Always been curious about what occurs "behind the scenes" in situations like this. Strange how airlines (and the flight attendants!) aren't held more accountable. Would have assumed the FAA would want to look into any in-flight medical emergency.
I'm going to guess the FAA is, like a bunch of other regulatory agencies, struggling to meet its obligations with the insufficient funds funneled into it.
Not quite -- the FAA is a classic example of "regulatory capture". Originally they policed the airlines, but now they explicitly state their mission is to assist the business interests of the corps they're supposed to regulate.
I can't speak for other aspects of FAA oversight, but my limited experience with DO-178B (A process for certifying software for safety-critical applications) has been mostly positive. While the process is rather heavy (and restrictive, regarding development/certification methodology), the outcomes seem to be quite good.
Can you provide some examples of where the FAA is doing poorly due to regulatory capture in regard to safety?
This article was linked on HN last fall I believe: http://www.vanityfair.com/news/2015/11/airplane-maintenance-...
Basically the airlines are outsourcing maintenance to places like El Salvador, Mexico, and China. The FAA has very little capacity for providing the same level of oversight previously conducted in US-based maintenance facilities. Scary.
Yikes. Horrifying stuff. If you've ever read the book "Poorly Made in China" it's kind of frightening to imagine the same techniques being applied to airplane maintenance.
I was wondering similar things... Why aren't there required 'debriefing' of medical staff and plane staff immediately following in-air medical emergencies? If, for nothing more, to confirm protocols were followed and determine if adjustments are warranted.
Aside from that, the fact that disturbing other passengers was even remotely a concern in the case where a person is laying on the floor in a medical emergency is sickening.
> Why aren't there required 'debriefing' of medical staff and plane staff immediately following in-air medical emergencies?
IMO this suggestion is worth its weight in gold. Imagine what sort of a (valuable) resource could be created out of a databank of information culled from such incidences, growing with time.
And is there ever any accountability for pax who are not "fit to fly" (note: I'm not saying that's the case here!) taking the chance and flying anyway?
With regards to the kit which was not aboard the plane, I have a few quick questions from anyone in the know.
Missing were:
- Aspirin
- Nitroglycerin
- Masks
- Fluid cleanup kits
- Airways
I'm assuming the latter three are one-time-use. I'm assuming the former two have expiration dates. Does anyone have info on how often these items might be used aboard flights and/or actually reach their expiration dates?
I'm asking specifically to see how much money is saved by not stocking up and simply assuming that the resulting lawsuits and fines are cheaper than keeping kit stocked. I simply can't attribute this kind of neglect to human error. Someone has to have done the math on this.
Nice. I'm not sure I'd trust military research all that much given how the VA has to deal with the aftermath of defects in medical policies and research by the DoD, but hey at least someone's researching it.
VA hospitals generally support university research, not military research. The military has their own hospitals and more importantly their own field casualty care systems. Source: I am a physician researcher at a military medical center.
As far as trusting research, you can probably find a good solid reason to distrust any research. Whatever your politics you can probably find something you disagree with about any given funding agency. But in that case we should just revert to our Neanderthal selves and solve all of our problems with clubs. What you should be doing is thinking critically about the introduction and method section And comparing them to the results. If you're in the field, you should know the authors or at least something about them and their methods.
Some things - adrenaline comes to mind - have a very short time frame until expiration and frequently newer atock isn't available when ordered. I assume expired stock is often used.
In medical use you don't use pure nitroglycerin; you typically dilute it with other stuff. For example https://en.wikipedia.org/wiki/Nitroglycerin_(drug)#/media/Fi... shows that the IV solution is 40mg of nitroglycerin per 100 mL of solution, or about .04% by mass. I doubt it's very explodey.
Of course even if you want to explode stuff you normally don't use pure nitroglycerin either, because it's _too_ explodey. According to https://en.wikipedia.org/wiki/Dynamite#Form dynamite is 20-60% nitroglycerin nowadays. Still a lot more than 0.04%.
As my siblings are saying, the same molecule but different concentration. This is the reason why you should handle dynamite in gloves: otherwise you absorb nitroglycerin through skin, lower your BP and faint.
Don't ask how I know this: Nitroglycerin tablets come in a tiny, sealed glass jar. It's a weird little container. So I wonder if it's short-lived in air / humidity. If so, then replacing it periodically might be the prudent thing to do.
Even at my workplace, which is a much more tame environment, somebody goes around and checks the contents of the first aid kits that are located around the buildings, periodically.
I doubt this is the result of any conscious optimization process. If it were, it would have been turned into a profit center - eg aspirin billed at $100/pill to the passenger who "requested" it. Who wouldn't want to get in on the hospitals' racket?
IIRC, passengers don't get to request anything. The kit stays closed, except for medical professionals. For good reasons - handing out meds likely entails liabilities, and no airline wants that.
More likely: what's being optimised are cabin check proceedures between flights, or reporting cases / incidences of use. Possibly also raiding of supplies by parties with access -- cabin crew or cleaners would be highest on my list.
But the point remains: Delta initiated a 17h flight with a lethal head flight attendant and a half-stocked medical kit, and have failed to follow-up on the incident. I'd like to see the FAA's incident report.
