6/2/2014. Stuff Happens! If there is a Physician, Paramedic, or Nurse, on board please identify yourself to the Flight Attendant!

Size: px

Start display at page:

Download "6/2/2014. Stuff Happens! If there is a Physician, Paramedic, or Nurse, on board please identify yourself to the Flight Attendant!"

Meagan Johnson
8 years ago
Views:

1 If there is a Physician, Paramedic, or Nurse, on board please identify yourself to the Flight Attendant! Brian W. Gross, MD, FACC, FAHA Southern Oregon Cardiology 11 th Annual Oregon Cardiovascular Symposium June 7 -, 2014 Sheraton Portland Airport Hotel Portland, OR. I have no industry relationships regarding this or any presentation Stuff Happens! 1

Gross, MD, FACC, FAHA Southern Oregon Cardiology 11 th Annual Oregon Cardiovascular

2 1) Scope of problem 2) Fuselage Physiology 3) Fit to Fly? 4) What can happen? 5) What Equipment? 6) What options? 7) DVT myth or reality? 8) Legal implications N Engl J Med 2013;368: Worldwide billion passengers per year They reviewed 10% of global traffic over 34 months 11,920 In-Flight Med Emergamong 744 million passengers 16 medical emergency / 1 million passengers 1 medical emergency / 604 flights Diversion 7.3% of flights Fuselage Physiology Oxygen Dynamics or why you should have stayed awake during high school physics and 1 st year medical school physiology Cabin Pressure Effects on Oxygenation Cabin Pressurized to feet For healthy Pts, the po 2 drops from 95 to 56mmHg (only 4% reduction in O 2 carrying capacity) i.e., flat part of O 2 -Dissociation Curve) For CardioPulptswith low resting po 2 the equivalent altitude results in a profound decline in O 2 carrying capacity = Hypoxia 2

75 billion passengers per year They reviewed 10% of global traffic over 34 months 11,920 In-Flight Med Emergamong 744 million passengers 16 medical emergency / 1 million passengers 1 medical

3 Fuselage Physiology Oxygen in Flight Normal Patient: PaO2 at sea level 95mmHg drops to 56 mmhg - 4% drop in oxygen carrying capacity PulmPatient: PaO2 at sea level 70mmHg could drop dramatically - 20% drop on the steep part of the curve Fuselage Physiology Cabin Pressure Boyles Law P x V = Constant At Altitude 30-40% gas expansion occurs resulting in minor abdominal &aural discomfort in normal Pts, but painful distentionin at Risk Patients: (Ear Problems Pneumothorax, Eye Surgery, ileus ) Potential Problems for Pneumatic Splints, Foley Catheters, ET Tubes, Gastro Feeding Tubes (Recommendation: use H 2 0 instead of AIR) Fuselage Physiology Cabin Pressure Take-Off Landing 3

occurs resulting in minor abdominal &aural discomfort in normal Pts, but painful distentionin at Risk Patients: (Ear Problems Pneumothorax, Eye Surgery, ileus )

4 Fuselage Physiology - Air Quality Low Humidity (10-20%) Problem for Asthma & Eyes Infectious Disease Long flights or sitting within 2 rows of infected person, places passengers at documented risk for TB, Smallpox, Influenza, Cholera, Measles Fuselage Physiology - Psychology Violence Air Rage #*!+^* 25% Fueled by Alcohol It Starts Before Boarding 4

passengers at documented risk for TB, Smallpox, Influenza, Cholera, Measles Fuselage

5 And Escalates Before Take-Off Who Shouldn t Fly At 8000 feet, gas expands 35% Who Shouldn t Fly At 8000 feet, gas expands 35% 5

6 Fitness for Safe Air Travel Simple test can they walk 50 meters or climb 1 flight of stairs w/o severe dyspnea? po 2 sea level will require O 2 in Flight Air Carrier Access Act of 1986 Prohibits airlines from discriminating against passengers with disabilities, but airlines reserve the right to refuse passage to those who are not medically fit to fly. Personal Medical Equipment Oxygen-Requires 48 hrnotice & a prescription. Passengers can not use their own oxygen equipment during flight because it is deemed a hazardous material (ie, ValuJET) and must arrange oxygen supply at departure & arrival Passengers may carry Syringes and Needles with pharmacy labeled injectable medicine 6

refuse passage to those who are not medically fit to fly. http://www.everythingspeech.

