Time Stamps

  • 04:40 Emergency Medical Kit (EMK) Standard Contents
  • 08:50 Role of Ground-Based Medical Support & Flight Diversion Decision-Making
  • 19:35 Interpreting Hypoxia at Altitude
  • 22:06 In-Flight Liability
  • 23:35 Common Chief Concerns & Useful Additional Medications
  • 24:53 How to Be Resourceful in an Austere Environment

 

Sponsor:Ā Oakstone CME

Use the code “CORE25” for 25% off:Ā https://www.coreimpodcast.com/MKSAP

 

Show Notes

  • In Flight LiabilityĀ 
    • Aviation Medical Assistance Act of 1998 (US)
      • Protects the liability of individuals responding to an inflight emergency:Ā 
        • ā€œAn individual shall not be liable for damages in 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 medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.ā€Ā 
      • Only applicable to US based airlinesĀ 
        • However, most countries do have similar laws preventing litigation of responding individuals.Ā 
          • Many European countries actually have laws which mandate that citizens have a ā€˜Duty to Assistā€™ those in distress, as long as responding does not put oneself in danger.Ā 
  • How to be resourceful in an austere environmentĀ 
    • Commercial flights are challenging to provide medical care!Ā 
      • Maximize the resources you DO have available:
        • Utilizing other passengers!Ā 
          • Ā Find other medical professionalsĀ 
            • NursesĀ 
            • Respiratory therapists
            • Other physicians
            • Other passengers organize medications
          • Poll passengers for resourcesĀ 
        • Setting up communication with ground-based medical support early
        • Maximize the limited space and privacy
          • Especially if the patient needs to be supineĀ 
            • Labor
            • CPR
          • Collaborate with the cabin crew to move the patient
            • Galley
            • Other areas that can be curtained off

Transcript

Dr. Erin Truitt: We were flying back from Austria. It was a nine-hour flight. We had settled in. The flight was actually somewhat empty. We were about to get lunch, and I heard someone choking behind me, or at least that’s what I thought. I looked behind me, and actually, the woman seated right behind me was having a seizure, and she was blue and bleeding from the mouth, and full tonic-clonic seizure, and actually was choking. She had vomited and was aspirating. She’s blue, and so I was trying to feel for a pulse, and I couldn’t feel a pulse. I called for a doctor and called for help.

Dr. Shreya Trivedi: And you didn’t get the, is there a doctor on board?

Dr. Erin Truitt: No, no, I did not. Well, obviously, I am a doctor, which is great, but it was pretty clear to me pretty early that she was really unwell and that I might need help. And at that point, everyone around is looking at us, and I was trying to pull her into the aisle, thinking I was going to need to start CPR in the aisle. So again, just kind of thinking immediately, I need help with this. That did hurt me, though, because the flight attendants came up with their actually really impressive pack of medications, but also assumed I was not a doctor and tried to push me out of the way. So, at some point, I had to clarify, I am, in fact, a doctor. I’m looking for more help. And I was pretty lucky because another doctor on the flight was an emergency department physician. And so she showed up to see what was going on. And at this point, I still hadn’t found a pulse. I was trying to pull the woman into the aisle, and the seizure broke, which was great news.

Dr. Shreya Trivedi: Yes. Thank goodness the patient’s seizure broke, and that was great news indeed, but the story did not end there. Welcome to a special Core IMĀ  episode on in- flight emergencies. I’m joined by the wonderful Dr. Sophie Goemans.

Dr. Sophie Goemans: Hi, everyone. I’m Sophie. In-flight emergencies is a topic that I learned so much about talking to pilots from airlines about in- flight emergencies, people who’ve built careers in osteo environments, and of course, doctors who have braved through it themselves.

Dr. Erin Truitt: Hi, I’m Erin Truitt. I am a nocturnist at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

Dr. Sophie Goemans: And I thought the best way to go through the learning points would be to listen to Erin’s wild story and use it as a jumping-off point.