I responded to a few in-flight emergencies on international flights. Each airline has its own idea of what should be in the emergency kit, and there really no standards/regulations that I am aware of.
Aspirin is easy to ask for from other passengers. Same with Nitro : either the patient IS known for angina, and usually has his own, or he's not, and I would not suggest giving nitro "just in case" with the disastrous side effects it can have.
Are you in the US? The FAA has a strict set of minimum medical equipment for each flight with a flight attendant. [1][2]. European regulations require a lot more but don't actually apply to most flights in Europe as they only require an EMK for flights going more than 60 minutes from any airport. Even then, it seems like many European airlines carry a lot more than their American counterparts, though less than the ICAO recomendations [3]
> Sphygmonanometer = useless. You can't hear fuck.
A systolic pressure is still a useful datapoint. If you want to get a diastolic pressure, see if you can't track down a paramedic (a modern widebody jet isn't much louder than the back of a rig).
> Stethoscope = almost useless. You can't hear fuck.
See above...
> Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though
Most people don't know how to use any of this stuff... That's why they page for a doctor...
> Saline solution, 500 cc. As good as two glasses of (holy) water by mouth.
That's enough to make a difference for a preload sensitive heart failure pt.
> Analgesic, non-narcotic, tablets, 325 mg = Tylenol. Who cares
Someone in pain?
> Lidocaine. Have no idea why anyone would want that.
As an antiarrhythmic, I'm sure. A "hail mary pass" at best, but worth a shot, I guess.
>> Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though
> Most people don't know how to use any of this stuff... That's why they page for a doctor...
In Australia we teach OPAs in Advanced First Aid (not the first aid certification that most people get, but it's a component of the training that workplace first aid officers at any large business must undertake). I'm not sure whether flight attendants are required to undergo that training but it would not be unreasonable to make them.
Of course, as you say, when you can page for a doctor...
Antihistamines will not reverse anaphylaxis. If the patient has progressed to anaphylactic shock, they need epinephrine (and you might as well give them the half liter of fluid in the kit as well).
Not really. Even regular tablets begin to act in 20 min, even faster with the sublingual ones.
> Seems like a good idea for anaphylactic shock?
A very bad one, actually. Some people might want to give an antihistamine first (completely useless in anaphylaxis, by the way), and see what happens, instead of going straight to epi.
When you cannot know the provider's experience, its better to assume for the worse, and give one, and one only choice = EPI.
The medical kits in the US are usually quite extensive [1] (and even more so on long-haul flights into Europe), and I've never heard of someone running into a half-stocked one before. Often airlines will carry more than one so that if the first one gets used (even if one item from it gets used), they still have a second one on board to meet the letter of the FAA mandate. From the FAA: "If the air carrier elects to have only one AED and one EMK on board, if that AED is inoperative or that EMK is incomplete, the aircraft may not be dispatched."
Most of the meds have an expiry date of at least a year. Most airlines contract with someone like Banyan who handles supplying and refilling/recertifying the medical kits.
The list of mandatory supplies is longer than that; those were probably just the ones this particular doctor was looking for. As of April 12, 2004 the FAA requires an emergency medical kit containing 25 specific items (https://www.law.cornell.edu/cfr/text/14/part-121/appendix-A).
Given the general markup on anything certified for use in aviation, I suspect the cost is on the order of $1000 / year / plane; my guess is that the EMK had been used and not restocked rather than Delta deliberately understocking medical supplies.
That is essentially as bad. They're running an airline - a business predicated on checking everything when you land a plane. Not restocking life-saving emergency medical items after use is inexcusable.
Not defending them but it could be possible the plane had a quick turnaround and the crew in charge of checking failed. I've had flights where they didn't even get the cleaning or catering crew in.
Honestly if a flight is that tight to schedule they should just delay to make sure everything is right.
If you're a FA and the emergency medical kit gets used on the flight, I imagine you would remember that when the plane lands. Forgetting that you had an emergency on board and not restocking the kit takes an incredible amount of thoughtlessness.
It could also have been pillaged by a drug addict. The check list may be "Check the medical kit is in board", and only checking the contents every 10 flights. Quite a low probabiliy that this happens together with a myocard problem and a problematic flight attendant, though.
Nitroglycerin has a fairly short half life and doesn't love being exposed to air. Aspirin like any drug has a shelf life but not an unusually short one. Masks etc are going to have an expiration but unless the package is damaged are likely fine. Airways being invasive require closer management. Tetracycline is one of the few drugs that I am aware of that most practitioners will not use past expiration because of reports in the literature that old tetracycline caused kidney damage.
There are well defined SOPs in healthcare for when a sealed kit is opened. It is taken out of service, restocked, QCd, and returned to service. There was no mention of O2 administration in this article but the oxygen kit also requires routine checks and maintenance.
The biggest issue with airways is making sure the blade has batteries. Had a guy show up to a doc-in-a-box I was staffing and they had a full complement of tubes and blades, but no batteries. That is one time you really want batteries.
Many whole aircraft have been lost to human error, most often outside the cockpit. I don't think it's too hard to believe as a reason for the medical kits not being restocked.
In contrast to this story, my wife (a doctor) did attend to an ailing passenger on a transoceanic flight. The attendants were more than helpful, and my wife expressed surprise at how well stocked their medical kit was (drugs etc).
