Having traveled for 20 hours to reach Addis Ababa in Ethiopia at 3 AM on January 17th…I did not know if I could gather up the energy to get in a jeep and travel 130 kilometers that same morning to see the school that our group of LA Associates of Save the Children had funded. But when I and the three women who went on this trip arrived, we forgot our fatigue as we were met by hundreds of children, parents, village elders and horse back riders(!) who sang and cheered as we traversed the dirt road leading to the village and school.

Until this year, in order to get to a school for primary education the children had to walk two hours each way from their village! The little ones could not do it, and the older girls were not allowed to attend school unless they had separate latrines. These children and their parents dreamed of their chance to acquire an education; they knew it was the only way they could break their existing bonds of poverty. Save the Children has worked for decades with the government of Ethiopia to help establish schools throughout the country. Once those schools are built and supplied the government then provides the teachers and together with the community continues to run them. The local school often becomes the center for democratic participation in governance, child health, child rights and community welfare. It was with this in mind that the LA Associates of Save the Children raised the funds to establish the school in this village. The opportunity our journey afforded us to experience the joy and gratitude of the children and their community was extraordinary. Save the Children is an amazing global organization and we now have a West Coast presence here on LA. I feel honored to be a part of it…

Rather than go on with words, I thought I would share some of the pictures we took during our visit. Yes, I usually share medical information on this website… This time I hope you agree; giving children a future is medicine for all of us!

I just returned from Ethiopia where there is a very high level of premature birth, infant death and mortality in the first five years of life. I plan to delve into this in detail and show you pictures of the school that the LA associates of ‘Save the Children’ and I built in a small community about 50 miles outside of Addis Ababa. However, I need time to collate our pictures and write a full story to share with you. Quite frankly, I’ve been jet lagged this week and coming back to the practice has kept me busy. But I did come across an article in the New England Journal of Medicine about prevention of preterm parturition (delivery) which I would like to share with you.

The author states that in the United States, the annual rate of preterm births (before 37 weeks of gestation) was 11.7% in 2011. Unfortunately, the rate in the United States remains nearly twice the rate of that in European developed nations. Premature birth in the United States accounts for 35% of deaths in the first year of life and an estimated annual cost exceeding $26 billion. Babies born before 24 weeks of gestation rarely survive without serious handicaps and even after 24 weeks their mortality and morbidity can be significant. Before gestation of 32 weeks, we see serious neurodevelopment complications and even in babies born before 36 weeks gestation there are often difficulties with respiration, their ability to maintain their body heat, feeding, as well as an increased risk of health problems and death in childhood.

And here are some of the risk factors that were listed in this article: black maternal race, previous pregnancy with an adverse outcome, infection in the bladder or pelvic area, smoking, extremes of bodyweight and social disadvantage. Premature delivery may also be impacted by maternal depression, prepregnancy stress, poor diet, assisted fertility and periodontic disease. A previous preterm birth is a strong risk factor for future preterm birth; a preterm birth increases the risk of future preterm births by a factor of 1.5 to 2. The author also points out that short cervical length as measured with the use of transvaginal ultrasound at 18 to 24 weeks of gestation is a consistent predictor of an increased risk of preterm delivery regardless of all the other factors. Hence many obstetricians do look at cervical length with ultrasound at around this time of conception.

The article becomes very medical with terms that are basically written for the obstetricians or other medical practitioners, so I won’t get into too much detail. But the author did make a very nice summary of the current measures that may prevent preterm labor. Here it is:

  • Change reproductive health care to reduce the incidence of multiple pregnancies and scheduling births after 39 weeks unless there is a medical indication.
  • Identify and treat medical risk factors in early pregnancies (e.g. genital urinary infection and poor nutrition) may help (but so far there is no data that this is truly effective in reducing preterm birth rates).
  • Knowing that previous preterm birth and a short cervix as measured by transvaginal ultrasonography are major risk factors for preterm birth.
  • Using progesterone supplementation in women with the previous preterm birth, a short cervix or both is recommended for women with these risk factors.
  • Cervical cerclage (putting a special stitch on the cervix to help keep it closed) reduces the risk of recurrent preterm birth among women with a short cervix.

