CODE 44 in the E.D.

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CODE 44 in the E.D.
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CODE 44 in the field
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CODE 44..in the air
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CODE 44 at 30,000 feet

• Gregory L. Roslund, M.D.
• November 9, 2004

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CODE 44 at 30,000 feet

• I. Introduction
• II. Case 1 (Introduction)
• III. Pathophysiology of in-flight emergencies
• Common in-flight emergencies
• What makes this environment different?
• IV. Case 1 (Conclusion)
• V. Epidemiology

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CODE 44 at 30,000 feet

• VI. Who is fit to fly?
• - contraindications to air travel
• VII. Resources
• - Enhanced medical kits
• - Automated External Defibrillators
• VIII. Legal Liability
• IX. Costs
• X. Anecdotal stories
• XI. Conclusions

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CASE 1 The Mile High Crisis
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CASE 1 The Mile High Crisis
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CASE 1 The Mile High Crisis
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CASE 1 The Mile High Crisis
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CASE 1 The Mile High Crisis
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CASE 1 The Mile High Crisis
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Flight attendant Is there a doctor on board?
We have a medical emergency!
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Flight attendant (again) Is there a doctor on
board? If you are a doctor, please come to Row
5. We have a medical emergency!
!_at__at_!!
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I think this boy sitting here is a paramedic
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How do you assess a patient without any equipment?

• Airway
• Breathing
• 70 times per minute
• Labored, gasping
• Equal chest expansion
• No tracheal deviation
• Circulation
• Adequate radial pulse (100 beats/minute)

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How do you assess a patient without any equipment?

• Disability
• Grimacing
• (-) responsive to voice
• () responsive to pain
• (-) following commands
• Large pupils (reactivity?)
• Tremulous, agitated
• Exposure
• diaphoresis

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How do you assess a patient without any equipment?

• Collect data from family/passengers
• Wallet
• Age (36 yo)
• Language barrier (patient from Scotland)
• Medications
• Bracelets (epilepsy)

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How do you treat respiratory distress on an
airplane?

• Supplemental oxygen via nonrebreather mask
• Rebreathing via mask/bag

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What medical resources do I have on an airplane?

• Enhanced Emergency Medical Kit
• Automated External Defibrillator
• Glucometer
• Medical consultants via satellite
• Passenger medications

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What DONT we have?

• Automated External Defibrillator
• Pulse oximetry
• Benzodiazepines
• Pain medications
• Anti-emetics
• Bronchodilaters
• Epinephrine
• Antihistamines
• Aspirin, Nitro

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How can I use these resources?

• Blood pressure
• Vital signs
• Dexi
• Heart exam
• Lung exam
• IV access
• IV fluids

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Son, do you want me to land this bird in Denver?
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What do you do when youve maximized your
resources?

• Emergency diversion to Denver, CO
• Total critical care time 60 minutes
• EMS intercept

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So.what did this guy have?

• Asthma exacerbation
• COPD exacerbation
• Pneumothorax
• Pulmonary Embolism
• Hyperventilation Syndrome / Anxiety
• Acute MI
• Acute CHF / Pulmonary Edema
• Toxic ingestion (Cocaine, Ecstasy, etc.)
• Seizure Disorder

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Common In-flight Emergencies
Dowdall N. BMJ 2000 321 1336-1337
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Gendrau et al. NEJM 2002 346 1067-1073
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What makes this environment different?
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What makes this environment different?

• Barometric pressure 5000 8000 feet above sea
  level
• PO2 drops from 95 mm Hg to 56 mm Hg in healthy
  person
• Boyles Law
• 30 volume expansion of gases

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What makes this environment different?

• Expansion
• Post-op patients
• Patients with feeding tubes, urinary catheters,
  cuffed tracheostomy tubes
• Pneumatic splints
• Plaster casts
• Low humidity
• RAD exacerbtion

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Who is fit to fly?

• The Air Carrier Access Act of 1986
• Cardiopulmonary patients
• Supplemental O2 required for resting pO2 lt 70
• Complicated patients
• May carry syringes with needles and meds
• Diabetics
• Psychiatric patients

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How can we prevent in-flight emergencies?