After the flight, the airline gave her some duty free goodies on the spot, and a few days later, a one-way business class ticket (I guess to make up for the fact that she sat with this ailing passenger for most of that transoceanic flight).
The article didn't mention what airline. We were flying Singapore Airlines. Service does make a difference.
Ah, Delta. I flew Delta, once (in the 80s). On the return flight, the flight was "delayed" till the next morning, and despite being a frequent traveller, they basically told me to go away and come back.
Needless to say, I swore to never fly Delta again after that. As an aside, I had a lot of good experiences whenever I flew Southwest.
I'll trade you my own anecdotal experience: Delta is by far the most professional and comfortable airline I've flown with.
The difference in quality when comparing Delta to other airlines is stark enough to me that I will book with them, even if the flight is slightly more expensive or less convenient.
All airlines suck, because they don't bother trying to avoid turning their problems into your problems good and hard.
I've generally had better experiences with Southwest than other domestic airlines, and that includes spending the night in an airport because Southwest canceled my flight due to "snow" when nary a flake was seen at the destination.
Delta, I don't even know why they bother publishing a schedule. But I'm sure our relative experiences are completely dependent on specific airports and time of day.
(I have flown Singapore once and the actual flight service was fantastic. But I'm not going to drop my guard over one uneventful data point, and even they haven't pushed back against the molesters)
I don't have enough experiences. I should have qualified my lead-in statement as "domestic airlines".
After taking the Singapore flight, I did joke about flying across the US via Asia just for the better service. But (thankfully) I still have no idea how they handle problems.
I want to believe that there are still businesses that believe in customer service and doing the right thing, and not just for customers who have paid an out-of-touch price. But part of me thinks it's just a matter of time until "market efficiency" gets to them as well.
I'm not sure where the market efficiency will lead us in this case. I personally am happy to pay ~20% more to fly with a non-US carrier. However, they are making that really hard. First off availability is an issue. How many different fights leave from SFO to Tokyo Haneda (I don't like Narita) on a Friday morning? Then you have these alliances where you book one airline and it gets swapped out for a different carrier. I've in the past booked a particular flight because it was operated by Air Canada and they switched it to United(?). We were flying via Canada to avoid this and still it happened. The market is not as perfect as buying soda off a shelf. I believe that if it was ahs foreign carriers were showed domestically US carriers might be in big trouble. But maybe I underestimate how much price matters to most people.
I fly Delta all the time (including internationally). I hear this anecdote that the US airlines are so much worse, so I have to ask. How are foreign airlines that much better?
My delta flights are almost always on time and are usually a little early. The only big delays I've experienced are because of weather, which all airlines experience. The international meals are fine, as in, I wouldnt pay any more money to get a better meal.
My experience is that US domestic flights are terrible, but US international flights are much better. Not as good as non-US carriers, but pretty good overall.
As another anecdote, I went from seldom flights to fairly regular, and the only US airline that has not made me feel like garbage is Delta. I don't particularly care about arriving "on time" except in extreme circumstances. I care about being comfortable and treated well. And while Delta like every other airline does its share of shoving people into uncomfortable seats for long periods of time with little sustenance, they have by far made that more tolerable than any other US airline I've tried. To the point I almost always book on their website rather than any other option.
Tons of stuff. Food on the plane, facilities in the lounges, free newspapers and magazines, choice of entertainment, friendliness and helpfulness of the staff, choice of drinks, quality of the seats, space in between the seats, quality of pillows (business class), flexibility in terms of carry-on luggage, clear information on website, useful website for reservations and what not, reasonable price, and so on, and so on.
Like I said, delta food is fine on international flights (maybe I'm easy to please). Whenever I use an airline lounge, I just envision it's a pretty lame way to make up for the fact that you aren't flying direct.
Quality of the seats for delta is good for comfort+, which is in the same price range as regular economy for 'nice airlines'.
Choice of entertainment has been the in-flight system loaded with a bunch of new and popular movies for free, which is good enough for me.
Price is always in competition for the cheapest. There is a reason the airline is so large...
Not sure what you mean about flexibility of carry-on...
Kinda cool for business class folks. But if your flying business class on almost any international flight you can press a button at any time to get whatever drink mixed up for you.
They've treated me with respect. They've changed flights for me to have a quicker flight. For the most part.. they've been a heck of a lot better than Delta. I liked NWA, not Delta.
Would you pay less money to get a better meal? Because for example I've found that Emirates is cheaper and has better service and food than Delta, or really any of the major US airlines.
To add some data to this discussion, in 2015 FiveThirtyEight found that Delta flights typically took 4 minutes less compared to other airlines, whereas Southwest flights typically took 1 minute more. This takes delays and cancellations into account.
Almost all airlines pale in comparison to Asian budget carriers. I've flown (from best service to worst): Scoot, ANA, and United recently (all on 787-9s).
One of the Scoot flights had some sort of medical emergency. Who knows what happened, but from what I could tell the guy lived. The closest we got to a medical emergency on the United flights was the food.
I have flown Delta several times in international flights. Business class. Their service was always piss poor compared to ANA, Lufthansa or even Air France. United was certainly better than Delta while still inferior to the others I mentioned. Delta ranks as the very last airline I would choose.
