Medical events in commercial aviation represent a recurrent operational and safety challenge, particularly in the context of increasing passenger volumes, extended flight durations, and an aging population. The International Civil Aviation Organization (ICAO) recognizes inflight medical emergencies as safety-relevant hazards that may influence flight operations, including diversions and crew workload.
Remote Medical Advisory Services (RMAS) have therefore become an integral component of Airline Safety Management System, providing real-time medical expertise to support crews and operational centers. However, RMAS are often considered as isolated interventions rather than part of a broader continuum of care. A First-Middle-Last Mile framework offers a structured systems-based approach to understanding and improving RMAS effectiveness.
FIRST MILE represents human preparedness and organizational readiness prior to the onset of a medical event, encompassing the training and competency of cabin crew, flight crew, gate agents and ground staff. Cabin crews are designated by ICAO and IATA as the primary onboard medical responders. Their ability to recognize time-critical conditions, perform first aid and basic life support, and accurately communicate clinical information is fundamental to effective medical response. The quality of data generated during this stage directly influences downstream medical decisions. Equally important is the role of gate agents and ground staff in identifying unwell passengers before boarding and coordinating with airport medical services. Positioning and training as the ‘First Mile’ align with Safety Management System (SMS) principles by emphasizing early hazard identification, risk mitigation and data fidelity as determinants of medical and operational outcomes.
MIDDLE MILE constitutes the operational core of RMAS. This phase includes the competency and efficiency of the Remote Medical Command Center (RMCC), comprising emergency physicians, paramedics and medical coordinators. Physicians providing aeromedical advice must integrate clinical judgment with an understanding of aviation physiology, cabin environment limitations, and operational constraints such as time to destination and diversion airport capability. Efficient internal workflows, standardized protocols and clear escalation pathways are essential to timely and proportionate decision-making. Communication infrastructure is a defining element of the Middle Mile. While traditional voice-based systems remain common, the latest App-based communication platforms offer distinct advantages: stable connectivity, structured clinical data capture, multimodal information exchange and time-stamped documentation. These systems enhance situational awareness, reduce cognitive load on crew members and support medico-legal governance and quality assurance.
LAST MILE involves the transition from RMAS care to definitive ground-based medical treatment following landing or diversion. Effective handover to airport emergency services and local healthcare providers is essential to maintain continuity of care. Comprehensive transfer information should include symptom evolution, interventions/treatment and clinical rationale. Variability in global airport medical infrastructure underscores the importance of standardized handover protocols and pre-arrival coordination. The Last Mile also functions as a learning mechanism within the RMAS ecosystem. Post event review, outcome analysis and integration of lessons learned into training and management protocols enable continuous improvement and closing the safety loop.
The First-Middle-Last Mile framework conceptualizes RMAS as an integrated continuum rather than a standalone service. Aligning human preparedness, command center performance and communication infrastructure with SMS principles enhances patient safety, reduces unnecessary diversions and strengthens operational resilience in commercial aviation.
Author: Dr. Surendra Sodhi
Chief Advisor of Aeromedical Services
*Find out more about MD Onboard's engagement in the IATA's Strategic Partnerships Program on the partners directory.
