Hrev_master [page 104] [Emergency Care Journal 2024; 20:12863] Emergency Care Journal 2024 volume 20:12863 Abstract Traveling physicians will likely be called for medical assis- tance on board. In-flight medical emergencies (IMEs) are common and occur in a complex environment with limited medical resources. This study evaluated senior medical students’ willing- ness, understanding, confidence, and attitudes toward IMEs and their willingness to respond to them. This cross-sectional study was conducted among senior medical students in the College of Medicine, King Saud University, Riyadh, Saudi Arabia. These medical students were sent a self-administered online question- naire, which consisted of basic demographic data, a survey to eval- uate IME experiences, and a 10-item questionnaire to assess the attitude of students. Among 302 medical students, 52.3% were males, while 66.9% were over 22 years old. The prevalence of stu- dents who attended life support training was 62.6%, which was highly significant among the 5th-year level (p = 0.001). Neutral attitudes were found in most students (87.7%); 4.6% had positive attitudes, while 7.6% had negative ones. Being at the 5th-year level and having previous participation in life support training were associated with an increased attitude toward in-flight medical emergencies. The attitude of senior medical students toward IMEs was less than desired. However, the attitude was better among 5th- year medical students who attended training courses on managing IMEs. Thus, participation in training courses influenced the will- ingness to manage such cases. Subsequently, longitudinal studies are needed to extract more data on the knowledge and confidence of medical students toward IMEs. Introduction In-flight medical emergencies (IMEs) are surprisingly com- mon and often unfold in a complex environment characterized by limited medical resources and heightened safety concerns. These incidents pose exceptional challenges for physicians and other individuals involved in air travel.1 With statistics indicating an average of one medical emergency per 604 flights, the likelihood of a traveling physician being called on to provide medical assis- tance while onboard is significant.2 Studies examining in-flight emergencies have highlighted the relatively low death rate among commercial passengers, estimated at approximately 0.31 to 0.34 per million passengers. Cardiovascular events account for approx- imately 70% of these incidents.3 However, for the individual who has volunteered to offer aid, these statistics hold little significance in the face of the responsibility of caring for an ill passenger. Globally, the body of literature comprises various reviews and case reports delving into IMEs.3,4 However, comprehensive studies focusing on the readiness and confidence of senior medical stu- dents in responding to IMEs remain scarce. IMEs pose significant challenges for travelers and healthcare providers. Airline cabin crews serve as first responders to IMEs, which makes their training in first aid and emergency procedures crucial for passenger safety. Previous research has emphasized that the “appropriate training of crew members, availability of adequate medical resources, and improved dialogue between aircraft and ground doctors contribute to positive outcomes for medical issues on board.” Moreover, incorporating advanced telemedicine solu- tions further enhances safety and reassures passengers during flights.5 While licensed physicians often address IMEs, medical students may also find themselves in situations where they are the only available healthcare professionals. Limited research on senior medical students’ preparedness, confidence, and attitudes regard- Correspondence: Yazeed Obaidallah Almutairi, Department of Family and Community Medicine, College of Medicine, King Saud University, P.O. Box 11495, Riyadh, Saudi Arabia Tel.: +966536358208 E-mail: yazeed.almutairi0@gmail.com Key words: in-flight medical emergency, senior medical students, knowledge, preparedness Contributions: Conceptualization: YA, SA, and AS; Data curation: YA, MA, and AB. Formal analysis: MA, and AB; Funding acquisi- tion: None. Investigation: YA and NA; Methodology: AB and NA; Project administration: YA, SA, and AS; Resources: MA and AB; Software: MA and AB; Supervision: SA; Validation: NA; Visualization: SA and AS; Writing – original draft: MA and AB; Writing – review & editing: YA, NA, and SA. Conflicts of interest: the authors declare no conflict of interest. Funding: not applicable Ethical approval: approval reference number 23/0802/IRB in October 2023. Received: 27 July 2024. Accepted: 30 September 2024. Early view: 15 October 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12863 doi:10.4081/ecj.2024.12863 