Dr. Shreya Trivedi: Yes, it is so good. I got to say, Sophie, thank you so much for doing this because I would always sweat when I’d hear, “Is there a doctor on board?ā€ And maybe after this, I will sweat a little bit less. So, back to our story. So at this point, the woman’s seizure broke, and then Erin had to think, what does she do now?

Dr. Erin Truitt: She was completely postictal. I would put my husband in charge of trying to talk to her because her brain cells weren’t holding hands yet. We were trying to find emergency contacts in her phone. And so me and this other doctor were trying to go through what can we do in this moment? Their pack of medications was great, but it was all in German. Mications would say their European brand name and then their generic name, but they weren’t the standard medications that I was looking for and I didn’t recognize a lot of them and the alphabetizing of them was very different because of the language. So I’m looking through their packs and I asked them if they had WiFi. They don’t have WiFi on this flight. It was actually pretty comprehensive, but I couldn’t find Ativan, which is the first thing I was trying to look for. So they had diazepam tablets, which I thought would be useful, but we couldn’t find them. And so what we could find was actually rectal diazepam. This 20-something-year-old woman that I’m going to be administering rectal diazepam here on this airplane right now, unless it’s really dire. I had decided with the rectal diazepam, if she needed something, it was just going to go under her time. I figured it would absorb. If I had to give it,

Dr. Shreya Trivedi: That’s. That’s a good pharmacy question. Can you take something rectal?

Dr. Sophie Goemans: I mean, that makes sense. Capillary beds. I think I would make the same assumption in the air without wifi.

Dr. Erin Truitt:Ā  I was thinking mucus membrane, I couldn’t imagine how different it would be. I’m trying to go through things like, okay, seizure, what are our ABCs? Can’t find a pulse ox. I have no idea what she’s oxygenating, but she was talking to us.

Dr. Shreya Trivedi: Okay. Let’s pause here and talk about what are the resources that all airlines carry. This is what we would find in the emergency medical kit, or you might hear the term EMK thrown around.

Dr. Sophie Goemans: Yeah. So we sat down with Dr. Melissa Madison, who has gone through her own in- flight medical emergencies, and she’s gone on to write about the EMK or emergency medical kit.

Dr. Melissa Mattison:

My name is Dr. Melissa Madison. I’m the chief of hospital medicine at Massachusetts General Hospital in Boston. The contents of the emergency medical kit are defined by the FAA, and I don’t think they have been defined or redefined since 2006. So you will not find Narcan in the emergency medical kit. You might say, “Why the heck not? ” You can buy it over the counter. Why would we not have that there? Well, 2006 was a different era. Now, that’s not to say that you won’t necessarily find Narcan on the plane. So the airline is required to carry certain things. That’s the EMK, the emergency medical kit. The airline then has up to its discretion the ability to augment that kit. And some airlines do very much augment the kit, particularly on long-haul flights. One of our colleagues, years ago, I remember, was flying Japan Airlines from Japan to Boston and had to respond to an emergency, and the kit that Japan Airlines had had pressors. It had fluids. It had all kinds of stuff.

Dr. Shreya Trivedi: And there’s quite a bit of variability on different airlines.

Dr. Sophie Goemans: And that makes it hard to prepare for an in- flight emergency from the ground. If it’s an American-based flight, you’ll have at least a manual blood pressure cuff, one of those flimsy yellow cephaloscopes, equipment for CPR, and just one IV start kit. Medication-wise, you’ll have a 500cc bolus, antihistamines, an EpiPen, nitroglycerin, and aspirin for ACS, D50, and somehow atropine makes a list too. But again, these requirement minimums are for US-based flights only, and the kit organization is not standardized at all.

Dr. Shreya Trivedi: Yes. Thank you for that rundown of what to expect. So, back to our patient who had a seizure, now comes the next important question that makes most of us pause.

