“Is There Someone On Board?”

Many paramedics enjoy traveling for continuing medical education. Out-of-town learning opportunities at the larger EMS meetings are a great option for broadening one’s knowledge and developing oneself outside the day-to-day workplace. Flying across the country in a sun-drenched jet is ideal for opening your mind and thinking about career development.

“Is there someone on board with a medical background?”

A traveling Attack One crew member, immersed in thoughts like those above, is startled back to the reality of unplanned events. He rings the call button above his seat and tells the flight attendant, “I’m a paramedic.”

“Thank you,” she says. “We have a patient who appears to have a medical problem.”

That’s an understatement. The man looks exactly like Attack One’s last patient, who arrested in the rig just outside the doors of the ED: grey, diaphoretic, eyes full of fear.

“Hello, sir,” the crew member tells him, “my name is Jeff. I’m a paramedic.”

“Thank you,” he says. “Please help me.”

A rapid history reveals that this man has had no history of heart disease. He reports a sudden onset of crushing chest pain about 10 minutes ago, and is now short of breath, diaphoretic, light-headed and nauseated. It seems like he read the textbook. His only relevant history is hypertension.

A member of the flight crew asks what Jeff needs, and he requests the airplane emergency kit. Soon he has a blood pressure kit, IV administration set, defibrillator and oxygen. Then he gets a tough question from the flight attendant: “The pilot needs information about the passenger’s condition so he can contact medical control and decide about diversion.”

Medical control?

“Yes,” the attendant says. “Each airline has online medical control, available through the pilot, that provides guidance from an emergency physician on medical care and decisions like diversions.”

Give me just a minute, Jeff tells her.

He conducts a quick and careful exam using equipment from the kit. The passenger feels better lying down across the seats. His blood pressure is 80/palpable (it’s hard to hear on the aircraft), pulse slow and regular at 60, respiratory rate 28, skin cool and diaphoretic.

A really good physical exam is needed. Lying down, the man has no neck vein distention. His lungs are perfectly clear. No heart murmur. He is nauseated, but hasn’t vomited. His abdomen is flat and nontender. No peripheral edema. No neurologic deficits.

Jeff needs to make some decisions. He is not allowed into the cockpit to talk to medical control, so he writes down the most important points for the pilot to relay.

Patient is a 52-year-old male with classic symptoms of acute MI. Sudden onset of chest pain 20 minutes ago, short of breath, diaphoretic and nauseated. Only history is hypertension. Perfusing poorly with BP of 80 and clammy skin. Lungs clear and neck veins flat in reclining position. Dyspneic. No allergies. Only treatment so far is oxygen by mask.

Jeff knows the flight destination is three hours away and there’s no safe way to get the man that far. He recommends diversion to the closest safe airport and setup for rapid transfer to a heart center.

He gives the note to the flight attendant. No one else on the flight has a medical background, so he’s working alone, but the surrounding travelers are aware of the passenger’s emergency and willing to assist.

Wishing he had his checklist for acute MIs handy, Jeff remembers a few things:

• Aspirin if no allergy or contraindication;
• Nitroglycerin if perfusing OK and no Viagra-like medications;
• Oxygen, morphine, beta blockers if no contraindication;
• Ask questions regarding possible thrombolytic therapy.

The patient is nauseated, so he’d like some antiemetic. The airplane kit has an intravenous setup and nitroglycerin, but no aspirin, morphine or antiemetic.

What might the other passengers have? Asking this over the intercom could result in useful medications or supplies. Jeff requests the flight attendant to ask if any passengers have aspirin, a pulse oximeter or Phenergan.

The patient has great veins, so starting an IV with a big line is easy. How fast? Jeff thinks back to his last cardiac class. Many acute MIs are located at the inferior wall and have classic symptoms of nausea, bradycardia and hypotension. Often these patients are sensitive to nitroglycerin, which drops their pressure further. Patients with inferior-wall MIs don’t respond well to beta blockers because they’re already bradycardic. Their perfusion may improve with fluid boluses, however, since inferior MIs often affect the right ventricle, and increasing the filling pressure in that ventricle improves flow through the lungs and to the left atrium. If this patient were in shock, he would have rales in his lung and neck vein distention. He has neither. A fluid bolus would be a great idea, and may improve his pressure and perfusion. Jeff starts a 250cc fluid bolus, asking a nearby passenger to assist in holding and monitoring the IV bag. Another passenger offers to hold a finger on a pulse. Good, Jeff thinks, a perfect cardiac monitor.

The flight attendant returns with good news:?The pilot has been granted a diversion to a nearby airport; it’s about 45 minutes to the gate. Medical control is aware of the patient’s condition and suggests no nitroglycerin. Jeff is glad to hear he was on the right track. Another passenger has aspirin, and one has Phenergan in oral form. No one has a pulse oximeter.

The patient is still feeling nauseated, but a cool washcloth on the forehead and a reclining position have helped dramatically. Jeff administers the Phenergan and aspirin with a small sip of water. A 250cc fluid bolus is infused, and the man’s blood pressure rises to 96/palpable. His neck veins remain flat, and his lungs are still clear. A repeat bolus of 250cc would be OK, since the first bolus brought improvement and no signs the man is not handling the fluid well. His nausea diminishes with the fluid, and his skin color and temperature also improve. He is less diaphoretic and less short of breath. His pulse is in the 50s. Jeff reports this to the flight attendant to pass on to the pilot and medical control.

The second fluid bolus and a little time improve things further. The chest pain diminishes, but is still present. The nausea disappears. The patient’s blood pressure jumps to 110/70 (the diastolic is now audible); his pulse is 54 and regular.

Since the patient can’t sit up, he’s strapped in place as the plane prepares for landing. Once on the ground, he’s met at the gate by a medic unit. Turnover is easy. The heart center is 15 minutes away, and Jeff is invited to accompany the patient if he desires. Thanks, he tells the crew, but he needs to continue on. As the grateful patient is taken out the back door of the aircraft, he asks for Jeff’s contact information, as do representatives of the airline.

Hospital Course

The patient is rapidly transported to a hospital with immediate cardiac lab capability. On arrival in the ED, he is assessed by the emergency physician and a cardiologist, then moved to the lab. He has a high-grade blockage in the artery providing blood to the inferior wall of the heart. It is opened, and a stent is inserted. There is little damage to the myocardium, and he is released from the hospital a day later.

Case Discussion

Prehospital EMS management of acute myocardial patients brings a broadening range of treatment options. Each option has positive and negative potential effects. There are different forms of myocardial infarction, making certain treatment options more or less desirable. Each option also has contraindications. This case demonstrated proper use of the treatment options, preventing complications that would have been difficult to manage in the environment of a commercial aircraft in flight.

Out-of-uniform prehospital providers should provide Good Samaritan services to persons having medical emergencies. Commercial airlines have arrangements with online emergency medical direction services, so medical emergencies on aircraft will not force the Good Samaritan to make critical decisions he or she is not comfortable with (like those involving aircraft diversions).