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Addressing a community need: assessing the confidence and attitude of senior medical students in responding to in-flight emergencies Yazeed Almutairi,1 Maha AlQahtani,2 Abdullah Binghaith,2 Saud Alsayed,1 Abdulelah Sharaf,1 Nasser M. AbuDujain,1 Saleh Aljarallah1 1University Family Medicine Center, Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, Riyadh; 2College of Medicine, King Saud University, Riyadh, Saudi Arabia Non -co mmerc ial us e o nly ing IMEs in Saudi Arabia highlights a critical knowledge gap in this region. Thus, our study aimed to fill this gap by comprehen- sively evaluating senior medical students’ understanding, confi- dence, and attitudes toward IMEs and their willingness and self- perceived competency in responding to such emergencies while considering their potential roles in future emergency medicine practice and the unique medico-legal implications they face. Materials and Methods Study design, participants, and setting This study employed a cross-sectional design to examine the preparedness of senior medical students at the College of Medicine, King Saud University, Riyadh, Saudi Arabia. Participants included male and female students in their fourth and fifth years of medical school (i.e., senior students). The study was conducted between December 2023 and February 2024 with 302 of 570 senior medical students who were recruited using snowball sampling. The sample size calculation was based on a 5% margin of error and a 95% confidence interval (CI). The initial estimated sample size of 230 was increased to account for potential non- response, which resulted in the final target sample size of 302. Instruments This study utilized a questionnaire developed by Alarifi et al.,6 which consisted of sociodemographic, academic, and personal his- tory information via ten items on a 5-point Likert scale: i) demo- graphic information (i.e., age and sex); ii) academic information (i.e., the current year of study); and iii) personal history information (i.e., the frequency of participant travel, and whether the participant underwent training courses in IME management, whether the par- ticipant received life support training (i.e., Basic Life Support [BLS], Advanced Cardiovascular Life Support [ACLS]) or attended another course with its name, the course type, and the number of times attended. If the participants affirmed attending life support training, they encountered two subsequent inquiries. First, they were asked to identify the conditions covered in the courses they attended, with multiple options available. Second, they were asked whether they had provided medical assistance during an IME. In the event of a negative response, the participants were required to spec- ify the reason. Attitudes toward IMEs were assessed using a 10- item questionnaire, with 5-point Likert scale categories ranging from “strongly disagree” (coded as 1) to “strongly agree” (coded as 5). The first three statements assessed the participants’ knowledge of available medical supplies on commercial airplanes, their under- standing of the training level of commercial aircrew in managing IMEs, and their comprehension of the collaboration between the aircrew, ground-based medical control, and onboard volunteer healthcare providers during such emergencies. The subsequent three statements pertained to the participants’ willingness to man- age IMEs. Specifically, they were asked if they would identify themselves as doctors and offer assistance, if they would refrain from intervening if another individual was already assisting, and if they would offer help despite being unfamiliar with the nature of the emergency, even if they were the only healthcare professional on board. Lastly, four statements sought to evaluate the partici- pants’ confidence and concerns regarding IME management. The participants were asked about their fear of potential medico-legal implications, whether they believed they required additional train- ing in this area, their confidence in their existing medical training to render assistance during such emergencies, and their current level of confidence in responding to and providing competent care during an IME. The total attitude score was calculated by adding the ten items, so scores ranging from 10 to 50 points were generated. The higher the score, the higher the attitude toward in-flight emergen- cies. Furthermore, 50% and 75% were used to classify attitude lev- els: scores of less than 50% were considered negative, 50% to 75% were neutral, and above 75% were positive. Data collection procedure and ethical approval The KSU Institutional Review Board approved this project with approval reference number 23/0802/IRB in October 2023. An online survey was created through Google Forms and sent to