Dr. Erin Truitt: Her color was back. She looked much better, and eventually she was able to tell us she had a seizure disorder, but her last seizure had been four years ago, all in the context of drinking alcohol, which she hadn’t had. And she took Lamictal every day, and she had her pack of Lamictal like we were able to find it. We gave her an extra dose of it. I was sitting there trying to use this glucometer that they had, and I kept just getting error. I just gave her a bunch of sugar packets. If she’s hypoglycemic, we’re just going to fix that. I probably can’t hurt her. But what I did start to do at that point was collect everything that we might need. The pack of stuff was just, it’s huge. It’s all over the place. And while she was doing okay, I’m like, Okay, here are the sugar. Here’s the diazepam, here’s the IM diazepam, here’s the intubation kit, IVs, whatever, just trying to put it all together so we could find it faster if we needed it. Then the flight attendants asked us, ā€œwell, do we land playing?” And that was a question that I knew was coming and also had no idea how to answer. At this point, she was pretty aware of what had happened and was just in tears. Home for her was the United States. She did not want to be dropped off in Berlin to go to a hospital there. She wanted to go home, and everyone else on the airplane just staring, which also makes the whole situation very hard. And so I decided I was not going to make that decision and ask them to talk to their ground crew.

Dr. Shreya Trivedi: Wait, hold on. What exactly is ground crew?Ā 

Dr. Melissa Mattison: If you remember one thing from this podcast, I would suggest that you remember that every airline pretty much will have ground support that you can call. Every airline contracts with a company that has people on the ground who are physicians who are available twenty-four-seven, who they can call, and those physicians are trained to know how to respond to basically any emergency on a plane. They know based upon what type of aircraft you’re on, what type of emergency medical kit is available to you, and they can tell you, “Get the emergency medical kit. There should be X, Y, and Z in it, do this, that, and the other thing,” and so on.

Dr. Sophie Goemans: And how the communication happens can take several different forms. Because Erin’s flight didn’t have Wi-Fi, Aaron basically was dictating a message to the flight attendants who were attempting to write it all down and then the pilots would radio down that message to the ground crew who was then communicating with a doctor and then that whole chain would be communicated back the other way. If you have Wi-Fi, it’s as simple as a phone call to a consulting doctor on the ground. Whichever form you have, the ground support can be really helpful with the decision of whether to land the plane or not, especially if it’s not a quick fix situation.

Dr. Shreya Trivedi: Yeah, I know for me, my takeaway is like, okay, I’m going to get that communication set up in the beginning or delegate that to someone else if it’s going to take a lot of time.

Dr. Sophie Goemans: Absolutely.

Dr. Melissa Mattison: If you’re on a flight and you’re asked to respond to a medical emergency and it’s clear that it’s a legit situation, immediately ask the flight attendants to set up ground support.

Dr. Erin Truitt: And so it took actually about an hour for that doctor to come back with the decision that it sounds like everything is fine. I have wondered a lot about whether I should have done something differently here. They told me initially I’d have to make that decision within the next hour to hour and a half. It took that doctor about an hour to get back to us. So at that point we were kind of running out of space, and I think they said that they would land in Berlin, and then there were other airports that they could land in before we go across the Atlantic. But that was really what they were trying to get me to decide, is, do we land before we are over the ocean, and then we’re in a bad spot? And at this point, I was thinking to myself, this is a person with a known seizure disorder who just had a one-time seizure, came out of it without any intervention, at first looked pretty unwell, but then was pretty clearly like, at this point, she was with it. Her neuro exam was normal. By the time she had kind of woken up and we could do a full exam, she seemed well. And she’s telling us this story. She had been flying from Africa. She hadn’t slept for 24 hours. She hadn’t eaten. She had gotten stranded in an airport all night and hadn’t been able to get any rest. And so I guess I was just kind of imagining we gave her this extra Lamictal, like, probably this will be okay. Then we did go over to the Atlantic, and I left my seat and sat next to her because she was, I think, pretty understandably scared. The other doctor there had told her, and I didn’t know this, that you were more likely to have a seizure when you were falling asleep and waking up from sleep, which I didn’t know, but apparently is true, and this poor woman hadn’t slept for a day and a half and now was afraid to fall asleep. I was afraid that if she didn’t sleep, the same reason that she got her first seizure is still there. And so she’s like trying not to sleep. I’m trying to tell her I think she should just sleep if she needs to sleep. There was also the question of she hadn’t eaten, and the other doctor, the emergency room doctor, I think very understandably was concerned about her having anything to eat or drink because if she had another seizure and needed to be intubated on the flight, that was going to be a problem. But it led to this kind of place where I think the things that made it more likely for her to have a seizure weren’t actually fixed. I moved to sit next to her for the flight, and I don’t know, it was pretty nerve-wracking. I wouldn’t put on my headphones. I sat there and read a book really awkwardly.

