In-Flight Emergencies

Today’s TR Pearl was inspired by an actual in-flight emergency i helped out with last year.

The Case

You’re on a flight home from vacation, finally fell asleep only to be woken up by your girlfriend: “Wake up, that passenger is having a seizure.” You look across the aisle and just your luck

You ask the flight attendant for the medical kit and to find out if there are any other medical professionals on board. The patient continues seizing but has their seat belt on preventing them from sustaining traumatic injury. What do you do next?

 

But first, lets take a step back and review in-flight emergencies

Background:

In the study linked above Peterson et al reviewed 11,920 in flight medical emergencies from 5 domestic and international airlines between January 1, 2008 and October 31, 2010. This equates to 1 emergency per 604 flights.

The most common problems were:

Syncope/Presyncope – 37.4%

Respiratory Symptoms – 12.1%

Nausea/Vomiting – 9.5%

Cardiac Symptomts – 7.7%

Physician passengers provided medical assistance in 48.1% of cases

Aircraft diversion occurred in 7.8% of cases

 

What Can You Do?

First, if you decide to help, airline staff might ask you for proof you’re an actual doctor. The FAA suggests airline personnel make a good faith effort to “check the credentials of passengers holding themselves out as medical professionals.”

The FAA requires all airlines have some basic medical equipment (full list). This includes an AED, basic airway equipment, IV set up with IVF, tourniquet. Medications include ASA, atropine, antihistamines, ibuprofen, albuterol, dextrose, Epi, sublingual nitro. Of note there are generally no benzos (although some airlines do carry them)

Utilize the flight staff. All flight attendants are credentialed in CPR and the used of AEDs. However, the flight crew is not allowed to administer any of the medications in the emergency medical kit.

Many airlines have contracts with hospitals to provide assistance via air-to-ground communications.

The flight staff may ask you if the flight needs to be diverted or landed emergently. Consider making this decision in conjunction with the doctor on the ground.

 

Can I Be Sued?

Yes, of course you can be sued. This is America, anyone can sue you for any reason

The Aviation Medical Assistance Act of 1998 does provide some broad protections:

“LIABILITY OF INDIVIDUALS.—An 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.”

Note that this law does not require you to act, but seemingly provides some legal protection if you do. The law also does not touch upon the subject of compensation for acting. I’m not going to get into the subject of Good Samaritan laws and post hoc compensation, but i’d recommend declining any type of payment for your actions.

 

Resolution of the case:

I managed this seizure as any of us would.

The patient continues to convulse as i comb through the medical kit and quickly realize there is nothing of use

He’s alone, there are no meds in his pockets, and no one knows which bag is his

An elderly GI doctor comes by, but promptly leaves after learning i’m an ER resident (thanks dude)

After what seems like forever the patient stops seizing, is post ictal but with normal vitals and otherwise nonfocal exam

His mental status starts to normalize, he tells me has a seizure disorder and hasn’t been taking his meds (surprise) as he has been boozing/doing drugs all weekend

I speak with med consult on the ground, who arranges for a paramedics to meet us at the gate. The rest of the flight was uneventful.

 

 

 

 

 

 

 

 

 

The Cat’s Out of the Bag

Noninvasive cardiac testing comes in multiple forms. There is the dobutamine or exercise stress echocardiography (DSE/ExSE), myocardial perfusion scintigraphy (MPS)–single photon emission computed tomography (SPECT), and cardiac magnetic resonance imaging (CMR). There is also a growing imaging technique CTA coronary studies which have come about due to the advances in CT technology allowing for faster scanners with increased image acquisition at lower radiation levels. Multiple studies have shown comparison of CT imaging as non-inferior to the other modalities of noninvasive testing, and some studies actual show an increased sensitivity at detecting clinically relevant lesions requiring invasive catheterization when compared to classic stress testing. So why do we still admit our chest pains for stress and echo?

