This is our first in a series of 3 posts entitled "Out on a Limb." We're going to be looking at the practice of Emergency Medicine in environments very different than the Emergency Department. Each post will be accompanied by a series of questions, with a discussion in the comment section facilitated by the post authors. In approximately 1 month (July 15), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during our Grand Rounds. Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points. Looking forward to a great discussion!
You are enjoying a cocktail on the way to Hawaii on a well earned vacation when a voice comes aloud overhead, “Attention all passengers. If there is a doctor or health care provider present, we ask that you please come to the front of the plane immediately.” From your vantage point in the back of the plane, it becomes clear very quickly that no one is volunteering. You find yourself being stared at by a plane full of people as you make your way to the front, to find a morbidly obese Caucasian female with a flight attendant at her side. You start your encounter…
She is a 60 year old hypertensive, diabetic, smoker who is complaining of mild epigastric abdominal pain that she feels kind of like “my reflux” but it’s not getting better despite eating almost a bottle of Tums, which usually does the trick. You notice she feels clammy but is not frankly diaphoretic. You are able to take a respiratory rate which is 18, her pulse feels regular at 90, and you don’t have a thermometer, blood pressure cuff, or stethoscope.
You reassure the patient and then the flight attendant takes you by the hand and walks you to a corner by the lavatories: “What do you think, doc? If we emergently land now we can touch down on the mainland. If we don’t land now we’ll be over ocean and will have to turn around. If we can make it the next 90 minutes to Hawaii without doing either, you’ll be saving the airline about a half a million dollars, and we will find a way to make it worth your while…
Q1 - What do you say to the flight attendant? What is your thought process? What do you do from a medical standpoint, if anything?
Q2 - Is there an argument that you should have basic medical supplies on you at all times for such occasions?
You make it to Hawaii without landing the plane. The flight attendant kisses you on the cheek and tells you that you are the best doctor in the world, and for helping out the airline, they offer you one year of unlimited travel.
Q3 - Do you accept? What factors influence this decision?
You decide the patient looks ok and this indeed is likely reflux and to press on to Hawaii. You are 40 minutes over the ocean and you are called back to the front of the plane. The patient is clutching her chest, is diaphoretic, wide eyed and then falls over unconscious into the aisle. You can’t palpate a pulse. You start CPR. There is an AED on the plane...
Q4 - You don’t have a conduit for giving rescue breaths. Do you perform mouth to mouth?
Q5 - How do you manage the CPR? Do you recruit others in the plane to do compressions while you lead?
You get the AED on the patient’s chest and she has a shockable rhythm. You deliver a shock and she regains a pulse but remains unconscious… she then loses it about 3 minutes later. You continue to deal with this same problem until the flight attendant states that it is time to land. It is turbulent out and the landing promises to be more so. EMS will be awaiting your arrival on the ground.
Q6 - Do you continue CPR or get back in your seat for landing?
We're looking forward to seeing your thoughts on this case! When responding please indicate the question you are responding to with Q1, Q2, etc.