on commercial aircraft.
The first talk in this three-part session delivered in Monday’s Euroanaesthesia programme was by an expert who can see both the doctor’s side and the legal issues – UK-based Adam Sandell, who works as both a barrister and a general practitioner. He confronted the audience with a theoretical situation they may face on any international flight: you are an Italian anaesthetist, flying from Budapest to New York on a French airline. An announcement goes out: “If there is a doctor on board, would you please make yourself known to the cabin crew immediately?” A Scottish passenger is in labour at 28 weeks’ gestation. Do you have to offer help? If you do help and something goes wrong, can the new mother and her child sue you for clinical negligence? Which country’s courts would hear the case? And what should you do in this situation to avoid legal problems?
The concluding message of his talk was that as long as a doctor was not negligent, he or she need not fear any legal action for coming to the aid of someone on a flight or in another kind of emergency.
In the second talk, titled ‘is there a doctor on this flight?’, Michael Bagshaw, who is visiting Professor of Aviation Medicine at King’s College London and visiting Professor at Cranfield University, UK, discussed the issues surrounding medical treatment on commercial airliners. He said: “Although the crew are trained to handle common medical emergencies, in serious cases they may request assistance from a medical professional travelling as a passenger. Such assisting professionals are referred to as Good Samaritans.”
He discussed how in some countries it is a statutory requirement for a medical professional to offer assistance to a sick or injured person (e.g. France), whereas in other states no such law exists (e.g. UK or USA). Some countries (e.g. USA) have enacted a Good Samaritan law, whereby an assisting professional delivering emergency medical care within the bounds of his or her competence is not liable for prosecution for negligence. In the UK, the major medical defence insurance companies provide indemnity for their members acting as Good Samaritans. Some airlines provide full indemnity for medical professionals assisting in response to a request from the crew, whereas other airlines take the view that a professional relationship is established between the sick passenger and the Good Samaritan and any liability lies within that relationship. Professor Bagshaw said: “Up to the end of 2016, there is no record of any successful action for negligence or professional malpractice arising out of a Good Samaritan act on board a commercial airliner.”
He emphasised the importance of having and maintaining both first aid kits and more advance medical supply kits on the aircraft (ensuring they contain correct drugs for common emergencies), and making sure crew are fully proficient in first aid, resuscitation and basic life support.
A more recent development on commercial aircraft has been to the deployment of automated external defibrillator (AED). The European Resuscitation Committee and the American Heart Association endorse the concept of early defibrillation as the standard of care for a cardiac event both in and out of the hospital setting. However, the protocol includes early transfer to an intensive care facility for continuing monitoring and treatment, which is not always possible in the flight environment. Professor Bagshaw said: “Despite this inability to complete the resuscitation chain, it is becoming increasingly common for commercial aircraft to be equipped with AEDs and for the cabin crew to be trained in their use. This is partly driven by public expectation. Experience of those airlines which carry AEDs indicates that there may be benefits to the airline operation as well as to the passenger, such as avoiding the need for an emergency diversion.”
Some types of AED have a cardiac monitoring facility, and this can be of benefit in reaching the decision on whether or not to divert. For example, there is no point in initiating a diversion if the monitor shows asystole, or if it confirms that the chest pain is unlikely to be cardiac in origin.
He concluded: “Lives have been saved by the use of AEDs on aircraft and diversions have been avoided, so it could be argued that the cost-benefit analysis is weighted in favour of carrying AEDs as part of the aircraft medical equipment. Nonetheless, it is important that unrealistic expectations are not raised. An aircraft cabin is not an intensive care unit and the AED forms only a part of the first-aid and resuscitation equipment.”
The final talk on in this session was on “Ethical decision making and triage during major incidents”, given by Dr Matthias Helm, Armed Forces Medical Centre Ulm, Germany.