Linda E. Pelinka, MD, PhD Medical University of Vienna a nd Ludwig Boltzmann Institute

“Is there a MEDICAL PROFESSIONAL

ON BOARD this aircraft?”Challenges at 35.000 ft

Linda E. Pelinka, MD, PhDMedical University of Viennaand Ludwig Boltzmann Institute

for Experimental & Clinical TraumatologyVienna, Austria, European Union

TRAUMA

BasicsPathophysiologyMedical EquipmentCommon problemsEmergenciesLegal Aspects

Basics

StatisticsWorldwide, ~1 million people are

traveling by air at any given time>700 million Americans travel by air

in the US~one per 10-40,000 passengers will

experience an medical emergency.U.S. Federal Aviation Administration. Moving America safely:

annual performance report 2005. http://www.faa.gov/air_traffic

Sand M et al. Surgical & Medical Emergencies on board European Aircraft:10189 cases. http://ccforum.com/content/13/1/R3

>50% of passengers age 50 or over have at

least one health issue(s)

Emergencies will become more frequent

as % of elderly increases

Goodwyn T: In-flight Medical Emergencies: an Overview. Brit Med J 2000; 321:1338-41

There are more deaths from in-flight medical emergencies

than from airline accidents.

In 2006:550 medical diversions59% were 50 or older

63 passengers died in-flight

National Transportation Safety Board and Med Aire

In the Air, Health Emergencies rise quietly

The death of an AA passenger flying from Haiti toNYC has cast a spotlight on the growing number ofmedical emergencies on commercial jets, a trendthat has escaped public notice because airlinesaren’t required to report such incidents.A MedAire analysis shows that such incidents nearly doubled from 2000-2006,

from 19 to 35 per million passengers.

USA TODAY, Dec 2008

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In the Air, Health Emergencies rise quietly

According to analysts, this is due to 2 factors:79 million baby boomers are entering

retirement, but continue traveling habits established when they were young.

Flights are going farther and lasting longer. Av. length of a flight in 2000: 1,233 mi

Av. length of a flight in2006: 1,347 Max flying time today: 20 hrs

USA TODAY, Dec 2008

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“if you are ill, an airplane is the worst place to be…

“… you are trapped at 35,000 ft.”David Stempler

President of the Air Travelers’ Association.

Pathophysiology

Setting on Board: passenger’s point of view

Very cramped everywhere

(seat,

restroom)

Three-dimensional

motion of

aircraft

Very dry

DehydrationHemoconcentration & hyperviscosity

increase risk of thromboembolismThe mild hyperbaric changes during flight

are sufficient to cause increased activation of coagulation in healthy individuals with no thrombophilia compared with that in individuals seated and not moving at ground level.

Toff WD et al: Effec of hypobaric Hypoxia, simulating Conditions during long-haul air travel on Coagulation, Fibrinolysis, Platelet Function and Endothelial Activation. JAMA 2006; 295: 2251-61.

Humidity

Low, typically 10-20%

Low humidity has a propensity to

exacerbate reactive airway

disease and dehydration

Hocking MB: Passengr Aircraft Cabin Air Quality: Trends, Effects, SocietalCosts, Proposals. Chemosphere 2000; 41:603-15

Commercial cruising altitude

7010-12,498 m

Cabin Pressurization to 2438 m:What happens?

Humpreys S et al: Effect of high Altitude Commercial Air Travel on O2 Saturation. Anesthesia 2005; 60: 458-60

Atmospheric cabin pressure drops

PaO2 drops from 95(12.7 kPa) to 65mmHg (8.7 kPa)

Oxyhemoglobin sat drops from 95-100% to

90%

Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77

The passenger cabin is pressurised to 1524—2438 m. This reduced pressure within the passenger cabin results in lower syst. PaO2 and oxyhaemoglobin (oyx-hb). For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension.


