In-Flight Medical Emergency: Physician Kit
The case
About 6 hours into an 11-hour Air New Zealand flight from London to Los Angeles, the flight crew requests medical attention for a passenger.
The patient is a 74-year-old man reporting light-headedness, nausea, and syncope. He had been feeling generally ill throughout the day prior to boarding the plane, and during the flight he had an episode of non-bloody emesis and diarrhea. After returning to his seat from the lavatory, he had a 10-second episode of unresponsiveness which prompted his wife to call for help. A brief review of systems is otherwise negative (specifically, he denies fever, chest pain, shortness of breath, abdominal pain, or back pain).
He reports a history of non-insulin dependent diabetes (on metformin, generally poor glycemic control) and hypertension (on ramipril). He denies any history of coronary disease or stroke. He also denies previous chest or abdominal surgeries.
On my arrival to his seat, he is pale and diaphoretic. Another physician (internist from the UK) had already arrived and was getting vital signs. His radial pulses were thready. It was a real challenge to get a manual blood pressure (cheap stethoscope), but we agreed we both heard some Korotkoff sounds around 110-120 mmHg. The flight crew placed him on face mask oxygen. I requested the physician kit and checked his blood sugar which was 10.6 mmol/L (equivalent to about 190 mg/dL). We then assisted him to the galley.
His lips and mucus membranes were dry. Cap refill was 3-4 seconds. The rest of his limited examination was unremarkable (heart, lungs, abdomen, neuro).
Initially, I gave him 300 mg of aspirin, kept him on supplemental O2, and attempted oral rehydration. He wasn't able to take more than a few sips of water so I started opening the IV pack in anticipation. In the meantime, we had him lie down to attach him to the AED (as there was no other way to do cardiac monitoring). The crude tracing on the AED looked ok, and he had a sinus rhythm with a normal rate.
As soon as I was ready to obtain IV access, he said he felt ill again. He started retching while supine, so we immediately rolled him onto his side. The EM gods must have been smiling on us because, somehow, while simultaneously holding him in right lateral decubitus to allow him to safely vomit I was able to pull his left arm behind him and pop a 18-gauge angiocath into the forearm.
We gave him two 500-mL boluses of normal saline and 10 mg of metoclopramide IV. We kept a written log of everything we did and the flight crew intermittently reported to MedLink, the ground-based medical response system (staffed by emergency physicians). We watched him for about 2 hours, and during that time his symptoms and perfusion improved significantly. Our working diagnosis was acute gastroenteritis with resultant dehydration and syncope.
The brush up
This patient scared me for multiple reasons:
1. He's an old guy with comorbidities who looked ill and had signs of potential hemodynamic instability;
2. He may have presented with an ACS equivalent, sepsis, DKA, or some other critical disease process that I wouldn't be able to work up;
3. I had only a vague idea of what kind of diagnostic/therapeutic resources might be available on the aircraft.
This post isn't a comprehensive review of in-flight medical emergencies (IFME). As emergency docs, we are well-trained and prepared to approach any acute medical problem, even at nearly 40,000 feet in the air (within the context of available resources, of course). However, a couple specific questions came up for me in caring for this patient that I want to address:
What equipment and medications are required to be available in a standard airline Emergency Medical Kit (EMK)?
This is what Air New Zealand specifically stocks on board. Pretty awesome (there was even a manual suction device)! This image was adapted from a presentation on IFME given by an Air NZ aviation medicine physician.
Now, not every aircraft will have this comprehensive of a set. In the United States, the Federal Aviation Administration (FAA) requires that all aircraft operating with a maximum payload of at least 7,500 pounds and with at least one flight attendant carry, at minimum, one AED and one EMK with the following contents:
FAA EMK minimum requirements
In Europe, the International Civil Aviation Organization (ICAO) sets similar guidelines (including AED) for aircraft with the capacity to carry at least 30 passengers flying for at least 60 minutes:
ICAO EMK minimum requirements
Both organizations require that flight crew members have training in basic life support and AED operation.
What might NOT be available:
- Cardiac monitoring/EKG: some AEDs may have display tracing capability, but don't expect this
- Specific drugs: Worth noting is the lack of requirement for anti-epileptics, glucagon (FAA guidelines), and anti-arrhythmic drugs (other than lidocaine, both guidelines)
- OB delivery equipment
What is your responsibility as a volunteer physician with regard to medical decision making and potential aircraft diversion?
In the US, physician passengers volunteering medical services are protected against liability for damages, unless found to be guilty of gross negligence or willful misconduct (the "Good Samaritan" provision of the Aviation Medical Assistance Act of 1998). In the UK, individual airlines decide whether or not to provide volunteer physicians with indemnity. Most do, but make sure you ask. It is worth noting that you are no longer protected under these provisions if you request or accept payment for services.
In the above case, the flight crew informed me that indemnity was provided. Furthermore, because the ground-based medical response system had been activated (required when oxygen is administered, physician assistance is requested, the physician kit/EMK is opened, or there is any possibility of diversion), MedLink officially assumed responsibility for the patient, and any treatment we provided on board required their approval. In the absence of such a call center's involvement, volunteer physicians can make recommendations about diversion, but ultimately the captain must agree. In cases when the airline goes against a physician's recommendation to divert, liability then resides with them.
The conclusion
The patient rested for the remainder of the flight without further issue. His symptoms resolved. On landing, he agreed to ambulance transport for further evaluation, so I gave report to the EMS providers who took it from there (and before leaving I snuck a peak at their EKG, which looked fine). :D
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