Intervening on a flight

Air travel imposes several physiological stressors on passengers. For example, low cabin humidity can lead to dehydration, while the reduced air pressure at cruising altitudes causes relative hypoxia. Passengers may also experience sleep deprivation, disrupted circadian rhythms, and fluctuating blood sugar levels with inadequate oral intake. Emotional stress and anxiety can exacerbate pre-existing conditions, and alcohol or drug consumption further complicates matters. Additionally, prolonged sitting during long flights increases the risk of venous thromboembolic (VTE) events (1).

Interestingly, while Canadian regulations stipulate that any aircraft with at least 100 passenger seats must carry a medical kit, there is no legal requirement for an AED, although some airlines voluntarily include one. Aircraft with fewer than 100 seats are only required to carry a basic first aid kit (2). These kits and requirements can vary between airlines and internationally. If you’re further interested in the equipment carried, we encourage you to explore this resource (2,3).

As paramedics, we are trained to manage uncertainty and chaos, with limited resources. In the unique environment of an aircraft, where space is cramped, the cabin is loud, and lighting is dim, performing traditional assessments such as auscultation for lung sounds or blood pressure may be challenging. In these circumstances, taking a blood pressure by palpation may be more practical. It's also important to remember that aircraft cabins are pressurized to altitudes of 6,000–8,000 feet, which results in a normal oxygen saturation (SpO2) of around 90% (2) — a potential concern when treating patients with respiratory or cardiovascular issues.

There are two main factors to consider when deciding to what extent you choose to intervene. Primarily, there is a moral dilemma. As medical professionals we carry a social and moral duty to act in medical emergencies; however, in doing so, we open ourselves to medical-legal liability. Secondary to the moral dilemma, there are legal considerations on those duties including jurisdictional control, scope of practice, and professional standards.

The decision to intervene in these circumstances needs to balance public safety needs and personal legal liability risks.

Given these unique challenges, the question arises: in the event of an in-flight emergency, what can paramedics in Ontario do (morally and legally)?

Fundamentally, RPPEO supports the idea that paramedics use their knowledge, skills and training to help people who are experiencing medical emergencies. We appreciate the moral dilemma to act and support your decision to provide basic life support and first aid to people in need.

When faced with an ethical question, there is a rapid ethical decision-making model that we can use to approach the scenario (4). We thus ask ourselves three questions:

1. Impartiality - would I accept this action if I were the patient?
2. Universalizability - would I be comfortable if my colleagues acted this way in similar circumstances?
3. Interpersonal justifiability - can I supply good reason for the action, i.e. would my peers, public, superiors support it?

Provided you feel confident in the above, it would be reasonable to do what is best for the patient. As a further example, it would be if there’s a VSA patient on a flight, it would be reasonable to administer epinephrine. Having said that, if a medication without lifesaving potential is administered, that is less defensible.

The dilemma is complicated by the legal framework of Ontario, namely, the Regulated Health Professions Act and Ambulance Act. We acknowledge that these apply primarily in the province of Ontario; an extensive legal opinion is required to interpret the medical-legal liability for international jurisdictions and airspace.

Under the Ontario Ambulance Act, a paramedic is defined as someone employed by, or volunteering for, an ambulance service who meets specific qualifications to perform controlled medical acts delegated by a Base Hospital Medical Director. Under the Ontario regulations this definition typically applies to paramedics responding to 911 events or interfacility transfers.

Therefore, paramedics in Ontario are authorized to perform controlled medical acts in the capacity as an employee of a paramedic service. The Base Hospital Medical Director only delegates when paramedics are fulfilling their duties as prescribed by the Ambulance Act and prescribed Regulations.

This means that when paramedics are not on duty, paramedics are not under the Medical Director’s medical license or medical delegation authority, and therefore, not protected by their medical-legal indemnification. yle="text-decoration: underline;">If you choose to perform controlled medical acts while not-on-duty as a paramedic (e.g. on a commercial flight), you are choosing to practice medicine independently, as this is outside of the Ambulance Act provisions. This choice may cause you to be personally liable for your actions.

However, you can still provide life-saving interventions based on your CPR certification, including administering oxygen, performing CPR, using a bag-valve mask (BVM), and operating an automated external defibrillator (AED).

Succinctly, when it comes to controlled acts, your delegation relationship with the Base Hospital Medical Director only applies when you are fulfilling your duties a paramedic for your service.

If there is a physician present at scene, they can delegate to you as the regulated health professional responsible for the patient. However, they have their own set of requirements required to delegate. As a trained professional, you can certainly assist them and articulate your level of training and certification for them to decide if you can assist or if they can delegate to you in that moment. Having said that, there are some exemptions for emergencies (5).