Every time she would get up to go to the bathroom, you could just see, again, everyone in the cabin just staring at the bathroom door. It was a terrible anticipation. Well, it’s about four hours after the first seizure, which put us right in the middle of the Atlantic. And sure enough, I hear her breathing change, and I look over, and she’s having a second seizure.

Dr. Shreya Trivedi: No, I thought the story was over.

Dr. Erin Truitt: It’s not over. No, one of the flight attendants very helpfully came up real calm and was just like, “Just so you know, this is the worst place for this to happen.” It’s two and a half hours one way and two and a half hours the other way. What do you want to do? Sounds like at this point I may as well end us in Boston, but we did have him go ask the pilot if there were actual other emergency options in there, and the pilot got back to us that there were. We could land in Newfoundland or Halifax or something like that if it came to it, which would save us maybe like an hour, hour and a half. But either way, we were looking at at least an hour and a half still in a flight with maybe an emergency landing in the middle of nowhere, Canada if we had to, and Europe is no longer an option. And so at this point when she starts to seize the second time, we did actually have our emergency kit ready. I’m grateful to say I didn’t have to use the diazepam at all, which was good. She broke out of that one also spontaneously, but at this point, our level of worry was definitely increased because now we’re looking at two seizures. Is there a possibility of a third? And so we kind of went from having a little bit of planning over a worst-case scenario to real planning. At that point, we’re starting to map out in the airplane, where would we do the intubation? What else do we need for that? She’s going through all of the intubation medications, making sure she has an idea of the doses, things like that. And that’s when we realized that neither of us had placed an IV in probably like, or knows, seven years, 10 years. I’m not sure. Maybe since I was a resident in the ED during my rotation there, but I do want to, probably, I think I’ve done maybe a few lab draws since that time, but it was a real concern at that point.

Dr. Sophie Goemans: And so they asked the flight attendant to make another announcement to see if there was a nurse on board.

Dr. Shreya Trivedi: Ah, so smart. Man, I don’t know if I would’ve thought about that in the panic to be that resourceful, be like, “Hey, is there a nurse? Can someone else help with the IV versus feeling bad and convincing myself, okay, maybe I can do it. I did it on that one time.” And I think kudos all around for that smart thinking of knowing your own limits and that yes, this is still a team sport even if you are so many thousand feet above ground.Ā 

Dr. Shreya Trivedi: Did you find a nurse?

Dr. Erin Truitt: We did find a nurse, and when we asked her, she was the nurse who did outpatient IV vitamin infusion.Ā 

Dr. Shreya Trivedi: Oh, Amazing. Yes. You felt like you do this every day.

Dr. Erin Truitt: Yeah, She was like, “All I do all day is place IVs in people. I could do this. I can put one in stat if you need it. “ Great. So then we kind of talked through, do we put one in right now? This is another moment where I kind of feel like in retrospect, I should have just said yes, and then we would’ve had an IV. I could have done some fluids. She was pretty tachy at this point, which I think was just, I think she was pretty dehydrated, and she had broken out of the second seizure faster than the first one, which I found somewhat reassuring. And so I think in retrospect, I would have asked for that IV, but we didn’t. And then the discussion came back to her tachycardia. So at this point, we found a pulse ox, which was great and terrible because it showed us that she was tachy like 110s, 120s, and sometimes up to 130s and she was like borderline hypoxic, was satting right around 88 to 93 with a few good breaths. So then the question from the ED doctor who has seen this issue times was, could this be a PE from her travel that has caused hypoxia that has caused the seizure? And she was wondering about whether at this point we actually consider full-on anticoagulation. We had found Lovenox shots in their kit, but you start to realize like, well, I don’t know, because the other possibility is the seizure is from something in the brain or is probably not related at all. My thought was this is lowered seizure threshold in someone with a seizure disorder and we just haven’t fixed that problem. But you realize how limited you are when you can’t just go and get a scan and answer this question. And so fine, we diligently take the Lovenox out, we put it to the side as a last-ditch effort. If something happens and we’re coding her, then that is a thing we may use. Fine. And we put that aside. But these discussions become really interesting when you just have no info.

