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AIRLINE MEDICINE OVER THE YEARS
Prof Michael Bagshaw
1
First airline aeromedical department
➢ Eastern Airlines - General manager Eddie Rickenbacker➢ Miami 1926
2
First airline doctor
➢ Dr Ralph N. Greene – Eastern Airlines
3
ROLE OF THE FIRST AIRLINE DOCTOR
Principle of constant surveillance of aircraft and engine performance to be applied to pilots
➢Regular medical examinations
➢Be the family physician
➢Fly with them frequently
➢Technical reports on in-flight physiological measurements
➢Campaign for Federal law limiting airline pilots to 85 flying hours per month
➢Control and prevention of tropical ailments
4
MEDICAL CONDITION CONSIDERATIONS
Is the condition affected by reduction in ambient pressure, hypoxia or acceleration?
Is the condition static? If so, what is the degree of functional incapacitation?
Is the condition progressive? If so, is the course predictable or unpredictable?
5
▪ Can the condition result in sudden incapacitation?
▪ Can the condition result in subtle incapacitation?
▪ In the case of assessing fitness to fly as a passenger, does the condition impede mobility?
FLIGHT CREW MEDICAL
Poor predictive validity
What existing condition does pilot have?
- Not what condition is the pilot going to have?
Screening process
6
CREW INCAPACITATIONPartial or total
Causes: gastro-intestinal disorders
fatigue, disruption of circadian rhythms
anxiety, stress
barotrauma
hypoxia
carbon monoxide intoxication
acute pain from medical condition (eg renal stone, angina)
medication side effect
decompression sickness
7
INCAPACITATION
Sudden
Insidious
1% rule
8
THE 1% RULE
Risk of pilot failure assessed in same way as risk of failure of any component of the aircraft system
[Note Dr Ralph N. Greene – Eastern Airlines, 1926]
Target fatal accident rate (all causes) 0.1 per 1 million flying hours
0.1 in 106 or 1 in 107
Medical incapacitation ≤ 10% 1 in 109
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Medical incapacitation as proportion of all-cause fatal accident rate
10
THE 1% RULE
Critical periods of flight Take off & initial climb
Approach & landing
In 2 crew, trained 2nd pilot safely takes over in 99 of 100 incapacitations
Fatal accident result from 1 incapacitation per 100 at critical period 2nd pilot reduces risk by factor of 100
11
Critical and non-critical phases of flight with respect to medical incapacitation
12
THE 1% RULE ASSUMPTIONS
Critical portions of flight represent 10% of total flight time (average flight duration 1 hour)
Incapacitations occur randomly during flight
2nd pilot safely takes over on all incapacitations outside critical portions of flight
13
THE 1% RULE
Incapacitation rate of 1 in 106 hours equivalent to approx 1% per year
1 in 106 hours = 0.01 in 104 hours
= 1/100 in 104
= 1% in 104
= 1% in 1 year
(8760 hrs ~ 10000)
14
THE 1% RULE
Despite weaknesses, provides objective standard to assess medical fitness of professional pilots
15
Concorde SSTPassenger service 1976 - 2003
16
SUPERSONIC TRANSPORT
17
60,000 ft
210 minutes
18
19
CONCORDE SST
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OZONE
Biological effects:
Odour
Nose and pharyngeal irritation
Cough
Expectoration
Dyspnoea
Chest pain and respiratory distress
21
OZONE
Occupational exposure limit:
0.1 ppmv, 40 hr working week over 5 days
22
SUPERSONIC TRANSPORT
Ozone
Thermally unstable
Transformed to molecular oxygen at 400 degC for 0.5 sec.
Concorde:
Climb and cruise – engine bleed air 400 degC (100% dissociation)
Descent – engine bleed air 300 degC (90% dissociation)
23
SUPERSONIC TRANSPORT
Oxygen equipment
Concorde cruising altitude up to 60,000 ft.
Airworthiness requirements –
Cabin alt not> 15,000 ft after reasonably probable failure (1 in 103 – 105 flying hrs)
Cabin alt not> 25,000 ft after remote failure (1 in 105 – 107 flying hrs)
Cabin alt > 25,000 ft only after extremely remote failure (<1 in 107 flying hrs)
24
SUPERSONIC TRANSPORT
Oxygen equipment
Example worst case scenario :
Loss of rear cabin window at 65,000 ft
& emergency descent within 30 sec –
Max cabin altitude <25,000 ft in 3 mins, declining to 15,000 ft 6.5 min after failure.
[Small cabin volume, engine high mass flow, small diameter windows, aircraft high rate of descent]
25
SUPERSONIC TRANSPORT
Oxygen equipment
Passengers & cabin crew –
➢‘Rubber jungle’ at 14,000 ft cabin alt
➢Portable equipment, one per cabin crew member, 30 min supply, 120 litre
➢Therapeutic equipment, 2% of pax or 2 persons (whichever greater), 30 min supply, 180 litre.
