In the coming days, my wife and I will be embarking on a trip to Europe. Predominantly this trip will be for a bit of adventure, however, the underlying motivation is the SMACC conference in Berlin towards the end of June.
I have flown internationally a handful of times in the past. On one of these occasions I was given some pause to think more critically about how I would respond in future if the call came over the loud speaker:
“Is there a medical professional on board this aircraft?“
Several years ago, I responded to one such call. My wife and I were traveling abroad for our honeymoon – we were peacefully reclining in the economy section of the plane when the first call came over the speaker:
“If there is a doctor on board this flight could you please make yourself known to cabin staff?”
I wondered to myself what could be happening and allowed my mind to wander, all the while assuming that there would be some able and willing physician on the plane who would sweep in and address any emergency that could be unfolding (n.b. I was relatively green at this point). After about ten minutes, a second call came over:
“If there is a doctor, nurse or other health professional on board would you please make yourself known to cabin staff?”
My wife looked at me, knowing quite well that I was already unbuckling my seatbelt. I presented to the nearest member of the cabin crew, introduced myself as an emergency nurse and asked if they still needed assistance. I was taken to the back of the plane where I found a patient who was experiencing a condition that I saw quite commonly in the ED (However, this condition suddenly felt very foreign when transposed several thousand meters above the ground).
For the sake of this post, I won’t talk about any specific details of the patient’s problem, firstly for privacy reasons and secondly because I think the nature of a patient’s problem often takes a backseat to the non-technical and logistic aspects of managing an unwell patient on a plane.
After helping the patient find a comfortable position and performing a brief primary assessment. I was briefed by another member of the cabin staff who informed me of the resources I had at my disposal. I was informed there was oxygen available and I was handed a large, reasonably well-equipped medical kit.
The medical kit was well stocked with various drugs, IV access equipment, fluids, dressings and limited assessment equipment. In a doctor and nurse team, there would be ample medication and equipment to provide throughout initial management to patients with a wide variety of presenting problems. The thing that stuck out to me was the variety of cardiac drugs available: aspirin, GTN, adrenaline all immediately accessible. There were also a wide variety of analgesic agents ranging from simple stuff like paracetamol to parenteral narcotics. However, being a lone nurse responder I felt myself highly unlikely to have the inclination to administer any drugs (thank god the patient in my case didn’t require any).
I was shown the automated defibrillator that was situated in the locker with the other medical gear. I was pleased to see this included, even in the early days of my practice. With my expanded comprehension of the concepts related to effective resuscitation, I feel even more reassured that these devices are widely available on commercial flights. As most will know, there are few well-validated interventions that improve outcomes for patients suffering cardiac arrest, and with these devices on board we have access to both of the big-ticket items – High-quality CPR and timely defibrillation. As someone who values the high-flying (no pun intended), cutting edge aspects of resuscitation, I would feel comfortable attempting resuscitation using oxygen, an AED and the assistance of the first aid trained cabin staff.
Fortunately again, my patient was not suffering cardiac arrest. They were, however, looking a little pale. I proceeded to take the sphygmomanometer and stethoscope and performed a simple assessment gathering the patient’s history and vitals. My patient was ever so slightly hypotensive. In the hospital setting, I would almost reflexively establish IV access and continue my assessment using more intensive tests to establish the cause of the hypotension. In the back of a plane with a basic medical kit, an ECG and full blood panel was unfortunately out of the question. So what do you do?
Sure there was enough gear for a line and some fluids, but again, as a reasonably junior nurse I would not feel comfortable poking a patient in the back of a plane, let alone starting a drip (which is something I wouldn’t have done without clarification even in the hospital setting). So I decided to utilize the planes ergonomics to help me out. The plane was flying (as planes often do) with the nose elevated above the tail. This allowed us to lay the patient down with her head on a pillow pointing towards the tail of the plane, giving us a kind of modified trendenleburg position.
While I was crouched down beside the patient, I noticed that the crew had done a marvelous job of cordoning off the back of the plane with curtains to ensure the patient was not subjected to a plane full of passengers peering around corners to get a glimpse at the spectacle. While this was fantastic, I did notice that the patient still have five or six crew standing around them for much of the assessment period. As in any location, care should be taken to maintain the privacy and dignity of all the people we look after – and consent should always be sought before attending any tests or treatments.
I stayed with the patient and after a few minutes, they began to feel better. Much to my delight (and to the benefit of my own blood pressure), they remained stable for the remainder of the flight. I continued to keep an eye on the blood pressure and watched for signs of mischief, but for the most part the management remained conservative. I took the rest of my time on standby to formulate contingencies against any change in condition i.e. what would I do if the BP remained low or if the patient needed pain relief. At the time, the truth of the matter is that I didn’t know the answer to a lot of these questions, and in mid-air it was not as simple and whipping out my phone for a sneaky Google search.
