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Beating the Odds

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Beating the Odds CABINSAFETY Beating the Odds Review of in-flight use of automated external defibrillators yields a more realistic picture of who survives. BY WAYNE ROSENKRANS | FROM ORLANDO n airline passenger’s sudden car- like others highlighted in this article, for those shocked by an AED within diac arrest during flight creates a emphasized practical applications of three minutes of collapse, he said. rare and stressful experience for newly available data sources. “In comparison with the passenger the responding flight attendants, MedAire’s data — representing 947 traffic, very few people die in flight,” Aand health outcomes of these events cases of in-flight use of an AED among Alves said. “The reality is that the have been significantly poorer than in airlines receiving assistance from the industry has 0.05 deaths per billion rev- gambling casinos although automated MedLink Global Response Center — enue passenger kilometers … one death external defibrillators (AEDs) are widely showed that when the AED was used to for every 7 million passengers carried. used in both environments. Yet feedback analyze electrical activity in the victim’s MedLink deals with 4.8 in-flight deaths to crews about in-flight “saves” and heart after signs of sudden cardiac ar- every month.” deaths involving AEDs has been scarce, rest, and the synthetic voice said “shock Sudden cardiac arrest was one of says Paulo Alves, a cardiologist and vice advised,” about one-fourth survived several natural causes of these deaths; president, aviation and maritime health, long enough to obtain hospital care (Fig- it has been the most common way an MedAire. He was among the presenters ure 1). Before AEDs, this mortality rate otherwise healthy person dies outside a at the 27th International Aircraft Cabin would have been 100 percent; neverthe- hospital. Ventricular fibrillation — an Safety Symposium in Orlando, Florida, less, the rate of saves documented in arrhythmia in which the heart quivers U.S., held April 27–29. His presentation, casinos has been up to about 70 percent rapidly — occurs in 70 percent of these 42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2010 CABINSAFETY cases, Alves noted. The AED’s shock is intended was the constant surveillance of casino customers to stop the ventricular fibrillation, enabling the by security systems and officers. body to “reset” a normal heartbeat. AEDs automatically record the sequence MedAire data reflect that although ven- and timing of the first responder’s actions to tricular fibrillation most often was documented enable medical review. Alves found examples of during the earliest parts of a flight, it also may in-flight rescuers performing cardiopulmonary have involved unwitnessed collapse in the middle resuscitation (CPR) with only five to 47 chest of a long-haul flight — that is, the passenger’s compressions per minute, most often five, and loss of consciousness was not observed within excessively long pauses between sets of 13 com- three minutes by other passengers or cabin crew. pressions to give two ventilation breaths. This “Sometimes they were sleeping, so others did not was contrary to the 2005 guidance recommend- identify the collapse,” he said. “Many people who ing more than 100 compressions per minute. started feeling ill went to the aircraft lavatory “Carrying AEDs has been a historic move and collapsed there. It was also difficult to notice for the aviation industry ... something fantastic whether a person was breathing or not, especially ... and flight attendants saving lives in about 24 under low-light conditions.” The primary distinc- percent of cases has been remarkable given the tion from casinos, Alves concluded, apparently remoteness of hospital care,” Alves said. “But In-Flight AED/Monitor Utilization, January 2001–December 2008 All uses of AED/monitor (947 cases) Monitoring only (609; 64.3%) AED used (338; 35.7%) No shock advised Shock advised (VF) (256; 75.7%) (82; 24.3%) Survival to hospital (21–23; 25.6%–28.0%) Other Other 5% Respiratory 6% 7% Crew Diabetes Nurse 14% 7% passenger 17% Neoplasia Not reported 9% 55% Physician Cardiac passenger 16% 64% Category of person Category of patient's who operated the AED/monitor pre-existing medical condition AED = automated external defibrillator; VF = ventricular fibrillation Note: These in-flight medical events occurred among airlines receiving assistance from the MedLink Global Response Center. “Survival to hospital” numbers represent the range of data accuracy. Source: MedAire © Andrea Danti/Fotolia © Andrea Figure 1 WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2010 | 43 CABINSAFETY there are chances for improvement. We recom- CRM skills, perhaps the diversions could have mend a high level of