Obviously these prevention tactics have been issued for physicians who are treating pregnant women. I know that many of my readers will not have to deal with obstetrical problems. But as we increase our knowledge about women’s health and the medical issues that impact our future generations, I felt that this data was important … if not for each of us, certainly for our daughters and perhaps granddaughters. I will get back to you about my Ethiopia trip next week.

As I sat down to write this website, my iPhone and iPad both beeped with a new message. It was from the CDC with a flu alert. So I thought it was appropriate to pass this on to you. (I was going to write about an article in JAMA about the “Ingredients for successful and interventions to improve medication adherence.” Just briefly…I have to relate some of what was written!… on average, 50% of CDC is alerting clinicians nationwide medications for chronic diseases are not taken as prescribed. There are new options to deliver patient education. These include mobile health technologies in which text messaging is used to remind patients to take their medication on time. Electronic monitors could help them check their blood pressure, glucose, physical activity and weight. There are new pill monitoring technologies that include electronic pill caps, smart blister packaging and digital pills. And finally there are now online resources and social media outlets that help support individuals with specific chronic diseases and build support communities. Okay… I did it; now on to flu.)

The CDC is a alerting clinicians nationwide about cases of severe influenza. Apparently from November through December 2013, the CDC has received numerous reports from several states of severe respiratory illnesses among young and middle-aged adults, many of whom are infected with a specific virus called the influenza A (pdm09) (pH1H1) virus. Data indicate that for the 2013/14 season, if this virus continues to circulate widely, the illness that occurs will disproportionately affect young and middle-aged adults. Hence, they are recommending that all individuals who are six months and older would have not yet received an influenza vaccine this season be vaccinated. All the available vaccine formulations this season contain aPH1N1 component and the CDC does not recommend one flu vaccine formulation over another.

Many of you know that as soon as you enter my office, we offer a flu vaccine but you can also get it at most pharmacies and health care facilities. I know that some of you feel that because you never had the flu and you are otherwise healthy, that you don’t have to worry. In the past, we all thought high-risk individuals were those who were elderly, very young or were immune compromised. But now it appears that it’s healthy young and middle aged adults who are at risk.

The CDC’s nationwide notice also encourages all persons of all ages with influenza like illness to seek care promptly in order to determine if treatment with influenza antiviral medication is warranted.

I wanted my last newsletter of the year to be somewhat positive. So I will positively try to ward off potential evils and continue to champion an agenda of appropriate prevention. Unless you plan to spend the next few months around people wearing masks or you are going to wear one yourself (and not touch anything), it would be very good idea for you to get the flu shot.

Aside from my proclamation of potential flu emergency I do want to offer the traditional “Have a happy and healthy New Year! ” And I will try to help keep my patients and readers healthy and up to date on medical articles and news in the year come.

As many of us try to consider and perhaps atone for past bad behavior (sins?) this Yom Kippur I want to point out a review that appeared in the September 5 issue of The New England Medical Journal. It was an article titled “The behavioral and dietary risk factors for noncommunicable diseases”. In other words, what are the worldwide behavioral misdemeanors that cause disease and death from noninfectious causes. There were a lot of graphs and statistics about the “death burden” of disease in men and women and the behavioral factors that caused them. I just want to give you some of the more startling statistics.

Let’s start with smoking… We all know that smoking impacts mortality from cancers, cardiovascular and respiratory diseases. It also effects diabetes and tuberculosis. Exposure of pregnant women and children and nonpregnant adults to second hand has also been found to be associated with infertility, miscarriage, premature delivery, fetal malformation, childhood respiratory diseases and many of the same diseases that are associated with active smoking. There are now more than 1 billion (that’s billion with a B) smokers worldwide and a rising number live in low and middle income countries. The prevalence of smoking has fallen below 20% in Australia and Canada and in areas of the US but has risen among men and women in Central and Eastern Europe, among women in some Western and Southern European countries, and among men in East Asia. An estimated 60% of men in some countries in Eastern Europe and East Asia smoke. Tobacco smoking and exposure to secondhand smoke together are responsible for about 6.3 million annual deaths worldwide and 6.3% of the global burden of disease. (In other words, we should consider that tobacco is one of the most deadly weapons that mankind has developed).

