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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, February 15, 2016

In flight emergencies

It was back in 2005, when I was flying from New Delhi to Chennai (about 2:30 min flying time) to start my medical school. Everything was all good until I heard this:

Is there a doctor on board? We have an emergency..
Is there a doctor on board? We have an emergency..

I (was going to become a medical student but..) could do nothing to help a man who was breathless. He was placed on an oxygen mask and fortunately he got better. As a layperson I had no clue about what was wrong with him. 

It was then when I realised how important it is to have some sort of basic understanding about common ailments, not only for all the physicians (regardless of their field of specialisation) but for everyone esp when we are flying 30,000 feet above the ground. And now, it is not uncommon for physicians to fly across the continents to attend various conferences and meetings. For those of us who have been into this, would know that even as emergency health care providers, it can be really challenging to manage an "in flight emergency".






First thing, we need to be familiar with the equipment available, at least have some idea about what would be available to you. You would be left with no excuse if you screw up this and if you happen to be an emergency physician. 


Contents of in flight Emergency Medical Kits (you may not have all of this available)

Assessment Supplies
Sphygmomanometer 
Stethoscope
Gloves


Airway and Breathing 

Oropharyngeal airways 
Bag-valve masks (3 sizes)
CPR masks (3 sizes) 


Intravenous Access 
Intravenous administration set 
Saline solution, 500 ml 
Needles, Syringes

Medications
Analgesic tablets
Nonnarcotic 
Antihistamine 
Aspirin
Atropine
Bronchodilator inhaler 

Dextrose, 50%
Epinephrine

Intravenous lidocaine 
Nitroglycerin tablets



How to go about in flight emergencies:
  • Introduce yourself and state your medical qualifications.
  • Ask the passenger for permission to treat, if feasible.
  • Request access to the medical kit.
  • Use a language interpreter, if necessary, but be aware of patient privacy.
  • Focused history and physical examination, obtain vital signs.
  • Administer treatments within the scope of your qualifications.
  • Recommend diversion of the flight if the patient’s medical condition is critical.
  • Communicate and coordinate with ground-based medical resources.
  • Continue to provide care until the emergency medical condition is stabilized or care is transferred to other qualified medical personnel.
  • Document the patient encounter. 


Specific Problems
For the most of them, you would be providing only the basic and common sense care. If it is really getting out of control, get diverted and land ASAP to the nearest airport where reasonable medical care would be available. They key is to stick to the basics and don't forget that there are major restrictions in terms of the kind of stuff that you can do in a hospital.

  • Syncope (rule out hypoglycaemia, lay flat and elevate the legs, fluids if needed)
  • ACS (O2, Aspirin, Nitrates, Reassure)
  • Cardiac Arrest (Chest Compressions, Shock, Ice)
  • Dyspnea (O2, beta 2 agonists, needle decompression)
  • Stroke (No Aspirin in a suspected stroke, rule out hypoglycaemia)
  • Seizures (Left lateral position, O2, rule out hypoglycaemia)
  • Psych (Calm them and Restrain them)
  • Minor trauma (Immobilze, cold compresses, Analgesics)

And it was once again, I came across a similar situation but by this time I was an EM Trainee and it was a flight that got diverted and landed on emergent basis. I was rotating at Airport Medical Centre. It was around 7PM, when we received a call that asked for a physician saying 


"This flight has been diverted because a passenger was complaining of chest discomfort and breathlessness". 

We (a physician and two nurses) got braced up for this and literally rushed to the aircraft with the resuscitation kit. And as we reached there, I entered the aircraft, it was packed with 180 passengers and they all were staring at me hoping that I would fix this man's problem. I heard people mumbling, Oh..the doctor is here... (sigh of relief for them and it was horrifying for me, imagine 180 strangers who are going to observe/film the scenario). 

Well, I guess this was not enough, there I saw a 70 year old gentleman who was on oxygen, drowsy, breathless, sweaty. His wife, held my hand and said, doctor please do something and narrated his past history. I asked him if he was fine? He opened his eyes for a second, nodded and pointed towards his chest. And I got a sigh of relief, because he was at least responding (So probably he is not going to get intubated on board). My nurses quickly got an IV, checked vitals. He was put on the monitor and then...It was Ventricular Tachycardia (with pulse) with pressures of 80/60!

Medical centre was 4-5 minutes from the Aircraft. And I was left with these three options:
1) Push Amiodarone, though he was unstable and then shift to the medical centre
2) Do the heroic act of Sync Cardioversion in the Aircraft 
3) Do nothing, Just rush to the medical centre and then do Sync Cardioversion

I somehow stood away from the urge of pushing amiodarone and shocking was out of question in the aircraft.  We rushed to the medical centre in less than 5 minutes and he was reverted with the third sync shock and it was all good after that. Everyone was happy (patient, family and most importantly the cardiologist).


Take Home: In flight emergencies, 
  • Introduce yourself, ask for their permission to treat
  • Know what is the usual equipment available
  • Stick to the basics and know your limitations


References:

Nable, Jose V., et al. "In-Flight Medical Emergencies during Commercial Travel." New England Journal of Medicine 373.10 (2015): 939-945.

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