Comprehensive Aviation First Aid and Cabin Crew Medical Training Guide

Course Agenda and Legal Framework for Aviation First Aid

This training program is structured over a two-day period followed by a practical assessment. Day $1$ covers general principles, aviation physiology, medical assessments, in-flight medical emergencies, and first aid equipment. Day $2$ focuses on travel health, basic first aid, travel hygiene, and specific lifesaving procedures including the recovery position, choking maneuvers, cardiopulmonary resuscitation (CPR), and the Basic Life Support (BLS) algorithm for adults, children, and infants, as well as the use of the Automated External Defibrillator (AED). The practical portion of the training mandates individual proficiency in CPR (all age groups), the use of the AED and pocket masks, choking maneuvers ($5$ back slaps and $5$ abdominal thrusts), the recovery position, portable oxygen bottle usage, bleeding management, EpiPen application, pulse checking, and engaging in at least $3-4$ first aid treatment scenarios involving demonstration and detailed explanation.

Legal compliance for this training is grounded in the European Union Aviation Safety Agency (EASA) PART - CC and ORO regulations. Airline operators are legally obligated to ensure all cabin crew members possess the knowledge and skills necessary for first aid. Initial training must cover life-threatening medical emergencies, CPR, injury management, and first aid equipment. Recurrent training occurs annually to address selected elements of first aid, while Aircraft Type/Operator Conversion and Differences training focuses on procedures and policies specific to the airline operator.

General Principles and Cabin Crew First Aid Responsibilities

First aid is defined as the initial assistance provided to a person who is ill or has become unwell until professional medical assistance arrives. The priorities in first aid are established as follows: always check safety first, do no harm, preserve life, alleviate suffering, prevent the condition from worsening, and promote recovery. When managing a medical case, cabin crew must function as a coordinated team. This team ideally consists of two crew members providing direct first aid to the casualty, one crew member communicating with the flight deck, and at least one additional crew member monitoring flight safety and the wellbeing of other passengers.

Cabin crew duties vary based on the severity of the situation. For unwell passengers or those with minor injuries, crew should establish symptoms, plan actions, ensure correct positioning, provide aid rapidly and calmly, reassure the passenger, and inform the flight deck. In cases involving seriously ill, unconscious, or seriously injured passengers, the flight deck must be informed immediately, the Basic Life Support (BLS) algorithm must be initiated, and a public announcement (PA) should be made to call for volunteer medical personnel on-board. Regarding medication, crew should let the passenger self-administer drugs and never force pills or liquids into the mouth of an unconscious person or someone unable to swallow. If surgery is anticipated, nothing should be given by mouth ($NPO$). A record of all drugs or fluids taken, including the exact time and dosage, must be maintained.

Communication, Reporting, and Survival First Aid

The flight deck must be informed immediately of any medical situation on board. During critical phases of flight such as taxi, take-off, and landing, contact with the flight deck should be limited to emergency situations like sudden cardiac arrest. When calling for medical volunteers, crew should take the volunteer's data and ask about their medical qualifications, noting that the volunteer's decision is not binding. The Commander (Pilot in Command - PIC) holds the final decision regarding the disembarkation of ill passengers or making an intermediate landing. Crew may also contact ground-based doctors via radio for instructions or order airport medical services or an ambulance. If the airline uses a Medical Support Ground Provider, contact is mandatory to obtain assistance, though the PIC retains final authority over diversions.

Documentation is a critical legal and safety requirement. Any non-standard or unusual medical situation must be documented using a Medical Incident Report Form, which must be submitted no later than $24$ hours after the duty. These reports are analyzed to address identified safety issues. Furthermore, crew must be prepared for Survival First Aid, which applies in normal operations or wilderness scenarios such as crashes or diversions. Key survival skills include managing heatstroke, burns, fractures, severe bleeding, and hypothermia or frostbite, while focusing on the core survival needs: location, protection, water, and food.

Aviation Physiology: Pressure, Humidity, and Dehydration

The aircraft cabin environment is unique, characterized by a pressurized cabin that maintains a constant pressure equivalent to an altitude of $1600 \text{ m}$ to $2400 \text{ m}$. While this protects healthy organisms from oxygen deficiency, it can be problematic for passengers with respiratory or circulatory diseases whose adaptive mechanisms are impaired. Relative humidity in the cabin is extremely low, ranging between $10\%$ and $20\%$, because the system draws outside air which averages only $12\%$ humidity. To compensate for fluid loss and prevent dehydration, individuals should drink at least $2 \, dl$ ($200 \, ml$) of still water per hour of flight.