all participants. The nature and purpose of the study, the primary investigator’s contact information, and an explanation of the con- fidentiality and data anonymity policy were provided. Consent to participate was given by clicking on the informed consent link. After reading the informed consent statement, the participants clicked “Next” to access the study’s survey, which took approxi- mately 5 minutes to complete. Statistical analysis Categorical variables were described as counts and proportions (%), while continuous variables were computed and expressed as the mean and standard deviation. The differences between attitude scores related to sociodemographics and student IME experience were calculated using the Mann-Whitney z-test. Normality was assessed using the Shapiro-Wilk and Kolmogorov-Smirnov tests. According to the results, attitudes followed a non-normal dis- tribution. Thus, a non-parametric test was applied. Moreover, a chi-square test was used to determine the relationship between par- ticipation in life support training according to the basic demo- graphic characteristics and the experience of senior students in IMEs. A p-value of less than 0.05 was considered statistically sig- nificant. All statistical data were analyzed using Statistical Packages for Social Sciences (SPSS) version 26 (Armonk, NY: IBM Corp., USA). Results The study enrolled 302 senior medical students. Approximately two-thirds (66.9%) were over 22 years old. Over half (52.3%) were males, and 51.7% were at the fifth-year level (Table 1). When examining the experience of medical students regarding IMEs (Table 2), only 2.6% had attended training courses related to the management of IMEs, while only 10.6% had previ- ously encountered cases of IMEs. The most commonly encoun- Article Table 1. Basic demographic characteristics of the senior medical students (n = 302). Study variables N (%) Age group ≤22 years 100 (33.1) >22 years 202 (66.9) Gender Male 158 (52.3) Female 144 (47.7) Academic year level 4th-year level 146 (48.3) 5th-year level 156 (51.7) [Emergency Care Journal 2024; 20:12863] [page 105] Non -co mmerc ial us e o nly tered medical emergencies aboard were cardiovascular events (40.6%). In this case, 31.3% of the respondents offered medical assistance. Among those who did not (n = 22), the most common reason was another doctor attending to the patient (36.4%). Approximately 60.9% believed that an IME should cover all spe- cialties. The prevalence of medical students who participated in previous life support training was 62.6%. BLS was the most prominent life support training course type: 52.4% attended at least once. In addition, 44.7% traveled on airplanes at least once annu- ally. Regarding the assessment of attitudes toward IMEs (Table 3), the three statements with the highest ratings were “I need more training in managing in-flight medical emergencies.” (mean score: 4.49), “I am afraid of the medico-legal implications that may arise from my assistance in an in-flight medical emergency” (mean score: 3.91), and “I will stay out of an in-flight medical emergency if someone else is already offering their assistance” (mean score: Article [page 106] [Emergency Care Journal 2024; 20:12863] Table 2. Experienced of in-flight medical emergencies (n = 302). Variables N (%) Received training courses in the management of in-flight medical emergencies Yes 08 (02.6) No 294 (97.4) Have you ever encountered any in-flight medical emergency before? Yes 32 (10.6) No 270 (89.4) Type of medical emergency being encountered (n = 32) * Allergic reaction 02 (06.3) Cardiovascular (e.g., syncope, chest pain) 13 (40.6) Gastrointestinal (e.g., nausea/vomiting, diarrhea) 10 (31.3) Neurological (e.g., strokes, seizures) 05 (15.6) Psychological (e.g., acute anxiety, psychosis) 08 (25.0) Respiratory (e.g., asthma exacerbation, suspected pneumothorax) 03 (09.4) Others 05 (15.6) Have you provided medical assistance? (n = 32) Yes 10 (31.3) No 22 (68.8) If no, please provide a reason (n = 22) No reasons 05 (22.7) There was another doctor 08 (36.4) Lack of knowledge 07 (31.8) Others 02 (09.1) In your opinion, training on an in-flight medical emergency has to be covered in which specialties? * All specialties 184 (60.9) Emergency medicine 125 (41.4) Family medicine 31 (10.3) Internal medicine 19 (06.3) Obstetrics and Gynecology 32 (10.6) Pediatrics 16 (05.3) Surgical specialties 19 (06.3) Others 05 (01.7) Have you received any life support training? Yes 189 (62.6) No 113 (37.4) If yes, what type of training (n = 189) Basic Life Support (BLS) 146 (77.2) Advanced Cardiovascular Life Support (ACLS) 06 (3.2) Both 34 (18.0) Others 03 (01.6) How many times have you taken (life support training)? (n = 189) None 18 (09.5) Once 99 (52.4) 2–3 times 71 (37.6) 4–5 times 01 (0.50) How frequently