The next deadly sin that was listed in the article was alcohol. Alcohol consumption is responsible for about 2.7 million annual deaths and 3.9% of the global burden of disease. Alcohol is a major contributor to cancers, chronic liver disease, unintentional injuries, alcohol-related violence, neuropsychiatric conditions, and in regions such as Eastern Europe where there is a high prevalence of binge and harmful drinking, cardiovascular diseases. As a matter of fact, alcohol consumption is the leading single because of disease burden in Eastern Europe and is one of the top three risk factors along with high blood pressure and obesity in much of Latin America where it ranks ahead of smoking. In Russia and neighboring countries, men (especially those of low socioeconomic status) consume very large amounts of spirits either regularly or though binge drinking. Alcohol consumption may be responsible for 1/3 to 1/2 of death among young and middle-aged men in Russia!

Sin number three is excess weight and obesity. We know it increases the risk of disease or death from diabetes, heart disease, stroke, cancers, chronic kidney disease and osteoarthritis. It’s estimated that currently, excess weight is responsible for about 3.4 million annual deaths and 3.8% of the global burden of disease. According to the article, the global prevalence of obesity which is defined as a BMI greater than 30, doubled between 1980 and 2008 and is 29.8% among men and 13.8% among women. This is equivalent to more than half a billion obese people worldwide. The United States has had the largest absolute increase in the number of obese people since 1980, followed by China, Brazil, and Mexico. (Please don’t read this while you eat dessert…other than fruit!)

Next let’s go to diet and nutrition. The authors calculated that low dietary intakes of fruits, vegetables, whole grains or nuts and seeds or a high dietary intake of salt are responsible for 1.5% to more than 4% of the global disease burden. We know that Mediterranean diets are healthy, but recent data show that the consumption of animal fats and high calorie foods is increasing in Mediterranean countries such as Greece. There are even more drastic dietary changes in Asia; China is rapidly adopting a western, animal-based diet and has one of the largest worldwide increases in serum cholesterol levels.

I don’t want to leave the reader with the thought of “woe is the world and there’s nothing that can be done.” There are major successes and tobacco control in many high and middle-income countries and the hope is that these can be shifted to lower income nations. Harmful alcohol consumption and cigarette smoking has been curtailed by public policies including taxes as well as limits to age and place of use in many western countries. The governments in Eastern Europe and Latin America have to be pay attention to these successes and follow some of the same policies. There has also been progress in lowering blood pressure and cholesterol levels in high income countries and parts of Latin America. There is obviously much to be done as regarding weight gain and exercise. But once more on the plus side (a non weight comment), we have seen successful efforts in limiting trans fat and salt consumption. World-wide public health policies seem almost philosophical to most of us but each of us can start our own health policy with individual social and political decision-making and better health habits.

On this evening of Yom Kippur, I want to repeat the age old blessing: “May you be inscribed (next year and for many years to come) in the book of life”.

Let me start this week’s website article with a blessing: Shana Tova. As many of you know this is the beginning of the Jewish New Year and I did not want to commemorate the holiday by writing this article on the actual Rosh Hashana holiday. In the spirit of holiday planning, I am writing this on the preceding Monday, September 2. Yes, this is Labor Day, a time to reflect and celebrate the labors of others as well as my own. But reading medical journals and reporting on them is not, in my view, labor. I actually enjoy it! Moreover I suspect that many of my readers, friends and relatives are out shopping the sales, so I don’t feel guilty.

This week’s JAMA included an article titled “Acute Abdominal Pain and Abnormal CT Findings”. It’s meant to show physicians and ultimately their patients why CT scans should he performed when appendicitis is suspected. CT results have saved as many as 40% of patients with suspected appendicitis from unnecessary surgery. Interestingly, women are more likely to undergo unnecessary appendectomy than men.

