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GeorgeC
What Happens when You are The Doctor on the Airplane?
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marcoseddi
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Good article
I have a first aid kit I got in a lot of other stuff I bought when Independence Air went out of business (along with a whole pile of replacement CO2 cartridges for the life vests, etc..). It does have a pretty good selection of drugs in it that I can identify from my years as a paramedic. I'm pretty sure some 1:1000 epi is in there.
HighFlyingA380
Cleared for Takeoff
I obviously wasn't there, but here goes a little armchair quarterbacking:
No emergency/precautionary landing?!? Especially after the doctors initial efforts seemed to make things worse? Sure, the doc said it wasn't necessary then, but if it did become necessary, it would take some time to get down. Aside from any (basically zero) chance of legal action against the pilot should something happen, I personally wouldn't want that on my conscience. Knowing there would have been an easy solution for me to save a life, but decided against it...
Again, It's easy for me to pick it apart not being. I'm not saying the pilot was dead wrong and made a bad choice. Just saying, with the information presented, I can't see myself following the same course of action.
What are ya'lls thoughts on it, from the pilot's point of view?
No emergency/precautionary landing?!? Especially after the doctors initial efforts seemed to make things worse? Sure, the doc said it wasn't necessary then, but if it did become necessary, it would take some time to get down. Aside from any (basically zero) chance of legal action against the pilot should something happen, I personally wouldn't want that on my conscience. Knowing there would have been an easy solution for me to save a life, but decided against it...
Again, It's easy for me to pick it apart not being. I'm not saying the pilot was dead wrong and made a bad choice. Just saying, with the information presented, I can't see myself following the same course of action.
What are ya'lls thoughts on it, from the pilot's point of view?
GauzeGuy
Pre-takeoff checklist
I wouldn't see the need in this case. A physician is present, has all the necessary equipment and is administering the proper interventions according to the patient's condition. Moreover, the pilots I'm presuming didn't have the necessary training to evaluate the patient for themselves. I spent 15 years in health care and often times multiple interventions may be necessary to resolve or stabilize a condition. The doc clearly had a ton of options available and they were effective.
FWIW, here is the standard treatment for what that patient had going on: http://emedicine.medscape.com/article/135065-treatment#aw2aab6b6b1aa
flyingmoose
Pattern Altitude
Good aticle to read, thanks.
Well he could have made the decision to divert if he wanted to of course, but in these situations you really kind of give that decision to the doctors you are in contact with on the ground and in this case in your aircraft. I am not going to pick apart his decision, he obviously made the right call and that is that.
I remember being in training and hearing them say that you can ask for a doctor on board if you need help with something, but don't expect any of them to raise there hands because of the liability they assume in that situation. In the litigious would we live in im not surprised but it looks like from the information that he provided that never happens. anyway good story.
It was an advertisement for Medikit, not to detract from the story. I remember when I was a kid on a family roadtrip vacation when we rolled up on a major MVA, my dad got out and started going to work triage style until the primary responders showed up, mostly staunching bleeding. I remember one person who went through a windshield laying halfway through spurting blood...couldn't help her... on and on it went. A couple months later at home came an official looking envelope from whatever state it was and my dad didn't want to open it because he figured he was gonna be getting sued or some other BS because, well, people died under his care. Instead he received a commodation from the govenor.
BTW, Medikit is a pretty good service, if a bit pricy, it's one that I've used offshore. You end up with various stages of kit and an on call Dr that knows how to communicate with a layman.
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That article/interview matches my experience in similar situations. Both times, the FO was sent to the back to talk to me about diverting. In neither situation did I feel that a diversion was necessary (one would have been to Iceland). On one of the trips, they did however descend to an altitude that allowed sealevel cabin pressure and we received a direct approach and no taxi delays. The medical kit was indeed very complete and the cabin staff was very professional and helpful.
HighFlyingA380
Cleared for Takeoff
Don't get me wrong, I definitely see where ya'll are coming from, but I still just can't see myself taking this same course of action.