Dr. Sophie Goemans: Was there any discussion about what is a normal pulse ox on an airplane?

Dr. Erin Truitt: Yes. So I knew that it was lower than typical. And in fact, I put the pulse ox on myself to test it first and I was sadding around 96 to 97%. I figured that that was probably normal, and so this was still probably lower than what that would be

Dr. Sophie Goemans: Smart. Again.

Dr. Shreya Trivedi: Another good place to pause. Pulse ox. All right. How much do we pull our hair out that the patient is actually hypoxic? Is she sitting at that 88, 93%?

Dr. Sophie Goemans: Yeah. So in a plane, you’re flying at 35,000 feet above the ground. However, the cabin is pressurized to about six to 8,000 feet. So being in an airplane is equivalent to being at the top of a relatively tall mountain. Think top of a ski resort or top of a hike. So your oxygen would reasonably be a little bit lower than what’s expected for a healthy lung at sea level, somewhere between 93 and 96%. But someone who has lung disease with their oxygen curve already shifted to the left, you could have significant hypoxia develop, which is why COPD patients, for example, are sometimes recommended to use oxygen when flying.

Dr. Shreya Trivedi: Yeah, no, fair. But our lady, she doesn’t have lung disease, not that we know of. She’s two seizures in and her O2 is sitting at 88 to 93%. So that is lower than what we’d expect. And so I guess we’re dealing with a mild degree of hypoxia to add to the equation.

Dr. Erin Truitt: At this point it was like, can we actually just get her some sort of benzo to last these last few hours? And someone in the cabin was overhearing this discussion and was like, “Hey, I have a Xanax.” And we’re like, “Okay.” She pulls this tissue out of her pocket and is opening it up and there’s half of a pill in there and she’s like, “I’m pretty sure it’s a Xanax.” It’s from her sister because she gets scared on flights. And I was like, “Do you know the dose?” And she was like, “Well, I think it was one milligram. And so this is half of that. ” And at that point we just decided good enough we had her take the Xanax. We did make it across the whole way. As we were getting closer to landing, I had talked to the flight attendants about can we get the emergency medical people to come on the flight to take her off? Because at this point, she’s still kind of borderline hypoxic, and I just really felt like she should be seen in an emergency department. So they take her off and everyone else on the plane, it’s just this big sigh of relief. And as we’re leaving, the pilot came out. It was just kind of this odd experience. He shook my hand and shook my husband’s hand and said something really kind of over the top about, thank you for saving our flight. And then you get out, and you just wait an hour for your baggage.

Dr. Shreya Trivedi: Ah man, what a story. It is amazing to me how resourceful you have to be. And I am so glad for a good ending, but I do wonder what if things hadn’t gone well? What if she’d aspirated more after a second seizure? Maybe worst case being going into a PA arrest and even passing away. That is so awful to think about, but I also imagine that’s a lot of the reasons why people don’t volunteer. They’re worried about the liability aspect.

Dr. Sophie Goemans: Yeah, that’s a great question. So I sat down with a pilot from one of the major airlines, Zachary Triplett.

Pilot Zachary Triplett: So in 1998, the Aviation Medical Assistance Act, the AMAA, was basically passed. And what that does is that ensures that any medical volunteers on the aircraft, including physicians, you can’t be held responsible in federal or state court for anything that happens on board an aircraft outside of gross negligence in a situation. So anytime you volunteer, you don’t have to be nervous that you’re going to be held responsible for the outcome of the situation because you did it in good faith.Ā 

Dr. Shreya Trivedi: Phew. that is such a relief to hear. And so maybe that last point about the pulse ox also think about they couldn’t actually find a pulse ox initially in that story. And so it begsĀ  question, what should we be bringing with us? And you’ve thought about this so much, so what are you bringing on airplanes these days?