Appendectomy is the most common emergency operation United States. The usual symptoms include pain around the umbilicus (belly button) which increases over time, a mild fever and less routinely, loss of appetite, nausea, vomiting and constipation. The exam by a physician usually shows that the abdominal is rigid, that there is pain with flexion of the right leg and exquisite tenderness in the lower right abdomen, whereas deep palpation on the left lower abdominal area does not cause the same distress. The white cell count may be elevated but is not specific for the diagnosis of appendicitis and, frankly, there are no other diagnostic blood tests for acute appendicitis.

Since CT scans have greatly reduced the misdiagnosis of appendicitis, especially in women, they are now used in most emergency rooms. In a 10-year, single-institution review that was published in the New England Journal of Medicine, the use of CT for suspected acute appendicitis increased from 19%, in 1998, to 93% in 2007 and was associated with a decrease in the negative (unnecessary) appendectomy rate, which fell from 17% to 8.7%. CT was even more impressive in reducing misdiagnosis for women younger than 45, decreasing negative appendectomy rates from 43% to just 7%. The authors of the article conclude that “Because of high misdiagnosis rates, women presenting with lower abdominal pain or any atypical presentation for appendicitis may benefit from CT imaging.”

Bottom line: If you experience the sudden onset of mid abdominal pain that subsequently radiates to the right, your abdomen becomes rigid, you develop a fever with or without nausea or vomiting; don’t wait…see your health care provider or go directly to the emergency room. A doctor should examine you, do a blood test to see if your white count is elevated and in most instances order a low-dose CT scan. This is the most reliable method to establish the need for emergency appendectomy. The goal is to diagnose appendicitis before the appendix ruptures. A laparoscopic procedure can then be done and in most instances you can go home the next day.

Hopefully none of this will happen on a holiday.

Patients often ask me whether I can predict if they will have severe hot flashes, night sweats and other symptoms of menopause when they go through this transition. My crystal ball has always been rather cloudy regarding the severity of future menopausal symptoms. What I can forecast with certainty is that we will all become menopausal by our mid 50′s or (often) even earlier. But perhaps this will help… there are studies that have looked at the correlation between PMS symptoms and menopause and have found that indeed the former may be predictive of severity of symptoms in the latter.

A new study was published in the journal Menopause briefly (!) titled “Past reproductive events as predictors of physical symptom severity during the menopause transition”. Initially, the author summarized past studies which have shown that there is a correlation between PMS and menopausal woes; one of which found that women who experienced premenstrual syndrome were five times more likely to report hot flashes during the menopause transition and were significantly more likely to report decreased libido, depressed mood, and/or poor sleep.

The article then went on to report on a recent study conducted in Canada in which 270 participants who had started the menopause transition were followed. The mean age at which menopause began in these women was 46.5 years. The women filled out a lot of forms: a menopause specific quality of life questionnaire, a menstrual distress questionnaire, a pregnancy experience questionnaire, a postpartum physical symptoms questionnaire, and an oral contraceptives side effects questionnaire. (My comment at this point is that having to fill out all these questionnaires could provoke anxiety and subsequent symptoms, but hey I am trying to be a non opinionated reporter.) I won’t go into the complicated statistical analyses, which took up pages… But in the end the present study did demonstrate that a history of premenstrual symptoms (i.e., pain, concentration difficulties, and water retention) as well as physical symptoms experienced during pregnancy were excellent predictors of menopausal symptoms.

Their association may be due to similarities in hormonal changes during the premenstrual phase and those of the menopausal transition. Remember, PMS symptoms are experienced late in the second half of the menstrual cycle before the period occurs. This is when both estrogen and progesterone levels are declining or low. The link between PMS symptoms and menopausal symptoms suggests that those of us who are or are “destined” to have hot flashes, night sweats and sleep disorders in menopause may be more susceptible to physical symptoms when hormone levels decline.

The bottom line doesn’t seem fair…that if you suffered from PMS you are more likely to have significant menopausal symptoms. Sorry, as I said before, I am just reporting. But I and other doctors are here to help you get through both!