awareness in the cabin to been averted. So we put ASAP reports under the identify victims as early as possible to deliver a microscope to determine what was happening, saving shock.” what was causing degradation of crew camara- derie and effective outcomes.” Broadening CRM Aviation safety action programs (ASAPs) in the Communication Breakdowns United States — voluntary, nonpunitive safety A paper on the causes and effects of recent com- reporting programs — increasingly provide munication breakdowns between flight crews insights into broader applications of crew and cabin crews will be published in mid-2010 in resource management (CRM), said Sandra the FAA International Journal of Applied Avia- Ingram, manager, onboard service–safety and tion Studies, said Lori Brown, the paper’s author security, United Airlines, and Vicki Jurgens, and a faculty specialist in the College of Aviation, chairperson, Safety, Health and Security Western Michigan University, U.S. “The indus- Committee, Association of Flight Attendants– try actually has added communication barriers,” Communications Workers of America, and a Brown said. “The only barrier reported to have United Airlines purser. been improved over the past 14 years was aircraft “CRM developed [originally] as an open- systems familiarization for cabin crew. Survey door concept,” Jurgens said. “We no longer have respondents’ main concern was obtaining an ad- an open door … and we are not sure that cur- equate preflight briefing. Many said briefings are rent CRM training goes far enough … not only only given to the purser/lead flight attendant.” in the way that we handle passengers but in One respondent wrote, “Having just how we handle ourselves.” A common language, completed my annual CRM [training], I was re- safety culture and synchronization of informa- minded just how little the flight attendants know tion must be integrated across all airline systems, about what’s happening up in the front. There Ingram added, and ASAP event review com- needs to be a fundamental shift in thinking … mittees should not hesitate to delve deeply into to rebuild the relationship.” Another said, “It is flight attendant ASAP reports that may seem not uncommon, when working in the back, to insignificant by their numbers alone. have never met the flight deck crew when we fly “We have started seeing reports of incidents just one segment. That is dangerous.” involving flow of information that are making Of 224 flight attendants surveyed, 55 percent us uncomfortable, one [incident] resulted in a reported that they have been hesitant to report a diversion,” Jurgens said. “If the communication problem and 16 percent indicated that they had is flawed, we put ourselves at risk. … So we experienced a situation in which they did not have to make sure that our CRM training not report a problem to the flight deck because they Top to bottom: only touches our crew but everyone who works assumed the pilots would already know about Alves, Nesthus and with our crew.” Rifts between flight attendants the problem, Brown said. “Of 51 pilots surveyed, Karlsson and gate agents may result in one group or the 41 percent indicated they had situations where a other abdicating responsibility for decisions or flight attendant did not report a problem.” actions that affect safety, for example, she said. “We employ a risk ranking because we know Midway Overrun Lessons that [the issue in] any one of the ASAP reports Evacuation lessons from the December 2005 acci- has the potential for great damage,” Ingram dent in which a Boeing 737-700 overran Runway noted. “We have had minor incidents, just a 31C at Chicago Midway Airport (ASW, 2/08, p. personality conflict, all the way up to diversions 28) were summarized by Larry Parrigin, man- of aircraft and other significant events. If some ager, in-flight services curriculum and program Photos: Wayne Rosenkrans Wayne Photos: of the flight attendants and pilots had used their development, Southwest Airlines. The Midway 44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2010 CABINSAFETY evacuation took an estimated five to 10 Revised training has flight atten- Free Realistic Training minutes. The collapsed nose landing dants practice adapting memorized Struggles to overcome budgetary gear caused the aircraft to come to a procedures and commands to fit the constraints and provide realistic stop in a nose-down, tail-high attitude circumstances. “In this evacuation, the recurrent-training experiences have with forward doors close to the ground. forward slides had inflated parallel to been alleviated at a small Swedish Slides at the L1 door, overwing exits and the ground onto a landscaping berm,” airline through partnerships based aft doors were deployed, and aircraft res- he noted. “The flight attendants at on bartering for resources,
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