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EMS at 35,000 Feet: Part 2
Last month, I shared stories of two ALS calls I had responded to while flying to and from China in 2002. While both patients recovered fully en route, it became clear to me that resources, in terms of personnel and equipment, are very limited on aircraft. Though many flights travel each day over vast expanses of water, most airlines carry only minimal medical supplies: an AED with no screen, 500cc of normal saline, a few IV catheters, limited drugs, an OB kit and minimal airway-management supplies. So what does one do when faced with a true emergency at 35,000 feet?
One of the most important tools paramedics have is their heads. Our training has provided us with the ability to rapidly assess a situation, determine a plan and put it into effect. We are trained to ask for help when we need more resources or equipment. But what happens when there is not enough equipment and no help available?
Cyclist Down
In August 2002, I was returning from a business trip in China when, shortly after takeoff, a call was made asking for a doctor. We had just left Shanghai’s Pudong Airport and were still climbing when the call went out. I rang my call bell and identified myself to the flight attendant as a paramedic. She told me a patient had passed out and was seizing in the coach section of the aircraft. I made my way back and found a 30-year-old Caucasian male, supine, pale, diaphoretic and semiconscious. He was being attended to by his father, who was a general physician from Connecticut. I introduced myself as a paramedic and asked what had happened. The father told me that the patient was talking normally prior to takeoff, though feeling somewhat sick to his stomach, and as the plane took off, he became unresponsive and seized. At that time the doctor had laid his son down on the floor and called for help.
The plane was still climbing, which resulted in the patient’s head being elevated several inches above his feet. I first suggested we remove him from the narrow aisle and elevate his feet. As space was limited and the patient was unresponsive, we found it easier, given the circumstances, to elevate the patient’s feet where we were until we leveled off and could determine what was happening. The patient had shallow respirations and a heart rate less than 60, and was hypotensive. The father told me that the lower-than-normal vitals were not unusual, because the patient was a long-distance bicycle racer and was in good physical condition. Acknowledging this, I asked if the patient had a seizure history, how long they had been in China, if there was any relevant medical history, etc. The father stated they had been in China on vacation for several weeks and that the patient was healthy with no meds or allergies. I asked about the patient’s most recent meal, and his father said it had been in Shanghai the night before, nothing unusual, and he didn’t recall if the patient had eaten breakfast. It was clear the patient had voided both bladder and bowel. After being on oxygen by NRB and having his feet elevated for a few moments, the patient became conversant and filled in some holes in his history.
It turns out the patient had not been feeling well since the night before. He had eaten a normal dinner, but afterward, while walking down the street, he’d consumed a Chinese drink known locally as sour milk. The patient had purchased this beverage from a street vendor. Within hours of consuming the beverage, he’d developed stomach cramps and endured several bouts of nausea. He’d slept a few hours before having to wake for the flight home. He had not had breakfast and had suffered a stomach ache all morning, with a few more loose bowel movements prior to boarding the aircraft.
With the patient able to ambulate with assistance, we moved him to the rear of the aircraft near the lavatories, where he could put his head toward the tail of the aircraft, elevate his feet and rest a bit more comfortably on several blankets we laid down for him. At this time, the captain came back and asked us if it was necessary to return to China or divert to Tokyo. I was being asked whether we should divert a plane with 300+ people on board before passing the point of no return—flying over open ocean and not able to return to land on the western side of the Pacific. What a decision to make! The father and I discussed the matter, he called his medical director via the satellite phone in the cockpit, and I spoke with the patient.
It was clear the patient had not told his father about his late-night snack and illness afterward. The initial concern was whether the patient had developed some cardiac-related illness or seizure disorder that was just now manifesting itself, or if it was a simple case of food poisoning. Based on the patient’s history and physical condition, and without being able to properly evaluate his cardiac rhythm, we had to make a judgment based on limited data. It was agreed that the patient was probably hypovolemic due to fluid loss caused by the diarrhea, and that the sudden pooling of blood in the lower extremities caused by takeoff had caused the patient to pass out. The question was whether the patient needed more than the 500cc of normal saline on board, and if even that would allow him to stabilize for the remaining 8–9 hours of travel time.
After talking with the patient—who was feeling better but still not able to sit up for longer than a moment—and the father, we decided to try to see if the patient could tolerate fluids by mouth. If so, we felt comfortable that we could slowly rehydrate him over time and get him to San Francisco. If he could not tolerate anything by mouth or if his diarrhea returned, we would consider diverting to Tokyo. We had less than an hour to make the decision.
The father said he was comfortable monitoring the patient, and as I felt he was now properly aware of the history and what may be happening, I excused myself and returned to my seat. A few moments later, the chief purser came to tell me the patient was sitting up and sipping apple juice! I immediately told her that was a bad idea and returned with her to the patient. Being a new dad (three kids four and under), I recalled my wife telling me that sometimes certain juices can exacerbate an upset stomach, and apple juice was one of them. I suggested to the patient and his father that he not drink that and offered another suggestion.
During my youth, I often traveled to Pakistan to see family. More than once I got sick while there, and was given a homemade revitalization drink, a sort of Gatorade, to replenish my fluids. This drink had lemon juice and sugar and often brought me around in a day or so. I proposed that I make a similar concoction for the patient, and both the father and patient agreed it was a good plan. So, with a little help from a few flight attendants, I made a supersweet lemonade and gave it to the patient to sip. After about four glasses of this drink, the patient stated he was feeling somewhat better. We now had about 10 minutes before having to decide whether to land or continue on.
