The In-Flight Emergency

Author: Alexis Germain

Picture this. You’re flying to your brand new residency program with your brand new medical degree and your brand new responsibility. The dreaded announcement comes out over the intercom “Is there a doctor on board?”

With an incidence of 1 medical emergency out of every 604 flights, it’s not an entirely unlikely scenario you may find yourself in. And thanks to the Aviation Medical Assistance Act passed by congress in 1998 medical providers assisting during an in-flight emergency are considered good samaritans with liability protection. Simulating the in-flight emergency provides a versatile exercise in which a medical problem must be managed with limited resources, and can prepare students to face the constraints of in-flight medical care.

While the pathophysiology of medical problems in the air is often similar to that on the ground, there are some additional factors to consider. At cruising altitude the cabin is maintained at an air pressure approximating an 8000 ft elevation. Decreased air pressure in the cabin leads to expansion of trapped air and can lead to increased pressure that become significant in patients with recent abdominal or intraocular surgery, a preexisting pneumothorax or pulmonary bleb, sinus infection, or URI. The lower air pressure additionally leads to a mild hypoxia due to lower partial pressure of oxygen. Consider this when assessing shortness of breath, particularly in patients with COPD that may be chronically hypoxic. Prolonged stasis from long distance travel may predispose patients to DVT and pulmonary embolism. Traveling in general may be stressful. Consider dehydration, particularly in cases of syncope. 

First step, know what you’re working with! The following items are available on all domestic flights. Note that equipment can be highly variable on international flights. 

Contents of Domestic In-Flight Medical Kits 

Assessment supplies Sphygmomanometer, stethoscope, gloves
Airway and breathing Oropharyngeal airways, bag-valve masks (3 sizes), CPR masks (3 sizes), Oxygen capable of delivery at 2-4 L/min
Intravenous access Intravenous administration set, 500 mL saline solution, needles, syringes
Medications Analgesic tablets, nonnarcotic; antihistamine tablets; antihistamine, injectable; aspirin; atropine; bronchodilator inhaler; dextrose, 50%; epinephrine, 1:1,000 solution; epinephrine, 1:10,000 solution; intravenous lidocaine; nitroglycerin tablets
Basics First Aid Bandages, splints, AED
Other resources Ground based medical support

Flight attendants are certified in CPR

Maybe (items not required by law, but possibly available) Glucometer, antiemetics, anticonvulsants, and additional cardiac medications. Note, controlled substances are not carried on US planes. 

SOURCE: Nable JV et al. N Engl J Med. 2015;373(10):939-945, based on FAA requirements for all commercial airliners in the United States.

Setting

Ensure your simulation accurately depicts the constraints of in-flight medical care. Define a row and aisle.

Roles

1 simulator, 1 patient, 1 flight attendant (acts as the communication to the pilot and may assist with CPR), 1-2 fellow passengers

Medical Problem

The most common causes of requests for medical assistance are syncope or pre-syncope (37.4%), respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%). Choose a medical emergency that requires utilization of the on board tools available, and delegation of tasks within the medical response team. For instance a cardiovascular emergency requiring CPR may require the simulator to have a crew member provide compressions, and select a bystander as a timekeeper while he or she places an IV to administer epinephrine. A concise overview of the most common in-flight medical emergencies with suggested management and pertinent history can be found in the 2018 JAMA article titled In-Flight Medical Emergencies: A Review (https://jamanetwork.com/journals/jama/fullarticle/2719313).

Communication:
A challenge of this scenario is clearly and effectively communicating with the flight crew, pilot, and ground based medical support (GBMS). When an emergency is brought to the attention of the flight crew, they notify the pilot who then contacts ground based medical support. When a request for assistance from a medical provider goes out, the volunteer should approach the flight crew and clearly identify their name and credentials. Once a volunteer becomes involved his or her assessment and recommendations will be relayed down this chain of communication to GBMS. It may be effective to write down the information required to prevent details from being lost in translation.

Also consider how the un-involved passengers may impact the situation. More than ever it is important to maintain control over the scene, provide clear directions, and minimize the crowd around the patient. 

Decision Making:
Ultimately it is the pilot’s decision whether to continue on as planned with a request for EMS to meet at the gate, request expedited landing at the original destination, or divert and make an emergency landing. The final medical recommendation will come from GBMS. However, advice from medical providers on board can strongly influence the final decision. If the simulator does not provide a recommendation, have the flight crew prompt him or her after an initial history and physical. If the patient requires immediate treatment to prevent loss of life or limb, or is otherwise unstable a diversion may be necessary.

Many factors filter into the pilot’s decision to land the plane. For instance, aircraft often take off with more fuel than safe to land with. A safe landing may require dumping of fuel, which some aircraft are not capable of. In addition to operational concerns, a diverted landing may result in direct costs in the hundreds of thousands of dollars. 

Complications:

Consider adding additional complications to the simulation, particularly if multiple providers are participating. This is an uncontrolled environment in which you are likely to have a large audience. Another passenger may panic creating a distraction, having a lower level provider attempting to take control of the situation, or getting pushback on the decision to divert the plane from crew or ground control. 

For additional practice with a case that is already fully written and ready for implementation check out the interactive case at the end of the SIMS Casebook which can be downloaded for free from the Apple Books Library.

 

DIY Hemorrhage Control Simulator

Author: Cannon Woodbury

You were just on your way to grab a quick snack from the break room when you hear the overhead announcement, “Trauma team to room 5, trauma team to room 5.” You speed walk over to the trauma room and arrive just as triage wheels a patient in with their right arm covered in blood-soaked blankets. The triage nurse announces “This is a walk-in with a possible stab wound or GSW, likely arterial” and just then removes the patient’s blankets to reveal the wound. Bright red blood spurts across the room, painting a thin red line down your scrubs from 5 feet away. What do you do next?

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Oh, the Places You’ll Go…with sim!

Author: Alyssa Thomason

Picture this…

It’s your first year of med school – you’re eager, you’re excited, you’re ready to save some lives and change the world. Except you spend most of your day in class where you couldn’t feel further from that dream. You start to wonder how any of what you’re learning fits into your bigger picture. How can you be expected to figure out what is important without any context? As you complete your umpteenth flashcard this week, you yell “AM I EVER GOING TO USE ANY OF THIS?!”

In a mad grasp for relevance, you sign up for nearly every student group on campus. You thought that with a name like “SIMULATION SOCIETY” you’d end up in the matrix taking a quiz on red and blue pills. Instead, you learned about how to recognize disease, work in teams, and handle yourself in a crisis. It may just be playing doctor, but better to fumble talking over a case with your classmates rather than with a critically ill patient.

Continue reading “Oh, the Places You’ll Go…with sim!”

What is a simulation competition like?

Author: Evan Strobelt

I climbed the steps to the stage, my heart pounding as I approached the mannequin hidden underneath a sheet. The judges’ eyes seemed to pierce into our souls as we assumed our positions, their expressions refusing to reveal any hint of their emotions. I took my place at the head of the bed and stared back into the faces of several hundred strangers sitting in the audience, expectantly awaiting the beginning of the case. Silence fell on the room for a brief second before the room descended into a chaos. EMS attempted to shout their report above the sounds of the monitor’s beeping and our mannequin’s agonizing screams. I added my own contribution to the noise and yelled out “Airway’s intact!” Our team began to sift through the chaos and worked on systematically breaking down the case, simultaneously diagnosing and treating. The furious scribbles of the judges and the eager faces of the audience faded into the background as we immersed ourselves in the puzzle. 

Continue reading “What is a simulation competition like?”

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