ARTICLE IN BRIEF
Neurologists recount the challenges of responding to in-air medical emergencies.
Toledo, OH, neurologist Mark G. Loomus, MD, was flying Paris-to-Atlanta a few weeks ago when — somewhere past London — the call sounded. A young man had just taken a bite of food when he became dizzy, clammy, and tremulous. Dr. Loomus got the passenger to the floor, elevated his legs, and placed a jacket and blanket over him to warm him up. A family practitioner, who also volunteered to help, asked the flight crew if they had a blood pressure cuff (yes), and glucometer (no).
“I was relieved to have someone to work with, and glad she thought of some of the more common causes, like hypoglycemia, while I was considering vertebrobasilar dissection, stroke or MI [myocardial infarction],” Dr. Loomus admitted. “Out of one's element, you don't necessarily think the way you would in the hospital or the office.” He decided not to divert the plane to Heathrow, and fortunately, the patient, a probable victim of dehydration and hypotension, turned out just fine.
Because there are no standards for monitoring in-flight medical emergencies, and airlines are not required to report them, their precise incidence is not known. But they are far from rare. Reports in the US have quoted figures ranging from 13 to 33 events per day on board airplanes. One study relayed a rate of one incident per 33,600 to 39,600 passengers, and another, of one incident per 11,000 passengers. Airlines handle medical emergencies of the nearly three million passengers that fly worldwide daily by counting on the good graces of physician passengers. If you fly frequently, you've likely heard this request on the loudspeaker at one time or another, as neurologists told Neurology Today.
WHO IS MOST QUALIFIED?
After a distress call is sounded over the loudspeaker, and doctors converge at the aisle next to passenger in distress, a peculiar kind of exchange typically ensues, when specialty and credentials are compared. A psychiatrist may trump a dentist, but not a surgeon, and as Asmahan Al-Shubaili, MD, head of the neurology department at Kuwait's Ibn Sina Hospital found out on one occasion when she was dismissed at the scene, a paramedic may trump all. But there were no paramedics offering to take over during a flight from London to Los Angeles in 2000, when she attended to a febrile, sick-looking young accountant who was traveling to the US for a licensing exam, after having just been diagnosed with pyelonephritis. He had been treated with intramuscular antibiotics for two days and was given vials to take for the remainder of his course. On that occasion, she was abandoned by another doctor who had initially answered the call, and left to the task of removing his clothes, administering the IM antibiotic, antipyretics, and applying cold compresses. The patient finally improved in the final hour of the nine-hour flight. It depends on the nature of the problem, of course, since many neurologists have special skills.
David E. Thaler, MD, PhD, was landing in Boston a few years ago, when a 20-something man seated in front of him dislocated his jaw after yawning to clear his ears, causing his mouth to be stuck open. “The flight attendant brought me the medical kit — pretty meager, but it had what I was looking for: gloves. I put my thumbs into his mouth, pushed slightly downwards on both sides of the lower molars while my fingers applied slight forward rotation around the angle of the mandible,” he said. Dr. Thaler asked him to try to close his mouth and not bite him, and a second later, there was an extremely satisfying click.
How did the director of the Comprehensive Stroke Center at Tufts Medical Center know how to do this? Just the week before, he'd been asked to consult on someone who had sudden “speech difficulty” on the oncology ward.
“It became obvious pretty quickly that the cause was a mechanical limitation of mouth closure,” said Dr. Thaler, who later asked for step-by-step directions on how to treat a dislocated mandible, little realizing that the opportunity would arise so soon. (Dr. Thaler said a senior colleague summed up the teaching point: “If you can hang them upside down and the mouth is still open, then it's not neurological.”)
TO DIVERT OR NOT TO DIVERT?