This time we decided that if the patient was able to stand long enough to change his clothes and clean himself up, we’d continue on. So, with some assistance from his dad, the patient went into a lavatory, cleaned up and came out looking and feeling much better, though still not 100%. The father and I conferred with the captain, and it was decided that the correct diagnosis was most likely hypovolemia secondary to diarrhea caused by drinking a spoiled dairy drink the night before. As the patient was tolerating the lemonade and feeling better as he consumed it, we were all comfortable continuing the journey. I once again returned to my seat, and a few hours later the patient and his father walked up and told me he was feeling better and had actually eaten a few crackers.
Bad Fish Story?
With that problem resolved, I returned to some work I had started previously. About two hours later—five hours into the nine-hour trip—the chief purser tapped me on the shoulder. She stated that there was another medical emergency on the upper deck of the 747, and that as I was trained to make quick evaluations in the field, she wanted me to look at the patient.
As we walked to the upper deck, she told me the patient had been in the bathroom seven times in the past hour, and this time was near passing out and somewhat wedged in the lavatory. (Airplane lavatory doors are bifold and fold into the lavatory, so if someone is on the floor in the lavatory, you cannot easily open the door.) I approached the lavatory door and called to the patient. He was able to get up off the floor and allow me partial access. As I stuck my head in, I found a mid-40s Caucasian male, diaphoretic, nauseated and in obvious gastrointestinal distress, who stated that he had developed a sudden onset of cramps, nausea, pain in his flanks and diarrhea. Sitting, he said, caused tremendous pain. With some coaxing and assistance from the chief purser, the patient left the bathroom and was taken to his seat, which was, fortunately, at the forward bulkhead, allowing us room to let him lie down and bend his knees near his chest for comfort.
At this point we were nearly 3½ hours from landfall and close to four hours from a gate. Due to his pain, the patient would not allow me to palpate his abdomen. He remained restless. He denied chest pain or shortness of breath, and was somewhat hypotensive and tachycardic. His respirations were 24 and shallow. The patient stated he had eaten the fish entree shortly after takeoff (now close to five hours earlier), but denied any allergies to seafood. The patient acknowledged he’d had a kidney stone several years earlier, but said this pain was not similar to that. Besides that, he had no significant medical history and took no medications.
Knowing there was someone with greater experience in this area on this plane, I asked the chief purser to summon the father of the earlier patient. When she asked why, I told her that my initial assessment was that the patient may have food poisoning from his earlier meal or possibly was having another kidney stone, but the possibility existed that there was some other, more serious problem, and two heads would be better than one. I also asked her to inform the pilot that this was a potentially serious situation and that we would need to land as soon as practical.
The father of the earlier patient came upstairs, and I informed him of the patient’s situation, history and my tentative diagnosis of food poisoning based on the timing, nature of pain, diarrhea and nausea. The doctor said I may be right, although this could be a recurrence of the kidney stone as well, or perhaps some other, more problematic ailment. We agreed that I should start the IV, run it at about 100cc/hr., place the patient on oxygen, and we would monitor. With about two hours still to go, the IV was in place, about 150cc were on board, and the patient had started to relax in a right lateral recumbent position, with his knees bent. The pilot was informed that this patient would need an ambulance upon arrival.
As we were preparing to land, the chief purser asked us to help the patient to his seat for landing. Unfortunately, the only position of comfort for this patient was as he was on the floor: on his side, with knees bent. It was agreed, with the pilot’s permission, that the doctor and I would take the two seats where the patient had been and brace him against the bulkhead during landing. The patient remained stable during the landing, though he became quite uncomfortable during the approach, possibly from the compression of gas within his mostly empty bowels. (Ever watch a bottle of water that you opened and closed at altitude compress during landing? The pressure change is amazing!) We were cleared for an emergency landing and met at the gate by Los Angeles firefighters and paramedics. I briefed them on the situation, and assisted in loading the patient onto a stair chair and transporting him off the plane.
We never knew what this last patient’s diagnosis was. As with many of our patients, once he was out of our hands, we lost the trail of contact. The first patient was kind enough to write to me a few weeks later and tell me the problem did indeed seem to be food poisoning, and that he felt the lemon drink had helped him recover more quickly than plain water may have. It was nice to have that followup.
Conclusion
As more and more of us travel more frequently and over longer distances, we can expect that the incidence of medical emergencies at altitude will increase. While it would be nice to have AEDs with screens (so we can see EKGs), more than 500cc of normal saline and more than a few rudimentary pieces of airway equipment on board, it is probably hard for an airline to justify the added expense, non-revenue-generating weight and additional maintenance, given that flight attendants are not trained in the use of much of this equipment and the frequency of such emergencies is still somewhat limited. The question one must ask is, are airplane EMS kits properly equipped to manage several patients at once, or one patient for a long period of time? It is not unreasonable to imagine a case where a group of travelers could all be struck with food poisoning at once, or where more than one person develops cardiac or respiratory difficulty after traveling abroad. What is clear is that, as on land, we are limited with resources and options when a medical emergency occurs at 35,000 feet. Paramedics will have to use the most important tools in their toolboxes when such cases arise—their heads!
