hypothetically

[APACHE3]

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You're flying to London from New York. its an 8 hour flight. about the 4th hour, a passenger has a generalized seizure, with LOC. seizure last about a minute. As the only doc on board, do you tell the pilot its ok to go on to London (4 more hours) or land in Greenland or Iceland so patient gets to hospital? I was thinking about this the other day (because I travel lot)..and NO..I don't have too much time on my hands! ha! What would you do? I guess CP, severe abd pain...any scenario. Actually I did have a passenger "pass out" next to me. I was never sure if he just fainted, or hypogylcemic, seizure, MI or what. I cleared the seats out of our row, so he could lay down, put O2 face mask on him and just monitored his vitals until we reached airport ( 1 hour later). I guess it could have been worse. plus I was just (and still) a med student.

 

[Febrifuge]

Easy; I'm an EMT, so I'd ask the flight crew to put me on the radio to medical control. ...Oh, the joys of not being the "boss."

Is the patient travelling alone, or is there a family member or trusted friend who can give some history? It seems a shame to divert the plane if this is "a small spell, compared to the one at the picnic that one time," and the person needs rest and orange juice.

Does your hypothetical come with vital signs? 😀 I do believe they hide a sphygnomomanomaneter* in the medical kit on any modern passenger jet.


* i know.

 

[APACHE3]

Say he's alone..no family or friends. yeah, most planes these days have defibrillators, etc. BUt would that really help the seizure patient? thats why I was wondering, I can't get dilantin level at 20,000 feet, so will he seize again? Will it be worse? Will I loose his airway? My feeling would be to ask the pilot to divert to nearest airport, just to cover my bu%%. And yes, all the passengers would kill me!

 

[USCDiver]

First of all, he said "sphygnomomanomaneter" not defibrillator.

A good compromise would be to wait for the patient to become more alert and get a history then. Check his luggage, if he's on dilantin or whatever, you can load him when he comes around. Ask around for someone who may be a diabetic and check his FSBS.

Maybe I'm talking out of my ass, though. I had Wisdom Teeth-ectomy x 4 this morning and I'm all hopped up on Perocet....mmm Percocet.

 

[DropkickMurphy]

I'd continue on to London if he didn't seize again immediately. Having been on a flight that I had requested (and got) diverted to Rejya....Rejak.....that place in Iceland (never can spell it) for a cardiac patient, but for a patient that had only a single isolated seizure, I would feel comfortable continuing on, barring there are no other signs that something more sinister is going on (head bleed, etc).

 

[FoughtFyr]

As a medical control doc for an airline (part of our residency) I would actually elect to land. With no history, limited physical exam, etc. you can't tell a CVA from a toxidrome from a simple seizure. Without that important context, you err on the side of caution. That said, it can cost an airline thousands of dollars to divert, so you can't do it lightly.

My best actually air medical call was for a airline crew member who had (I'm not making this up) a swollen leg for three days, now c/o dyspnea (worse on exertion), hemoptysis, and CP. When I asked the pilot if there were medical personnel on board, I was informed the patient was a "Navy medic", whom the crew generally relied on in medical crises. They were equidistant (over the Pacific) from Japan and Hawaii. I advised the patient be placed on O2, the cabin be pressurized to as close to sea level as possible and that the flight be expidited. I also advised that the patient take an ASA, and that she not be left alone (physically speaking) for any period of time (I wanted someone there if she coded). They were able to shave over an hour off their flight time by making best speed as opposed to the normal economy cruise speed, and the pressurization apparently helped a bit. She did "make it" until they landed in Japan but I never heard what the final Dx was (although I could guess...)

- H

 

[CS_22]

As a medical control doc for an airline (part of our residency) I would actually elect to land. With no history, limited physical exam, etc. you can't tell a CVA from a toxidrome from a simple seizure. Without that important context, you err on the side of caution. That said, it can cost an airline thousands of dollars to divert, so you can't do it lightly.

My best actually air medical call was for a airline crew member who had (I'm not making this up) a swollen leg for three days, now c/o dyspnea (worse on exertion), hemoptysis, and CP. When I asked the pilot if there were medical personnel on board, I was informed the patient was a "Navy medic", whom the crew generally relied on in medical crises. They were equidistant (over the Pacific) from Japan and Hawaii. I advised the patient be placed on O2, the cabin be pressurized to as close to sea level as possible and that the flight be expidited. I also advised that the patient take an ASA, and that she not be left alone (physically speaking) for any period of time (I wanted someone there if she coded). They were able to shave over an hour off their flight time by making best speed as opposed to the normal economy cruise speed, and the pressurization apparently helped a bit. She did "make it" until they landed in Japan but I never heard what the final Dx was (although I could guess...)

