Cardiac arrest at 40000 feet

[mobey]

I agree Doc. Small, frail, elderly man......

Work him for 15min and call it.

Rarely are we doing any favors by pounding on the chest of an elderly person for any longer.

Reality is, we don't know weather to use the Atropine or Lido, so we should really use neither, or both. I would prolly use both. We have 2 Epi amps, once they are gone the code could be justifiably terminated IMHO.

Move the body to an area with less people and finish the flight.

In these here parts, when we are not "for hire" (on duty) we are covered by specific laws that let us make choices based on scene assessment and equipment availability. This is one of those times.

[spenac]

So now we have done the compressions.

Did AED ever say shock? Yes? Shock resume CPR check pulse after a full set of compressions. Any pulse? Breathing?

No to shock or pulse then lets continue CPR push our epi. Follow the ACLS standard check pulse analyze with AED etc.

No ROSC per current ACLS stop efforts go enjoy rest of the flight.

If ROSC supportive care until turn over to the waiting Paramedics.

[HERBIE1]

What we should have done was get our drink on as soon as the flight started, then we could avoid this whole situation. Since we missed that opportunity we need to start working the guy. I wouldn't divert the plane just yet. Let's work this guy through a few rounds of drugs and see where we are at that point. If we have no pulse, confir with the medical control and pronounce. Continue on to the final destination and let the airline handle the body however they are supposed to. If we are able to get a pulse back, then divert the plane and hope he doesn't code again. Diverting a plane is no small decision. There are far reaching affects that the airline has to consider. If you have someone that you are going to work for 45 minutes while you divert, there is no benfit in diverting as this person is not going to make it.

Doc, I've dealt with airlines and medical situations many times. I know it's an expensive decision for an airline to divert(refunds, hotel rooms, rebooking, transportation fees, fuel costs, food vouchers, etc), but trust me, they will do it for far less "serious" reasons than you think. They look at it from a liability standpoint.

Personal experience-Flying to Vegas from Chicago with my girlfriend, one day- years ago. About an hour into the flight, we hear the "is there a doctor on the plane" announcement. I look at my g/f- who was also a medic- and we wonder what happened. Saw nothing going on in our immediate area. A few minutes later, we hear "Is there ANY medical professional on board?" Uh oh.

I volunteer, tell the flight attendant who I am, and offer to show her my license. She says there is a sick passenger at the rear of the plane. There is an approximately 30 year old woman, writhing in pain and moaning in the aisle. MAJOR drama. At the time, the only medical kit available was a BP cuff, a stethescope, O2, and a couple dramamine tablets. This was pre-AED days.

To make a long story short, the best we could figure was that she had eaten a bad Polish sausage in the airport in Ohio a few hours ago, and now had abdominal cramps, diarrhea, nausea. Her vitals and exam were unremarkable, no PMH, nothing appeared to be serious. The flight attendent pulls me aside and says the pilot wants to know what I want him to do- if we should divert or not. Huh? Me?

I explain the situation, I speak to the pilot, and he asks me again. He says he could land in about 45 minutes, or carry on to Vegas, another 2.5 hrs or so. I asked what his flight doctor, Med Link, etc wanted to do. They put it back in my hands. I am totally amazed that I am the only medical person on the plane(not even a podiatrist or chiropractor) and I am put in this situation. I tell him she SEEMS to be fine, but it's his plane, and HIS call. I explain to the woman the options and she says she does not want to land early- she'll be OK. We help her to a seat, the rest of the flight was uneventful, and we land, with EMS meeting us at the gate (she ended up refusing transport). Talking with the flight crew as we were leaving and find out the woman and her boyfriend had a little spat shortly after take off, so I think this was also her way of getting some attention from him and everyone else. She may very well had some GI upset- no way to know, but a plane load of people were almost diverted based on my decision- because of a lovers quarrel, and me in the middle of it.

The upside of that situation- lots of free booze after I helped, the flight crew was very attentive(much to the dismay of my girlfriend, LOL) and later, a thank you letter and a pair of tickets from the airline. We were also upgraded to !st class for the trip home.

I deal with airlines frequently now. They are usually VERY conservative- if there is any question, they will either keep a person from boarding, OR divert the plane. I guess the extra costs are nothing compared to the the liability they may incur from a lawsuit.

On long overseas flights, people DO die- sometimes they are discovered dead in their seat, or something happens over the ocean, where diversion is simply not an option. They put the body in a an empty rear seat, in a rear galley, etc, and keep people away.

[ERDoc]

Herbie, I'm not saying that they won't divert but it is a huge decision. You are right about fears of litigation being a big part. Let's say the same pilot put you in the same position with the pt from the OP. Would you tell him it is time to divert?

If the AED is not firing we either have PEA or asystole, neither of which are compatible with survival in this situation. Would anyone really work an asystolic code for 45 minutes under far from ideal circumstances?

[HERBIE1]

Herbie, I'm not saying that they won't divert but it is a huge decision. You are right about fears of litigation being a big part. Let's say the same pilot put you in the same position with the pt from the OP. Would you tell him it is time to divert?