With Air France, the breakpoint is making Gold Status in Flying Blue (their frequent flyer scheme). Irregular traveller or Silver or below? If there's a problem with your journey, you own it. Gold and above? If you encounter a hiccup, they own it, and if you show the folks in the business lounge your card they'll go out of their way to fix things for you.
(I was once flying economy on a Delta seat paid for by someone else, and the Delta flight was late enough coming in that I was going to miss my onward connection. But I had Gold Status to fall back on: AF picked up the ball, bumped me a class, and re-routed me on one of their own flights so that I got to my destination, a bit later than planned but the same day, rather than being dumped in Detroit overnight.)
I'm British, a KLM/Air France frequent flyer, and visit the US a lot (so I end up on a lot of Delta code-shares -- flights booked via KLM/AF but operated by Delta).
Delta are the best of the "big three" US carriers in terms of customer service, and considerably better than American or United. On their intercontinental services they <em>try</em> to measure up to their non-US carrier alliance partners. Nevertheless, they're in third place relative to KLM or Air France as far as the passenger experience goes.
Relevant bit: I was on an AF trans-Atlantic flight a couple of years ago when a passenger a couple of rows behind me became unwell, and the passenger at the other side of my center aisle turned out to be a doctor on her way to a conference. Rubbernecking discreetly, I observed the cabin crew prioritizing the sick passenger's wellbeing and fetching the doctor the emergency kit and all the support she needed. Anecdata is not data and all that, but what I saw was what you'd hope to see in such a situation, not the fiasco described in the OP.
This thread rapidly devolves in to people name-checking favourite airlines.
I will have flown ~100 sectors by the end of this year, to ~45 airports, about 2/3rds long-haul, and all but a handful in J or F. It's not an especially unusual year.
Service varies much more on flights with any one carrier much more than it varies between carriers. Seats vary depending on plane deployed by carrier as much as they vary between airlines. About the only constant is the amenity kits, food, and crew uniforms.
The best service I've had this year was on China Airlines (an ROC carrier, not a PRC carrier), and the worst by far was Asiana (out of South Korea). I have no trouble believing next year I'd have the complete opposite experience.
Service in any industry can be such a variable. I've sat in a restaurant and had outstanding service while watching the couple next to me get terrible service from the same server, culminating in that server accidentally crushing the reading glasses of one of the other diners. I got lucky, they didn't.
In short, in my experience: when booking flights, it's generally worth just ignoring any claims of service excellence or otherwise, and looking at the food and seats you'll get on the specific airplane you'll be flying on. I'd take the Vietnam Airlines 787 Dreamliner with the Zodiac Cirrus seats any day over a Singapore Airlines A330 with the 7811 seats, and if I was flying in Y, I'd be basing my decision purely on a combination of seat dimensions and how new the airframe was.
I usually fly with Singapore Airlines. The service is always exceptional. One time (out of about a dozen trips) the flight was cancelled due to engine issues. After explaining I had a conference to attend and the next flight would mean missing one out of three days, they booked me an United ticket and offered me some points as an apology for the "inferior service". It was.
IIRC, in the US, airlines are required by law to book you on the next available flight on any airline. Of course, they prefer to keep you on their own planes, and it is probably impractical to move every single passenger, anyway, so you do have to ask.
In the EU there are similar laws. Compensations start as soon as a plane is delayed by more than two hours. My dad has gotten quite a substantial chunk of money back on a regular vacation ticket after it was delayed for a few hours.
You have to ask, but I have noticed in recent years that they're quite open about the fact that the program exists, with posters all over most airports.
On the flipside, I think there is a sort of loophole that some cheap EU airlines use, where if all the passengers board the plane, they can keep you delayed (and boarded) for a few hours with no compensation. I've been stuck outbound from Gatwick, sitting in the plane for 2.5 hours with no food and no compensation, due to illness causing shortage in the flight attendant staff. I believe they knew about the delay before they boarded us.
I'm confused by this. EU passenger rights http://europa.eu/youreurope/citizens/travel/passenger-rights... also apply to planes that arrive late. Hence, if they make you board the plane and wait, presumably you will also arrive late, and be entitled to a compensation.
I suppose the difference is that you're more likely to claim compensation whilst you've got nothing better to do than waiting to get on a plane in a terminal full of posters telling you to claim that compensation than once you've actually made it to wherever you're going.
Weather delays must not count. I've had a mechanical failure turn into a weather delay. We get a free hotel room the first night of the delay, but slept in the airport the rest of the delay because it was "due to weather."
I'm not sure what the conditions are, but the airlines are required to do that by law under certain circumstances. Maybe someone more knowledgable could chime in?
For flights to/from EU member countries, Regulation 261/2004 is applicable. I guess Rule 240 would be the US equivalent.
It can be tricky to get the airline to comply when they deny responsibility. So there are intermediary agencies that do the claim paperwork (and take the legal actions if necessary), taking a small percentage of the reward only if successful.
With the help of an intermediary, I successfully invoked Regulation 261/2004 against KLM after a flight was cancelled due to mechanical failure. The correct reward was ultimately transferred approximately one year after the original flight.