- H

I have absolutely nothing to add to this conversation, I just thought I'd ...

 

[bartleby]

If the guy had a MedicAlert bracelet or you could find some other evidence of a known epilepsy disorder and there was no evidence of status (prompt recovery of consciousness) I'd continue the flight.

Otherwise, there's relatively little to gain by sitting on somebody for an extra couple of hours in a situation where you have essentially no diagnostic and minimal therapeutic capability.

 

[docB]

As with all incidents on airplanes you should attach the AED and then jiggle the pt's chest (like doing a sternal rub) to simulate VTach so the machine advises a shock. Keep doing this until the pt either bursts into flames or you deplete the AED battery. Then you should stand and survey the carnage and with a self satisfied tone say, "Well, my work here is done." Calmly go back to your seat. Don't be surprised if the stewardesses offer you free airline tickets and so forth.

 

[stoic]

i'd inform the captain that it was imperitave for the patient for me to fly the plane for a bit 😀

 

[APACHE3]

Hmm..I never thought about that. And yes, the airline did send me a $50 voucher for helping the patient and flight crew!! As for the hypoth., I would divert. Thats why we get paid the big bucks to make the hard decisions..and ruin everybody's vacation!!! 😀

 

[southerndoc]

Hmm..I never thought about that. And yes, the airline did send me a $50 voucher for helping the patient and flight crew!! As for the hypoth., I would divert. Thats why we get paid the big bucks to make the hard decisions..and ruin everybody's vacation!!! 😀

That's considered a form of payment. If the patient later sues, you can be held liable since you accept remuneration for your services (even if not paid directly by the patient).

 

[Annette]

Would you still get the voucher ($50!) if the patient caught on fire from the AED and burnt the seats?

 

[wthomp03]

As with all incidents on airplanes you should attach the AED and then jiggle the pt's chest (like doing a sternal rub) to simulate VTach so the machine advises a shock. Keep doing this until the pt either bursts into flames or you deplete the AED battery. Then you should stand and survey the carnage and with a self satisfied tone say, "Well, my work here is done." Calmly go back to your seat. Don't be surprised if the stewardesses offer you free airline tickets and so forth.

Sounds like you are speaking from experience.

 

[APACHE3]

OK, so the patient is diverted to Iceland. As the "doc" on board the flight, do you "release" the patient to the EMT's or should you travel to the hospital with him to give report to accepting physician?? As for my voucher, I never used it...so no law broken...whew! 😎

 

[beriberi]

I would guess being on a plane is a lot like being on a cruise ship--you are not under US law. (On a ship, you are under maritime law. Anybody know what you would be under on a plane?) In any case, I bet your liability is minimal, free plane tickets or not. Under maritime law you can only be sued for actual damages, not for pain and suffering (in my understanding). Which means there is no harm in letting grandma wait out that seizure.

In a different vein, what conditions cause a seizure that are reversible/treatable and whose outcome will be affected by reaching medical care 2-3 hours early? Maybe I am getting a bit burnt out, but the only thing that comes to mind is ICH of some sort and those people never seem to do well post ventriculostomy. Especially if the person returns to normal, what needs to be done (in the next feew hours)?

 

[FoughtFyr]

I would guess being on a plane is a lot like being on a cruise ship--you are not under US law. (On a ship, you are under maritime law. Anybody know what you would be under on a plane?) In any case, I bet your liability is minimal, free plane tickets or not. Under maritime law you can only be sued for actual damages, not for pain and suffering (in my understanding). Which means there is no harm in letting grandma wait out that seizure.

In a different vein, what conditions cause a seizure that are reversible/treatable and whose outcome will be affected by reaching medical care 2-3 hours early? Maybe I am getting a bit burnt out, but the only thing that comes to mind is ICH of some sort and those people never seem to do well post ventriculostomy. Especially if the person returns to normal, what needs to be done (in the next feew hours)?

Not much, but given the reasonable possibility of decompensation the PIC (pilot in command) is going to want that individual off his/her plane. You have to remember that aircrews are a bit touchy when it comes to anything out of the ordinary. They want NOTHING to take up extra resources that might be needed in an emergency. They can be quite adamant about this.

As for liability and / or traveling with the patient...
Liability is extremely limited (regardless of compensation) and actually a great deal of it is on the PIC as opposed to the physician/nurse/EMT etc. There is an international treaty known as the "Warsaw Convention" that covers this. See: http://www.aviationlawcorp.com/content/intlairline.html#international

"What about Accidents on International Flights not Involving Physical Injuries or Mishaps not deemed Accidents?