Since this scenario, I have had more time to think about the ins and outs of emergency response in an airplane. The more I thought and read, the more I came to feel that nurses (and particularly emergency / critical care nurses) can play a few major roles in the management of these situations.
- Assessment – Nurses generally have well-established assessment skills. Being able to perform a general assessment including a visual assessment, vitals, and a history can help establish some management goals. Even if achieving those goals is beyond your means as a lone nurse in a big plane, it can help you to escalate the situation as needed.
- First aid – Having the ability to perform advanced first aid with a high degree of proficiency can be useful in the management of a wide variety of different situations. In the aircraft environment, consider the case of the unrestrained passenger during turbulence. Occasionally you will hear a story in the news about ‘passengers injured during turbulence’. In this instance, an emergency nurses assessment and first aid skills may be very applicable. Having the ability to control bleeding, apply dressings and immobilize injuries could potentially save a great deal of misery for the passengers and the crew.
- Basic life support – This is the most obvious but also the most terrifying case. While most airline staff will have received training in first aid and CPR, the likelihood that they have had to use their skills in anger is probably fairly low as a general rule. As critical care providers, we often have advanced skills in resuscitation – commonly including ACLS training. From this perspective, it is easy to imagine that we might feel like fish out of water when removed from our defibs and vents. However, if we remember that timely defibrillation and well delivered and coordinated CPR are the most meaningful interventions for an arrested patient (even in our current ACLS guideline), you can see that you have the potential to make a difference. While higher-level airway equipment may not be available, remember that removing foreign bodies and providing simple airway maneuvers is still very useful.
After the first hour with the afflicted passenger, another member of the crew greeted me. This time it was the first officer (or co-pilot of the plane). He thanked me for helping out before hitting me with another question I had not considered.
“Do we need to divert the plane or should we carry on to the destination”
Again, as you could imagine I was puzzled by how to respond to this question. In hindsight, this is where the value of a high-quality assessment comes into play. Effectively this is mid-air triage. I did another set of vitals and discussed this proposition with the patient who had requested that we continue to the final destination for reasons that were well substantiated. At this point, I felt comfortable that the additional 2 hours was manageable and confirmed with the officer that we could continue.
This area is a little tricky, and to be completely honest there isn’t a good ‘one size fits all’ answer on how to approach these questions. I mention this because I think it’s worth keeping in the back of your mind if you have to perform this type of assessment. Even in comparison to some of the decisions I make daily, the decision to divert hundreds of people to land in an unexpected country weighed on my mind (with no real consideration to the cost of diverting an airplane of that size – vaguely discussed on the web as fitting between $65,000-$100,000). However, in making these decisions it’s worth remembering why you responded in the first place – for the benefit of the patient. If at any point you are worried that this patient will have a worse outcome if they have to wait for the final destination, this should be clearly communicated to the flight crew.
Curiously, after four hours of continuously observing this patient in the back of the plane, I was introduced to a professedly well-regarded doctor who seemed quite concerned he had not been involved in this scenario from the start. While I was initially taken aback by his blunt address, I explained that I too was curious as to why I was left with this patient when there was potentially a more qualified provider only meters away from me the entire time. I think the communication associated with this scenario was limiting in that once any provider was located (i.e. Me – Emergency Nurse with mild to moderate level of experience), the appeal for assistance ceased. In future, I would make a point of asking the cabin staff to continue asking for medical assistance if I was the sole provider responding to an in-flight emergency.
One thing that I was not previously aware of but I think is essential for all responders to know about is the availability of ‘MedLink’ – a telecommunication-based advisory link to an emergency physician provided by a company called MedAire. While MedLink is available in aircraft from a wide variety of providers around the world, it is worth asking if this service or something like it is available if you find yourself in such a situation. In future, this would be among my first questions.
The quote below is from MedAire’s own website and I think it summarizes the service nicely:
“Medical volunteers can assist the MedAire physician with gathering vital signs and administering any medications or treatment recommendations. Volunteers can rely on the immediate knowledge MedAire physicians have on the medical equipment available on the aircraft, medications available, and their location within the medical kit. If no medical volunteer is present, MedAire can confidently provide instruction to crewmembers”
Statistics
A paper published in the New England Journal of Medicine in 2015 reported that a medical emergency took place once for every 604 flights. This equates to 16 emergencies per million passengers or 44,000 cases each year around the globe. The NEJM article reported that this figure was likely underestimated as the data was collected by a telemedicine call center (like MedLink) who were probably not consulted for minor mishaps.