do you travel via airplane? (in a regular year) Never 48 (15.9) Once a year 135 (44.7) 2–3 times a year 97 (32.1) More than 3 times in a year 22 (07.3) Non -co mmerc ial us e o nly 3.67). In contrast, “I have an adequate understanding of what med- ical supplies are available on commercial airplanes” showed the lowest rating (mean score: 2.29). Based on the above attitude items, the mean attitude score was 30.2 (SD=4.55), with negative, neutral, and positive attitudes of 7.6%, 87.7%, and 4.6%, respec- tively. When exploring the differences in the attitude score related to sociodemographic characteristics and experiences with IMEs, a higher attitude was associated with being a 5th-year-level student (z=2.313, p=0.021) and previous attendance at training courses for IMEs (z=1.936, p=0.024; Table 4). When measuring the relation- ship between participation in life support training, basic demo- graphic characteristics, and experiences with in-flight emergen- cies, 5th-year medical students were likelier to have attended pre- vious life support training than 4th-year medical students (p= 0.001). Other variables showed no significant relationship with previous participation in life support training (p>0.05; Table 5). Discussion This study investigated senior medical students’ willingness, understanding, confidence, and attitudes toward IMEs. Although the overall mean attitude score indicated above-average threshold ratings, most students were neutral (87.7%) toward being involved in IMEs. Several studies have discussed the level of understanding of healthcare providers toward IMEs. For instance, Ng and Article Table 3. Assessment of attitude toward in-flight medical emergencies (n = 302). Statement Mean ± SD 1. I need more training in managing in-flight medical emergencies. 4.49 ± 0.78 2. I am afraid of the medico-legal implications that may arise from my assistance in an in-flight medical emergency. 3.91 ± 1.01 3. I will stay out of an in-flight medical emergency if someone else is already offering their assistance. 3.67 ± 1.06 4. I would not offer assistance if I am not familiar with the nature of the emergency, even though I am the only healthcare professional onboard. 2.94 ± 1.20 5. would identify myself as a doctor and offer assistance in the event of an in-flight medical emergency. 2.82 ± 1.10 6. My medical training has given me adequate knowledge and skills to render assistance during an in-flight medical emergency. 2.67 ± 1.02 7. I would currently feel confident responding to an in-flight medical emergency and providing competent care. 2.53 ± 1.01 8. I have an adequate understanding of the manner in which the aircrew, ground-based medical control, and the onboard volunteer healthcare provider collaborate to manage an in-flight medical emergency. 2.49 ± 1.11 9. I have an adequate understanding of the level of training of commercial aircrew in managing in-flight medical emergencies. 2.38 ± 1.08 10. I have an adequate understanding of what medical supplies are available on commercial airplanes. 2.29 ± 1.09 Total attitude score 30.2 ± 4.55 Level of attitude N (%) Negative 23 (07.6) Neutral 265 (87.7) Positive 14 (04.6) Table 4. Differences in the score of attitude related to the basic demographic characteristics and experiences with in-flight emergencies (n = 302). Factor Attitude Z-test p§ Score (50) Mean ± SD Age group ≤22 years 30.1 ± 5.62 0.112 0.910 >22 years 30.2 ± 3.94 Gender Male 30.5 ± 4.87 0.806 0.420 Female 29.8 ± 4.17 Academic year level 4th-year level 29.3 ± 4.37 2.313 0.021 ** 5th-year level 30.9 ± 4.59 Received training courses in the management of in-flight medical emergencies Yes 33.8 ± 5.20 1.936 0.024 ** No 30.1 ± 4.51 Have you ever encountered any in-flight medical emergency before? Yes 29.8 ± 4.08 0.741 0.459 No 30.2 ± 4.61 Have you received any life support training? Yes 30.2 ± 4.42 0.252 0.801 No 30.1 ± 4.78 [Emergency Care Journal 2024; 20:12863] [page 107] Non -co mmerc ial us e o nly Abdullah reported that the knowledge score of doctors regarding the management of IMEs was below the average threshold and that the overall confidence of physicians was unsatisfactory.7 Katzer et al. found that the average knowledge score regarding IMEs was 64%, and their confidence in responding to IME cases was deemed low.8 However, comparing medical students’ knowledge before and after lectures and simulation cases, the knowledge score of the paired test increased from 61% to 91%, which suggested that stu- dents may improve their knowledge after attending a course on IMEs,9 in agreement with other studies.10 Increasing academic year level and attendance to training courses in the management of IMEs were associated with better IME attitudes. This finding agrees with a study conducted by AlShamlan and their group of licensed physicians