Sunday, June 5, 2011

In Flight Emergencies

A recent article in the NY Times When Doctors Are Called to the Rescue in Mid-flight on inflight emergencies brought a flood of memories back for me. The landscape has changed dramatically from the first time I got involved in an "inflight" emergency.
In the the first incident that I can recall it was only just inflight. I was accompanied by two nurse friends (Sarah and Wendy) I had worked with at my hospital as we escorted a group of terminally sick children on a trip of a lifetime to Disney from the United Kingdom. We were on the final leg returning home and the plane (this was PanAm) had left the gate in Miami. I had spotted a gentleman across the aisle who was looking very distressed. My colleagues noticed the same thing and we had a brief exchange on how we might deal with a patient given the close quarters of the aisles and seats. As the plane taxied to take off position he because increasingly uncomfortable, short of breath and diaphoretic (sweaty). As the engines were spooling up I was at his side calling passengers to see if anyone had an sub-lingual Glyceryl Trinitrate (GTN aka Nitroglycerine). Since that incident I used to carry a spray with me on every aircraft ride until the liquid rules at which time it became impossible.
We administered borrowed GTN, aborted the take off roll and returned to the gate. By the time we got to the gate and the paramedics boarded the plane he had improved and his vitals had returned to normal. The US Paramedics were quite dismissive - to their view there was nothing wrong with him and we had wasted their time and the airline's. The gentleman asked our advice on what to do - should he proceed with the flight or get off and be checked out. Sadly in most of these cases we never find out what happens but I am pleased to say that he elected to leave and be checked out on the ground.

Since that incident I always carry my stethoscope and used to carry other items - mainly because the airlines had little in the way of medical equipment or drugs. Since the banning of liquids and the overly aggressive nature of security much of this equipment has been either confiscated as as security risk or just not worth the hassle of security delays.

Much has changed and in my most recent involvement I was pleasantly surprised to open a medical kit with both equipment (intubation, IV fluids and IV equipment, forceps) and also and a case full of useful drugs (useful in this instance include IV agents for heart, seizure and hypoglycemia) or sometime both:
Firstaidkit

But as Dr Abramson points out: “With some planes, it’s a hospital in a box, and they have everything you could ever want. But often they look like they’ve been picked over.”

There are probably better controls these days especially since many of these kist contained controlled drugs and the regulations now require equipment to be available but I'm betting ymmv

In many cases the in-flight kit includes and Automatic Emergency Cardiac Defibrillator (AECD) - often abbreviated to AED which attaches to patients and will assess rhythm and administer shocks semi automatically. I've had occasion to use one of these one time. This was the model on the aircraft I was on at the time:
Defibrillator-with-ecg-display
Attaching it to a patient who had no discernible blood pressure was unconscious and once connected in apparent asystole that spontaneously reverted to sinus rhythm before the shock was administered (much to the relief of the patient who woke up to find himself attached to the device as it issued an audible warning of rhythm problems)

From my own personal recollection my experiences have included the following conditions
- kidney stone
- psychotic episode
- alcohol intoxication
- gastritis/food poisoning
- angina
- severe migraine
- hypotension of unknown etiology

The general incidence of in flight emergencies has risen

Since the earliest days of commercial aviation, airlines have coped with medical emergencies in flight by calling on physicians who happen to be passengers. And as more people travel by air, the number of emergencies has risen accordingly. “Passenger health is becoming more and more of an issue, because of increased life expectancy and more people flying with pre-existing conditions,” said Dr. Paulo Alves, a vice president at MedAire, a company that provides crew members with medical advice from physicians on the ground.

My personal experience has been cyclical with a spate of incidences followed by none for months. But the experience is challenging at best:

Airborne calls for medical assistance pose a singular challenge for physicians, who find themselves suddenly caring for a stranger whose history they don’t know, often with a problem well outside their specialty, in a setting with limited equipment but no shortage of onlookers scrutinizing their every move

What I found interesting was that despite being in a deep sleep (working as a junior doctor gives you all the skills necessary to sleep anywhere, anytime and any place) I have had several occasions where the announcement requesting medial assistance is like your own child's cry - it stands out and woke me up.

As for thanks - I've received everything from snide remarks (Miami EMT's) to thanks, bottles of wine and my personal favorite the opportunity to sit in the jump seat for landing (fantastic view and a rare opportunity to watch the landing process first hand). Like my colleagues your desire to help is vested in the original intent that is among the purest expressions of their Hippocratic oath. It would always be nice to know how the patient did following intervention but I'm willing to bet that privacy regulations make this a challenging request to fulfill even if the patients who would likely be willing to share the outcomes

There remain challenges in the system and with the improvement of medical equipment and drugs. But the identification of individuals available to help is still relatively poor. Like Dr Abramson:

He also books his flights with “Dr.” in front of his name. “That’s so that if I’m asleep, they might wake me,” he said. And he doesn’t take sleeping pills or drink alcohol in flight. “The last thing you want to do is be woken up and not be with it,” 

my flights are all booked with "Dr" in front of my name but since that moniker is used by a wide range of people (PhD's, dentists, vets, optometry, chiropractor, pharmacy, psychology, homeopathy, physical therapy, lawyers) and then there are the British Surgeons who go by Mr, Mrs or Miss.

I have also had instance of being asked to provide proof of my medical degree. To a set of flight attendants on one flight my inability to show my medical degree relegated me to observer as the dermatologist and medical student attempted to deal with a falling blood pressure of unknown etiology. Lufthansa do have a program that allows you to fax your medical degree to their offices and they mark your frequent flyer record with an annotation that shows up whenever you fly to alert the flight crew that you are a doctor and willing to be called upon when you fly - that seems smart but is not replicated by any other airline to my knowledge. 

If I had a wish list it would include some means to validate my ability to help by providing my medical degree to the airlines, the opportunity to review the equipment and support ahead of time (in all instances where I have opened medical kits I have, with permission, dug into the box extensively to find out what is available for future reference) and some formal reporting mechanism and follow up.

We all step up to the plate when asked - it would be nice if the airlines acknowledged that in some way as they lean on these resources on a daily basis and provided support and acknowledgement that was not as arbitrary as it is today.

What has your experiences been - have you had in flight problems and how did you deal with them. Are there any air lines better than others at managing this request and in the support they provide?

Posted via email from drnic's posterous