GauzeGuy, according to your article, it states the three (presumably main) items needed for treatment are "high-flow oxygen, cardiac monitoring, and intravenous (IV) access." According to the doctor himself, he didn't have, but definitely wanted, a pulse oximeter. Which according to my admittedly very limited knowledge, is about the only way, aside form blood samples, to measure blood oxygen saturation. Not sure about you, but every educational institution I've been to, a 66% is pretty bad.
And considering how fast this sprang up, as well as how easy it would be on the aircraft to become exposed again, it seems to be a terrible place to treat and observe someone. Even your cited article concurres: "Patients who have refractory or very severe anaphylaxis (with cardiovascular and/or severe respiratory symptoms) should be admitted or treated and observed for a longer period in the emergency department (ED) or an observation area."
Again, not condemning these actions, since it obviously worked out well; I just have a hard time understanding, given the factual evidence, why a precautionary landing was not made. It seems kind of hypocritical, especially on a pilot forum. What do we always say about flying into bad weather? It's always better to be on the ground wishing we were in the air, than in the air wishing we were on the ground. Same should apply in this situation too, if that sentiment was true. And I'd be willing to bet, if she would have had the reaction worsen and then die, everybody would be condemning the pilot for not landing sooner. Just sayin'.
GauzeGuy
Pre-takeoff checklist
Liability should not be an issue for those who render good faith assistance in the air:
1998 Aviation Medical Assistance Act:
"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."
mchesney
Pre-Flight
You must have some ems/public safety knowledge to use the MVA acronym...although they call them MVCs now
HighFlyingA380
Cleared for Takeoff
Seems Henning is omnipotent. I don't even know the guy, but he seems to weigh in on about every thread, regardless if content, with technical advice and a story about his involvement. BTW, was I correct in guessing MVA means Motor Vehicle Accident?
GauzeGuy
Pre-takeoff checklist
Pulse oximetery, etc, is nice to have, not a need to have. When I used to teach first responders, a couple things I liked to remind them: 1) if you need a BP cuff, Pulse Ox, etc, to tell you a patient is in trouble, then you missed something a while ago. 2) treat the patient, not the machine. The number is always nice, but that number must be correlated with other findings.
Secondly, remember the doc on the airplane was doing prehospital care, not definitive care. In other words, he wasn't trying to run a hospital up there. I'd agree that for definitive care (hospital based) that you'd want a few more tricks up your sleeve. For a reasonably stable patient, the doc apparently had what he needed.
Also remember that paramedics, EMT's, etc, routinely make these decisions in the field. Which hospital to go to, ground versus air transport, etc. It is very reasonable for a qualified person to make a call to NOT use the closest hospital or fastest means of transport if the circumstances justify it.
I'd agree diversion is always reasonable, but if you have someone who knows a ton more than you do who's saying it's safe to continue, that is different.
If a licensed physician took responsibility for the care of the patient, I'm not sure how the pilot individually would have been liable? Moreover, there are docs on the ground also monitoring the situation. The airline, I'm sure would have been sued for negligence in the situation though.
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It shouldn't. Some federal law doesn't stop an ambulance chaser from suing you in some Mississipi court. These indemnification laws are worthless without a cost recovery provision (iow the person suing you is liable for your defense cost after the case is dismissed, this is found in some castle-doctrine self defense laws).
The problem is, my my various medmal insurance policies are all tied to work done within the confines of either employment or a geographic limitation, so if in-flight assistance created any legal entanglements, I would have to pay for the defense out of pocket. This has never and will never stop me from rendering assistance to someone in need (funny enough, one time I assisted a lawyer in business class who ended up with a seizure from low blood sugar after he skipped breakfast. His son was smart enough to tell me this fact only after the paramedics had taken his dad off the plane).
mchesney
Pre-Flight
Yep...although now called "motor vehicle collisions" because "accident" implies no one is at fault. I'm sure there's a lawyer somewhere we can thank for that clarification
Doggtyred
En-Route
If treated appropriately, with adrenalin, the issue should resolve. The observation is recommended in case the triggering allergen outlasts the treatment and a repeat treatment is required.