Airline insurance defense lawyers have successfully defended the airlines and their insurers against various tort claims resulting from wrongdoing on international airline flights that do not rise to the level of an actual "accident." The airlines have always taken the position that various mishaps or illnesses outside their control were not "accidents. " further they argued that emotional distress did not result from physical injury was not a damage payable under the Convention. The United States Supreme Court has supported the airlines in a landmark decision this year. The Supreme Court has held that an "accident" for purposes of the Convention, means "an unexpected or unusual event or happening which is external to the passenger." Thus, where the Warsaw Convention applies, international passengers will not be able to recover against the airline for emotional damage claims where there is no physical injury or for mishaps not caused by airline fault such as illnesses or passenger transgressions. As an example of how confusing the laws can be, just last year, the Ninth Circuit Court of Appeals in California paved the way for domestic passengers to bring garden variety tort claims (a "tort" is a civil wrong) in U.S. Courts resulting from incidents on domestic airline flights that do not involve "accidents" just the opposite of international flights."​

As far as travelling with the patient, I can only relate a personal experience. While an EMT-P (a few years back), I answered a medical assistance overhead page on a flight to South Africa. A physician (an OB/GYN) also volunteered. Together we worked a full arrest (no shock indicated) for over an hour, 40K ft. over the Pacific. Eventually, with the concurrence of the PIC and ground based medical control, we terminated resuscitation. The plane made an unscheduled landing in the Azores and the OB was asked to stay with the patient/corpse until a local doctor could arrive. As this would take some time, the OB's family and their luggage were off-loaded. I assume he was compensated. I was given lots of in-flight goodies, including a bottle of nice wine, and a voucher for new clothes as bodily fluids had wrecked mine and I had to attend a conference the evening we were to arrive in SA.

- H

 

[leviathan]

* i know.

Hahaha, you are awesome Feb. 😀

 

[craig_rt]

I would guess being on a plane is a lot like being on a cruise ship--you are not under US law. (On a ship, you are under maritime law. Anybody know what you would be under on a plane?)

I think that the plane, once airborne, is under the jurisdiction of the destination.

Craig

 

[Doczilla]

Regarding the initial complaint, I'm not sure I would divert the plane for a patient not in status epilepticus who has a well documented history of seizures, takes medications, and has occasional breakthrough seizures. A single, short, isolated seizure in this kind of patient is not an emergency. Virtually anyone else, yeah, we'll be stopping in Iceland.

OK, so the patient is diverted to Iceland. As the "doc" on board the flight, do you "release" the patient to the EMT's or should you travel to the hospital with him to give report to accepting physician??

Not sure about Icelandic EMS law. Here in the states, of course, depends. If as a physician you have done or ordered something done to the patient outside the protocols or scope of care of the prehospital provider, then you'll have to go with them (i.e., if you gave rectal valium and the transporting crew is BLS). This can be sorted out by a quick call to the EMS medical control. If you've done anything at all, it warrants at least a courtesy call to medical control (again, receiving service, not the airline's med control) If on the other hand you haven't done anything beyond BLS, then you may not have to accompany the patient. As a medic, I had to get an online order from medcom for the on scene physician to release care to me.

Now when I work football games, I send people to the hospital via medic pretty frequently without contacting med control. Then again, I work in the same system.

'zilla

 

[indiamacbean]

Just a thought:
We had a talk by one of the EM faculty at Pitt who spends time working as medic control for various airlines. he made the good point that if you are ever stuck on a long flight and need access to meds that your "patient" doesn't have, particularly common ones (nitro, albuterol, etc) that you can get on the intercom and see if any other passengers are flying with these meds. he said a large airplane is pretty much a flying pharmacy. just a thought that might come in handy some day.

 

[FoughtFyr]

I think that the plane, once airborne, is under the jurisdiction of the destination.

Craig

Actually read my post above. It is under international law as agreed to by the Warsaw Convention. This is something I regularly do as part of my residency (medical control for international flights).

- H

 

[FoughtFyr]

Regarding the initial complaint, I'm not sure I would divert the plane for a patient not in status epilepticus who has a well documented history of seizures, takes medications, and has occasional breakthrough seizures. A single, short, isolated seizure in this kind of patient is not an emergency. Virtually anyone else, yeah, we'll be stopping in Iceland.

