EMS at 35,000 Feet: Part 1

Most of us take air travel for granted, thinking nothing of hopping on a plane and flying across a state, the country or even around the world. As more of us live away from our extended families or travel for business, it is our only means of timely travel.

One result of this increase in air travel is that more travelers are taking to the skies on long trips across the country or ocean. Such flights can be taxing on the system. Long periods of time seated in cramped seats, significant time zone changes and extended periods without sufficient sleep can have an impact on healthy individuals and can dramatically exacerbate conditions such as diabetes and cardiac or respiratory problems.

What happens when a medical emergency occurs at 35,000 feet? More interestingly, what happens when the emergency happens and you are four hours from land? Let me share some experiences I had in 2002.

Is There a Doctor in the Air?

As paramedics, we are trained to be prepared for most things and ready to improvise where possible. We learn to rapidly assess, triage and prioritize. We keep the big picture in mind and develop plans that use all available resources, account for transport time and always keep in mind the patient’s condition. When we have our own equipment with us, all this is easy. Even when we’re providing mutual aid, we are comfortable in our environment. But what happens when your tools are limited or nonexistent and some of the decisions you make can have impact on hundreds of people? That is EMS at 35,000 feet.

In early 2002, I was traveling from San Francisco to Shanghai. I was comfortably seated when a page went out asking for a doctor. I notified a flight attendant that I was a paramedic and could assist if needed. She asked to see my credentials, which, by chance, I had with me, and she asked me to follow her toward the back of the airplane. We were well into our trip, somewhere over the middle of the Pacific Ocean, about four hours from the closest landfall.

As I approached the rear of the plane, I saw several flight attendants standing next to an elderly Chinese woman, and two doctors trying to evaluate her. One was a cardiac surgeon from New York; the other was an anesthesiologist from California. The patient was lying supine across three seats, knees bent, in obvious distress. I introduced myself and identified myself as a paramedic. At that point one of the doctors filled me in on the situation: The woman was in her mid to late 60s, returning to China, and had developed dizziness and chest pain. She was pale and diaphoretic. One of the doctors had decided she was having a heart attack and asked the flight attendant for any equipment, including a heart monitor. A heart monitor! We’d be lucky to get an AED! I reminded the good doctor of our location and told him my guess was we’d be lucky if we got a first aid kit.

United Airlines gave me a nice surprise when we were presented with a moderately well-stocked kit with a 500cc bag of normal saline, some IV catheters and drip sets, ET tubes and laryngoscopes, a sphygmomano­meter and some other items. The AED had no screen, so there was no chance to monitor the patient’s cardiac rhythm.

The anesthesiologist excused himself, as he seemed well out of his comfort zone, and I stepped in to assess the patient’s vitals, which showed her to be hypotensive and tachycardic, with a slightly elevated, shallow respiratory rate. No edema was noted in her extremities, and her lungs were clear. The cardiac surgeon and I discussed the patient’s condition and tried to obtain a history. As the patient was not able to speak English, and neither of us spoke Chinese, we needed the help of a translator to determine the events leading up to this episode, her history, meds, etc. We were able to determine that the patient had a heart history (but not what sort), that she’d been seated the entire trip thus far, and had started to feel uncomfortable about an hour prior to calling for help. Her primary complaint was feeling dizzy and weak, and she stated the chest pain was all over and non-radiating. She had taken some small, round herbal pills when the discomfort began, and we were not able to determine what they were. The patient was placed on oxygen via NRB. It was agreed that she was probably not having a heart attack, and we decided to start an IV and monitor her.

Besides being four hours from landfall, we were probably five hours from landing. I started the IV and then conferred with the surgeon about what rate we should run. He suggested a bolus of 250cc, which normally would be a great idea, but I cautioned that we

had no cardiac monitor and no way to give her more than the 500cc onboard. We then agreed to set a rate that would give her the 500cc over two hours. That would buy us some time and allow us to monitor her and determine if she was simply dehydrated or having other problems.

Over the next two hours, the patient stabilized, her vitals returned to within normal limits, her breathing became easier, and by the time the IV fluid was gone, she was more oriented and able to sit up. As we were out of fluid, the IV was discontinued, and I monitored the patient for another two hours until we were preparing to land. Upon landing, the patient was taken off the plane in a wheelchair.

We will never know what caused her event or what resolved it. Was she simply dehydrated? Did she have an MI that passed? Was she developing a PE? Did the IV and supine position help, or did the pills solve her problem? We’ll never know.

What I did learn was that most airlines carry simple AEDs and minimal ALS equipment, and in case of a true emergency over the water, there is little you can do but monitor the patient and stretch the limited resources as far as you can.

Three Hours to Landfall & Counting

During another trip a few months later, coming into San Francisco from Shanghai, another call went out for a doctor while we were still about three hours out. Once again, I offered my assistance. This time, no doctors responded, and I was presented with an elderly Chinese gentleman (who again spoke no English) experiencing heart palpitations. Unlike my first patient, this man was still seated. He was pale, somewhat diaphoretic and had taken some unidentified homeopathic medicine prior to my arrival. His wife, who spoke limited English, stated he had a history of fast heartbeats and that he sometimes became quite ill during these episodes.

A quick assessment found the patient to be hypotensive, his pulse over 180 bpm and thready, respirations shallow but regular. With no way to monitor the patient’s cardiac rhythm, it was difficult to tell what was happening or develop a treatment plan. As I was talking to the patient’s wife and the chief purser, the patient coughed. Reassessing, I was relieved to find the patient’s rhythm had returned to a more normal rate of 80 bpm. His skin color was also returning to normal. He told his wife he felt much better, and after reevaluation, we decided the episode had passed.

Was it the cough, the unknown medicine or just good luck that converted the patient to a more normal rhythm? What would have happened if his rate had remained unstable? What if we had lost his pulse? Could we have performed CPR for three hours until landing at SFO? Would it have been sensible to start? What would you have done?

Part 2 of this article will appear in the December issue.