A First-Class Simulation: In-Situ In-Flight Medical Emergencies Curriculum for Emergency Medicine Residents Aboard a Commercial Airliner

Introduction: In-flight medical emergencies occur in an estimated one out of 604 flights. Responding in this environment poses a unique set of challenges unfamiliar to most emergency medicine (EM) providers, including physical space and resource limitations. We developed a novel high-fidelity in-situ training curriculum focused on frequent or high-risk in-flight medical scenarios while replicating this austere environment. Methods: Our residency program coordinated with our local airport’s chief of security and an airline-specific station manager to arrange the use of a grounded Boeing 737 commercial airliner during late evening/early morning hours. Eight stations reviewing in-flight medical emergency topics were reviewed, five of which were simulation scenarios. We created medical and first-aid kits that reflect equipment used by commercial airlines. Residents’ self-assessed competency and medical knowledge were assessed both initially and post-curriculum using a standardized questionnaire. Results: Forty residents attended the educational event as learners. Self-assessed competency and medical knowledge increased after curriculum participation. All tested aspects of self-assessed competency had a statistically significant increase from a mean of 15.04 to 29.20 out of a maximum score of forty. The mean medical knowledge score increased from 4.65 to 6.93 out of 10 maximum points. Conclusion: A five-hour in-situ curriculum for reviewing in-flight medical emergencies increased self-assessed competency and medical knowledge for EM and EM-internal medicine residents. The curriculum was overwhelmingly well-received by learners.


Introduction
In-flight medical emergencies occur during approximately one of 604 flights with an average of 44,000 inflight medical events worldwide annually [1]. The Aviation Medical Assistance Act of 1998 compels the Federal Aviation Administration (FAA) to maintain a list of medical supplies required to be carried aboard every commercial airliner within the United States. Each plane is required to have one medical kit and one to four first aid kits, depending on the number of passengers [2].
Flight attendants are trained in Basic Life Support resuscitative care, but many medical events will exceed the training of on-board airline staff, requiring assistance from passengers who have more advanced medical knowledge [3]. Physicians from other specialties have demonstrated varying levels of confidence [4,5] and willingness [4][5][6], caring for airline passengers requiring medical assessment and treatment. Emergency medicine (EM) physicians have the requisite knowledge and skillset to manage medical emergencies, however, doing so in a cramped environment, with limited medical supplies, and a lay audience is not routinely a part of EM training. This curriculum strives to replicate these resource limitations.
Previous publications of in-flight medical emergencies described individual simulation scenarios [7,8], a curriculum for medical students consisting of a lecture and a simulation scenario [9], a simulation-based curriculum for medical students participating in a wilderness and extreme environmental medicine elective [10], and use of a mobile phone application for assistance with management of in-flight medical emergency scenarios [11]. These educational interventions were held in standard simulation settings. To our knowledge, this is the first publication describing an educational curriculum for in-flight emergencies held on a commercial airliner.
To train EM physicians to assess and treat passengers in-flight, we developed a high-fidelity training curriculum focused on high-probability or high-acuity in-flight medical scenarios conducted aboard an actual airliner. The purpose was to execute an in-situ in-flight medical emergencies curriculum that reinforces resuscitative and management principles for managing common emergencies in this austere environment.

Study setting, design, and population
This study demonstrates the implementation of an in-flight medical emergency curriculum. The curriculum was designed for EM and emergency medicine-internal medicine (EM-IM) residents and employed in April 2022. The study was approved by the Ohio State University Wexner Medical Center -approval 2022B0164.
The study setting was a local international airport in conjunction with a United States-based global airline which included access to a passenger terminal and a Boeing 737 airliner. The training occurred while the airliner was on the ground, absent of passengers and flight crew. Participants included EM (three-year program) and EM-IM (five-year program) residents from a university-based, tertiary care teaching hospital. Each of the eight learning stations was facilitated by a paired faculty member and resident. Three simulation staff attended the event to run two 3G® SimMan manikins (Laerdal Medical, Wappingers Falls, NY). In total, 73 residents, fellows, faculty, and simulation staff attended.