While there don’t seem to be official AHA/ACC guidelines in the US for CTA coronary studies as a first line testing modality, the National Institute of Health and Care Excellence (NICE) in the UK has released guidelines as of last year making such a change. This is based on large meta analysis studies as well as multi-center trials internationally which have shown that CTA coronary studies are not only highly effective as imaging for risk stratification but also can be a very cost effective option. The cost effective analysis for the NICE guidelines are based on the UK health system, but there are multiple smaller studies done in the ED settings in the US which do show a positive cost effective analysis when compared with stress/echo as a first line testing modality.

So who can you use this on? Based on the studies done, the exclusion criteria is quite minimal. Those with contraindications to IV contrast (allergies, renal issues, etc.) or those with known arrhythmias (CT image acquisition timing is based on a regular rhythm) cannot undergo this type of imaging. There is also an increased risk of radiation exposure compared to the other studies and should be taken into account in younger or pregnant populations.

As of today, however, this form of imaging should be done/ordered in conjunction with the institution’s cardiology department as current national guidelines have not (yet) defined it has a first line imaging modality for CAD workup.

Bottom Line: CTA coronary studies are a sensitive and cost effective first line imaging technique for most patients requiring cardiac risk stratification/workup and may be becoming a guideline in the US as it already has in the UK.

References:

Moss, Alastair J., et al. “The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease.” Current Cardiovascular Imaging Reports, Springer US, 27 Mar. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5368205/.

Foy, A J, et al. “Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-Analysis.” JAMA Internal Medicine., U.S. National Library of Medicine, 1 Nov. 2017, www.ncbi.nlm.nih.gov/pubmed/28973101.

Rahsepar, Amir Ali, and Armin Arbab-Zadeh. “Cardiac CT vs. Stress Testing in Patients with Suspected Coronary Artery Disease: Review and Expert Recommendations.” Current Cardiovascular Imaging Reports, U.S. National Library of Medicine, Aug. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4613789/.

The Nerve!

You’re in your Intake/Fast Track shift and you see a 94 year old patient who had a trip and fall earlier today and now has elbow pain. The elbow is tender and xray shows a fracture dislocation. You call your local ortho and they want to do a closed reduction in the ED, but you know that’s going to be incredibly painful and you don’t want your kind elderly gentleman to suffer. So what do you do?

One option regularly done in the ED is procedural sedation or conscious sedation. This comes with the inherent risks of overdosing sedation medications leading to apnea and need for intubation or other complications. This risk is increased in an elderly man and can be deemed too risky for the ED based on other comorbidities.

Another path less traveled in the ED is used in the OR regularly and involves regional blocks. These can be highly effective at anesthesia and are used in the OR setting for multiple extremity surgeries. So what block could our gentleman use? A supraclavicular block can give good regional anesthesia to the elbow region to undergo a closed reduction in relative comfort. When done right, it results in anesthesia of the upper limb below the shoulder because all trunks and divisions of the brachial plexus can be anesthetized. These should be done under US guidance because of the close proximity of the subclavian artery as well as the pleura in order to make an arterial puncture or a pneumothorax less of a risk. Below are some instructions and a video for any interested in learning this block.

Link to Instructions

Link to Video

Bottom Line: Think about a regional nerve block when faced with any procedure that may require procedural sedation or large amounts of local anesthesia. And a little anxiolytic can also be combined to increase your overall patient satisfaction score.

References:

Barton, Joel, and Sylvia H. Wilson. “Regional Anesthesia for Elbow and Hand Surgery.”Minimally Invasive Surgery in Orthopedics, 2015, pp. 1–6., doi:10.1007/978-3-319-15206-6_8-1.

“Ultrasound-Guided Supraclavicular Brachial Plexus Block.” NYSORA The New York School of Regional Anesthesia, 13 July 2017, www.nysora.com/ultrasound-guided-supraclavicular-brachial-plexus-block.

ThePainSource. “Ultrasound-Guided Supraclavicular Brachial Plexus Nerve Block – SonoSite.mp4.” YouTube, YouTube, 4 Dec. 2010, www.youtube.com/watch?v=ztOIvfjsB-U.