I got €400 compensation from Ukraine International Airways under the EU regulations after simply sending them a letter requesting it, after a 30 hour delay.
In the US, before deregulation FAA Rule 240 [1] covered this scenario. Now the specifics between airlines, but the place to look is the 'Conditions of Carriage' contract that each airline is required to abide by.
This Consumerist article [2] is out of date (2007), but it covers every airline's contract and I believe it remains mostly correct.
1.) In the United States disobeying any of flight crew (including flight attendants) is a federal crime.
2.) The pilot-in-command has the ultimate authority on the flight. If it is a life and death situation and you're getting static from someone, escalate to the PIC. You won't make any friends, but you may save a life.
My dad, a physician had to catheterize a passenger on an air new Zealand flight, and they offered him a free business class upgrade on his next flight. He found the crew helpful and was impressed they had a foley catheter onboard.
An incredible anecdote about a different incident from that thread:
> I'm going to share this story passed on to me by an anesthesiologist. He was on a trip from Canada to to Europe to visit family. He doesn't enjoy flying very much, even less so without anyone he knows to keep him distracted. So he purposefully got a late flight so he could sleep through it. Before boarding he took a few sleeping pills and downed a shot. He's an anesthesiologist, please don't try this at home. He boarded the plane almost last, did up his seat belt, and went nearly straight to sleep. Somewhere over the ocean he was half awake, in a lovely daze of drugs when he heard over the PA. "If there is a doctor on board the plane can they please identify themselves to the flight crew." He thinks about it for a minute, debating what to do and hoping someone else will say something before he has to. Finally he feels like he has no choice. He hits the call button on his seat arm and shortly after, a flight attendant comes to his row. He explains he's a Doctor and he'd like to help if possible. The flight attendant looks at him and says, "Sir, we called the Doctor for you, We've been unable to wake you for the past two hours, and we had to re-seat the passenger beside you because you were drooling on them."
Anesthesiologists are definitely a different breed. That approach (a few sleeping pills and a shot) definitely jives with my encounters with a few of them. Epic.
Once, on an SD to NYC red eye in which I take a prescription sleeping pill, the person behind me took the same one and two shots. Scared me but I guess not fatal for him.
Delta is either incompetent when it comes to preparation, or maybe the FAA has no actual way to force compliance with its rules so things like this get ignored. No matter what the rules are on an airline there is no excuse for putting people's lives secondary to them.
Flying to Australia on Delta isn't advised in any circumstance. I know they're cheaper than Qantas or Air New Zealand but you get what you pay for. Just don't do it.
I've given up trying to save money when flying. There's a list of airlines I trust, and I buy at whatever price their tickets are. The trip is either worth that much, or not worth going at all.
Not sure what's better as I have generally used them or Singapore, but I can vouch for the fact that their safety videos are excruciatingly, embarrassing, terribly bad.
I can't speak from personal experience, but my mum refuses to fly internationally to Australia with anyone but Qantas. From what she's related, US carriers are horrible, and I'd agree. Comparatively speaking, it's probably a coin toss as to who's better regarding Qantas/ANZ.
Though the bias of my heritage may be showing, I'd strongly suggest going with Qantas. ;)
I am sure there are horror stories for every airline so it seems unfair to gang up on Delta.
Actually, no. That isn't what I meant. I flew Delta a month ago and won't be doing so again. Free TV shows and new planes don't compensate for being late or having unfriendly staff members. Never mind this tale...
Interesting story and I can partially confirm. I have responded to a few on-flight emergencies on international flights and experience varies according to the airline.
Lufthansa has a really great kit to deal with agitated passengers, but nothing to deal with pain. Air Canada's kit is pretty worthless. Most airlines fall in between.
That being said, I find the doctor's requirement a bit unrealistic.
Airways ? Common, good luck placing an airway in the cramped flight conditions. A BVM [1] would be more useful.
IVs ... Completely useless, too. First, unless you have a good nurse on board, you wont be able to open up a good vein. Second, you cannot expect airways companies to store enough of IV fluids to make a difference either way. Third, fluids don't save lives unless you have other medications coming in the next few minutes.
The lack of nitro might be a good thing too. Rarely useful, and most likely to result in the passenger passing out/dying than helping anyone.
An 'airway' doesn't necessarily mean an ET tube. A simple airway adjunct (NPA, OPA, LMA, etc) would go a long way towards keeping an unresponsive pt's airway open without having to dedicate someone to monitoring it.
IV access is useful for administration of several drugs that airlines (in the US anyway) are required to carry. While lots of docs haven't placed an IV since residency, it's not _that_ hard a skill, and it's more than just nurses who start a lot of IVs... A nurse wouldn't even be my first choice in that situation. I'd hope there was a paramedic (or ER nurse) aboard.
As far as IV fluids go... There are plenty of situations where a 250-500mL bolus can make a significant difference. Given the limited diagnostic tools available, I'd give fluids to anything that smelled like an MI (barring any contraindications). For all you know it's an inferior wall MI, and that boost to their preload will help tremendously.
HN is not a place to argue medicine, but given that you're an EMT, I'll comment a little further.
1. Placing an IV in a sick, clamped patient IS difficult, even for experienced ER nurses.
If the patient is not sick, he doesn't need an IV. Its way easier to give drugs directly with a syringe than setting up an IV first.