Curriculum development
Our first step was to secure the use of a commercial airliner and establish airline and airport contacts. Local emergency management agencies who conduct regional airport system disaster exercises connected our residency education team with the airline-specific station manager (SM). The SM was our primary contact for obtaining airliner access and determining event feasibility. When approaching the SM, we outlined our proposed curriculum while highlighting public safety and public relations benefits for the airline and the community at large.
Planning discussions with the SM and airport chief of security (COS) began six months before the event. The date was chosen by considering moderate temperatures with a low risk of inclement seasonal weather. Training was held overnight to minimize the impact on airline and airport resources. The last flight for the airline came in around 20:30. Our event ran from 22:00-03:00. The COS allowed us to navigate security parameters and coordinate with overnight airport security and parking services. Approval of residency and clinical leadership ensured that residents had protected time off from clinical duties.  Learning station topics were chosen based on the possible need for flight diversion, frequency of reported in-flight occurrence [1,10], or if they were high-acuity pathologies that may be treated with equipment or medications commonly available on commercial in-flight medical kits. Five simulation-based learning stations included anaphylaxis, shockable rhythm arrest, syncope secondary to pulmonary embolism, anterior epistaxis, and an agitated passenger. Three discussion-based learning stations included aeromedical considerations, medicolegal topics, and what to do if oxygen masks drop/decompression illness.
Our EM faculty developed an eight-item self-assessed competency survey and a 10-item multiple-choice medical knowledge test that were given to the residents before and after the curriculum (Appendices). The competency survey was based on a five-point Likert scale. Questions for both assessment tools were identical both pre-and post-curriculum other than open-ended questions eliciting things that the residents enjoyed about the session and opportunities for improvement at the bottom of the post-curriculum competency survey. Pre-existing validated medical knowledge assessments for in-flight medical emergencies are not currently available in published literature.

Implementation phase
All participants underwent Transport Security Administration clearance. A list of materials was supplied to the SM and COS so items going into the airport could be monitored ( Table 2).

Equipment Quantity Description
SimMan®  The simulation staff arrived early for setup with a simulation vehicle displaying a university affiliation magnet. These staff were escorted onto the tarmac. Participants were escorted through security by the SM and COS. Once at the gate, the SM addressed safety precautions, including where to meet and how to exit the plane in case of an emergency. Entry into the flight deck was prohibited. During this time, facilitators set up their respective learning stations. Residents were assigned into groups, which were created to accommodate equal mixes of post-graduate level of training.
Learning station topics, locations, and topics are described in Table 3. Residents had approximately twenty minutes at each station, including debriefing led by the station's facilitating resident and faculty member. Debriefing sessions focused on exploring observed behaviors of each team and reviewing optimal management strategies. Four out of the five simulation scenarios occurred on the airliner (Figure 1). Residents rotated from front to back of the plane. Once residents completed the agitated patient station, they deplaned using rear airliner stairs, were escorted by security back to the jet bridge, and then continued with the gate-based stations.

Results
Forty-eight total residents attended the curriculum, forty (83.3%) as learners including thirty-three EM residents and seven EM-IM residents. Eight residents served as learning station co-facilitators. Resident learners included fifteen (37.5%) women and twenty-five (62.5%) men. Three fellows, one EM clinical pharmacist, and nine faculty attended as learners.
Medical knowledge scores increased from a mean total score of 4.65 out of ten points for pre-testing to a mean total score of 6.93 for post-testing ( Table 4). The largest score increase was for advanced cardiovascular life support (ACLS) medication availability in-flight and the most common type of in-flight emergencies, followed by questions regarding oxygen mask deployment and medicolegal considerations for rendering in-flight care. Self-assessed competency increased from a mean pre-curriculum score of 15.04 (range 8-23 out of a maximum score of forty) to a mean post-curriculum score of 29.20 (range 21-36 out of a maximum score of forty) with all assessed items reaching statistical significance ( Table 5).