Most of you know that I try to be very thorough (with a slight bias) when discussing hormone therapy and indeed, many of my previous website articles have dealt with the pros and cons of hormone therapy in menopause. So I certainly want to make sure to report on a study that recently came out in the American Journal of Public Health. Its title is “The Mortality Toll of Estrogen Avoidance”. The authors created a formula based on data that came out in the Women’s Health Initiative Estrogen Alone Trial. (Like so many studies this has an acronym: WHI -ET.) I’ll start with their conclusion; that at least 18,600 and possibly as many as 91,600 excess deaths occurred between 2002 and 2011 among women who had a hysterectomy and were between the ages of 50 and 59 years, as a result of their estrogen therapy (ET) avoidance.

ET protects the heart and bones and, of course, relieves menopausal symptoms. In the 1990s, more than 90% of women in their 50s who had a hysterectomy used estrogen therapy. But in July 2002, the investigators of the Women’s Health Initiative (WHI) published the results of the estrogen plus progestin trial and terminated the study because of adverse effects. There was a mass media rush to characterize hormone replacement as all bad. In less than two years, half of the women who are using systemic hormone therapy stopped. Compared with 2001, use of oral estrogen only among women aged 50 to 59 years with no uterus declined by almost 60% in 2004, 71% by 2006, and 79% in 2010 and 2011.

This decline continued despite the positive results that were later found in the WHI estrogen only trial which was published in 2004 and then again in 2011. It showed that the absolute total risk of death was reduced by 13 per 10,000 women per year among hysterectomized women aged 50 to 59 years who were using estrogen during 10 years of follow up. The researchers used this 13 per 10,000 women per year to calculate mortality associated with not using estrogen among women who had a hysterectomy. They then looked at the numbers of women who had hysterectomies since 2002 and with these numbers got to their estimate of close to 49,000 excess deaths. And that number may be low. The authors calculated the decline in use of oral estrogen only for their estimates. They did not include transdermal estrogen which has been found to be more effective than oral estrogen in preventing cardiovascular events such as heart attack and stroke. So if many of these women had used transdermal estrogen, their longevity might have been protected to a greater extent.

Poor estrogen, its had very negative press, and even when good results are published they do not receive the attention given the negative ones…Well that’s what makes news all the news that’s fit to get attention!

The medical profession has not yet discovered how to effectively prevent most risks of miscarriage or early delivery, but due to popular, demand the prevailing therapy is to give a “prescription” for bed rest. As a result, each year here in the United States, approximately 18% of pregnant women will be placed on bed rest at some point during their pregnancies. A 2009 survey of maternal – fetal medicine specialists found that 71% would recommend bed rest for preterm labor and 87% would recommend bed rest for premature rupture of membranes.

An article in the June issue of Obstetrics and Gynecology, published by the American College of Obstetricians and Gynecologists, points out that this advice is not only not supported by evidence but will probably cause maternal harm. (Yes, the sentence contains a double negative.)

One of the most important arbitrators in evidence – based medicine is the Cochrane Review. It is published by a group of researchers and statisticians who examine the studies on a particular subject which have been published in peer-reviewed medical journals and then use statistical analysis to assess the combined results and the validity of the conclusions. In a search of the Cochrane Library using keywords “bed rest” and “pregnancy”, the authors of the article found that the systemic reviews do not support “therapeutic” bed rest for threatened miscarriage, hypertension, preeclampsia, preterm birth, multiple gestation or fetal growth impairment.

The authors also propose that in addition to the lack of demonstrable benefit there are potential harms to prolonged bed rest for the mother. These include clots or venous thrombosis, bone demineralization, muscle atrophy, maternal weight loss, and maternal psychological problems. We know that bed rest increases the risk for clot formation in large veins which can then lead to pulmonary embolism. Well so does pregnancy. So from a clotting point of view, bed rest in pregnancy is a double thromboembolic whammy. One study that compared the incidence of thrombosis in pregnant women placed on bed rest with those who had no bed rest found their relative risk of a thromboembolic incident was increased by a factor of 19! Moreover lack of ambulation can be very detrimental to bone density. An important study examining bone loss in pregnant women with DEXA scans found that women on bed rest had an adjusted mean loss of 4.6% compared with 1.5% in ambulatory women.