Yeah, but the case given wasn't a known seizure patient. To quote the OP "You're flying to London from New York. its an 8 hour flight. about the 4th hour, a passenger has a generalized seizure, with LOC. seizure last about a minute. "

Not sure about Icelandic EMS law. Here in the states, of course, depends. If as a physician you have done or ordered something done to the patient outside the protocols or scope of care of the prehospital provider, then you'll have to go with them (i.e., if you gave rectal valium and the transporting crew is BLS). This can be sorted out by a quick call to the EMS medical control. If you've done anything at all, it warrants at least a courtesy call to medical control (again, receiving service, not the airline's med control)

Have a good friend and residency classmate who is from Denmark and just got back from a rotation in Iceland. There are two problems with your suggestion. First, who exactly are you counting on to translate that "courtesy call"? Second, who are you going to call? Iceland doesn't have an American style setup. Physicians ride their ambulances so there is no "calling in".

This is why you DO use the airline's medical control (and believe me, the flight crew won't let you near the patient without medical control knowing). We have protocols for these cases that meet the rules of the international treaties governing these situations. In-flight emergencies are very different than those on the ground because the Pilot in Command still maintains absolute authority over what goes on in the aircraft, even if a physician is present. The usual "hey, we are EMS, don't worry, we'll take charge" won't play in flight. Don't believe me? Ask anyone who has done medical control for airlines about the cessation of CPR for landng in poor meteorlogic conditions. Yes, the flight crew will order you to your seat and belted, even if that interupts CPR, should the PIC feel that your safety, and/or that of his or her crew, is in question.

If on the other hand you haven't done anything beyond BLS, then you may not have to accompany the patient. As a medic, I had to get an online order from medcom for the on scene physician to release care to me.

As a medic, or an EMT, or a bystander, or even as a physician you would act under the authority of the Pilot in Command who will, most likely, elect to act on his or her medical control's advice.

Now when I work football games, I send people to the hospital via medic pretty frequently without contacting med control. Then again, I work in the same system.

'zilla

And that is a COMPLETELY different situation.

- H

 

[Doczilla]

Yeah, but the case given wasn't a known seizure patient. To quote the OP "You're flying to London from New York. its an 8 hour flight. about the 4th hour, a passenger has a generalized seizure, with LOC. seizure last about a minute. "

Correct, but what I'm trying to say is that it is not automatically warranting a diversion just because the patient had a seizure. A little more history is needed.

Have a good friend and residency classmate who is from Denmark and just got back from a rotation in Iceland. There are two problems with your suggestion. First, who exactly are you counting on to translate that "courtesy call"? Second, who are you going to call? Iceland doesn't have an American style setup. Physicians ride their ambulances so there is no "calling in".

Never been to Iceland, so I'll take your word on both accounts. Depending on where you are flying, english may be widely spoken (Germany, for instance). And again, I don't know much about Icelandic EMS law. And if there are physicians on the ambulance, that renders the question by beriberi irrelevant, which was what I was addressing.

This is why you DO use the airline's medical control

I'm not suggesting that you not contact the airline's med control. What I am suggesting is that once on the ground, you attempt to make contact with the med control for the EMS service.

'zilla

 

[FoughtFyr]

I'm not suggesting that you not contact the airline's med control. What I am suggesting is that once on the ground, you attempt to make contact with the med control for the EMS service.

'zilla

I understood what you were saying, and what I am saying is that you don't. Besiding the logistical difficulties (translation, what "phone" are you going to use, what # do you call, etc.), it becomes a case of it is far better to beg forgiveness than ask permission. Calling directly leaves those actions you have taken, under the direction of the airlines medical control, open for debate. The individual answering the phone (if you do get a physician) may be quite uncomfortable with the idea of anyone other than a physician treating the patient. Now, assume that individual were "hot headed" and called the local PD who arrested you for practicing medicine without a license. Now, according to the "Warsaw Convention" they can't do that, but I don't know that many U.S. police officers that are well versed in international law, so I have to imagine that there are a few foriegn ones who aren't. So badness ensues until it is straightened out.

But all of this leaves aside the most glaring reason why you won't call local medical control - the aircrew isn't going to let you. You will treat the patent and "talk" to the airline's medical control through an intermediary in most cases. As soon as local EMS arrives, you can report off to them, but then you will be escorted back to your seat. They (the aircrew) aren't going to call the local folks and you aren't allowed in the cockpit...

- H

 

[Febrifuge]

As a medical control doc for an airline (part of our residency) I would actually elect to land. With no history, limited physical exam, etc. you can't tell a CVA from a toxidrome from a simple seizure.

Aha. So my vote would actually have been to call FF. So I totally got that one right. Ka-zinng!

Being a Postbac means I get my scraps-of-props where I can,
-Feb