Medical emergencies on board commercial airlines: is documentation as expected?

Introduction The purpose of this study was to perform a descriptive, content-based analysis on the different forms of documentation for in-flight medical emergencies that are currently provided in the emergency medical kits on board commercial airlines. Methods Passenger airlines in the World Airline Directory were contacted between March and May 2011. For each participating airline, sample in-flight medical emergency documentation forms were obtained. All items in the sample documentation forms were subjected to a descriptive analysis and compared to a sample "medical incident report" form published by the International Air Transport Association (IATA). Results A total of 1,318 airlines were contacted. Ten airlines agreed to participate in the study and provided a copy of their documentation forms. A descriptive analysis revealed a total of 199 different items, which were summarized into five sub-categories: non-medical data (63), signs and symptoms (68), diagnosis (26), treatment (22) and outcome (20). Conclusions The data in this study illustrate a large variation in the documentation of in-flight medical emergencies by different airlines. A higher degree of standardization is preferable to increase the data quality in epidemiologic aeromedical research in the future.


Introduction
Air travel has emerged as one of the most popular, safe and convenient forms of travel. In the past decade, the number of passengers travelling on commercial airlines has increased to almost two billion [1]. Because we live in an aging society, the average age of the passengers who are travelling with chronic disease and the number of chronic diseases per passenger is likely to increase in the future. For the European Union (EU), the EU's statistical analysis unit, Eurostat, has calculated that in the year 2060 over 30% of the entire EU population will be over the age of 65. For 2008, Eurostat reported the population over the age of 65 to be 17.1%. However, it is important to keep in mind that these statistics are solely based on age and have no relation to the actual health status of the EU population. Although it is likely that increasing age goes along with chronic diseases, it is not possible to make definite conclusions regarding the health status of future travelers around the world based on EU data [2]. Nevertheless, despite the fact that air travel is generally safe, an increase in in-flight medical emergencies is expected [3]. The next generation of aircrafts, such as the Airbus A380-900 (Airbus S.A.S., Toulouse, France) and the Boeing 777 LR (Boeing Commercial Airplanes, Renton, WA, USA), have an estimated cruising range of 15 to 17,000 km and a maximum passenger load of up to 960 passengers, which will further increase the chances that an in-flight medical emergency will occur during each flight [3].
A recent study reported preliminary evidence that the documentation of in-flight medical emergencies is not as consistent as one would expect. Of the 32 European airlines that were asked to contribute data on in-flight medical emergencies, only four airlines were able to potentially provide the necessary data [4]. In a commentary on the latter study, Ruskin discussed the idea of establishing an international registry of in-flight medical emergencies [5]. Thus, the present study was initiated as a descriptive baseline study to describe the documentation forms that are currently in use. Additionally, the data were compared to the recommendations of the International Air Transport Association (IATA), which is the largest airline-representing association worldwide and which has published a sample "medical incident form" in their Medical Manual [6].

Materials and methods
This study conforms to the applicable local requirements regarding the ethical and investigational committee review, informed consent, and other statutes or regulations regarding the protection of the rights and welfare of the human subjects participating in medical research (http://ClinicalTrials.gov Identifier: NCT01477684, approved by the Ethical Review Board of the Ruhr-University Bochum, Germany, registration number: 4096-11). This study originates from an academic university hospital. All of the airlines that were listed in the World Airline Directory were contacted and asked to submit a sample of their documentation form for in-flight medical emergencies, provided that confidentiality would be maintained and the airlines' names would not be disclosed [7]. The documentation form data were evaluated independently by two authors (MS and SM) blind to the name and type of airline. The authors reviewed and classified all available data into five sub-categories: non-medical data, signs and symptoms, diagnosis, treatment and outcome. The collected items were compiled into an electronic database (Microsoft Excel for Windows, Microsoft Corp., Redmond, WA, USA). Furthermore, each documentation form was verified for its adherence to the sample "medical incident form" published by IATA in their Medical Manual [6].

Results
A total of 1,318 airlines were contacted and invited to participate in this study (Table 1). A total of 10 airlines agreed to participate in the study. These airlines were based in Chile, Czechoslovakia, Germany, Switzerland, Turkey, the United Arab Emirates and the United Kingdom. Two hundred items were summarized into five sub-categories: nonmedical data (63), signs and symptoms (68), diagnosis (26), treatment (22) and outcome (20).
The two most frequent items in each sub-category were "date of incidence" and "passenger's name" (nonmedical data), "description of the injury" and "pulse frequency/minute" (signs and symptoms), "convulsive seizures" and "burns" (diagnosis), "application of oxygen" and "resuscitation" (treatment) and "documentation of diversion" and "death of a patient" (outcome). The items "date of incidence" and "passenger's name" were the only items that were documented in all 10 documentation forms described in this study. For exact details, see Tables 2, 3, 4, 5, 6.
When compared to the sample "medical incident report form" published by the IATA, we found that no airline (0/10) included in this study adhered to the latter form.

