For example in my company we don´t have an online doctor to ask for help, so the volunteer has to take care of the situation. Recognizing the problem as soon as possible and prescribing the necessary action (Is not going to be easy with such limited capabilities, sometimes is just impossible, but is better an overreaction), is important because commercial planes fly at 8 NM/minute, and depending where are you flying ( flying over the ocean or africa) 10 minute delays could mean another 30 extra min to land or even several hours if you have passed a no return point in the middle of the ocean.
Don´t hesitate to take control of the situation regarding the patient, stewardesses and other passengers:
- Ask for the medikit (only physicians are allowed to use it). I have seen some chief stewardess resisting to bring it, just to avoid having to write the compulsory report.
- If it is necessary to lay the passenger on the ground or other seats, bring him water or any other thing, just give the needed orders and ask for help.
- Ask the stewardesses to keep other passengers away if they are interfering too much.
- As soon as practicable give a report to the captain and if necessary ask him to land the plane. He will be waiting for it.
- If possible never declare a decease onboard , first you could be wrong!, and it is a bureaucratic mess. Is better to keep trying CPR till the emergency team can take care of the patient. We apply this in Europe although it is not a written rule, I don´t know how it works in USA.
-Remember when in doubt it is better to ask the captain to land. Everybody will lose an hour or two but a live will probably be saved.
Curious, what is type procedure to verify that someone really is a physician? The OP doesn't mention if a license was checked or otherwise. He relates having to speak to a someone on the ground before he could use the kit but doesn't indicate if any check of credentials was made.
It would be extremely frustrating to watch someone die (or at least get sicker), knowing there was equipment on board that could help them...
Everything in that bag is likely able to be used autonomously by a paramedic - it deals with acute care, not chronic, which unsurprisingly is what paramedics are used to dealing with:
* airway management / ventilation, up to emergency cricothyroidotomy
* ET / NG intubation, including RSI (rapid sequence induction, essentially sedation, anesthetization in preparation)
* bleeding control / fluid resuscitation
* pain management
* seizure / neurological
* cardiac events, drug administration, manual and automated defibrillation, pacing
* overdose / poisoning
* less common on an aircraft, but trauma, including burns
* medication administration via IV/IM/IO routes
Most paramedics work almost entirely autonomously via protocols and training, and do not require direct physician approval for drug administration (as opposed to nurses). This range of drugs is quite extensive (my county allows approximately 40, including adenosine, amiodarone, atropine, dopamine, etomidate, fentanyl, morphine, midazolam, lidocaine, furosemide, promethazine, succinylcholine, vasopressin).
I know for a fact that some airlines do have an on-call physician (the medical director for my paramedic program was one years ago, in addition to providing state-wide medical control for all flight based EMS services), I was just curious if the OP's airline did.
My question is mostly if the 'physcian' requirement could be circumvented if someone with medical training (other than a physician) were in contact with a physician on the ground. If, for example, I were to explain to a remote physician that there's someone on board who is experiencing A, B, and C, and I would like to do X, Y, and Z. If the doc concurs with the decision, would that be enough, or is there some set in stone policy that couldn't possibly be overridden?
I had a friend on a transatlantic flight that got stuck in Iceland (they tried to get the person on the ground and to a hospital but there wasn't really anything that could be done) for... a long time... because of this. And IIRC, letting them off the plane was not really an option either, so it ended up being not only depressing, but pretty miserable in other ways as well.
I must also say that when there is a person onboard with high fiver or symptoms of a contagious disease, in the USA you have to notify to the authorities (the Federal and State Quarantine and Isolation Authority I think) immediately. I didn´t know it before I read the manual as I am not currently doing intercontinental flights.
I also have a relative who is a doctor/med school professor who does a lot of traveling, and has had to assist the crew three times with in-flight emergencies. One was a heart attack, one was deteriorating condition of an unknown cause (the flight was diverted to evacuate this man) and the third was a guy who had intense bladder pains mid-flight which turned out to be the result of downing a huge quantity of beer before the flight and being unable to urinate.
intense bladder pains mid-flight which turned out to be
the result of downing a huge quantity of beer before the
flight and being unable to urinate
If we were intelligently designed, after all, I think God would call holding it for hours a "user error" and mark it "won't fix".