7 You re gonna need space DSC_0118 This isn t going to be your typical ER or ICU work space What Do You Have to Work With? 7

What Do You Have to Work With? http://www.jems.

8 Who s Got Your Back? MedAire U Of Pittsburgh Emergency Medicine Department STAT MD Program What s in My Pocket? result in diversion or death 8

9 In-Flight Events EVENT TYPE Cummins etal N = 1107 DeJohn et al N = 1132 Dowdall N = 910 Vasovagal 4% 22% 8% Cardiac 20% 20% 10% Neurological 8% 12% 9% GI 15% 8% 28% Respiratory 8% 8% 5% Traumatic 14% 5% 3% NEJM 346:1067 (April 4, 2002) 9

20% 10% Neurological 8% 12% 9% GI 15% 8% 28% Respiratory 8%

10 American Airlines (6/1/97 7/15/99) High Risk Stress, Gate Race, Circadian, Low O2 200 Applications (191 in Aircraft / 9 in Terminal) 99 LOC, 62 CP, 19 SOB, 8 N, 3 Dizzy, 3 Palp 1st Shock Success 13/14 (1 DNR Request) 40% of CV Ptssurvived to HospDisch No Inappropriate Shocks AED Applied 1 per 3,288 Flights Arrest 1 per 21,654 Flights NEJM 343:1210 Oct 26, 2002 Virgin Atlantic has Video Imaging, VS, 12 lead EKG, O2 Sat, AED Transmission to Ground Based MD s General Approach to In-Flight Event Flight Crew is Responsible Volunteer is to assist not take control Ask permission to assist (Let Crew run the AED). -Find a place to attend your patient -Use Oxygen prn - Familiarize yourself with the Medical Kit -Consult with ground based medical support regarding Diversion 10

has Video Imaging, VS, 12 lead EKG, O2 Sat, AED Transmission to Ground Based MD s General Approach to In-Flight Event Flight Crew is Responsible Volunteer is to assist not take control Ask

11 Unresponsive Passenger AED, O2, IV Access,? D50 Angina ASA, NTG, O2 Asthma / Respiratory Bronchodilator MDI, O2 Vasovagal Raise the legs, cool compresses to forehead Acute Allergic Reaction Diphenhydramine poor iv, +/- sc epinephrine Abdominal Pain or Headache Lower Altitude or Raise Cabin Pressure On-Board Assistance Was Rendered by Physician 48.1% Nurse 20.1% EMS 4.4% Other Health Care Provider 3.7% 11

compresses to forehead Acute Allergic Reaction Diphenhydramine poor iv, +/- sc epinephrine Abdominal

12 In-Flight Medical Events Frequency 1 per 35,000 Passengers 30 Domestic Flight Events per day 13 Domestic Flight Events per day Require Ground-Based Assistance 13% of Events Require a cost of $3,000 -$100,000 per diversion) Cardiac: 46% Neuro: 18% Resp: 6% NEJM 346:1067 (April 4, 2002) NEJM 346:1067 (April 4, 2002) Economy Class Syndrome 1 VTE per 4646 long haul-flights 0.5 VTE per 1 million travelers on Day of Travel 27 VTE per 1 million travelers within 2 Weeks of Travel Kevin O, Hwang, MD, MPH 12

(April 4, 2002) NEJM 346:1067 (April 4, 2002) Economy Class Syndrome 1 VTE per 4646 long haul-flights 0.

13 Medical Liability No successful litigation has been brought against a physician who rendered in-flight assistance In the US, Canada, & United Kingdom, physicians are not legally bound to render assistance Aviation Assistance Act of 1998 Good Samaritan Act protection providing aid is voluntary, in good faith, and w/o monetary compensation 13

legally bound to render assistance Aviation Assistance Act of 1998 Good Samaritan Act

14 Relax Joaquin what else could possibly happen? 14

Ready to Join the Mile High Club? A Ra6onal Approach to In- Flight Emergencies. David S. Bullard, MD, MEd, FACEP, FAWM March 1, 2015

Ready to Join the Mile High Club? A Ra6onal Approach to In- Flight Emergencies David S. Bullard, MD, MEd, FACEP, FAWM March 1, 2015 Disclosures None 2 Objec6ves Recall the prevalence of in- flight emergencies