Generally, the first thing a pilot does is contact his Flight Link, or whatever doc/service they have for medical advice. I guarantee that pilot will turf all medical decisions to someone else.

As for diversion- if it were solely MY decision- It would all depend on the time factor- how close is the nearest appropriate airport, time of day, and how far is the final destination. Clearly, diverting to some smaller city with limited medical facilities, maybe dozens of miles from the airport, in the middle of the night- I see no reason. We all know the chances of a positive outcome in such a case are infinitely small, but it all boils down to a legal issue. My guess is that unless their final destination is still hours away, they would simply be told to fly on and hope for the best. Diverting would be a waste of time, money, and efforts.

If the AED is not firing we either have PEA or asystole, neither of which are compatible with survival in this situation. Would anyone really work an asystolic code for 45 minutes under far from ideal circumstances?

I'm not arguing the likelihood of success in such a case.

Again, advise the flight doc of the situation, and I would suspect that once you used whatever tools you had at your disposal, and did a few minutes of unsuccessful CPR, you would be told to terminate your efforts. Even under a legal microscope, I would think you would be on pretty solid ground with such a decision. Extraordinary circumstances, etc.

The only thing I would question is the airline's official policy for such situations. I am quite certain they have official procedures in place(subject to revision by a doc, maybe) that deal with such situations.

[Just Plain Ruff]

ok, sorry been out for a while. Migraines and kids don't mix if you know what I mean.

The AED never advised a shock.

the Iv is started and you only have 500ml so use it judiciously

You do cpr and give the 2 rounds of EPI and you do not feel a pulse nor does the AED recommend a shock.

You are on the radio with med control out of New York.

CPR is still in progress with 2 flight attendants and one other person who offered to help.

The pilot asks if you think they should divert. Knowing what you know as a EMS provider and not withstanding the advice from some of the best on this board what do you tell the pilot?

Do you tell him to divert and work this guy till you land?

Do you call the code in flight and advise the pilot to continue to Houston?

There are NO right or wrong answers here. Just trying to make people think.

Let's add this one thing into the mix. This is a 27 year old female mother of 3 in arrest with her children watching. Do you do anything different?

[HERBIE1]

ok, sorry been out for a while. Migraines and kids don't mix if you know what I mean.

The AED never advised a shock.

the Iv is started and you only have 500ml so use it judiciously

You do cpr and give the 2 rounds of EPI and you do not feel a pulse nor does the AED recommend a shock.

You are on the radio with med control out of New York.

CPR is still in progress with 2 flight attendants and one other person who offered to help.

The pilot asks if you think they should divert. Knowing what you know as a EMS provider and not withstanding the advice from some of the best on this board what do you tell the pilot?

Do you tell him to divert and work this guy till you land?

Do you call the code in flight and advise the pilot to continue to Houston?

There are NO right or wrong answers here. Just trying to make people think.

Let's add this one thing into the mix. This is a 27 year old female mother of 3 in arrest with her children watching. Do you do anything different?

Sad that this is a young mother of 3, but it does not change the situation, nor the likelihood of a positive outcome. Less than ideal conditions, limited resources, and limited options. Like doc said, if the AED does not advise shock, then clearly the person is in PEA or aystole- neither of which means a good outcome. I'm thinking if this mom recently delivered, we could be talking about a PE or something similar, where there is nothing we can do to change. If you are in the back of your rig, or in an ER, then you would probably work a bit longer, maybe go a bit deeper into your ACLS protocols, but the outcome would probably not change. Talk to the flight surgeon/service, and see what they say. The decision to divert depends on flight time to final destination, time of day, available options to land, etc.

[spenac]

Age etc does not change. Work 15-20 minutes if no ROSC code is stopped. No need to divert. Make sure the airport locates relatives to help with the children.

[ERDoc]

The age may not make a difference to any of us, but I bet it would make a difference to the pilot/airline. If you said not to divert, I can almost guarantee that the airline would overrule you. It's one thing to have an eldery passenger die but to have a young mother die in front of her kids is a PR nightmare. Unfortunetly, for those not in the medical field (and those that have watched too much Rescue 911 and ER) CPR always works. I can't say I would blame them in a case like this to make the decision to divert.

[Just Plain Ruff]

Doc, I think you are absolutely correct.

The airline is going to divert probably no matter what. 79 or 29 years old.

The decision to stop the code is not yours. It is the medical controls that the airline uses. If you decide to stop then I can guarantee that the flight attendants will continue based on what I discussed with the flight attendants I talked to today on my flight.

One of the attendants I talked to today said she went through this situation about 6 months ago and the person in question was a 84 year old guy who arrested an hour outside of denver and they diverted to colorado springs.

I know that we as providers know the end result of all our work in these types of patients but no-one on the plane wants to continue on for 1-2 hours flying with a dead person especially when on most planes these days have places to put a dead person.

Calling a 80 year old is not as bad for the airline but calling a 29 year old would I think be out of the question for the airline.

So those advocating the calling of someone who doesnt' get ROSC, what about a child or an infant? Would you work them for a couple of rounds and then call them?

It's not so cut and dried is it?