So just to confirm, you're saying that if (for example) I hold my pee for whatever reason, after a certain point, I might not be able to pee unless they catheterize my bladder?
Maybe that guy suffered from the Shy bladder syndrome .
Generally speaking, this is done with an ultrasound, but in a pinch, you could likely just palpate the bladder.
I must admit, some secret part of me always hopes I'll be in a situation on an airplane where they need an emergency perl script written . . .
On a flight from Sydney to Vancouver earlier this year, the in-flight entertainment system on my plane was broken. I spoke up: "Hi, I have a doctorate in computer science and I know a bit about these systems... want me to take a look?"
I was surprised when they agreed, brought me up to the front galley, and showed me their interface to the entertainment system (alas, the server itself was in the ceiling and not accessible). I ended up pulling out my laptop, borrowing a cat5 cable from one of the flight attendants (all of mine were in my checked suitcase) and running tcpdump on the plane's network. Alas, while that allowed me to diagnose the problem, I lacked the serial cable needed to connect to the server's console and wasn't able to fix it.
I considered sending DHCP responses to the server myself, but decided that injecting traffic would be too risky during flight... especially since I was flying back from a conference where one of the speakers had been talking about inadequate firewalling between IFE systems and aeronautical control systems.
How is this possible? Why do they even need to be on the same network?
Furthermore, the IFE might not need to talk to critical control systems, but they both might need to talk to some of the same other systems. Cabin lights seem like a likely candidate. Displays for the pilot, too. And maybe maintenance fault logs.
It can be a real hassle to have totally isolated systems on different networks. You can do it, but you need a Good Reason. The easy thing, from an engineering perspective, is to make it so everything can talk to everything.
One of the top 5 questions you don't want to hear over the loudspeaker while flying on a supersonic jet.
There was never any problem with the flight, and he never found out what happened. Probably something like the co-pilot had a problem that prevented them from continuing to act as the co-pilot, and they wanted to maintain sufficient redundancy just in case.
Why would electrical engineers fly to a conference on a Concorde? What good would an aeronautical engineer be _in flight_?
> "Why would electrical engineers fly to a conference on a Concorde?"
The airline was moving a Concorde to a different facility (ie, it wasn't part of regular scheduled service). They decided to "upgrade" a bunch of passengers who were scheduled to be on a different type of aircraft. They moved the whole group of engineers together.
The stewardess asked for a "Concorde engineer", who was needed for after landing. It had something to do with the way the Concorde hooks up to the loading bridge at the terminal (it may have something to do with the unusual height of Concorde?)
His scariest stories weren't due to the criticality of the patient, but rather the incompetence of the provider on board the plane (to the point that he, on several different occasions, had to instruct the flight crew to 'please keep him away from the patient for the rest of the flight'). Just because someone is a 'doctor' doesn't necessarily mean they're well equipped to handle a medical emergency (note: the physician interviewed here managed the patient perfectly appropriately).
It's possible he was just pandering to the room of soon-to-be paramedics at the time, but he said he generally instructed the flight crew to ask for a paramedic before a physician, simply because they're generally more comfortable working in the 'austere' medical setting found on a plane.
Apparently they were on shift one Saturday afternoon, when a call came through for a Code 2 (Cardiac Arrest) at a local racecourse.
Anyway, it was about 15 minutes away so they took off in a hurry, all the while receiving notes on their terminal regarding the job. Apparently it went along the lines of this:
Initial: Unknown Age, Cardiac Arrest, Racecourse etc
Update: CPR in Progress
Update: Doctor has self accounced at scene.
Update: Doctor has called patient as deceased. CPR ceased.
It took another 5 minutes for the paramedics to get to the racecourse, and they still unloaded their gear and made their way to the patient. When asking for the doctor, they found that it was actually the racecourse veterinarian who had made the call.
If I had a dollar for every time a dermatologist or podiatrist tried to be 'helpful' on an emergency scene... I could probably buy a coffee at Starbucks... The same goes for 'nurses.' If an ER nurse wants to help out, that's great. Invariably though, it's a nurse at a nursing home or dialysis center...