Passengers with pre-existing lower sea-level oxy-hb sat have greater declines during flight. E.g., a passenger with mild COPD with a sea-level PaO2 of 70 mm Hg PaO2 to about 53 mm Hg or oxy-hb sat of approximately 84% at a cabin altitude of 2438 m


pO2 Drop at various Altitudes 8

7

6

54

3

2

10

3032

3438

45

5461

6973

8189

100

20 40 60 80 100 120

Altit

ude

in k

m

pO2 in mm Hg

pO2 drop by ~30 mmHg between sea level and

cabin press. level (2400m) vs ~4 mmHg

between 6000-8000m)

mod acc to Stueben, U. Flugmedizin Med. Wissenschaftliche Verlagsges. Berlin, 2008

low cabin pressure

lower alveolar pO2 (55-70 mmHg)lower arterial pO2 (~90%)

Curdt-Christiansen, C. et al: Principles and Practice of Aviation Medicine. World Scientific, London, 2009.

increasing edema

Effect of Aircraft-Cabin Altitude on Passenger Discomfort

Muhm JM et al. N Engl J Med 2007; 357: 18-27

The frequency of reported complaints associated with acute mountain sickness (fatigue, lightheadedness and nausea) increased with increasing altitude and peaked at 2438 m. Most symptoms became apparent after 3-9 hrs of exposure.

Cabins in new Airbus A380,

Boeing 787, pressurized

at 1829 m

Hypoxia

Preexisting cardiac

and/or pulmonary

and/or psychological

issues

Cabin pressure

Mild Hypoxia

68-Year-)ld woman with Chest Pain during an Airplane FlightPicard, MH et al. New Engl J Med 2010; 363/27: 2652-61.

History of hypertension and hyperlipidemiaFlight from the Middle East to Europe:

Gradually developing chest pain and pressure, fluctuating intensity, not radiating. Resolves spontaenously after several hours

Subsequent flight Europe to U.S.: Chest pain recurs.

Is Air Travel Safe for those with Lung Disease?

Coker RK et al. Eur Resp J 2007; 30: 1057-63

This prospective, observational study

showed that 18% of passengers with COPD

have at least mild respiratory distress

during a flight.

Cramped Space & Immobilization

Have been linked to 75% of all air-travel cases of venous thromboembolism

Greatest frequency of theomboembolism in non-aisle seatsCesarone MR et al: Venous Thrombosis from Air Travel: the

LONFLIT3 Study – Prevention with Aspirin vs LMWH in high-risk subjects. Angiology 2002; 53: 1-6.

ThromboembolismRisk peaks up to four-fold

when flight duration >8 hRisk factors: Dehydration, immobility,

hypobaric hypoxia, obesity, malignancy, recent surgery, h/o hypercoagulable state

Oral contraceptives increase risk 16-foldBusiness vs coach class no effect on

incidenceAryal KR & Al-Khaffaf H. Eur J Vasc Endovasc Surg 2006; 31: 187-99.

Jacobson BF et al. S Afr Med J 2003; 93: 522-528.

Boyle’s LawThe volume occupied by a gas

is inversely proportional to the surrounding pressure.

Thus, at cruising altitude, gas in body

cavities expands by 30%:

Boyle’s Law & BarotraumaHealthy passengers

minor abdominal

cramping, ear

pressure

Passengers after recent surgery

Bowel perforation,

wound

dehiscence

GuidelinesDelay flying for

12 h after scuba diving (1 dive) w/o deco

24 h after several dives or 1 dive + deco

7-10 dys after diverticulitis

2 wks after major surgery

Medical Guidelines for Airline Travel, 2nd Edn. Aviat Space Environ Med 2003; 74 (suppl): A1-A19

Boyle’s Law &

Effect on Medical Equipment

Gas expansion inPneumatic splintsUrinary cathsFeeding tubesET tubes (instill water instead of air)

Medical Equipment

Emergency Medical Kit

Device

Stethoscope

Blood pressure cuff

Bag-mask resuscitator

1 required, child/infant optional

Oral airways 3 sizes required

Emergency Medical KitDrugNitroglycerin 10 tablets min.Aspirin 4 tablets min.Albuterol 1 metered-dose inhalerDextrose 50% 25g min.Oral Antihistamines 4 tablets minIv Antihistamines 2 amps minIv Epinephrine 1:1000 2 mg min (allergic react.)

Emergency Medical KitCardiac Resus Drugs

Iv Epinephrine 1:10,000 2 mg total min

Atropine 1 mg total min

Lidocaine 200mg total min

Emergency Medical KitDevice opt. provided on

intercontinental flights: Tempus ICState of the art telemed

monitor

Transmits info incl digital pics, video to ground based

physician

Automated BP cuff, glucometer, capnometer, 12-ld ECG, pulse oximeter

Provides on-screen, step-by-step instructions

Opioids

- Nalbuphine and Morphine –

are provided by some carriers

Emergency Medical Kit

Drugs optionally provided on intercontinental flights

Ondansetron

Nalbuphine !