Dehydration occurs when fluid loss exceeds intake, preventing normal body functions. Symptoms of mild to moderate dehydration include dry skin, chapped lips, a scratchy throat, itchy nose, dry eyes, dry mouth, dizziness, and headache. Severe dehydration is characterized by rapid breathing, a rapid heartbeat, muscle weakness, severe dizziness, and potential unconsciousness. Alcohol exacerbates these effects because it increases dehydration, and dehydration, in turn, increases the effects of alcohol on the body. Furthermore, altitude can reduce the sense of taste by up to $30\%$ due to the impact of low humidity and lower air pressure on taste buds. Both prescription and over-the-counter drugs can have more pronounced effects at altitude, potentially leading to impaired judgment, drowsiness, and blurred vision.

Hypoxia and Hyperventilation

Hypoxia is a life-threatening condition defined as a lack of sufficient oxygen in the cells, resulting from low blood oxygen or poor circulation. External causes include cabin depressurization or gas poisoning, while internal causes include lung conditions, bleeding, heart problems, shock, and choking. Recognition signs include rapid breathing, difficulty speaking, cyanosis (bluish-grey lips and fingertips), anxiety, headache, nausea, euphoria, and an inability to perform simple tasks. If hypoxia is suspected, oxygen must be provided, the passenger monitored, and emergency medical assistance sought if symptoms worsen or unconsciousness occurs. The Time of Useful Consciousness (TUC) is the maximum time a person can make rational decisions without supplemental oxygen. Factors reducing hypoxia tolerance include fatigue, physical effort, alcohol, and nighttime conditions (where night vision is affected first).

Hyperventilation, or over-breathing, is often triggered by panic, anxiety, or acute stress. It involves rapid, shallow breathing that causes carbon dioxide ($CO_2$) levels to drop abnormally low. Recognition features include unnaturally fast breathing, red skin color, panic, dizziness, tingling in the hands, and cramps in the hands/feet. Treatment involves making the casualty comfortable, remaining calm, and coaching them to slow their breathing. Giving sips of water can help. While oxygen does not help hyperventilation directly, it is safe to provide if it is difficult to distinguish the condition from asthma or a heart attack. If using a paper bag for re-breathing, do so cautiously; coaching is considered the superior method.

Barotrauma, Altitude Meteorism, and Decompression Sickness

Barotrauma results from the expansion of gases in body cavities during ascent and their contraction during descent. If gases cannot communicate freely with the outside—often due to a cold, sinusitis, or allergic rhinitis—trapped gas causes pain or tissue damage. Ear barotrauma affects the middle or inner ear and is managed by chewing gum, yawning, or performing the maneuver of taking a breath, pinching the nose, and swallowing air. If the eardrum bursts, slight bleeding may occur; this should not be blocked but rather soaked up with a dressing. Sinus barotrauma is similarly caused by blocked passages. Altitude meteorism refers to the expansion of gas in the stomach and intestines by up to $25-30\%$ at altitude, causing bloating and abdominal pain. Relieving this condition requires the passenger to pass gas, burp, or use the toilet.

Decompression sickness is a rare but severe condition caused by rapid atmospheric pressure changes, most common in scuba divers who fly too soon after diving. Dissolved nitrogen gas forms bubbles in the blood and tissues, causing joint pain, rashes, paralysis, or death. Treatment includes providing oxygen, asking about recent diving history, and moving the aircraft to a lower altitude (higher pressure). The casualty should be kept in a comfortable position without raising the legs and will eventually require hospitalization in a hyperbaric chamber. Air sickness, a form of motion sickness, is also common and is managed by leaning back, sitting closer to the front of the aircraft, avoiding digital screens, and focusing on a distant land point while consuming only light food like crackers.

Medical Assessment and Vital Signs

Assessment begins with the Primary Survey using the BAP rule (Brain/Consciousness, Airways/Breathing, Pulse/Circulation) and the AVPU scale. The AVPU scale categorizes response as Alert (awake and talking), Voice (responds to verbal stimulus), Pressure/Pain (responds to a squeeze of the hand or ear pinch), or Unresponsive. To check breathing, one must "Look, Listen, and Feel" for $10 \text{ seconds}$ after opening the airway with a head tilt/chin lift or jaw thrust. If the casualty is breathing, they go into the recovery position; if not, CPR begins immediately. The brain can only survive approximately $3 \text{ minutes}$ without oxygen; irreversible damage occurs within $3-5 \text{ minutes}$, and brain death occurs within $7-8 \text{ minutes}$.

Secondary Assessment involves gathering a detailed history using the SAMPLE interview: Signs and symptoms, Allergies, Medication, Previous medical history (including pregnancy), Last oral intake, and Events leading to the incident. If pain is present, the WILDA assessment is used: Words to describe pain, Intensity ($1-10$), Location, Duration, and Aggravating/Alleviating factors. A Head-to-Toe assessment (Body Check) is performed if trauma is suspected, looking for bruising, bleeding, swelling, pupil response, and fractures. Vital signs monitored include breathing rate, oxygen saturation (indicated by skin color), body temperature (normal is $37^{\circ}C$), and pulse rate. Pulse is checked only on conscious victims for $30 \text{ seconds}$ and multiplied by $2$. Normal pulse rates are: Adults ($60-100 \text{ bpm}$), Children ($70-140 \text{ bpm}$), and Infants ($90-150 \text{ bpm}$).

