In-flight medical emergencies are becoming a concern to airlines and their passengers in light of the increasing number of air passengers. The SQ flight was from Sydney, Australia to Singapore. The whole journey took about eight hours. Three hours into the flight, a 58-year old woman began complaining of central chest pain radiating to her left arm, shortness of breath, and a dull aching pain in her right lower limb. She described the chest pain as having started like a heavy stone sitting on her chest. The strength of the in-flight medical emergency system and some points are discussed in this article

Wong, Kam Cheong

University of Queensland eSpace

Singapore Med J 2009; 50(5) : 551L e t t e r  t o  t h e  E d i t o r
In-flIght medIcal emergency: an experIence wIth SIngapore aIrlIneS
Dear Sir,
As a fellow doctor, I would like to draw your attention to a critical issue regarding a medical emergency encountered 
during an air flight, with reference to my personal experience in treating a passenger while I was flying with Singapore 
Airlines on January 12, 2008. The purpose of this letter is to highlight the strength of the in-flight medical emergency 
system and some points for discussion.  
 In-flight medical emergencies are becoming a concern for airlines and their passengers in light of the increasing 
number of air passengers. It has been reported that close to two billion people travel on commercial airlines each year.(1) 
The incidences of significant in-flight emergencies are approximately one per 10,000 passengers to one per 40,000 
passengers, with one death occurring per three to five million passengers.(2)  
 The SQ flight was from Sydney, Australia to Singapore. The whole journey took about eight hours. Three hours into 
the flight, a 58-year-old woman began complaining of central chest pain radiating to her left arm, shortness of breath 
and a dull aching pain in her right lower limb. She described the chest pain as having started like a heavy stone sitting 
on her chest. After giving the passenger an oxygen supplement, the flight attendant immediately summoned help from 
other crew members and the captain, who paged for medical assistance on board.  A registered nurse and I went to see 
the patient.
 Her chest pain and right lower limb pain were persistent while she was receiving the oxygen supplement. Her 
medical conditions included hypertension, obesity and a left mastectomy due to breast cancer many years ago.  She 
denied diabetes mellitus, heart disease, smoking and lung diseases. On examination, she was afebrile, tachycardic (111 
beats per minute), hypertensive (140/70 mmHg), and hypoxic (her oxygen saturation obtained from a pulse oximeter 
was 88% on air and 99% on 15 L/min oxygen supplement via a non-rebreather mask). She complained that the mask 
made it difficult for her to breathe and attempted to remove it. A few minutes after removing the mask, her oxygen level 
dropped to 88%–90%.  We persuaded her to keep the oxygen supplement through the mask. When her oxygen saturation 
level maintained at about 100%, the oxygen flow-rate was reduced to 5 L/min and her oxygen saturation was maintained 
at about 96%–99%.  Her lungs were clear to auscultation, the abdomen was soft and non-tender and her heart sound was 
dual without a murmur. However, she had moderate pitting oedema on her right ankle and mild right calf tenderness on 
palpation.  The provisional diagnoses included angina, myocardial infarction and pulmonary embolism.
 The patient was transferred from the economy class to a business class seat so that more space would be available 
for cardiac pulmonary resuscitation in case of cardiac arrest. Telecommunication with the medical team at the Singapore 
Changi Airport was established.  The patient was given a tablet (600 mcg) of glyceryl trinitrate (GTN) sublingually 
and 300 mg of aspirin orally. She was stabilised clinically, i.e. her chest pain and shortness of breath eased. Her vital 
signs were stable (heart rate was regular at 90–95 beats per minute, blood pressure was 130/60 mmHg, her oxygen 
saturation was 96%–99% on 5 L/min of oxygen supplement). The medical team was on standby for the patient once the 
airplane landed.  The patient was handed over to the medical team to carry out further investigations in order to rule out 
myocardial infarction and pulmonary embolism.
 The strengths of the Singapore Airlines in-flight medical emergency system include:
	 • The ability of the flight attendant to recognise a sick passenger and call for help immediately.