Naloxone

Oxygen

Masks and nasal tubes available on board.

Emergency bottles provide O2 at a fixed rate of 4

liters/min.Sufficient for 75 min.

Medication and technology are expensive but may still

be cost-effective

Diversion can cost from US$10,000 to $100,000 depending on the route

Equipment ChallengesAuscultation (pulm., BP) difficult due to

ambient engine noise. Alternative: radial pulse palpation for syst BP.

Aviation portable O2 bottles have only 1 of 2 settings: “low”=2 l/min and 4 l/min=“high flow”, far lower than flow used for EMS.

O2 tubing for bag-valve resuscitation are not required to be compatible with these on-board O2 bottles.

Equipment ChallengesAEDs on board not required to have

ECG screen, though ACLS meds are provided.

When AED does have screen, it is limited to a leads II/paddles view.

Glucometers not mandatory, though 50% dextrose is. Ask if any passenger on board would be willing to share personal glucometer.

Equipment ChallengesSince 9/11, phones have been largely

removed from cabins and cockpit doorshave been secured.

Info must be relayed via intercomfrom the back of the plane

or via flight attendant’s headset to pilots,who then relay info

to doctors on the ground

AEDAutomated External DefibrillatorAA first US airline to equip its fleet in

1997, first cardiac arrest save 1998.Mandatory for US commercial carriers.

(Aviation Medical Assistance Act). Aircraft with inoperable AEDs are

allowed to make “a few flights” until a replacement can be found.

AEDAutomated External Defibrillator

AEDs are still not mandatory for

European commercial carriers

(European Aviation Safety Agency).

No AEDs on Intercity aircraft in

Europe.

Positioning the Patient

Remove patient from seat, gripping him/her from behind.

Positioning the PatientIf possible, position potential

emergencies next to the aircraft’s door

or in the galley, horizontal to flight

direction against front wall.

Make sure all trolleys are secured.

Stueben, U. Flugmedizin/Flight Medicine. Medizinisch Wissenschaftliche Verlagsgesellschaft Berlin, 2008

Make sure there is enough space behind pat’s head in case of intubationMake sure there is enough space beside pat’s chest in case of cardiac massage

Telemedicine: MedAireGround-based service utilized by airlines.VHF radio or satellite phone contact to ED

physicians at MedAire.Arizona-based company providing

emergency med advice to airlines carrying ~half of the 768 million passengers on US

flights each year.Takes responsibility for deciding if flight diversion is appropriate.

Medical DiversionPilot’s decision onlyDepends on weather, appropriate airport

facilities, terrain, landing weight, fuel: e.g. impossible right after take off:

Weight of aircraft + full tanks exceedsmax weight for landing

(e.g. take off NYC, earliest landing Boston)

Flight diversions due to onboard medical emergencies on an

international commercial airline.

5386 telemed contacts/5yrs.Av. 2.4 diversions recommended/100 callsTelemed decrease 2006-2007 was

accompanied by an increase in diversions.

Valani R et al, McMaster University, Hamilton General Hospital, Ontario, Canada. Aviat Space Environ Med 2010; 81: 1037-40

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Flight diversions due to onboard medical emergencies on an

international commercial airline.

Most common causes for diversionCardiac (26%)Neurological (20%)Gastrointestinal (11%)Syncope (10%)

Valani R et al, McMaster University, Hamilton General Hospital, Ontario, Canada. Aviat Space Environ Med 2010; 81: 1037-40

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Telemedical Assistance for in-flight Emergencies on Intercontinental

Commercial Aircraft

3-yr prospective study, commercial airlineMedical incidents: n=3364 Use of telemedicine: 9% (n=275)Most cases were middle aged, not elderlyNeurological, non-psych telemed cases:27% (n=83, 27 required diversion, 275 did not.No non-diverted patient deteriorated

Weinlich M et al, Dept of Trauma Surgery Goethe Univ. Frankfurt, Germany. J Telemed Telecare 2009; 15: 409-13

Pediatric emergencies on a US-based commercial airline

7-yr retrospective study, commercial airline1 ped call per 20,775 flights2/3 calls in-flight, 1/3 pre-flightMean age 6 yrsMost common complaints: infectious disease, neurological, respiratory emergencies.

Moore BR et al, Dept of Ped. & Adolscent Med, Mayo Clinic,Rochester, NY. Pediatri Emerg Care 2005; 21: 725-9.