Discussion
Although not legally obligated to render aid in the United States, the commercial airline industry relies on healthcare professional passengers to render care for acutely ill co-passengers. In order to prepare our EM and EM-IM residents to treat in-flight emergencies, we developed a novel in-situ simulation-based curriculum. Resident self-assessed competencies were highest for obtaining vitals on flight both pre-and post-curriculum and were lowest for describing legal aspects of rendering care and physician liability. However, all assessed topics for self-assessed competency had statistically significant increases from pre-to post-curriculum. The largest gains in medical knowledge were related to medications available on a flight and on relevant flight operations.
To date, the described curriculum is the only model successfully performed aboard an actual commercial airliner. Conducting the training on an aircraft allowed for learners to appreciate rendering care in a cramped environment with ergonomic considerations not typically encountered in the emergency department and difficult to replicate in a typical simulation laboratory. The benefits of in-situ simulation, including human factors impact of practicing in the expected clinical space, have been supported by multiple studies [13,14]. Operating in this unique training environment offered participants a chance to practice in-flight resuscitation with a level of immersion and ergonomic accuracy not yet previously described. Overwhelmingly positive qualitative feedback obtained on the post-curriculum assessment survey highlighted the perceived value of assessing passengers in the actual physical space encountered on a commercial flight.
Previously published in-flight medical emergency simulation scenarios were held in a dedicated simulation center or educational facilities [7][8][9][10][11]. One utilized a critical actions checklist for performance assessment but did not report these results [7]. A hypoglycemia in-flight emergency simulation case did not report any objective or competency-based results from their training [8]. One group assessed the perceived confidence and comfort of fourth-year medical students [9], and two utilized unvalidated medical knowledge exams [9,10]. Lastly, one study evaluated two scenarios using scenario-specific checklists, measured time to critical actions, global rating scores, and self-assessment readiness and willingness surveys [11]. Checklists were internally cross-checked for content validity by the authors, but they noted that external validity checks could not be performed due to a lack of existing performance expectations for those responding to in-flight emergencies.
Our curriculum implementation was facilitated by our first author and other EM faculty who were familiar with local emergency management agencies. Interested parties may reach out to those who conduct regional disaster drills for these contacts. Once airline-specific SM and airport COS personnel are identified, reviewing mutually beneficial outcomes such as positive publicity for the airline and airport, increasing inflight medical emergency management skills for passengers, and strengthening connections which may be used for regional disaster drills may be useful.
EM physicians are well suited to assist during in-flight medical emergency scenarios. All medical providers called upon to provide care on an airliner should be resourceful and utilize medical kits and supplies such as ice, other passengers' medications, and the in-flight communication system to receive assistance from oncall ground medical providers.

Limitations
The medical knowledge test and self-assessed competency survey were unvalidated, included a short test/retest interval, and utilized lower-level Kirkpatrick assessments [15].
The number of scenarios was limited by physical space, leading to six to seven learners per group. Group sizes may have decreased the amount of hands-on time at each station. Two of our simulation scenarios included cardiopulmonary resuscitation, which led to the inclusion of two 3G® SimMan manikins, ambulance gurneys for transport, laptops and wireless mice for manikin control, and extension cables with supply cables for power. It would be more resource-effective to use confederates.
Curriculum execution may be challenging for programs near airports with high flight traffic. We worked with one airline, so our experience may not extrapolate similarly with other airlines. Undoubtedly, different airports have varying security protocols to be navigated. In addition, the successful execution of simulations like this hinges on some factors that are simply out of the control of those planning the event. Weather conditions delaying incoming flights, after-hours airport staffing, and miscellaneous security concerns have the potential to interfere with successful simulation execution.

Future directions
One suggestion was to use radios to contact confederate pilots or medical ground control to initiate the discussion regarding diversion. Other cases may involve management of pediatric passengers, treating multiple simultaneous patients after a turbulence event, or involvement of emergency medical services. Medical students and interdisciplinary teams may also benefit from this training framework.

Conclusions
A five-hour in-situ in-flight medical emergencies curriculum on a commercial airliner was well received by residents and improved knowledge and self-reported competency. Learners most appreciated the in-situ setting and simulation-based scenarios. Establishing early contact with the SM and COS was crucial for event planning. Hosting the event at a low airline traffic period allowed for ease of movement within the airport and through security.