Respiratory and Immune System Emergencies

Asthma is characterized by airway constriction, inflammation, and mucus. Recognition signs include wheezing, difficulty speaking in full phrases, coughing, and anxiety. Treatment involves making the casualty comfortable (leaning forward), using their reliever inhaler (usually blue), and providing high-flow oxygen. If the second dose of the inhaler fails or exhaustion leads to respiratory arrest, emergency assistance is vital. Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease managed similarly to asthma. Allergic reactions occur when the immune system overreacts to allergens. Severe reactions (anaphylaxis) involve fast progression, difficulty breathing, and a drop in blood pressure. Treatment requires removing the allergen, providing oxygen, and using an adrenaline auto-injector (EpiPen). The EpiPen is pushed firmly into the outer thigh at a $90^{\circ}$ angle (through clothing if necessary) and held for $10 \text{ seconds}$. A second dose may be needed after $5-10 \text{ minutes}$.

Histamine Poisoning (Scombroid poisoning) often results from eating spoiled fish and mimics an allergic reaction. Symptoms include facial flushing, nausea, burning in the mouth, and abdominal cramps. Treatment includes checking vital signs, making a PA for a doctor, and helping the passenger take their own antihistamines if available. Close monitoring is required to ensure the passenger does not descend into anaphylaxis or lose consciousness.

Nervous System, Cardiovascular, and Circulatory Disorders

A stroke is caused by a blood clot (ischemic) or bleeding (hemorrhagic) in the brain. Assessment uses the FAST acronym: Face (dropping), Arm (weakness), Speech (difficulty), and Time. Treatment requires a comfortable position (legs not raised), oxygen, and emergency landing, as treatment within $3 \text{ hours}$ is critical. For headaches and migraines, crew should offer water, rest, and a wet towel on the forehead; severe cases involving fever or confusion require medical personnel. Seizures can be Minor (blank staring, minor twitching) or Major (unconsciousness, stiffening, convulsions). During a major seizure, do not restrain the person or put anything in their mouth; pad the area to prevent injury and place in the recovery position afterward. Febrile seizures in children (birth to $5 \text{ years}$) are caused by rapid temperature rises and require cooling the child by opening air outlets and removing extra clothing.

Cardiovascular conditions include Heart Attack, Angina Pectoris, and Sudden Cardiac Arrest (SCA). A Heart Attack involves a blocked blood flow and muscle death; recognized by central chest pain, breathlessness, and a feeling of impending doom. Treatment includes a semi-sitting position, high-flow oxygen, and encouraging the use of prescribed medication like Nitroglycerin or chewing Aspirin (if not allergic). Angina is temporary chest pain relieved by rest. Sudden Cardiac Arrest is an electrical malfunction where the heart stops; treatment requires immediate CPR and the use of an AED. Deep Vein Thrombosis (DVT), or "Economy Class Syndrome," involves blood clots in the legs. Prevention includes movement and hydration. If the clot travels, it causes a Pulmonary Embolism, marked by sharp chest pain and sudden shortness of breath. DVT treatment involves rest and immobilization; never massage the affected area.

Shock, Diabetes, and Gastrointestinal Issues

Shock is a life-threatening failure of the circulatory system. Types include Hypovolemic (fluid loss), Cardiogenic (heart failure), Allergic (anaphylaxis), and Septic (infection). Recognition signs include pale, cool, sweaty skin, and rapid breathing. Management involves stopping any bleeding, using an EpiPen for allergies, providing sugary drinks if relevant, loosening tight clothing, lying the casualty down with legs raised, and keeping them warm. If the casualty is pregnant, they must lie on their LEFT side. Diabetes leads to Hypoglycemia (low sugar) or Hyperglycaemia (high sugar). Hypoglycaemia symptoms are rapid (hunger, sweating, irritability) and treated with juice, honey, or chocolate. Hyperglycaemia develops gradually and requires professional hospital treatment. If unsure of the type, always give sugar.

Gastrointestinal disturbances like vomiting and diarrhea can result from air sickness, food poisoning, or infection. The main risk is dehydration, especially in children and the elderly. Treatment involves providing still mineral water for slow sipping, relocation near a lavatory, and using protective equipment for cleaning. Alcohol intoxication is managed by assisting the person to a safe place, placing them in the recovery position if unconscious, and never inducing vomiting or giving painkillers, as the combination can be fatal.