Common Problems

How common are medical problems during flight?

Minor medical problem not requiring medical assistance: every150th passenger

Medical care: 1 of 10.000 passengers

Medical emergency: 1 of 50.000 passengers (~6% cardiac)

Time Zone Changes & altered Meal

Times Hypoglycemia in insulin

dependent diabetics though diabetic meals can be provided.

Passengers on other strict drug regimens, (e.g. for epilepsy)

Passengers who have packed their medication in the hold.

Fear of Flying

Unruliness (aggravated by alcohol)

Psychovegetative dysregulation:

tachycardia, sweating, hypotension

(aggravated by sedatives and/or

dehydration)

DehydrationProlonged sunbathing and/or partying

on last day of vacation

Dehydration (e.g. hot location, last

minute rush/stress, lack of foreign

currency to buy drinks)

Cabin pressure

Dehydration & Dry Atmosphere Dry cabin atmosphere irritates

mucous membranes Duration of flight exacerbates

dehydration Drinking alcohol exacerbates

dehydration. Altitude enhances the effect of

alcohol, contributing to “air rage,”

Air Ragehours of dry cabin

atmosphere irritate mucous membranes Drinking extra fluid helps,Drinking alcohol opposite effect. Intoxicating properties enhanced at altitude.smoking ban in nicotine addicts.

Motion SicknessSymptomsApathyPallorSweatingOver-sensitivity

to noise, smell

Hypersalivation

AggravationAlcoholTurbulenceSudden de- or

accelerationNoise, smellsHeat

Vaso-Vagal Syncope

40 % of cardiovascular emergencies

on board are syncopes.

Most common causes:

motion sickness, dehydration,

fear of flying.

Responding to in-flight Medical Events 1

Be prepared to show med credentials or answer questions about degree or training

Obtain consent from affected passenger. Assume implied consent when passenger is incapacitated or unresponsive.

Do not fear litigation. Physicians have been deposed, but no litigation has ever been brought forward against a responding physician.

Responding to in-flight Medical Events 2

Request and establish communication with the airline’s ground med support for advice and consultation regardless of how minor or serious the in-flight event is.

Request the enhanced emergency med kit (many airlines initially offer basic first-aid kit) but do not open it unless needed. Each kit has a placard listing contents.


Hypoglycemia

If conscious, administer oral glucose gelIf unconscious, establish iv accessAdult: administer D50 dextrose (1 amp)Child: dilute D50 dextrose 1:1 with

normal saline to prepare D25 dextrose and administer 2 ml/kg


Motion Sickness:What can you do on board?

Move patient to seat in the middle of the plane

Keep head steadyEyes shutNo alcoholMetoclopramideDimenhydrinateScopolamine patch

Vasovagal Syncope

Lay pt supine

Elevate legs

Apply cold compress to forehead


Emergencies

Altering Cabin Pressure

Cabins are pressurized but airlines can

legally alter pressure to the equivalent of 8000 ft.

Emergencies in the Air

Exacerbation of pre-existing medical problems caused the vast majority of in-flight emergencies (65%).

Respiratory problems were most common. 50% asthma-related, 33% due to forgotton medication.

Syncope accounted for 25% of all incidents and 91% of all new medical problems.

Qureshi A, Porter KM. M. Emerg Med J 2005; 22: 658-59.

Hypertensive CrisisUrapidil available on all aircraftNitro Spray and/or capsules available

on all aircraftOral calcium antagonists available on

some aircraft

Consider Diff Dg: Stroke, MCI,hemorrhage from ruptured aneurysm, thus

Medical diversion if possible

TachycardiaPositioning, oxygen, ivAmiodarone 2 150mg ampsLidocaine 1-1.5 mg/kgLast ditch measure: Defibrillation AED will not discharge below ventriculartachycardia of 180 because its automaticrhythm-detection is programmedaccordingly.

Arrhythmia

Horizonal positioning aisle, galley, business class seat

I.V., fluid, oxygen Monitoring with AED Sedation Have CPR ready

Suspected Myocardial InfarctionO2, Aspirin 325mg poNitroglycerin 0.4 mg subling every 5 min

up to three doses or Morphine sulfate 3 mg iv or im.

Request cabin altitude reduction to increase cabin pressure

Some airlines carry AEDs with a cardiac rhythm display to help assess rhythm.