26
SUPERSONIC TRANSPORT
Oxygen equipment
Flight crew –
➢On demand dilution system, delivering 150 litres/minute BTPS up to 35,000 ft.
➢Pressure breathing up to 30 mmHg.
➢One-handed quick-donning mask –
Donned within 5 sec
Communicating within 7 sec.
27
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Cosmic RadiationVariation of Particle type with Altitude
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Muons
EM Showers
Protons
Charged Pions
Neutrons
Pe
rce
nt
of
To
tal
(%)
80
70
60
50
40
20
10
30
0
Altitude (ft)
0 10 000 20 000 30 000 40 000 50 000 60 000
SUPERSONIC TRANSPORT
30
SUPERSONIC TRANSPORT
31
SUPERSONIC TRANSPORT
32
SUPERSONIC TRANSPORT
33
SUPERSONIC TRANSPORT
34
SUPERSONIC TRANSPORT
35
Radiation Summary
36
37
38
39
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• Performance with time on task (TOT)
41
• Performance with time of day
42Department of Behavioral Biology, Walter Reed Army Institute of Research
Sleep and performance
San Francisco
London
43
Circadian Phase - London
44
Circadian Phase – San Francisco
45
Sleep and alertness
46
0
5
10
15
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
major sleep episode
MS
LT
sco
re (
min
)
Local time (hr)
SSS scale
1
.
.
4
.
.
7
SSS
A
B
MSLT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
A:SSS – Subjective measurementB:MSLT – Objective measurement
MANAGING TRAVEL FATIGUE
Review trip schedule
Decide on appropriate strategies sleep sleep scheduling good sleep habits napping
alertness sleep scheduling strategic use of naps strategic use of caffeine
47
MANAGING TRAVEL FATIGUE
Other strategies light exposure
diet
special diets have not been shown to be of any scientific benefit
gentle exercise
improves NREM sleep
avoid within 2-3 hours of bedtime
48
49
EPIDEMIOLOGY
British Airways flight crew 1950 – 1992
[Irvine D, Davies DM. The mortality of British Airways pilots 1966-1989: a proportional mortality study. ASEM 1992; 63: 276-9]
➢6209 pilots, 1153 flight engineers
143 500 person years of observation
➢life expectancy at age 55 - 65
4 - 5 years better for long haul crew
2 - 3 years better for short haul crew
➢cases of leukaemia less than expected
➢no excess of cancer apart from melanoma
Comparable with other studies
50
51
EPIDEMIOLOGY
Air New Zealand Pilot Morbidity Study[Sykes AJ et al. A study of Airline Pilot Morbidity. ASEM 2012; 3(10): 1001-1005]
➢595 pilots Nov 2009 – Oct 2010cf New Zealand Health Survey 2006-2007
➢Pilots lower prevalence most medical conditions
➢Exceptions: Kidney disease 3.3% vs 0.6%
Melanoma 19/1000 vs 0.4/1000
➢No excess of cancer apart from melanomaComparable with other studies
52
DVT - TRAVELLER’S THROMBOSIS
Increased media interest following a passenger death sensational reporting
‘airlines to blame’
‘airlines not informing passengers of the risks of air travel’
scant attention to scientific facts and level of knowledge
airlines ‘guilty until proven innocent’
53
Daily Mail, 18th November 2000
54
TRAVELLER’S THROMBOSIS
Virchow, 1856 Venous Thromboembolic Disease (VTE), precipitated by venous stasis
induced by immobility
Virchow’s Triad1. reduction in blood flow
2. change in blood viscosity
3. damage/abnormality in vessel wall
55
TRAVELLER’S THROMBOSIS
‘.... As is so often true of venous thrombosis, this group of cases reveals a tendency rather than a proved relation of cause and effect.’
Homans, J. NEJM 1954, 250, 148-149
56
57
TRAVELLER’S THROMBOSIS
CONCLUSION
Current evidence –
Any association between symptomatic deep vein thrombosis and travel by
air is weak.
Incidence less than impression given by media publicity.
58
TRAVELLER’S THROMBOSIS
Is the flight environment a factor?
low humidity
relative hypoxia
What is the evidence from crew?
59
TRAVELLER’S THROMBOSIS
Johnston et al Review of UK CAA medical records 1990 - 2000
12782 professional fixed wing pilots
incidence of DVT 0.21/1 000/yr
16/27 cases had well documented predisposing factors
of the remainder 2 sustained DVT as passengers
‘....this relatively low incidence would suggest that VTE is indeedmultifactorial and the aircraft cabin per se does not pose anoccupational risk.’