I don't mean to imply these folks aren't skilled professionals, but prehospital medical emergencies are generally well outside their experience, and the confusion that arises from that can be dangerous.
There are daft people in every field, but I would be delighted to have most of the derm residents and attendings I've met in an emergency (in fairness, I should note that this is a small sample, drawn from a couple top-tier hospitals, and biased towards people who do volunteer backcountry search and rescue).
Like I said, I'm not try to discredit these folks as skilled (and in many cases, extremely smart) individuals.
However, a couple weeks of a rotation through an ER during med school isn't really going to prepare you well for prehospital emergencies (SAR, on the other hand, can be great training for that). Making an assessment and clinical decisions based on fairly limited information isn't something I've found most physicians to be comfortable with, especially in an emergency setting.
My list of 'glad to see you' docs is pretty much: ER, OB, and Anesthesia.
I think I'd be happy for a vet to do some doctoring.
The call was for a human, the 'doctor' who called it was a vet at the racecourse.
The other passengers on the flight actually did applaud her, which was cute, but I think they mostly did it because it meant that the flight didn't need to be diverted to Heathrow.
(Don't want to rant too much, but it irks me that TSA has, once or twice, confronted me on the things.)
Only had one close shave where some one diabetic had become and unconscious and thrown up in there sleeping bag - let me tell you seeing someone being carried towards you on a stretcher certainly gets rid of the hangover quick - this was pre mobile phones so i had to sprint to the public call box to call 999 (911)
Also, is it legal to just put a blanket on the guy, pretend he's sleeping, and then deal with it when you get to your destination? Our friends missed their connecting flight to Hawaii in LAX because of this ordeal.
If he had pulseless electrical activity, then there is an algorithm for that, too. Some would say that you aren't dead with PEA until you've got a needle in the second intercostal spaces bilaterally and one penetrating the pericardium.
Ironically, the one who survived was a prisoner who had cut his own throat. He had pretty much bled out by the time we got there, with a tiny little junctional on the monitor. Today he has 0 deficits, and it is like the event never occurred.
If CPR goes on for more than 10 minutes or so in a non-hypothermic patient (with no other interventions), your chances of survival are basically nil. This is is especially true if you have a limited number of people doing compressions. Effective compressions are extremely hard work, and rescuer fatigue is a huge issue with CPR (we switch every two minutes no matter how 'fine' the person doing compressions claims to be). I doubt you could maintain effective CPR on an aircraft for 30 minutes (I suppose you could get a couple dozen people involved, but that seems unlikely).
If I'm not back in 15 minutes, please stop... At that point enough damage has been done to my brain that I don't want to come back...
Having no medical training, I know how to perform CPR and was able to resuscitate him to get to the local hospital and then to Methodist in Indy. Every doctor attributed to him living past 30 minutes to my efforts .
Outlook looked somewhat good for the short term, but the longer he was in ICU his chances worsened. Due to longer term massive organ failure, he passed on 12/12/12. My dad was Wilbur Harold Crawley III: automotive, electrical, and acoustic engineer.
And unless it's started pretty much immediately, it won't even accomplish that, which makes it futile.
Not to sound insensitive, but I wonder what the alternative would be? Declare him deceased and then do what? See this comment elsewhere:
"If possible never declare a decease onboard , first you could be wrong!, and it is a bureaucratic mess. Is better to keep trying CPR till the emergency team can take care of the patient."
A nurse was onboard the flight but no insulin. We had to divert and my coworker was laid up in a Newfoundland hospital for 3 days.
The most common type of 'diabetic shock' is _hypo_glycemia (blood sugar too low). The treatment for this is simply sugar (if the patient is conscious, they can take it orally, if they're unconscious, then they need an IV with Dextrose).
I suspect most airline medkits carry dextrose (the one mentioned in the article did). I would imagine many of them carry glucagon as well (glucagon can be injected into the muscle, which is quicker and easier than establishing an IV, and it signals the liver to release its glycogen stores (by breaking it down into glucose (sugar))).