Cardiac Arrest

Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77

Place AED on patient. Some defibrillators incorporate a rhythm display that can help making decisionsFollow BLS or ACLS resus algorithmsIf resuscitation is stopped because of no return of spontaneous circulation, pt should not be pronounced dead officially on international flights (medico-legal reasons)

US Government Air Carrier Access Act May 2008

All US-based air carriers and foreign air carrier flights that begin or end in the USA

must accommodate passengers who need portable oxygen concentrators.

Non-discrimination on the basis of disability in air travel. Final Rule. Fed Regist 2008; 73:27613-27687.

Bronchial Asthma or COPD

Administer O2 and inhaled

bronchodilator (2 puffs per 15 min)

Request reduction of cabin

altitude to increase cabin pressure


PneumothoraxThe effect on pneumothorax was wellpublicised when, on a flight from Hong

Kong to London, Professor AngusWallace relieved a tension pneumothorax

with the aid of a catheter, coat hanger,and brandy bottle.

Wallace WA: Managing in flight emergencies. BMJ 1995; 311:1508

Acute Allergic ReactionDiphenhydramine po, im or iv.

Adults 25-50 mg, peds 12.5 mg.Severe generalized urticaria, angio-edema,

stridor or bronchospasmEpinephrine: Adults 0.3-0.5 ml, peds 0.01

ml/kg/dose 1 in 1000 solution im or sc every 5-10 min as needed. 3 doses in adults, up to 3 doses in peds.

Additonal fluids in anaphylaxisSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77

Acute Abdominal PainConsider administering antacidRequest cabin altitude reduction to

increase cabin pressure. That increases oxygenation & decreases gas expansion.

Administer paracetamol or ibuprofen. Some kits include morphine.

Consider administering an anti-emetic. Some kits include Ondansetron.


Acute Agitation or MisconductLook for med causes (hypoxia, hypoglycemia)If administering a benzo, be aware of poss

oversed (passenger taking several substaces)If physical restraint is needed, place restrained

individual in left lateral positionMonitor when using chemical or physical

restraints. High risk of complications in exerted, agitated passengers fighting restraints: hypoxia, metabolic acidosis, sudden death.


SeizureKeep pt away from nearby objects

Do not place anything in pt’s mouth

Administer Diazepam 0.1-0.3 mg/kg

iv or im for pediatrics, 5 mg iv or im

for adultsSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77

Extended travel with limited movement & rehydration are THE recipe for pulmonary embolism.

Add factors like birth control pills, obesity, age and/or smoking

and you are pretty much an event about to happen.

Anticoagulants for Air Travel?No formal guidelines existStill controversial, though RC trials

show benefit of LMWH for air travelers at moderate risk who do not take anticoags

Aspirin is not recommended alone as prophylaxis for any air traveler.Kuipers S et al: Travel and venous Thrombosis: A systematic

review. J Intern Med 2007; 262: 615-634.

Sudden Loss of ConsciousnessDifferential Diagnosis

Vasovagal syncopeAsystoleHypoglycemic shockApoplectic ischemic/hemorrhagic

strokeEpileptic seizureIntoxication (drugs, toxic agents)

Unresponsive PassengerPlace automated external defibrillator

pads on ptEstablish iv accessAdminister O2, D50 dextrose (1 amp) iv

for adult or D25 dextrose (2ml/kg) for pediatric, Naloxone 0.1-2 mg iv or im (available on some flights)

Follow BLS or ACLS resus algorithmsSilverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680: 2067-77

Consider DiversionAcute coronary syndromeChest painSevere dyspnoeaSevere abdom pain that doesn’t improveSevere agitationStrokeRefractory seizurePersistently unresponsive passenger


Legal Aspects

Does a medical professional who is a passenger have a duty to volunteer medical assistance?US, Canada and the UK: NO, unless there

is a pre-existing patient relationship.International law: country in which aircraft

is registered has jurisdiction. However, country in which incident occurs and country of citizenship of plaintiff or defendant can also have jurisdiction.

Hedouin V et al: Medical Responsibility and Air Transport. Med Law 1998; 17: 503-6.

1. Identify yourself, state your medical qualifications. Some airlines require proof of your medical qualifications.2. Obtain as complete a history as possible, inform passenger and family members (if present) of your impression, obtain consent before initiating any form of examination or treatment. Assume implied consent if pg. is incapacitated.

Medicolegal Recommendations

Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: 1067-73.