2. In those situations, I'll just lift the patients legs up to give him that 500 mL bolus, which will take exactly 10 seconds, and not require any skills at all. Bonus points, if I realize he's not fluid-depleted, I'll just them back on floor -- et voilà!.
I'm a paramedic. I place IVs in "sick, clamped patients" all the time, often in a moving vehicle... I still maintain it's not that hard (the doc in the article managed it twice).
You're not going to buy 500 mLs by raising someone's legs... 250, maybe. And if they _do_ have a positive response, you'd still hold off on fluids?
I see it as more of a friendly discussion than an argument, but I'll certainly respect your wishes if you'd rather not...
It was in the sense of that kind of discussion probably not interesting to most people on HN.
I don't doubt you place IVs in sick patients, I only doubt those IVs make any difference. I am not very familiar with prehospital/EMT literature, and I don't know if any studies have been done, and I certainly don't have any hard data, but I do prefer when paramedics give aspirin, stick in a combi-tube, do basic stuff, and just rush the patient to the hospital instead of wasted time installing and IV on-site, giving fluids and what not. I've seen a great many "heart attacks" treated with fluids in full-blown congestive heart failure. This is anecdotal of course.
Again, for the 500 bolus, I am not aware of any literature to support it as a life-saving measure, and I do believe that if the patient is gonna code without a 500 bolus, he will code with a 500 bolus, too. We're talking of a previously healthy person suddenly dying here -- in those scenario fluid rarely makes a different unless its profuse bleeding, in which case 500 mL is not enough anyways.
The big problem I see with fluids, stethoscopes, IV benadryl, and the like, is that these things are DISTRACTIONS that make people waste their time trying to get a blood pressure when its obvious the patient's in shock (or equally obvious he isn't). A quick, focused history and exam + Epi + AED + Albuterol are the real life-savers and where the emphasis should be on.
If EMS in your area is starting IVs and pushing fluids on scene, then yeah, that's an issue. Plenty of time to do that in the truck. My primary goal is to gather all clinically relevant information I can, establish any needed access (airway, IV, or otherwise), and stabilize any life threats. In short, to set up the ED doc with the best chance of success (a patient with all the 'prep' taken care of, and a good, clear picture of what's going on.
I do think you're focusing too much on the dying/not dying distinction. There is a pretty wide range in the middle, and much can be done to help those patients (even if it's only to improve their comfort and reduce anxiety). There are a lot of patients who aren't going to die in the next couple hours who would still benefit from one or more of the interventions available on an aircraft (including a 500cc bolus).
"Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore. 500 mL may indeed be enough (if it's not enough, they're gonna bleed out anyway).
I agree 100% that any provider dealing with a medical emergency on an aircraft (or anywhere else) should be looking at the patient, first and foremost, and not rummaging through a medical kit...
> focusing too much on the dying/not dying distinction.
Well, my point is that if they aren’t so bad, they don’t need IV fluids, and you can give them some juice with pretty much the same effect (I expect normal GI function).
> improve their comfort and reduce anxiety
The Lufthansa kit is great in that respect. Lots of Valium and Haldol to make plenty of passengers calm and happy.
> "Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore.
I know. That’s been the usual swinging pendulum through the years : give fluids, don’t give fluids, give just a little bit. I highly doubt all this matter except in a few situations in which the patients is pretty much assured to die on the plane: septic choc, severe bleeding, severe fluids loss (on flight cholera?).
Seriously, I’ve never seen an acutely sick patient who needed 500 of saline now. They either can wait till next week, or need 2L STAT. Now, the situation is completely different with the chronic/elderly patients slowly deteriorating during the course of many hours/days, and arriving in extremis, and being resuscitated with a little bolus. However, you don’t see those patients in planes because they don’t let them fly!
Alright, I'll concede the fluid point (maybe this is an argument after all ;). It is very unlikely you would find a patient on an airplane that would benefit from a relatively small amount of fluids, but would also be unable to take those fluids PO.
No idea why your posts are getting down-voted. This has been a mutually constructive discussion, in my opinion...
> It was in the sense of that kind of discussion probably not interesting to most people on HN.
If it's a civil, informed, high level discussion of the topic by experts, I think it's a good discussion for HN. (Just have some sensibility to avoid or explain the very technical details.)
Borrowing a paragraph from the guidelines:
> On-Topic: Anything that good hackers would find interesting. That includes more than hacking and startups. If you had to reduce it to a sentence, the answer might be: anything that gratifies one's intellectual curiosity.
> I find the doctor's requirement a bit unrealistic.
The article states that these items (airways, nitro, ...) were not just her requirements, but rather FAA mandated [1] items that did not appear in the flight's medical kit.
What an odd reply. I have placed airways in helicopters and Piper twin-engine aircraft that were serving as air ambulances. Those are far more cramped than a commercial airliner. Control of the airway can make all the difference when things go bad in a hurry.
IV fluids are critical in dehydration--no drugs to follow.
Oh. I wrote the foregoing and then I re-read the part about "a good nurse...open up a good vein" and I realized you are a troll with no medical experience or qualifications. Good one.