The authors go on to discuss the psychological suffering associated with prolonged bed rest during pregnancy. Women experience separation from their families and worry about their well-being. Studies have shown that depression, anxiety, hostility and self blame for a “problematic” pregnancy can result. There are also severe impacts on the children at home due to shifts in childcare as well as a financial burden from lost wages. In 1993 the societal cost of pregnancy bed rest was estimated to be $1.03 billion per year. Adjusting for consumer price index, that now equates to about $1.6 billion per year.

I personally know about the psychological impact, as well as the financial one, of bed rest in pregnancy. When I was pregnant with my second daughter, I self-diagnosed (I did my own ultrasound, don’t ask!) a large pelvic tumor which I thought might be malignant. So, at five months gestation I had abdominal surgery and a myomectomy. (The tumor was a benign fibroid and no I could not do my own surgery). I subsequently stayed home, at bed rest for the next 3 1/2 months. It was extraordinarily difficult and depressing. My older daughter was unhappy, as were my spouse, patients and colleagues. Did it make a difference? I now don’t know; I finally delivered a second, very healthy daughter at 40 weeks.

Given all these considerations (which did not include my experience), the American College Obstetricians and Gynecologists has stated that, “Although bed rest and hydration has been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects, such as loss of employment, should not be under estimated.”

This is probably one more instance where traditional medical advice is less than certain once the evidence is appropriately examined.

I have written several articles about the high consumption of salt and its unhealthy impact on hypertension, coronary heart disease and mortality rates in Americans. Well it would be remiss of me not to report on a May, 2013 Institute of Medicine review of 39 recent studies on the correlation of salt intake and cardiovascular risk.

Just to remind you, the 2010 Dietary Guidelines for Americans recommended a maximum daily consumption of 2300 mg of salt for healthy adults and 1500 mg for those at increased risk for heart disease (which includes anyone older than 51, anyone with diabetes or pre-diabetes and African Americans). The American Heart Association goes further and advises everyone to adhere to the 1500 mg limit, irrespective of age and race. (There go potato chips, commercial crackers, soups and even bread!) At present, we are a very salty population…the average US adult consumes 3400 mg (about 1.5 teaspoons) of salt daily.

So here is the less-may-not-be-best news from the Institute of Medicine. The studies they reviewed seemed to show that less than 2300 mg of salt a day was not as beneficial as previously thought, at least for those at increased risk of heart disease! They reviewed 39 studies and found that less than 2300 mg salt actually increased some cardiovascular risk factors such as blood lipids (fats) and insulin resistance which could lead to heart problems. (Just a reminder, insulin resistance is the inability to recognize and respond to insulin that is secreted after a glucose or sugar load; so the “frustrated” pancreas produces more and more insulin. High levels of insulin cause production of “bad” lipids and weight gain). The Institute also stated that no evidence suggested a benefit of an ultra-low sodium intake (less than1500 mg daily) in any population.

The researchers do point out, however, that health outcomes cannot always be distinguished from those of overall diet changes and completely accurate conclusions may be difficult. The report concludes (as usual for health declarations) that more trials are needed, especially studies of the effects of the 1500-2300 mg daily salt intake in different groups.

Please remember that the Institute of Medicine and its report does not suggest that people use salt freely. They agree that there is a link between high salt consumption and increase risk of cardiovascular disease and state that the average intake needs to be reduced. So I still would suggest that you pass on those salted potato chips, pretzels and commercial products that are literally steeped in sodium.