3. If consent has been given, carry out an appropriate physical examination. 4.Request an interpreter if the passenger you are assisting does not speak your language. 5. Inform flight crew of your impression.6. If condition is serious, request aircraft to be diverted to nearest appropriate airport.


7. Establish communication with on-ground med support staff, if available. Respect ground-based physician’s expertise & experience in managing in-flight medical events. 8.Document in writing your findings, impression, treatment, and communicationwith flight crew & on-ground med support.9. Do not use any treatment that you do not feel confident administering.


The Aviation Medical Assistance Act

Passed by Congress in 1998

Specifically protects physicians,

state-qualified EMTs, paramedics,

nurses and physician assistants.


“ An individual shall not be liable for damagesin any action brought in a Federal or State court

arising out of the acts or omissions of the individual in providing or attempting to

provide assistance in the case of an in-flight med emergency unless the individual, while

rendering such assistance, is guilty of grossnegligence of willful misconduct.”


Limits liability for volunteering physicians under the assumption that they act in good

faith, receive no monetary compensation and provide reasonable care.

Gifts, such as seat upgrades and liquors are not considered compensation.

Pertains to events that occur within US airspace and aircraft registered within the US.

Many airlines indemnify

volunteering physicians.

Written confirmation is provided by

the captain upon request.

Cocks R and Liew M: Commercial Aviation, in-flight Emergencies and the Physician. Emerg Med Australas 2007; 19: 1-8.

Keep in mind that “good Samaritan” statutes protect you only from liability

for actions that other competent persons with similar training

would take under similar circumstances.



Never officially pronounce a passenger dead,

even if you assess that resuscitation is futile

and cease treatment, especially on international flights.


Up in the Air – Suspending Ethical Medical Practice

Shaner, M. New Engl J Med 2010; 363/21: 1988-89.We were flying from the East Coast to the West. Aboutmidflight, a lady behind us reached frantically for thebaggage bin. She was trying to get her husband’soxygen tank. He looked about 70, eyes closed, righthand clutching his chest, grimacing in pain. Suddenly,his grimace faded and his arm dropped. Leaning over, I felt for a pulse. There was none. Aflight attendant approached. “I am a physician,” I said.“Let’s get him down to the floor.”


Shaner, M. New Engl J Med 2010; 363/21: 1988-89.We were flying from the East Coast to the West. Aboutmidflight, a lady behind us reached frantically for thebaggage bin. She was trying to get her husband’soxygen tank. He looked about 70, eyes closed, righthand clutching his chest, grimacing in pain. Suddenly,his grimace faded and his arm dropped. Leaning over, I felt for a pulse. There was none. Aflight attendant approached. “I am a physician,” I said.“Let’s get him down to the floor.”


Shaner, M. New Engl J Med 2010; 363/21: 1988-89.

We lifted him into the aisle. I shined a pocketflashlight on the dimly lit scene. He had stoppedbreathing; no pulse. Three other passengers joined us, an anesthesiologist, an oncologist and a surgeon. Mywife ran the code, I provided chest compressions, theanesthesiologist bagged the patient, the oncologistmanaged the equipment, the surgeon put in an i.v. andthen injected epinephrine intracardially.



We followed the protocol suggested by the AED. Itdid not discharge: its rhythm-detection program foundno rhythm that might be treated with defibrillation.The monitor showed a wide complex bradycardia withwhich we could not associate a palpable pulse. After25 minutes of basic cardiac life support, there was stillonly pulseless electrical activity. The 5 physiciansagreed:it was time to stop and declare the patient dead.



The flight attendant explained that if we stopped CPR,the airline’s protocol would require the cabin crew tocontinue it. In other words, CPR was going forwardwhatever we decided. We chose to continue it ourselves so that the fourflight attendants could attend to their duties during anemergency landing.We landed 45 min later. The patient died the same day.

TAKE HOME MESSAGES

Dehydration

Low Humidity

Mild Hypoxia

Pre-existing med Condition

Boyle’s Law

Keep in mind that

airlines canlegally alter pressure

to the equivalent of 8000 ft.

Consider DiversionAcute coronary syndromeChest painSevere dyspnoeaSevere abdom pain that doesn’t improveSevere agitationStrokeRefractory seizurePersistently unresponsive passenger


“good Samaritan” statutes

protect you only from liability

for actions that other competent persons

with similar training

would take under similar circumstances.


Keep in mind that

Linda E. Pelinka, MD, PhD Medical University of Vienna a nd Ludwig Boltzmann Institute

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