Actually, being at 30,000+ feet the air is extremely dry. Getting severely dehydrated during the flight is quite possible. More so if alcohol is involved.
I'm sorry, but I'm not aware of any airline stocking combitubes[1] or similar easy airways (or at least an i-gel LMA). A Guedel can be useful sometimes, but that's it.
Unless you have a rare scenario where you've got an anesthesiologist/experienced paramedic, it is completely unrealistic to expect a random doctor to be able to use anything else.
The problem with any of those though is that you have now inflated a balloon inside your patient in a low pressure environment. You'd better remember that when you descend and the balloon deflates...
Given that this was a 17 hour flight I would bet that this was probably the jnb to atl flight (Johannesburg to Atlanta). I fly that route frequently and this does not surprise me.
That's not something AEDs can do... An AED can tell you whether or not the patient is in one of two very specific rhythms or not. If the heart is in ventricular fibrillation or ventricular tachycardia, the AED will advise a shock is necessary, otherwise it will report "no shock advised". There are all sorts of nasty cardiac rhythms that an AED will no shock, and there is way to differentiate that.
There's a thread on the r/medicine discussion where someone asserts that some AEDs with a monitoring display can be manipulated to get at least some indication of the cardiac rhythm. I'm definitely not qualified to say if they're correct. https://www.reddit.com/r/medicine/comments/50q4fa/yes_there_...
On a tangent, not all doctors are suitable for emergency work. I used to work with a paediatric neurologist, who was excellent in her field and a respected specialist, and she told the story of the call going out on a plane for a man who was having a heart attack. She hesitated about it - she hadn't "done hearts" since medical school twenty years earlier. Just as she was about to volunteer, however, another doctor put his hand up... and he was a cardiologist.
If it were me unconscious on the floor, I'd take a pediatric neurologist that "hasn't done hearts" for 20 years over a flight attendant with 8 hours of "first aid" training.
Definitely. I'd rather have any medical professional (any doctor, nurse, emt, paramedic, etc.) attending me in that situation rather than someone whose medical training consists of a first aid course and maybe a CPR certification.
Oh, for sure. I certainly don't mean to disparage her skills, just that 'doctors' come in a lot of different varieties, and not all of them retain general medical skills.
I remember a friend who became a paramedic. My home state brought in ambulances-for-everybody. If you wanted an ambulance, the dispatcher couldn't say no anymore, you got an ambulance. And for people on low-income cards, those ambulances were free. So my friend got called out to a lot of junk calls (his term: "coughs, colds, and sore holes"), and said that it was a problem for the paramedics because their skills rusted - some paramedics reported only seeing one heart attack in a year, and they have to pause and think what needs to be done again.
Medicine is very much a 'use it or lose it' discipline, at least when it comes to the details.
The requirements are the ability to understand English and lift 50 pounds. No lifting required for a modern widebody anyway. Open the door and get out, that's your only job when you're sitting in the exit row.
That was my first response to the article as well. However, I do not put blame on the airline since his condition could not have been noticeable upon boarding. I would assume they would have done something about a noticeably sick passenger regardless of seat location. Instead, the passenger was incredibly selfish for taking an exit row seat considering they knew they were sick.
I'd like to know what airline this was so I can never fly them.
1) This obviously physically incapable person was sitting in exit row initially
2) The F/A of negative utility (the physician probably should have escalated to the pilot, or at least the purser.) That has to be a combination of training and personal incompetence. (Actually, she sounds like the lead flight attendant, which means she should just be fired.)
3) The medical kit. wtf.
Ah -- appears to be Delta, which I'd never fly on a 17h international flight anyway.
The only way for the stewardess to check if a customer can sit in the exit row is to ask, "Are you willing and able to help passengers in the event of an emergency?" If the customer has no obvious outward appearance that might cause an issue, there's no way to know. The person in question in the exit row had a syncopal episode; syncope is defined on Wikipedia as, "Syncope, also known as fainting, is defined as a short loss of consciousness and muscle strength, characterized by a fast onset, short duration, and spontaneous recovery." Having diabetes doesn't disqualify you from being an in exit row.
Your other critiques are warranted; the lead FA shouldn't have acted the way the story portrays her to, and the medical kit was woefully understocked.
As an aside, do you think that because it's Delta it makes it worse? Why would American or United or Southwest or Allegiant or Silver or any other airline be intrinsically better? This was a lapse in judgement for not having the medical kit stocked, possibly a large one, but one particular organization isn't necessarily worse than any other.
The training lapses and other personnel issues which put a flight attendant in the lead role on a top international route (so, one of their most senior/experienced; likely 50+ years old and with 20-30 years in the job...international routes are pretty highly coveted) are an independent issue from the stocking issue, and do come down on the airline as well.
The specific airline protocols makes all the difference... which isn't specified in the article. Also something as simple as all the medication being in a foreign language can be a stumblimg block on an international flight.
Don't all international pilots speak English as a requirement for talking with air traffic control? I would assume that if English is standard for pilots it would also be standard for emergency equipment (in addition to any other languages)
I really want to know what was going on in the one flight attendant's head. I mean, I'd actually like to hear it from her. It's possible that she's actually a horrible, soulless bureaucrat by nature, but I'd like to think that something else--fatigue, life circumstances--was messing with her and causing her to make really stupid decisions just then.