Environmental Conditions and Childbirth

Heat exhaustion is caused by salt and water loss (pale, clammy skin), while heatstroke is a life-threatening failure of the brain's thermostat (hot, dry skin, temp above $40^{\circ}C$). Treatment for both involves cooling the casualty with water, fanning, and cold packs in the armpits/groin. Hypothermia occurs when body temperature drops below $35^{\circ}C$. The casualty should be wrapped in a foil survival bag with extra clothing and given hot drinks. Frostbite affects extremities, causing skin color changes and numbness. Treatment involves warming the area in tepid water (below $40^{\circ}C$) and applying a light dressing; never rub the skin as this causes further damage.

Emergency childbirth consists of three stages: dilation, delivery, and afterbirth. Crew should set up the galley with blankets and tissues, support the baby's head (do not pull), and note the time of birth. The umbilical cord should not be cut. If the infant does not breathe within $1 \text{ minute}$, stimulation and pediatric life-saving procedures are required. A miscarriage (loss of fetus before the $20^{\text{th}}$ week) requires resting the mother, treating for shock if bleeding is heavy, and providing oxygen. In the event of death on board, the deceased should be laid down with eyes closed and arms crossed in a separate area if possible. The Commander submits a statement to authorities and looks after the personal belongings of the deceased.

Injuries: Bleeding, Wounds, Burns, and Fractures

Bleeding is categorized as capillary (droplets), venous (dark red, flowing), or arterial (pulsating light red, highest priority). Severe bleeding requires direct pressure with sterile dressings and raising the affected area. Internal bleeding is treated like hypovolemic shock. Vaginal bleeding requires privacy, and if heavy, the casualty's hips should be elevated and the opening covered with thick sanitary pads. Nosebleeds are managed by leaning the person forward and pinching the nose for at least $10 \text{ minutes}$. Wounds should be cleaned with water, disinfected, and dressed. If a foreign object is embedded, do not remove it; bandage around it.

Burns are classified into three degrees based on depth: $1^{\text{st}}$ (redness), $2^{\text{nd}}$ (blisters), and $3^{\text{rd}}$ (black/leathery skin). Treatment involves cooling with running water for at least $10 \text{ minutes}$ ($20 \text{ minutes}$ for chemicals) and applying a non-sticky burn dressing. Never puncture blisters or apply ice. Fractures are managed by immobilization using splints or magazines to prevent joints at both ends of the bone from moving. For open fractures, bleeding must be stopped before immobilization. Elevation slings are used for arm injuries, with the triangle bandage tied at the back.

Travel Health, Hygiene, and Specialized Procedures

Travel health requires crew alertness. Employees must not consume alcohol for a minimum of $8 \text{ hours}$ before duty. Narcotics and unprescribed drugs are forbidden. Blood or bone marrow donation should not occur within $24 \text{ hours}$ of flight duty. Sleep physiology involves Wakefulness, N-REM, and REM sleep. Fatigue results in slow reaction times and impaired memory. Stress, whether acute, episodic, or chronic, can trigger the "fight or flight" response. Nutrition should focus on proteins, fats, and complex carbs while avoiding sugary and highly processed foods. Immunizations are often required by the WHO for international travel.

Travel hygiene focuses on preventing communicable diseases transmitted through air, feces, food, blood, or bites. Measures include routine handwashing (at least $20 \text{ seconds}$ with soap), using Personal Protective Equipment (PPE), and treating all body fluids as infectious. Aircraft disinfection and disinsection (killing insect vectors with Pyrethroids) are performed pre-flight, "blocks away," or at "top of descent." Biohazard waste is managed using the Universal Precaution Kit (UPK), which includes germicidal disinfectants, absorbent towels, and bio-hazard bags.

Lifesaving Procedures: Recovery Position, Choking, and CPR

The recovery position keeps the airway open and allows fluids to drain. It involves straightening the nearest arm, placing the far hand against the cheek, and rolling the casualty onto their side using the far leg as a lever. Pregnant women must be placed on their LEFT side to prevent pressure on the Inferior Vena Cava. Choking is treated with $5$ back slaps followed by $5$ abdominal thrusts in cycles. For infants, back slaps are performed while the infant is facedown on the arm. If the casualty loses consciousness, CPR must begin.

CPR involves $30$ chest compressions at a depth of $5-6 \text{ cm}$ and a rate of $100-120 \text{ compressions per minute}$, followed by $2$ rescue breaths. For children and infants, CPR must start with $5$ rescue breaths before the $30:2$ ratio begins. An AED should be used as soon as possible. The operator should apply pads to the bare skin (one below the right collarbone, one on the left ribs) and follow voice prompts. For children ($1-8 \text{ years}$), specific pediatric pads or the adult pads in an anterior-posterior configuration should be used. CPR is only discontinued if the person starts breathing, a physician instructs otherwise, or the rescuer is too exhausted to continue.