Things that many lay people do not realize is that not every hospital is equal, not every town has a hospital, not every ambulance service is equal nor universally available everywhere. Even when a transport category airliner has a medical emergency they dont slam dunk into the first 6000 ft airstrip they come to - they land at the closest APPROPRIATE airport. Likewise, even in GA, when dealing with a medical issue, the closest airport may not be the most appropriate airport.
It may make perfect sense to fly an extra 10-20-30 minutes to an airport in a major population center than it would be to land at the closest grass strip in the country, where the ambulance may come from 20 minutes away. Chances are unless you know the area intimately you wont be able to know in advance. Being a towered field is probably a good indicator of a good place to land. Absent that, busy enough for an ATIS/AWOS is a good second place.
You messed up! Reykjavik is the best layover ever!
SteveinIndy
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Been there, done that on a medical diversion. I helped take care of a guy having a massive coronary on a Lufthansa flight several years back. I got stuck there overnight because I was delayed due to the case (long story) and they didn't want to hold the flight up. Not a bad place to get stuck at all.
Actually, you can thank the public health and injury prevention folks. You call something an "accident" and people tend to assume it's unavoidable or "the act of God".
It was Multiple Vehicle Accident the way I learned it meaning 'be prepared for a lot of people injured'.
SteveinIndy
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Ah...we used "MVA/MVC" as "motor vehicle accident/collision". For what you're talking about (where we know we're walking into more than just two or three cars), it's dispatched as a "possible MCI" (mass casualty incident).
Gotta love the evolution of acronyms...
brentee
Pre-takeoff checklist
Hmm....the one thing no one seems to have mentioned is what I would have been most worried about: airway management. IV's, drugs, etc are nice but, and I'm speaking from past and quite stressful experiences, a difficult airway with no equipment (except possibly a ball point pen) is a bad deal. I've had my share of pucker factor in a controlled, ER setting...hate to imagine it up there!!
SteveinIndy
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SteveinIndy
The three emergency cases I have seen pulled out on flights over the past fifteen or so years have at least a set of oral airways. One other had a Combitube and another had a full intubation kit.
Armageddon Aviator
Cleared for Takeoff
The physician was an experienced anesthesiologist.
He had access to advanced life support gear.
If the patient's condition had worsened, he could have performed endotracheal intubation and ventilated the patient with a BVM ( Ambu Bag ) and supplemental oxygen.
He established IV access and administered fluids, Benadryl and Adrenalin - that's the standard treatment for anaphylactic shock.
He could have pushed some steroids through that line if required...
He also had an AED - just in case.
Based on his training, experience and the available equipment, I believe that this physician made the right decision.
If the physician did not have formal training in emergency care and advanced airway management ( most physicians don't ) - then it would have been a totally different story and the plane would have probably been diverted...
I provided emergency care on three occasions while flying as a passenger on commercial flights.
Except for one case, where an intensive care specialist was also a passenger, the physicians ( without emergency care training ) were happy to let a paramedic (me) take over and handle the case...
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SteveinIndy
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Back when I worked on ambulances and as an RT, steroids were also part of the standard treatment. That said, I don't recall ever seeing steroids in any of the airline kits I have seen.
Same here. I've been "in charge" so to speak on two of three on board emergencies (two cardiac and one diabetic) I have encountered. The other one happened on a flight back from Las Vegas after an emergency medicine conference. There were at least six EM or critical care docs on board. If you have to have an in-flight medical emergency....
Armageddon Aviator
Cleared for Takeoff
Not sure what the airlines carry today in their medical kits...
Back in the nineties, EL-AL had Solu-Medrol ( methylprednisolone )and Ultracorten ( Prednisolone ) in the emergency pack...
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SteveinIndy
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Not sure about El Al today either. They tend to be well ahead of the curve on most things, especially emergency preparedness.