• Medications should be stored in carry-on bags
• Supplemental oxygen
• Must be acquired 48 hours in advance, patients
  cannot use their own equipment
• Diabetics
• Carry insulin, snacks, plan ahead for changes in
  time zones
• Ear conditions T tubes to prevent barotitis
  media

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Recommendations for patients at risk for DVT

• Support stockings
• Walking the aisle
• Isometric calf exercises
• Maintain adequte hydration

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Back in Denver, Colorado..
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CASE 1 The Mile High Crisis

• T 36.9, HR 112, BP 170/110, pulse ox 94
  on RA, no RR listed
• Gen healthy appearing male, not following
  commands, moving all extremities

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CASE 1 The Mile High Crisis

• Lytes Na 136, K 3.8, Cl 107, Bicarb 18,
  Glucose 143, BUN 9, Creat 1.1, Ca 8.9,
  Mag 1.7
• VBG (12 hours later) pH 7.29, pCO2 54,
  Bicarb 26
• CBC WBC 10.7, Hgb 16.4, Hct 50.1, Plt
  211
• LFT ALT 58, AST 64, Alb 3.1, Alk Phos
  61, T Bili 0.9, Dir Bili 0.2, Ind Bili 0.7

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CASE 1 The Mile High Crisis

• CXR hypoinflation with atelectasis
• EKG sinus tachycardia
• Troponin (-)
• Urine Tox (-) for ethanol, amphetamine,
  cocaine, codeine, barbiturates, benzos,
  cannabis, methamphetamine, morphine

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Whats the deal with this guy?

• PMH Asthma, Heart palpitations, and
• ETHANOL DEPENDENCE
• Airline forbade him from boarding plane two days
  ago because he was overly intoxicated

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Putting it all together.

• Hx of ethanol dependence
• Last drink was 48 hours ago
• Unresponsive, tremulous and moving all
  extremities
• Dilated pupils, tachycardic, tachypnic,
  hypertensive

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Delirium Tremens

• Presented tremulous with hallucinations
• Required a lot of Ativan in E.D.
• ICU on Ativan gtt 10 mg/hr Ativan boluses
  Tranxene
• Became interactive 3 days after admission
• Discharged to Scotland after 5 day hospital course

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Epidemiology of In-flight emergencies

• 1998 Aviation Medical Assistance Act requires
  airlines to record associated deaths
• No other data collection has ever been required
• FAA 2000 study 15 30 in-flight emergencies
  occur daily in the United States, up from 3/day
  in the 1980s
• Dejohn et al. The evaluation of in-flight
  medical care aboard selected U.S. carriers 1996
  and 1997. Washington D.C. FAA, Office of
  Aviation Medicine, 2000

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Epidemiology of In-flight emergencies

• FAA 2000 study
• - 1/40, 000 passengers
• - 13 resulted in diversions
• - 69 were handled by health care professionals
  (40 physicians)
• - Deaths 100- 300 per year

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Epidemiology of In-flight emergencies

• Airline studies 8 -86 of flights have
  physicians on board
• American Airlines study 85 of flights have
  physician on board
• 62 of physicians surveyed were involved in
  in-flight emergencies

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What resources are available?

• Personnel
• Crew members
• Assisting Passengers
• Physicians, nurses, and paramedics
• Equipment
• Emergency Medical Kits
• Automated External Defibrillators

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Crew Members

• One week of medical training out of 5 7 week
  course
• Basic first aid
• CPR
• Trained to use automated external defibrillators
• Annual refresher course

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1986 In-Flight Medical Kit

• Mandated by the FAA for flights gt 30 passengers
• Required items
• Stethoscope
• Blood pressure cuff
• 50 Dextrose
• Nitroglycerin
• Diphenhydramine

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2004 EMK

• EMK enhanced medical kit
• Proposed initially as part of the Aviation
  Medical Assistance Act of 1998
• Final rule issued by the FAA required complete
  kits in all planes with at least one flight
  attendant by April 2004
• Kits may only be opened by a physician on board

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2004 Enhanced Medical Kit

• Also required bandages, dressings, splints
• Optional
• - cardiac resuscitative meds
• - intubation equipment
• - sedatives
• Located left side overhead in first class cabin

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Virgin Atlantics additional items

• Atropine, Narcan, IV Valium, Glucagon, Lasix,
  Hydrocortisone (100 mg), Reglan, Digoxin PO
  tablets, Nubain IV
• Ergometrine IV
• Scalpel, suture set, vicryl sutures, prolene
  sutures, Xylocaine gel, Steri strips
• Foley catheter

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Other pharmaceutical considerations

• Passengers in-flight pharmacy
• Inclusion of Lovenox in EMK
• Patients at risk for DVT who develop acute dyspnea

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Chest Tube innovation

• 14 gauge Foley catheter
• Coat hanger
• Bottle of Evian with two holes
• Oxygen tubing
• Sellotape
• Brandy