Dr. Sophie Goemans: Taking a step back, I start by thinking about what are the most common chief concerns on an airplane. And in order, those are syncope, shortness of breath, GI stuff, so nausea, vomiting, diarrhea, and then finally chest pain. Syncope and chest pain, we actually have quite a bit in the EMK for those already. We have nitroglycerin, aspirin, a 500 cc bolus, dextrose. So I mostly focus on the GI and shortness of breath. So I’ll bring Imodium, Zofran for GI complaints and then potentially oral steroids for COPD exacerbation. And ideally you would also have Narcan and PRN inhalers, but a lot of those you can actually find from other passengers.

Dr. Shreya Trivedi: Yeah, that’s a smart list. Sophie, do you actually prescribe this yourself before uplight or how do you actually go about getting these things?

Dr. Sophie Goemans: Yeah, in theory, you can. That makes me a little bit nervous. So I just get my PCP to prescribe them for me, and I just tell her that it’s for my first aid kit. And after hearing Erin’s story, maybe I’ll start carrying a pulse ox too.

Dr. Shreya Trivedi: Yeah. I feel like the pulse ox for me is doable since I have one at home and would be easy to grab. I don’t know if I would have all my ducks in a row to prescribe it for myself before a flight or get someone else to do it for me. I might forget those things.

Dr. Sophie Goemans: Yeah. And if you forget, it’s all good. Use the crowd to be resourceful. I mean, looking at Erin’s story, she had other passengers organizing medications. She asked for an IV nurse. She used ground control, and she used meds from other passengers.

Dr. Shreya Trivedi: Yeah, that’s a great point because even in the beginning of the story, I was just impressed that she even asked for, “Hey, is there another doctor on board?” Even though she herself was a doctor, she just knew, Hey, I need more hands. And I love that about her. And I think that really lends into some final words of wisdom that Dr. Melissa Matson had for us.

Dr. Melissa Mattison: I think you want to try to stay within your scope. I think you don’t want to do something you’re not familiar with. I’ve heard about people trying to do all sorts of heroic things and I’m not sure that is it going to work. What we did when we responded to that case that I told you about was not heroic. I’ve heard of people on airlines where they’ve tried to mix up pressors like they had epi and an EpiPen and they had some fluids. They’re trying to make an Epi drip and I’m like, “What are you talking about? ” So I would just say use caution, use good judgment.

Dr. Sophie Goemans: So don’t feel like you have to do something heroic because you’re the doctor on board and at the same time, know that we can all have a role.

Dr. Melissa Mattison: I’ve heard of medical students, I’ve heard of residents feeling like I’m not worthy if I’m not enough. I mean, if there’s no one else on the plane, you may be all they have. And if an emergency medicine physician goes up, they’d be way more qualified than I would be because I’m an internal medicine hospitalist. And yes, I’m not unqualified, but I’m not the most qualified person to respond to an in- flight medical emergency. But say an emergency medicine physician responds and then I say, “Well, they don’t need me. ” Well, how do you know? You could actually go and be helpful. So do what you feel comfortable doing, but don’t feel like you’re not necessarily going to be a helper because you might actually be a helper.

Dr. Sophie Goemans: So practicing in an osteo environment is inherently uncomfortable because we’re not where we usually practice medicine. And so I think it’s all about finding that balance between what’s within our scope and being resourceful to apply our scope.

Dr. Shreya Trivedi: Yeah, very, very well put. Thank you so much, Sophie, and that is a wrap for today. If you found this episode helpful, our ask is to please share it with one other colleague, your team, or someone who may be going on a flight sometime soon. As always, opinions expressed are our own and do not represent the opinions of any affiliated institutions. Take care.Ā 

References