Mh, maybe. Been stuck there before, didn't enjoy it that much.
brentee
Pre-takeoff checklist
I suggested was that she take some oral Benadryl (an antihistamine) and try to relax a little bit, which she agreed to. I got a few Benadryl capsules from the medikit and gave it to her, and I told her that I'd check back with her in 15-20 minutes to see if she felt better. Since I was sitting just 2 rows behind her I didn't think I needed to stay next to her the entire time.
After about 15 minutes, she was still having difficulty breathing, so at that point I suggested giving her some oxygen, starting an IV, giving some fluids, and administering a little IV Benadryl to see if it would work faster than oral medications. About 5 minutes after I did this, she complained about feeling worse so I administered a shot of epinephrine (luckily, she had carried 2 Epi-Pen vials on board with her) in her thigh, which freaked her out but she felt a little better after that.
Sorry, but at this point I'd be requesting to land ASAP. Perhaps a better question is does it pass the "family sniff test?" If this was your child or mother, what would you do?
Again, a 300# lady with a likely difficult airway who has coded from a similar event in the past, minimal equipment, uncontrolled setting...this has the potential to go very wrong very fast.
After about 15 minutes, she was still having difficulty breathing, so at that point I suggested giving her some oxygen, starting an IV, giving some fluids, and administering a little IV Benadryl to see if it would work faster than oral medications. About 5 minutes after I did this, she complained about feeling worse so I administered a shot of epinephrine (luckily, she had carried 2 Epi-Pen vials on board with her) in her thigh, which freaked her out but she felt a little better after that.
Sorry, but at this point I'd be requesting to land ASAP. Perhaps a better question is does it pass the "family sniff test?" If this was your child or mother, what would you do?
Again, a 300# lady with a likely difficult airway who has coded from a similar event in the past, minimal equipment, uncontrolled setting...this has the potential to go very wrong very fast.
pericynthion
Pre-takeoff checklist
I don't know.. I've heard that one of the most dangerous situations in aviation is when two CFIs are flying together. Maybe it's the same with doctors.
Armageddon Aviator
Cleared for Takeoff
An experienced emergency care provider can generally perform a reliable evaluation of the case severity...
The patient didn't appear to be crashing...if she was fully conscious, without a dramatic tachypnea - and with a good hemodynamic status...I would have taken a similar decision...
The first class cabin of an airliner is a pretty "controlled" environment compared to some of the places I've been as a medic...
He had a laryngoscope ( I presume ) and endotracheal tubes, a BVM, an AED, IV access equipment, ACLS medications...sounds pretty adequate to treat such a case...
You cannot treat every patient as if it was your "child or mother" ( you never treat your family objectively...)
One more thing...how long would it take to make an emergency descent to the nearest airport ( with a decent hospital in the area ) ?
How long before she can be transferred to a waiting ambulance ? ( with or without Advanced Life Support available ? )
How long before she is admitted to the ER ?
What happens when you're in the middle of a transoceanic flight ?
You're crossing Africa on your way to Capetown...do you divert to some hospital in Congo or Rwanda ?
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steingar
Taxi to Parking
Personally, I have to question the wisdom of anyone with such severe allergies getting aboard a pressurized cockpit in the first place.
Armageddon Aviator
Cleared for Takeoff
brentee
Pre-takeoff checklist
The patient didn't appear to be crashing...if she was fully conscious, without a dramatic tachypnea - and with a good hemodynamic status...I would have taken a similar decision...
So, you'd make the decision to land after she starts crashing?
The first class cabin of an airliner is a pretty "controlled" environment compared to some of the places I've been as a medic...
Far less controlled than an OR, ER, or even the back of an ambulance. And, we're not taking combat or the site of a horrific accident here.
He had a laryngoscope ( I presume ) and endotracheal tubes, a BVM, an AED, IV access equipment, ACLS medications...sounds pretty adequate to treat such a case...
Why do you presume this? Also, why do you presume this will be a typical intubation? Ever intubate an obese pt with angioedema?!? Are you presuming there's a cric kit in the overhead, too? Again, this lady's coded in the past, she's complaining of her airway swelling, and she feels worse after the IV Benadryl. Maybe I'm just picturing her looking worse than she actually did.
