We Have Reached 10,000 Feet, You May Now Use Your AED

Ryan D. Pappal, BS, BA, NRP, MS-II
Washington University School of Medicine in St. Louis
@RyanDPappal

As an undergraduate, my experience as a paramedic guided me on my path to medical school. Now as a pre-clinical medical student, preparation for boards has taken over my focus, and my experiences as a paramedic have slowly faded into the background. But as I discovered on a flight back to St. Louis, some skills never truly fade.

After a weeklong break, I boarded a flight back to St. Louis to resume my studies as a rising second-year medical student. My life was about to transition from days relaxing in the sun to nights spent in the library with First Aid, Anki, and Step 1 question banks. No worries, I said to myself – this is my dream, and I certainly signed up for it.

I settled in and enjoyed a smooth takeoff and cruise to altitude. Not a minute after hitting 10,000 feet, a panicked man stood up, shouting “We have a medical emergency, here!” I looked up, expecting to see someone fallen ill to their stomach. Shockingly, I saw a lifeless man being yanked from the seats by fellow passengers about ten rows in front of me as a flight attendant asked overhead with a tinge of panic, “Is there any medical on board?” I expected the adrenaline to kick in, but nothing came; years of prehospital experience desensitized me to emergencies in public settings. I got up from my seat and hurried down the aisle as the man was placed on the floor. Joining me were two nurses, Colby and Staci. We had no idea who each other were when we took off, but now we knelt beside our patient as a team.

We encountered an older male, likely in his 60s or 70s, down with apparent agonal respirations. I checked for a carotid pulse but could not detect one. Staci squeezed into the row next to the patient and began CPR. Panicked passengers began yelling down the aisle to the flight attendants for an AED, and in moments one arrived along with two medical bags. Sitting at the patient’s head, I exposed his chest and applied the AED pads. “Analyzing heart rhythm,” was broadcast, and we cleared the patient. The AED indicated a shockable rhythm and charged up. With 100 sets of eyes watching, I delivered the shock, eliciting gasps from the on looking passengers.

Colby, having squeezed herself onto the floor between two rows of seats, resumed compressions. I opened the medical bags, searching for the essentials of resuscitative efforts: basic airway equipment, IV supplies, and cardiac drugs. Luckily, all the necessary items were inside, and I immediately began giving bag-valve mask ventilations while Colby set up IV equipment. After two minutes, we delivered our second defibrillation from the AED. As Staci primed a 500 mL saline bag, Colby started an IV on the patient, but during the stick, our patient began moving his arms. We paused compressions and searched for a carotid pulse. “I feel a pulse, irregularly irregular at about 100 bpm,” I read out to the team, our audience still looking on is disbelief. Time stopped for just a moment as we glanced at each other, finally taking in what had just happened.

After a quick set of vitals, our patient began mumbling and recovered consciousness. Then, we advised the flight attendants as to the gravity of this medical emergency, and the pilot decided to divert to the nearest airport. After a tense landing, EMS was soon onboard and transporting our patient to the nearest hospital.

I took a seat and filled out a brief history and code summary using a flight attendant’s tablet. After I took a moment to decompress, I called my mom, who had served as a nursing instructor for decades and inspired me to pursue emergency medicine. She offered her gleeful congratulations, and, I suspect, proceeded to frantically phone our entire extended family as soon as we hung up. As we readied ourselves for takeoff to resume our journey to St. Louis, I began to reflect. How had I found myself in a situation I could only imagine seeing on television? And how might cardiac arrests in flight differ in survivability from the many I had treated as a paramedic on the ground?

 

Almost any emergency can occur on board an aircraft, and the reduction in oxygen tension during commercial air flight can itself induce medical emergencies, especially in those with cardiopulmonary disease.1 Cardiac arrests account for a mere 0.3% of in-flight emergencies and yet are responsible for up to 86% of in-flight deaths. These in-flight cardiac arrests bear a survival rate of just 18%.2 For passenger-bearing aircrafts in the United States weighing 7,500 pounds or above, on board Emergency Medical Kits (typical contents summarized in Table 1) are required by the United States Federal Aviation Administration.3 However, the management of cardiac arrest in-flight presents considerable challenges. The austere environment of an aircraft in flight, as well as the long delay until delivery to a receiving hospital, likely contribute to the high mortality of in-flight cardiac arrests. Additionally, the percentage of in-flight sudden cardiac arrests presenting with a shockable rhythm is reportedly as low as 25%, reducing the likelihood of rhythm correction using defibrillation.4

When volunteering to assist in any medical emergency, be ready to follow the instructions of the flight crew. The Aerospace Medical Association has a list of general recommendations, including identifying yourself and your credentials, asking the patient for permission to treat (if possible), and remaining within your scope of practice.5 Request access to the aircraft’s medical equipment bags and treat with both you and the patient seated and restrained if plausible. As on my flight, the attendants may be equipped to directly contact medical control on the ground – coordinate your care as much as possible with the medical director communicating with the flight crew.

Luckily, our patient benefitted from a treatment course that was uncharacteristic of many in-flight cardiac arrests. First, our patient’s cardiac arrest was immediately recognized by his fellow passengers, who rapidly requested the aid of the flight attendants. Second, medical help was recruited rapidly by fellow passengers and by the overhead announcement from a flight attendant. Third, three medical professionals with considerable experience in adult cardiopulmonary resuscitation were onboard and volunteered immediately to assist in treatment. Finally, our patient presented with a shockable rhythm that was successfully converted on the second defibrillation. Further workup by EMS and at the receiving hospital revealed significant acute myocardial infarction that was resolved with percutaneous intervention, resulting in the placement of three stents. He was discharged home from the hospital two days later.

It’s rare for a medical student to have the privilege to save a life, and I am humbled by the experience I had aboard the aircraft with the help and direction of two incredibly passionate and professional nurses. Despite having helped with CPR classes for years, it was nothing short of surreal hearing the same Phillips Heartstart AED prompts that would play non-stop in my classes being broadcast on an aircraft while attached to a real patient. Since that day, I’ve found a renewed sense of energy to help tackle my schoolwork and studies, knowing that I have a gratifying and worthwhile career to pursue in emergency medicine.

 

References

  1. Gendreau MA, DeJohn C. Responding to Medical Events During Commercial Airline Flights. N Engl J Med. 2002;346(14):1067-1073.
  2. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of Medical Emergencies on Commercial Airline Flights. N Engl J Med. 2013;368(22):2075-2083.
  3. Isakov A. Management of inflight medical events on commercial airlines. In: UpToDate. Wolters Kluwer; 2018. Accessed July 17, 2018.
  4. Alves PM, DeJohn CA, Ricaurte EM, Mills WD. Prognostic Factors for Outcomes of In-Flight Sudden Cardiac Arrest on Commercial Airlines. Aerosp Med Hum Perform. 2016;87(10):862-868.
  5. Medical Emergencies: Managing In-Flight Medical Events. Aerospace Medical Association Air Transport Medicine Committee. 2016.