Discussion
This study is the first which investigates forms of documentation for in-flight medical emergencies that are currently provided in the emergency medical kits on board commercial airlines. Although we have to keep in mind that the results of this study are not necessarily representative due to selected samples, we were still able to observe a high degree of variance among the forms of documentation that are currently in use by the 10 different airlines in the present study. This is, however, not necessarily the case in other airlines which did not participate in our study. If airline passengers become ill in the cabin during flight, the majority of airlines carry medical equipment, which enables physicians and medical professionals on board to treat the patient [8,9]. Previous studies have shown a help rate of 85% for all in-flight medical emergencies [4]. According to the recommendations made by the IATA, in-flight medical emergencies should be documented properly for a variety of reasons [6]. The standards and recommendations of the International Civil Aviation Organization (ICAO) also list an "incident record form" as a necessary part of the first aid kit [10]. Furthermore, other authors have also advised proper documentation for the passengers that offer medical assistance during in-flight medical emergencies [11]. The reason for this recommendation is obvious. Although doctors and medical professionals who offer assistance on board an aircraft are covered by the Good Table 3 Signs and symptoms*

Airline A B C D E F G H I J Items
Blood pressure (mmHg) X X X X X Body temperature (°C) X X X X X X Consciousness -awake and cooperative (Y/N)

Coughing (Y/N) X X
Description of the injury/event (free text) Oxygen saturation X Pain -intensity (light/moderate/severe) X X X

Wound location X
Wound severity (mild/moderate/ severe) X X Samaritan law, basic documentation, including the patient's symptoms, diagnosis, treatment and administered medication and dosage, is essential in the event of a legal dispute [11]. Similar to any professional medical contact on the ground, documentation of an in-flight medical emergency is not only desirable from a medical standpoint but also from a legal point of view. Furthermore, paramedics and emergency physicians on the ground rely on important medical information and data, which can be secured in writing in-flight and facilitates the initial assessment of the course of an illness from its inception in the air to the point of patient handover. Most importantly, standardized documentation is necessary to facilitate data comparison in an international environment, such as in the aviation and aerospace industry, which includes over 2,000 different airlines worldwide. Each airline should develop its own medical care and incident policy. Without an incident reporting system, no incident management process can be developed. When faced with a patient who requires acute care under special circumstances, such as in flight in an airline cabin, such a process is highly desirable. Because there is no central registry, some airlines analyze their own events. The majority of passenger transportation airlines, however, are not documenting medical emergencies on board their aircrafts [4]. Because evidence suggests epidemiologic research of in-flight medical emergencies has an important impact on updating recommendations for the contents of emergency medical kits, reassessment of the present situation is necessary [5]. Ruskin has provided strong arguments in favor of a centralized registry of in-flight medical emergencies and states that it would tremendously facilitate the epidemiologic research of in-flight medical emergencies and the development of training materials for physicians preparing to volunteer or assist physicians in evaluating the patients' fitness to fly [5]. Furthermore, a registry would enable the airlines to provide information about the true incidence of specific illnesses that occur during flight because data would not be based on any one single airline.
Based on the results of this study, we believe that it is necessary for the appropriate national and international authorities and organizations to discuss a standardized form of documentation for in-flight medical emergencies. Based on the current data of in-flight medical emergencies and the finding that documentation varies greatly, it is impossible to initiate larger studies with multiple airlines from different regions of the world. The aeromedical community today is dependent on small studies with one or two participating airlines, which document by chance similar items that can be analyzed together. The scientific impact of these studies, however, is low due to limited data quality. Therefore, in the future, we should discuss standardized documentation protocols or an international registry for in-flight medical emergencies.
There are limitations that need to be acknowledged and addressed regarding the present study. The generalizability of the research findings are limited because this study includes only a very small number of participating airlines and there is a high degree of variance due to selected samples.

Conclusion
The data in this study illustrate a large variation in the documentation of in-flight medical emergencies by 10 different airlines. A higher degree of standardization is preferable to facilitate aeromedical research and to meet the recommendations that are published by the IATA.

Key messages
• Documentation of in-flight medical emergencies is inadequate due to large variation