You cannot treat every patient as if it was your "child or mother" ( you never treat your family objectively...)
I've been practicing medicine for a while now and I'm proud to say I ask myself that question often. Hope that never changes.
What happens when you're in the middle of a transoceanic flight ?
Well, you got me there! But, they were 2 hours from LAX. Probably a hospital or two on the way.
So, you'd make the decision to land after she starts crashing?
The first class cabin of an airliner is a pretty "controlled" environment compared to some of the places I've been as a medic...
Far less controlled than an OR, ER, or even the back of an ambulance. And, we're not taking combat or the site of a horrific accident here.
He had a laryngoscope ( I presume ) and endotracheal tubes, a BVM, an AED, IV access equipment, ACLS medications...sounds pretty adequate to treat such a case...
Why do you presume this? Also, why do you presume this will be a typical intubation? Ever intubate an obese pt with angioedema?!? Are you presuming there's a cric kit in the overhead, too? Again, this lady's coded in the past, she's complaining of her airway swelling, and she feels worse after the IV Benadryl. Maybe I'm just picturing her looking worse than she actually did.
You cannot treat every patient as if it was your "child or mother" ( you never treat your family objectively...)
I've been practicing medicine for a while now and I'm proud to say I ask myself that question often. Hope that never changes.
What happens when you're in the middle of a transoceanic flight ?
Well, you got me there! But, they were 2 hours from LAX. Probably a hospital or two on the way.
SteveinIndy
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HighFlyingA380
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Lot's of what-ifs there... The cabin was obviously not a very controlled environment, because it's possible she got the initial case due to circulating air particles. It'd be pretty easy for it to happen again and worsen the situation.
You also seem to be focusing on the physicians actions. I'm talking about the pilot's actions. Sure, the physician may wait to make the "land now" decision until it's needed, but he may not realize that it could be a good 30+ minutes after that call 'till they actually get on the ground.
And we're not talking about a transoceanic flight, or crossing Africa, or far away from a suitable landing site... He said they were right by KDEN. Not sure you can get a more suitable landing sight anywhere, as no hospital has a 10,000 runway. Regardless of how long an emergency decent might take (30+ minutes?), that's nothing compared to the 2.5 hours left in the rest of the flight.
Armageddon Aviator
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You fully understood what I said and meant - if her neurologic, airway, ventilation and hemodynamic parameters were OK - and you have the right training, experience and equipment, you can start treatment and reevaluate the patient after a while...as long as the patient is stable there is no need to divert immediately.
I spent 12 years treating severely injured patients in the back of cramped aircraft and noisy helicopters...maybe that's the reason I don't think it's such a big deal...try to intubate a patient in the back of a Huey while flying at low altitude...that's a bit more challenging that the first class cabin of an airliner...
I presume so because there was an intubation kit and a cric kit in the three cases I mentionned ( three different airlines )
And for the record, I did intubate an obese patient with angioedema ( I wouldn't say it was a piece of cake though...)
I did treat my patients with a lot of respect and empathy....i guess that most providers would be extremely stressed out if they had to treat their own family....
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brentee
Pre-takeoff checklist
Cric kits and advanced airway equipment?!? If you say so, but I'm betting a few simple oral airways are all they stock. And, if your plan B is cricing them, you really didn't put too much thought into plan A.
There's no reason to take chances with other people's lives. I knew a few guys like that...they'd make way too many attempts at critical procedures, or "monitor" their pt's while they slowly crumped before asking for help. Just never could see the bigger picture.
There's no reason to take chances with other people's lives. I knew a few guys like that...they'd make way too many attempts at critical procedures, or "monitor" their pt's while they slowly crumped before asking for help. Just never could see the bigger picture.
brentee
Pre-takeoff checklist
Doggtyred
En-Route
THere's also no reason to over-react, based on a stable clinical presentation because something MIGHT happen (or might not).
Its clear you guys have two different philosophies in management. Neither is necessarily wrong. I prefer to treat the patient, not the lawyers.... your mileage may vary.