working in Saudi Arabia.2 The willingness to assist in IMEs was associated with being male, being involved in a previous IME incidence, attending life support and IME courses, traveling more frequently, and working as a physician in the Central Region. Consistent with previous reports, Sayuti et al.11 indicated that, based on bivariate analysis, BLS training impacted knowledge and skills, which was also consistent with the study of Padaki et al.12 Moreover, in a paper conducted by Alsulimani et al.,13 medical students who com- pleted the BLS course exhibited significantly better knowledge than those who did not attend. No other variables showed a signif- icant association with knowledge. In our study, attitude levels did not differ significantly by age, gender, experience with IMEs, or life support training. Nearly two-thirds (62.6%) of the respondents had received cer- tification for life support training, particularly BLS and ACLS, but participation in training courses on the management of IME was suboptimal (2.6%). This finding mirrored the study of Alarifi and AlRowais.6 Only 36.8% would respond in IME cases. Interestingly, a similar percentage (36.5%) of the respondents believed they could offer competent care and asserted that their medical education was sufficient to treat IMEs (34.5%). Furthermore, 5th-year medical students were more likely to participate in life support training than 4th-year medical students. However, participation in life support training did not vary signif- icantly by age or gender, training courses in managing IMEs, or personal experience with IMEs. In the US,10 emergency medical residents’ self-competency increased after attending a 5-hour in- situ curriculum; residents showed high expectations of the curricu- lum. However, the author mentioned several limitations that could hinder the full implementation of this curriculum (e.g., air flight traffic, varying airport security protocols, and weather conditions). Medical students recognized help provided by another doctor (36.4%) and a lack of knowledge (31.8%) as the most common reasons for not providing medical assistance to IMEs. These out- comes were comparable to a study conducted by Ng and Abdullah.7 The willingness to assist in IMEs decreased if someone else responded to the case and the participant’s knowledge about managing IMEs was inadequate. Contradicting these reports, AlShamlan et al.2 disclosed that nearly half of physicians were concerned about the medico-legal consequences of their actions, such that standard guidelines should be available to respond to incidents like IMEs. This investigation was conducted only in one college, which limited the generalizability of the results. Furthermore, using snowball sampling might not accurately mirror the larger popula- tion. Conclusion and future directions The desirability of student participation in IMEs is complex. While students can provide valuable assistance, it is essential to consider the risks involved and the need for appropriate training and guidance. Encouraging students to participate in training courses and providing clear guidelines for when and how to inter- vene can help mitigate these risks and ensure their assistance is beneficial. BLS training may certainly impact the willingness to assist in IMEs. In addition, periodic training courses on IMEs are necessary to enhance the knowledge and skills of senior medical students. Article Table 5. Relationship between participation in life support training among the basic demographic characteristics and experiences with in- flight emergencies (n = 302). Factor Received life support training p§ Yes No N (%) N (%) (n = 189) (n = 113) Age group ≤22 years 60 (31.7) 40 (35.4) 0.514 >22 years 129 (68.3) 73 (64.6) Gender Male 93 (49.2) 65 (57.5) 0.161 Female 96 (50.8) 48 (42.5) Academic year level 4th-year level 78 (41.3) 68 (60.2) 0.001 ** 5th-year level 111 (58.7) 45 (39.8) Received training courses in the management of in-flight medical emergencies Yes 07 (03.7) 01 (0.90) 0.266 No 182 (96.3) 112 (99.1) Have you ever encountered any in-flight medical emergency before? Yes 21 (11.1) 11 (09.7) 0.707 No 168 (88.9) 102 (90.3) [page 108] [Emergency Care Journal 2024; 20:12863] Non -co mmerc ial us e o nly References 1. Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emer- gencies: a review. JAMA 2018;320:2580–90. 2. AlShamlan NA, AlOmar RS, Alrayes MM, et al. “Is there a doctor on board?”: willingness and confidence of physicians in the Kingdom of Saudi Arabia in assisting with in-flight medi- cal emergencies. BMC Emerg Med 2021;21:54. 3. 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Signa Vitae-J Anesthesiol Intensive Care J Emerg Med J 2024;20:59–67. Article [Emergency Care Journal 2024; 20:12863] [page 109] Non -co mmerc ial us e o nly