I imagine insulin is very rare. It doesn't keep for terribly long, most types need to be refrigerated, and the most common use cases are for things that don't come on 'suddenly' (generally someone experiencing severe hyperglycemia has had symptoms for hours or even days).
(I am not a doctor, but I am a diabetic who has experienced DKA.)
So now it's 3am GMT and he can't reach his doctor in the States. We're supposed to leave at 8am for the flight home. No pharmacy is open and even if they were, they wouldn't help him. Nurses at Heathrow couldn't help him either.
So he decided to risk it and see if he could make it all the way home without having any trouble. He went into shock 4 hours into the flight.
Even if they've reclassified it as a POM in the 25 years since I stopped doing that stuff for a living, if you could have found a pharmacy in the UK, then under the Emergency Sale and Supply regs the pharmacist could, on their own recognizance, dispense a sufficient supply of prescription-only meds to get the patient back home.
(Caveat: I am an ex-pharmacist. Any advice I could conceivably give you is over two decades past its sell-by date and needs checking.)
Edit Current emergency sale and supply regs are described here:
Were I ever to become diabetic (and manage to figure out my fear of needles), I'm pretty sure I'd carry around spare insulin, like an epi-pen.
(Is it something that can be carried around trivially? Or does it need to be refridgerated? You know what, maybe I'll just eat healthier.)
That said, insulin is used to treat hyperglycemia, which is usually not an acute incident. "Diabetic shock" refers to hypoglycemia, in which the individual needs sugar to raise their blood sugar to normal levels.
You get over it pretty quick when it is literally life-or-death, trust me ;-)
See, for example, this 2001 Australian document:
Diabetics experience a "honeymoon" period where they will experience some symptoms - almost always enough to trigger a trip to their PCP, urgent care, ED, etc. where they will be diagnosed and put on a treatment plan.
At most they will experience one event of being "very sick" if they don't get checked out at all during the months-long honeymoon before its found.
If most diabetics didn't know they were diabetic, most diabetics would be dead.
Everyone's a critic.
(edited: semi-conscious -> lethargic)
In retrospect I should have given her honey or the like just in case she was having her first ever diabetic shock.
Why would the doctor get sued? Why would that question even be asked? I didn't feel like any type of catastrophic event happened to merit a lawsuit.
There was an older fellow who had a heart condition for which he was taking medication. His reasoning had gone something like "I need to take one of these pills four times a day, but I'll be traveling, so I'll just take all four of them right before checking in". Needless to say, this didn't work very well, and he was having sort of issue with his heart as a result. The poor guy was so scared he literally shit himself.
My friend actually had to make the call whether we needed to land on an airport in Greenland to get the guy to a hospital. He thought about it for a minute and decided that the guy was going to live, so we continued to Amsterdam, where an ambulance was waiting.
As a "thank you" from KLM, my friend was allowed in the cockpit during landing (this was before 9/11), and he got a bag full of little bottles of alchoholic beverages. Unfortunately, he's a teetotaller.
Sometimes they will put a blanket over the body, sometimes they will pretend that the person is sleeping. Depending on the situation.
I don't really get into the details but that's the scoop.
Flight from SFO -> IAD last week. As soon as we took off, they asked for a doctor. He spent 2 hours treating the patient before they started drink service, and continued until we landed. We were all quite worried about the person, but found out at the end of the flight that they had overdosed on NyQuil. That made the whole ordeal fairly frustrating.
I have no idea how big a typical bottle of NyQuil is, but assuming it's somewhere in the ballpark of 10oz (we'll call it 300ml to make the math easy). NyQuil has 325mg/15ml, so our hypothetical 10oz bottle has ~6,500mg in it. That's certainly a respectable dose of Tylenol, but it's not likely to be fatal in a couple hours for an average sized adult...
I am surprised that it contained morphine. Pain killers would not help much in resolving whatever medical issue is occurring.
Besides, is it not dangerous to report the fact that morphine is available on a flight? Some medkits are easily accessible and can be taken when the flight attendants are not looking.
We went to a fractured tib/fib (Football injury) and we loaded him up with the maximum dose over the course of treatment (50 minutes or so) and it didn't even touch the sides.