	 • The facility for telecommunication between the medical team at the Singapore Changi Airport and the  
  “treating team” on board.
	 • Availability of a well-equipped first-aid kit on board.
	 • A medical-emergency-call-log system to keep track of the medical event.
	 • A prompt response from the medical team once the airplane landed.
	 • The excellent teamwork of the cabin crew.
 The following are some points for discussion:
• Electrocardiography (ECG) equipment should be made available. In case of a situation where there is no 
medical doctor or trained personnel to interpret an ECG on board, the ECG should be able to be transmitted 
Singapore Med J 2009; 50(5) : 552
to ground-based doctors, who are either in Singapore or a host country to which the plane will be diverted, 
for interpretation and advice on the necessary action.  The doctors should be capable of interpreting the ECG 
and advising management, bearing in mind the availability of facilities and medications on board which may 
vary between airlines. The capability of the air crew to follow the management advice will be enhanced with 
well-labelled equipment and medications, as well as clear instructions on how to use them. Nonetheless, it is 
a challenge for many airlines to install an advanced telemetry system that transmits video images, vital signs, 
12-lead ECG and oxygen-saturation data to ground-based doctors.(3) According to Gendreau and DeJohn, 
only one airline (i.e. Virgin Atlantic) has installed such systems on board its aircraft.(1)
• There may be controversies in managing a patient who has chronic airway disease with a high-flow oxygen 
supplement, as the patient may have a high risk of retaining carbon dioxide. On the other hand, hypoxaemia 
is immediately life-threatening and is very often seen in ischaemic conditions due to a probable myocardial 
event. It would be prudent to ensure a good flow of oxygen to ensure the adequacy of cellular oxygen for 
metabolism. At the present time, commercial aircraft cabins are required to be pressurised to the equivalent 
of 8,000 feet (2,438 m) or less. Some patients with pulmonary disease may experience significant 
physiological stress, exacerbation of their underlying illness and severe hypoxaemia during air travel.(4) 
• A review of the medical-emergency-call-log database will be useful to consolidate the findings of the 
frequency of emergency situations occurring during air flights so that adequate facilities and protocols 
can be upgraded accordingly.(5) A recent review by Urwin et al suggests collaboration between aviation 
providers to develop a common database of in-flight emergencies so that the contents of medical kits can 
be standardised in order to improve the quality of care in the air.(6)
• Medical personnel who offer help on board should be aware of the limited “good Samaritan” protection. 
He must render medical care similar to the care that others with similar training would provide under such 
circumstances. A recent review by Tonks states that industry experts say the risk of litigation is close to 
zero as long as the assisting passenger is working with the crew member as part of a team with shared 
responsibility for what happens.(7) 
 In short, Singapore Airlines has demonstrated an efficient system in managing a medical emergency during this 
air flight.
Yours sincerely,
Dr Kam Cheong Wong
Centre for Chronic Disease
School of Medicine
University of Queensland
Room 317, Edith Cavell Building
Royal Brisbane and Women’s Hospital 
Herston, Queensland 4029
Australia
Email: wongkamcheong@yahoo.com
referenceS
1.  Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med 2002; 346:1067-73. 
2.  Cocks R, Liew M. Commercial aviation in-flight emergencies and the physician. Emerg Med Australas 2007; 19:1-8. Erratum in: Emerg  
 Med Australas 2007; 19:286. 
3.  Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd. In-flight medical emergencies. Aviat Space Environ Med 2000; 71:832-8.
4.  Mohr LC. Hypoxia during air travel in adults with pulmonary disease. Am J Med Sci 2008; 335:71-9.
5.  Skjenna OW, Evans JF, Moore MS, Thibeault C, Tucker AG. Helping patients travel by air. CMAJ 1991; 144:287-93.
6.  Urwin A, Ferguson J, McDonald R, Fraser S. A five-year review of ground-to-air emergency medical advice. J Telemed Telecare 2008;  
 14:157-9.
7.  Tonks A. Cabin fever. BMJ 2008; 336:584-6. 


In-flight Medical Emergency: An experience with Singapore Airlines

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In-flight Medical Emergency: An experience with Singapore Airlines

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