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Medscape
21-05-2025
- Health
- Medscape
Doctor on Board? Handle Emergencies With These Five Tips
A medical emergency above the clouds, and you are the only doctor on board among the passengers — a situation doctors fear. What should you be prepared for? How can you avoid making wrong decisions? These questions were the focus of a session titled 'Aviation Medicine for Internists' at the 131st Congress of the German Society of Internal Medicine in Wiesbaden, Germany. Sven-Karsten Peters, MD, a cardiologist at Lufthansa Medical Service, offered practical answers to commonly asked questions. The following are five key tips to keep in mind before your next flight: 1. Legal Obligations On airplanes, the 'flag law' applies, meaning the legal system of the country where the airplane is registered governs the situation. For instance, German law applies to Lufthansa flights, whereas American law applies to United Airlines flights. The obligation of doctors to assist in medical emergencies varies across countries. In many European and Asian countries, there is a legal obligation to provide assistance. In contrast, in the United States, doctors are not legally required to help in medical emergencies. However, the Good Samaritan law protects first responders from legal consequences as long as they offer help voluntarily, without charge, and without gross negligence. Peters emphasised in his presentation that, to his knowledge, there has never been an international case in which a medical intervention onboard an airplane led to criminal or civil consequences for a doctor. Furthermore, first aid is covered by the aircraft's liability insurance. Exceptions include gross negligence and wilful misconduct. 2. Onboard Equipment According to a publication in The New England Journal of Medicine , syncope and presyncope account for 37% of medical incidents on passenger flights. Respiratory issues ranked second, representing 12%. Other common in-flight emergencies include nausea, vomiting, cardiac symptoms, and seizures. Onboard medical equipment is regulated by law, with standards. In Europe, the European Union Aviation Safety Agency sets these standards. Besides the required minimum — which includes an emergency medical kit — some airlines provide additional medical equipment that varies depending on the airline. 3. Emergency Protocols After you identify yourself as a doctor to the flight crew, introduce yourself to the patient and cabin crew, clearly stating your medical qualifications and expertise. Then, ask the patient explicitly for permission to provide treatment, involving a translator if needed. Take their medical history, perform a basic examination, and record their vital signs. Ask the cabin crew about available diagnostic tools. For example, airlines, namely Lufthansa, have a 12-lead ECG on board. Confirm emergency procedures with the crew and ensure the incident is documented. 4. Telemedical Support If you are the only doctor on board and a patient has a seizure but you are unsure how to treat status epilepticus, telemedical consultation can help. Airplanes can connect to ground-based medical centres via telecommunications, where trained emergency doctors are available around the clock to provide advice and support. 5. Unscheduled Landing As a doctor, one must work closely with the flight crew. Cabin crew members receive basic medical training and are usually eager to assist doctors. Deciding whether an unscheduled landing is necessary or possible can be challenging. As a doctor, you should discuss this with both ground-based medical support and cockpit crew members. However, the final decision rests with the captain. According to a study published in 2013, approximately 7% of medical emergencies result in aircraft diversion. The decision depends on factors such as the patient's condition, flight route, and availability of medical facilities on the ground.
Medscape
09-05-2025
- Health
- Medscape
Is Decision Fatigue Sabotaging Your Clinical Choices?
The decision-making process is a fundamental activity in the medical field. It translates into diagnosis, treatment selection, examination choices, provision of relevant information, follow-up scheduling, or the decision not to intervene. In recent years, decision-making processes in medicine have faced increasing pressure to comply with regulatory standards such as evidence-based medicine, patient-centered care, and patient safety. This context has made medical decision-making cognitively more intense, with internists making an average of 15.7 decisionsduring each patient visit. Consequently, for physicians operating in high-complexity clinical settings with heavy workloads and significant cognitive demands, the quality of their decisions may be compromised owing to fatigue resulting from repeated decision-making processes. Decision fatigue (DF) refers to the concept that making decisions is mentally taxing and impairs the quality of subsequent decisions. It is hypothesized that humans have a finite cognitive reserve for decision-making, and as this reserve depletes, executive function and self-control diminish, ultimately affecting the decisions that follow. Clinical Implications DF is of particular concern in medicine because of the critical nature of the decisions made by physicians and the potential consequences of suboptimal decision-making. In clinical practice, decision fatigue has been linked to various outcomes related to sequential decision-making processes, often concerning the timing or order of appointments. Notable examples include increased rates of antibiotic prescriptions later in the day, more conservative surgical recommendations with increased case prescriptions just before lunch, and a higher likelihood of physicians prescribing painkillers, such as opioids, later in the workday. However, most studies available to date have utilized retrospective observational designs, lacking preregistration or external validation. Additionally, the definitions of DF are often vague or inconsistent, resulting in weak cumulative evidence despite numerous reports on its effects. Research Insights A systematic review and meta-synthesis summarized the existing literature on DF in medicine, focusing on its definitions, determinants, and implications for clinical practice while attempting to address some unresolved questions. DF has been broadly defined as a reduced capacity to make decisions and regulate behavior following repetitive decision-making tasks. Although qualitative studies have not directly investigated DF, many have indirectly explored its impact on physician performance or patient outcomes. DF has been described as a consequence of cognitive overload, time pressure, acts of omission, and interprofessional disagreements. No qualitative study has analyzed DF by asking participants to define it or by observing its cognitive, emotional, or behavioral components. Nonempirical articles have examined the concept of DF more directly than empirical studies, describing its possible determinants and associated outcomes. These studies have shown that DF includes ego depletion, physical fatigue, burnout, and repeated or difficult decision-making. Other contributing factors include workload, dysfunctional work environment; implementation of new procedures; and pressure from colleagues, patients, and their families. Risk and Protective Factors At the individual level, risk factors include ego depletion or willpower exhaustion, where repeated DF depletes mental resources; self-perceived medical errors, which can increase stress and anxiety; uncertainty and inherent risks in medical practice; ethical challenges requiring careful reflection; and emotional challenges such as dealing with patient suffering or death. Female sex and residency status were notable sociodemographic risk factors. At the contextual level, the healthcare environment plays a crucial role, with high patient volumes, time pressure, inadequate support, and organizational culture exacerbating the pressure on healthcare professionals, making them more prone to DF. Protective factors against DF include various individual, sociodemographic, and contextual elements. At the individual level, effective communication skills, effective coping strategies, empathy and compassion, trust in one's instincts, motivation, a strong professional identity, the ability to seek advice, self-control and awareness in DF, high self-esteem, and tolerance for ambiguity contribute to greater resilience. At the sociodemographic level, being male, maintaining good mental health, a good quality of life, and good sleep quality were protective factors. At the system level, communication and ethics training, collaborative work environments, decision-making support tools, autonomy, professional experience, and a safe work culture provided resilience against DF. Key Considerations Clinical DF is a complex and multifaceted phenomenon with significant implications for clinical practice and patient outcomes. No current study has comprehensively defined clinical DF within a theoretical framework supporting hypotheses or research questions or provided a definition that could be used systematically. The analysis of risk and protective factors for clinical DF has identified contextual and individual factors with interrelated psychological dimensions. Given the results of this review, it is plausible to assert that clinical DF is a multifaceted cognitive and motivational process that influences a physician's decision-making capacity, driven by contextual and individual factors. These, in turn, are closely linked to psychological distress and an increased risk for errors in healthcare.