This week’s article is not meant to address the truly frightening experience in which the pilot gets on the intercom system and says “Well folks, we’re having some engine problems and have to make an emergency landing.” I do, however, want to discuss the incidence and risks of experiencing a major medical emergency while flying. As many of you know I’ve spent a lot of time on airplanes. I commuted over 10 years between Los Angeles and New York in order to do the Today Show. And since I have family in Israel, I fly to Tel Aviv frequently. Then there are the flights I take to see programs we have established in the developing world for Save the Children. Despite my frequent miles (and happily, frequent flyer points!) I can count on one hand the times I have been asked to assist an ill patient while on board a flight. The rarity of these requests was mirrored in an article that came out in the May 30 issue of the New England Journal of Medicine titled “Outcomes of Medical Emergencies on Commercial Airline Flights”.

The authors point out that worldwide, 2.75 billion passengers flying on commercial airlines annually. They reviewed the records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communication center from January 1, 2008 through October 31, 2010.. Did you know that airlines partner with healthcare institutions to deliver real-time medical advice from an emergency call center to airline personnel. I felt this was both impressive and reassuring. The airlines that they surveyed represented approximately 10% of the global passenger flight volume on those dates. The Communication Center received calls for 11,920 in-flight medical emergencies among an estimated 744 million airline passengers during the study period. And there were over 7 million flights by these airlines, so the representative incidence was one in-flight medical emergency per 604 flights. (A lot of calculations went into these numbers; but no wonder I was rarely called on…even I have not taken that many flights!)

The following data was reported in the survey: The average age of the passengers that had medical emergencies was 48; their ages ranged from 14 days (who would take a 14-day-old baby on a plane, these were not medical flights) to 100 years (wow). The most common medical problems were syncope, (fainting), (37.4%), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). And when the airplane staff requested assistance from any medical personnel on board the response was quite good; it was provided by physicians 48.1% of the time, nurses 20.1%, EMS providers 4.4%, and other healthcare professionals 3.7% of the time for these medical emergencies.

Aircraft diversion, i.e.landing before the plane got to the scheduled airport in order to take care of the ill passenger occurred in 7.3% of the medical emergencies. Of the 10,914 patients from whom post-landing follow-up data was available, 25.8% were transported to a hospital by emergency medical service personnel, 8.6 % were admitted to a hospital and only 0.3% died. The most common reasons for admission were possible stroke, respiratory symptoms and cardiac symptoms.

As an OB/GYN, I’ve often wondered how often planes have had to make non scheduled landings because a pregnant passenger was miscarrying or in labor. Ican attest to the fact that I was never called on to help with this type of emergency while flying.(Delivering a baby during a flight would have been a remarkable experience for the mother, the other passengers and the flight attendants; and could have garnered free future flights for the newborn and me!) The office reported that of the 61 cases of obstetrical emergency symptoms in their study most ( 60.7%) occurred in pregnant women at less than 24 weeks of gestation who had signs and symptoms of possible miscarriage. Only 11 occurred in women who went into labor beyond 24 weeks, of which, 3 resulted in non scheduled landings (and there were no in-flight deliveries.) So altogether, obstetrical symptoms were rare causes of in-flight medical emergencies. This supports existing recommendations that air travel is safe for pregnant women (and the other passengers on the plane who have tight schedules) up to the 36th week of gestation.

Based on their assessment of this data the authors estimate that 44,000 in-flight medical emergencies occur worldwide each year. So although medical emergencies during commercial airline travel is rare, on a per passenger basis they do occur daily and physicians and other healthcare professionals who are in the plane at the time can be called on to aid ill passengers.

I think this article is reassuring both for passengers and medical personnel who happen to be on a plane when a medical emergency occurs. The fact that we can get real-time medical advice from an emergency call center is extremely helpful. The airlines have also improved the emergency kits available for use.

A word of advice: if you have a medical condition it would be a good idea to have a card in your wallet that indicates the diagnosis and current therapies that you receive. You should keep your medications with you on the airplane, in your purse or a case that is under your seat rather than stored in the over head compartment or suitcase down below. Don’t board if you feel sick (especially if you have the flu…think of others seated near you). Take all your regular meds on time, hydrate and if you can’t eat the food served on the plane (or they don’t serve it) bring your own! The friendly skies can be medically friendly if we all do our part.

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