Johnston, RV, et al, Abstracts of the 49th ICASM 2001, Geneva, Switzerland
60
TRAVELLER’S THROMBOSIS
Is the flight environment a factor?
seated immobility
appears to act as one of multiple risk factors those with normal venous/haemostatic symptoms will probably not experience
traveller’s thrombosis
multiple journeys may result in a greater risk than single trips
61
Daily Mail, 18th November 2000
62
WRIGHT PROJECT
WHO Research Into Global Hazards of Travel
WRIGHT project aims to determine if the risk of VTE is increased by air travel
to determine the magnitude of the risk
to determine other factors in the association
to determine the effect of interventions
Study types within the WRIGHT project epidemiological
clinical
physiological
pathophysiological
63
WRIGHT PROJECT
Time scale 4 years from January 2002
Cost 12 million Euros
64
WRIGHT PROJECT
CONCLUSIONS
• To confirm if the risk of VTE is increased by air travel
Increased risk applies to all forms of travel (air, car, bus, train)
• To determine the magnitude of the risk
Absolute risk I in 6000 in healthy population
Risk doubles after 4 hours inactivity
• To determine the effect of other factors on the association
No association with hypobaric hypoxia
• To study the effect of interventions on risk
No effective intervention for healthy individual65
IN FLIGHT MEDICAL INCIDENTS
IN FLIGHT MEDICAL INCIDENTS
Airlines required to provide first aid training for cabin crew
Cabin crew responsible for managing any in-flight medical incidents
Regulatory requirements for carriage of first aid and medical kits Detailed policies at discretion of each nation and its airlines
67
IN FLIGHT MEDICAL INCIDENTS
Cabin crew trained ~
Recognise common symptoms of distress
First-aid
Basic resuscitation techniques
Use of emergency supplemental oxygen
Use of basic medical kit and OTC drugs
68
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IN FLIGHT MEDICAL INCIDENTS
Crew may contact ground-based medical service provider Airline medical department
3rd party provider (MedAire; SAMU; Mayo)
Crew may request assistance from on-board medical professional Medical kit released if appropriate credentials
70
MEDICAL TELEMETRY
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1995 – Professor Angus Wallace
Treated in-flight post-traumatic tension pneumothorax using:
coat hanger - trocarurinary catheter - cannulaused brandy bottle - under-water seal
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AEDS
Cost-benefit analysis Costs of acquisition, maintenance and training
Versus
Probability of need
Expectations of travelling public
European Resuscitation Committee & American Heart Association protocol includes early transfer to intensive care facility
78
AEDS
USA – carriage mandated by FAA: Air carriers with max payload >7500 lb with at least one flight attendant
Rest of the world: Optional
Carried by most major airlines
79
80
1986 – Dr Peter Chapman - Defibrillators
81
Dr Eric Donaldson - Defibrillators
82
Dr David McKenas - Defibrillators
83
Dr Paulo Alves - Defibrillators
84
2006 - RDT Tempus Remote monitoring kit
AEROMEDICAL ASPECTS OF NEW GENERATION CIVILIAN AIRCRAFT
85
A380 vs A318
86
First class 14
Club World (Business) 97
World Traveller Plus 55
World Traveller (Economy) 30
Total seats 469
87
88
A380
Does the introduction of very large passenger aircraft pose any unique aeromedical issues to: Passengers?
Crew?
Others?
If so, what needs to be done?
IN-FLIGHT MEDICAL INCIDENTS (IFMIS)
Incidence?
Outcomes?
Diversions? Incidence and Causation?
Medical contributions to outcomes?
Effect of high passenger capacity?
Medical Incidents - Age Profile
0
5
10
15
20
25
30
0 20 40 60 80 100
Pe
rce
nta
ge
Passengers Incidents Diversions
Enplanements and Medical Diversions per annum
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
2001 2002 2003 2004 2005
0
2
4
6
8
10
12
14
16
18
Enplanements
Medical Diversions
(Correlation coefficient 0.93)
Medical Diversion Rates 2000-2005
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2000 2001 2002 2003 2004 2005
Rate per Billion RPKMs
Rate per Million
enplanements
A380 DIVERSIONS - IMPACT
Safety Unplanned approach / unfamiliar airfield
May be hours from suitable airfield on ULR flights
Benefit to patient vs. risk to others
Logistics Airport compatibility – runway / taxiway / towbar
Challenge to receiving airfield - accommodation / medical
Inconvenience to pax
Costs? Fuel
Missed connections
Accommodation
Crew costs 94
ULR DIVERSIONS
95
MEDICAL EQUIPMENT ENHANCEMENT
More Defibrillators?
More EMKs?
Disposables?
Other equipment?
96
MEDICAL TELEMETRY
97
CONCLUSIONS ON IFMES
IFMEs are uncommon events
The high capacity fleet will have an increased medical incident rate per a/c
Airport compatibility issues and passenger numbers make diversions even less desirable.
Telemedicine devices may be a cost effective way to improve passenger outcomes and diversion decision making
Performance needs close audit
98
100
101
102
Where will it end?? Boeing/NASA Blended Wing
104
Questions???