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Automated External Defibrillators

• 1998 Aviation Medical Assistance Act
• All aircraft with more than one flight attendant
  must carry one by April 2004 (FAA mandate)
• Flight attendants are trained in their use
• First used by Qantas in 1990

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Automated External Defibrillators

• Deliver shock for V Fib and V tach
• Chance of survival decreases 7 -10 each minute
• Best AED biphasic with monitoring capability

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Automated External Defibrillators
Page et al. NEJM 2000 343 1210 - 1216
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Ground Based Medical Assistance

• Medlink and Medaire
• 24-hour, ground to air medical consultation via
  satellite
• Staffed by Board Certified EM physicians
• May reduce unnecessary aircraft diversions

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Ground Based Medical Assistance

• Air Canada, American Airlines, British Airways,
  Delta, Qantas, and Virgin Atlantic
• Some systems have capabilities to retrieve
  patient medical records
• 1997 ATA study found that Telemedicine resulted
  in 70 decrease in medical diversions
• Air Transport Association medical kit survey.
  Washington D.C. ATA 1997

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Medical Liability at 30,000 feet

• Good Samaritan Law passed by California in 1959
• NO legal obligation to provide aid
• IMMUNITY from malpractice suit if aid is provided
• Applies to outside of hospitals only
• Withdrawal of legal immunity if payment accepted
• Californias law is specificlly for physicians

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Medical Liability at 30,000 feet

• Failure to Act laws
• Assigns an affirmative duty to aid a victim in
  need
• Vermont, Louisiana, and Europe
• case against photographers present at accident
  scene when Princess Diana was killed

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Medical Liability at 30,000 feet

• .a physician shall give emergency care as a
  humanitarian duty unless he is assured that
  others are willing and able to give such care
• International Code of Medical Ethics of the World
  Medical Association, 1983
• A physician shall, in the provision of
  appropriate patient care, except in emergencies,
  be free to choose whom to serve
• Principles of Ethics of the American Medical
  Association, 1992

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Medical Liability at 30,000 feet

• Aviation Medical Assistance Act of 1998
• Good Samaritan provision
• Individuals (including physicians) shall not be
  liable for damages..in providing assistance in
  the case of an in-flight medical emergency unless
  the individual..is guilty of gross negligence..
• Protects commercial airlines

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Medical Liability at 30,000 feet

• Aviation Medical Assistance Act of 1998
• Other Good Samaritan stipulations
• Assisting passenger must render medical care
  similar to the care that others with similar
  training would provide under such circumstances
• Assisting passenger must receive no monetary
  compensation
• Travel vouchers, wine, or seat upgrades are not
  considered compensation

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Medical Liability at 30,000 feet

• Other countries (Australia, France) LEGALLY
  OBLIGATE physicians to assist in emergencies
• The country in which the aircraft is registered
  has legal jurisdiction
• Who else may have jurisdiction?
• The country in which the incident occurs, the
  country of citizenship of the plaintiff or the
  defendent

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What are the overall costs?

• Cost to divert a plane 100,000
• Cost Factors fuel, accommodations and
  connecting flights for passengers, overtime for
  pilots and attendants
• Goodwin. BMJ 2000 321 1338 - 1341

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What are the overall costs?

• Previous medical kit 54
• Enhanced emergency medical kit 600
  maintenance costs
• AED 3,200
• Crewmember training
• Ground-based medical assistance ????

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CODE 44 at 30,000 feet

• I. Introduction
• II. Case 1 (Introduction)
• III. Pathophysiology of in-flight emergencies
• Common in-flight emergencies
• What makes this environment different?
• IV. Case 1 (Conclusion)
• V. Epidemiology

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CODE 44 at 30,000 feet

• VI. Who is fit to fly?
• - contraindications to air travel
• VII. Resources
• - Enhanced medical kits
• - Automated External Defibrillators
• VIII. Legal Liability
• IX. Costs
• X. Anecdotal stories
• XI. Conclusions

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Conclusions

• Our role as traveling physicians
• Comfort with peripheral IV lines, oxygen
  placement and glucometer
• Sleep
• EtOH
• Where do we go from here?

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Conclusions

• (1) Expanded medical kits including
  benzodiazepines, neuroleptics, pain medications,
  anti-emetics, intubation equipment, and cardiac
  resuscitative drugs
• (2) Penalties for airlines who do not maintain
  adequate medical kits and AEDs
• (3) Mandatory ground-based medical assistance for
  all airlines