The moral of the story is that while these events are not THAT common, they are common enough for us to think about them. Moreover, in our current climate where people and living longer and subsequently living sicker it would be fair to assume that this number has the potential to increase in the coming years.
Legalities
In NSW, part 8 of the Civil Liability Act (2002, No 22) outlines the legal standing of ‘Good Samaritans’. The general idea of the ‘Good Samaritan’ Act is that a person who comes to the assistance of someone who is injured or at risk of being injured will not incur civil liability for acts or omissions made in an emergency situation if they are acting in ‘good faith’. To loosely paraphrase, if you have relevant skills in an emergency situation and you attempt to provide assistance to ensure the well-being of another person you are protected from lawsuits to a degree if your intention is to help and not harm.
Limitations and variations of this legislation exist in most parts of the world and often the variation of the law that is invoked stems from the region in which the aircraft is registered. For this reason, I would suggest checking your local legislation. In NSW, ‘Good Samaritans’ are also expected to assist ‘in good faith and without expectation of payment or reward’ – this seems obvious but if you are rendering assistance in ‘good faith’ you shouldn’t expect to be compensated for your service.
Also, this act does not remove liability from people who act against the best interest of the patient, performing actions that cause intentional harm or are intentionally negligent. Additionally, errors made while functioning under the influence of drugs or alcohol are not granted an exemption under this act.
Please remember that this is purely one nurse’s interpretation of the NSW legislation in conjunction with a review of the related literature. I don’t profess to have any formal legal training, I am just trying to be armed with as much knowledge as possible.
For a far more in-depth analysis of the ins and outs of Good Samaritan legislation I highly recommend having a look at Dr. Michael Eburn’s page. He is a Barrister (not a Barista) and his page hosts a smorgasbord of legal questions relating to emergency situations as answered by a pro (if you’re into that sort of thing). The link below will take you to a great description of how your individual ‘scope of practice’ is considered when applying the Good Samaritan principle.
https://emergencylaw.wordpress.com/2015/03/27/good-samaritan-legislation-and-scope-of-practice/
The whole NSW Act can be found by following the link below. This links directly to the Good Samaritan section and is a very quick read.
http://www.legislation.nsw.gov.au/#/view/act/2002/22/part8
My Tips
Know your rights and responsibilities – Understand your own scope of practice and the legislation surrounding emergency aid.
Introduce yourself – To the crew, state your qualification. Introduce yourself to the patient, use an interpreter as necessary and always ask for permission before performing an assessment or intervention.
Know your environment – Ask what resources you have available i.e. Medical packs, defibrillators, oxygen etc.
Know how to call for help – Ask cabin staff about MedLink or any other medical correspondence service that may be available. As a sole nurse responder ensure cabin staff continues to look for medical practitioners willing to help if they are available (due to their wider autonomous scope of practice).
Know your role – Provide high-quality first aid within your scope of practice. This will vary from practitioner to practitioner but as a rule, general first aid principles including patient positioning, injury management, and even basic life support measures are reasonable to attend if you are qualified provider and the patient requires these interventions. Do not perform treatments you are not qualified to provide or would not provide in your daily practice.
Avoid working outside of your scope of practice – While it is tempting to function with the level of autonomy that you work with in your acute care setting, it is important to remember that the standing orders and medical support we rely on for backup is not available in the majority of these cases. Performing good quality assessment and first aid can make a great deal of difference for an unwell patient.
Worst Case Scenario – In the case of a cardiac arrest on an airplane, remember that good quality CPR and timely defibrillation are by far the most meaningful interventions you can provide. Don’t get caught up in the things you don’t have and make the most of the things you do.
Document – It is always a good idea to keep a record of your encounter for your own records in case you are asked about your treatment at a later date.
Further Reading
- http://www.jems.com/articles/2010/06/handling-flight-medical-emerge.html
- https://www.acep.org/Clinical—Practice-Management/Be-Prepared-for-In-Flight-Medical-Emergencies/
- http://www.traveller.com.au/doctors-on-board-planes-what-happens-when-theres-a-medical-emergency-on-a-flight-gtpvri
- https://www.theglobeandmail.com/life/health-and-fitness/health/when-passengersfall-ill-at-30000-feet/article18593303/
The articles found at the links above provide further interesting perspectives into the logistics and principles surrounding medical emergencies on commercial aircraft. While covering similar principles I think they are worth a read if this subject peaks your interest. As is the NEJM article listed below.
References
Vable, J., Tupe, C., Gehle, B. & Brady, W. (2015). In-flight medical emergencies during commercial travel. NEJM. 373: 939-945.