Looking back we probably should have called for the IC guys and done some ketamine + realignment.
RSI uses a sedative and a paralytic. The sedative is almost always a benzodiazapine, and occasionally a dissociative or hypnotic sedative like ketamine or etomidate.
Morphine would be a _very_ poor choice for a sedative in an RSI protocol.
Our protocols call for vecuronium, atropine, etomidate, succinylcholine. However, we do also use fentanyl if indicated to deal with tachycardia and ICP.
One other thing I noted in the original article was bemoaning the lack of pulse oximetry, "to assess if patient was exchanging oxygen". Treat the patient, not the number. If your patient is in respiratory distress but has 100% SpO2, treat the distress. If your patient appears /comfortable/ and /normal/ at 90%, go with what seems appropriate to their case.
(In fact, our MPD excludes Pulse Oximetry and Blood Glucose from BLS protocols on the grounds of 'treat the patient' - though my opinion tends to differ on the latter).
There are a few extremely important caveats with pulse oximetry. PulseOx is useless if your patient isn't perfusing their periphery well (either due to hypothermia, or shock). You also need to consider that it only measures the percentage of hemoglobin that is bound to _something_, that something could just as easily be carbon monoxide. The other commonly overlooked issue is that certain types of lights (fluorescent lights are the worst offender) play havoc with pulseox meters. Your average fluorescent light will happily sat in the mid-80's. Be sure to cover the finger (or toe) that the sensor is on with something opaque.
Additionally if you panic you can easily imagine having trouble breathing, or that your trouble breathing is worse than it actually is. I have experienced this first hand when just relaxing removed most of my problems.
I spoke up, and the crew directed me toward the back. They already had this incredible medical kit opened in the aisle. I mean they had everything....ACLS drugs, defibrillator, suction, a complete mini-pharmacy, and what looked like a few plastic-7 wound and/or trauma kits at the least. I mean, I was practically drooling over this high-tech kit.
Of course, it was also at that moment that I started frantically running through cardiac code algorithms in my head, and pondering exactly how long it had been since I'd actually dealt with a code in a hospital, with plenty of trained staff, lab support, etc.
Of course, it wasn't any kind of life-and-death situation at all - a young person very stressed and anxious about relocating and the actual conditions of the flight, who'd been hyperventilating, hadn't eaten or had anything to drink for many hours, near-syncopal, etc etc.
I tried my hardest, but couldn't think of a single thing to use out of the medi-kit. I wanted to use it.
I just sat down next to her and listened, which is 90% of medicine anyway.
Southwest was great - gave me two round-trip tickets to anywhere for taking a few minutes to talk.
A colleague at University of Hawaii wrote a paper about dealing with psychiatric emergencies in the air. One thing that stuck out in the paper was the interesting phenomenon of what he called "honeymoon psychosis", with one of a young newly married couple away from home for the first time, possibly on their first flight, all leading to some interesting disturbances on those long pan-Pacific flights.
He'd been an army doc and was flying around as a volunteer physician, so he was qualified if anything bad did happen, but most of the time it just involved sitting in first class and talking with the patient. There are worse ways to spend a flight.
That's very reassuring. Any intubation equipment (or at least airway adjuncts (LMA, King, etc))? BVM?
(History: http://www.newmediamedicine.com/forum/modernising-medical-ca... )
It's a first-rate submission.
In the future, use ihackernews.com. It provides a mobile friendly link to stories using viewtext.org. The viewtext.org link for this story (http://viewtext.org/article?url=http://www.cockeyed.com/pers...) works perfectly on my phone.
It is one of my pet peeves when I come across some morsel of information online but I can't evaluate if it is still applicable because there is no timestamp anywhere.
In the current case, there is a timestamp of sorts at the bottom of the page: "Updated December 27, 2012 Copyright 2012 Cockeyed.com".
Here is blog owner's About page, last updated January 27, 2012: http://www.cockeyed.com/personal/about.html.
Bottom of the page would be OK, too, if people always put it there. But they don't.
Consistent date placement promotes efficient search engine result scanning (Google's date constraints are highly imperfect).
Then quit posting your personal problems here.