In every situation, that's the issue most pressing to the pilot. The burden weighs almost as heavily on neurologists as the burden of care. Who wants to cause an entire cabin to miss other flights or unnecessarily delay their vacation or business trips? Two years ago, Hackensack, NJ, neurologist Damon M. Fellman, MD, was confronted with the situation when he and his wife sat behind an elderly lady and her son on a flight to Phoenix. Peering between the seats, he saw her fall over sideways and heard her son call for help. When he stood to look over the seat, the woman was unconscious and stiff, exhibiting decorticate posture on one side. The stewardess came over with a walkie-talkie, instructing him to speak to the captain, and all eyes were upon him. “For a brief moment, I thought my movie career had just begun, but I placed her head down and she gradually revived,” he said, relieved that he was able to reassure the captain — and the others passengers — that the flight need not be interrupted.
Colonel Jonathan Newmark, MD, who travels so extensively for work that he has accrued several hundred thousand frequent flier miles, has responded to the call six times. “The most serious incident took place when I was flying overnight from Kuwait City to London, and the passenger immediately in front of me, a Pakistani gentleman who had been visiting relatives, began having shortness of breath,” Col. Newmark recounted. The passenger had been on vacation, and had been less than assiduous in taking his medications for congestive heart failure, all the while over-indulging in food and drink. “The pilot's major concern was whether he needed to divert; if you look at the map you will instantly see that a diversion in the first hour or two of that route, at a time when Iraq was a no-fly zone for commercial aircraft, would have been a very long detour.” Ultimately, after the patient was given oxygen, drank some water, and was made to swallow the pills he had brought along, he improved, and the flight was able to continue.
It's not only the lack of proper diagnostic equipment, limitations of treatment, and cramped space that can make air care difficult, but the language barriers that can be expected during international travel, as Roy C. Katzin, MD, medical director of the Stroke Service at Delray Medical Center in Florida, discovered on a flight to Italy with his wife and four children a few years back. He responded to the call about 45 minutes following take-off, after his kids stared at him in unison when he didn't immediately jump up. He found that a woman in the last row of the plane was lethargic and ashen, and she and her husband only spoke Bulgarian. “I asked for a medical kit and was given a plastic stethoscope which fell apart in my hands,” he said. “There was no blood pressure cuff, medication, or anything else but bandages!” Dr. Katzin checked her pulse, gave her water, and told the stewardesses to plan to divert because of a possible myocardial infarction. “But the language barrier notwithstanding, after drinking some water, her pulse improved, so we kept going,” he recalled.
Ian Seppelt, MD, a general -intensivist from Sydney, Australia, whose work includes neurocritical care, worked for five years in a medical retrieval service on an air ambulance. He warns that if things go badly mid-air, you're bound by the laws on the ground of the country you are flying over. “If the patient dies, it's best not to tell the pilot until on approach to your destination, otherwise he or she is obliged to land, and you will end up explaining yourself to authorities somewhere you may rather not be. Conversely, if the patient is deteriorating but alive, declaring ‘Med 1’ (highest level of priority) allows the plane to queue jump at air traffic control straight in to land without waiting,” he noted.
FLIGHT CALL: LESSONS LEARNED
Col. Jonathan Newmark, MD, deputy joint program executive officer of medical systems at the Joint Program Executive Office for Chemical/Biological Defense of the US Department of Defense in Falls Church, VA, has learned that surprisingly, there is little difference between the first aid kits carried domestically and overseas. Having survived six on-air emergencies, he offers a few words of advice:
- Don't expect much from the cabin staff. Their major concern is that a licensed professional assume responsibility for opening up the first aid kit because it contains controlled drugs.
- When the medications in the kit are insufficient, check patient belongings; most patients bring personal meds along with them. Be sure to first get the patient's permission or that of his or her companion, or ask the crew to approve it; otherwise you may be breaking the law. [Federal Aviation Administration regulations now require that all air carrier aircrafts carry automated external defibrillators and an enhanced medical kit that includes Benadryl and epinephrine ampules, albuterol, prefilled syringes with atropine, dextrose, epinephrine and lidocaine, and oral acetaminophen, aspirin, diphenhydramine, and nitroglycerin.]
- The crew will be extremely grateful if you can take care of the patient without a diversion. But if you think one is necessary, say so. It is the airline's responsibility to make it up to the passengers. Use good judgment.
- If you ask for it, the airline will alert ground staff and make sure there is a paramedic unit at planeside. This is easy to arrange and you should have a very low threshold for requesting it.