There's also the possibility that her behavior was exaggerated in the article. Unlikely? Maybe, maybe not. That said, there are some especially nasty people who are often in positions they have no business being. This may be such a case. I'd like to give her the benefit of the doubt.
I was also thinking of circumstances that may help explain her behavior. It's difficult, but here's what I came up with (this is merely speculation; I have no idea what may have been going through her mind): 1) She may have been afraid of getting fired if things weren't done exactly by the book, 2) she may have been afraid the airline would be liable for anything the doctor did (and perhaps, by extension, herself), 3) perhaps she knew something about the under-stocked medical supplies and fear or repercussions lead to her (re)actions, 4) she had zero empathy, or 5) simply distrusted the doctors.
In the case of #1, there's not much you can do outside rectifying the company's culture. If employees are so terrified of being fired for assisting, or allowing someone qualified to assist, in an emergency, there's something horribly wrong with that organization.
As for #2, the same may apply with #1, but if the airline is afraid of being liable for an in-flight emergency they shouldn't be in that business, and they certainly shouldn't place the burden of determining liability on the shoulders of a flight attendant when they can afford a legal team.
#3 is a bit of a stretch, but given the discussion above, it seems surprising to me that the medkit would be so sorely under-stocked. Possibly an extension of #2.
#4 is probably the real culprit, although your explanation of stress or life circumstances may be much more likely. Perhaps she was tired and cranky. (Still, not an excuse, but people do strange things when they're tired or ill.)
#5 is also a possibility, but if you're trapped in an aluminum cylinder tens of thousands of feet above the middle of an empty ocean, you really ought to reconsider your career choices if the only people who might be able to save a passenger's life are the very people you don't trust.
There's another point I read above that I agree with. If the flight attendants aren't letting you do what you can to help a passenger, perhaps getting the pilot-in-command to assess the situation might be a better option if time and circumstance allow. They likely don't want to be held responsible for someone dying on their aircraft, and they probably have experience with in-flight passenger-related emergencies. They can instruct the flight crew on an appropriate course of action, even if that action is to simply stay out of the way.
Oh, one other possibility is that the head flight attendant seemed overly preoccupied with other passengers' comfort. In a situation like that where someone might die, passenger's comfort probably shouldn't enter the equation. Sure, you don't want to endanger them, and maybe you don't want to inconvenience them (much), but if it's a life or death situation... give me a break!
That latter assumption, save with the stress of the situation rather than "something else", is pretty much encapsulated in the physician's choice of "decompensated" to describe her. That's an interesting word! I'm glad I had cause to look it up.
My wife ( a doctor ) had to attend to a patient who had a medical episode on Singapore Airways (might have been the a Sydney to Singapore or a Singapore to London flight ). According to her, things went well, the air crew were professional and helpful, equipment was available.
There was another doctor on the flight who volunteered his help. The two doctors liased and decided that my wife's training and skills were more relevant to the situation.
My wife was thanked and given symbolic remuneration ( which she will probably never bother to cash in ). She felt valued and will probably be willing to help again if in a similar situation with Singapore Airlines.
Similar experience, although less dramatic circumstances, on a Qatar flight.
I was asleep, when my wife awoke my and volunteered me to address the needs of a passenger passing out in the aisle of the plane. I asked for equipment to check his vitals. Bp was on the low side so I asked he remain supine with his legs slightly elevated. There was a lady sitting next to us who criticized my every move (she felt I wasn't getting an accurate pressure because he was laying down, but I was more concerned with maintaining his pressure than having it bottom out further). The passengers were upset he was laying in the aisle. Turns out the lady next to me was a physician as well, but she never volunteered this or assisted in any way. He eventually got better and I allowed him to return to his seat.
I checked on him as we landed and left the plane. Medical services came with a wheelchair to take him off. No appreciation from the crew on this, but I guess that doesn't matter at the end of the day. barring the criticism I received for how I was handling it, the situation ended well.
Its interesting that the other doctor did not volunteer this information. I did pool lifeguard training a few years ago (in the UK) and was told that as this training is at a higher level than basic first aid training I would be legally required to notify my status and presence in an emergency, and that not doing so could leave me open to prosecution. Do doctors not have any obligations such as this laid upon them?
Every medical student hears horror stories where a doctor acting as a good samaritan in less than optimal conditions results in the person who was helped suing them afterwards.
On my first aid training (UK) we were told that no court has ever passed a conviction based on someone trying to provide help in an emergency. It's only one data point, but it seems morally right to me.
I don't know about that. I don't know how the people who told you that can be sure.
Also you aren't really talking about criminal convictions but rather, civil actions which may never end up in front of a judge except to finalise things.
These things can take years and you're dealing with no foal, no fee lawyers.
Medical litigation can be an incredibly stressful situation and commonly there are coached clients who will look people in the eye and tell outright lies.
These type of scummy lawyers won't go after joe soaps from whom
nothing can be recovered.
Also as a doctor on a flight, can you be sure that your insurer will cover you for your work outside the jurisdiction for which you're insured?
In germany all emergency aid is privileged in the sense that the law bars any suit against you (except probably purposefully causing damages and injury) and all insurance claims are covered by the Berufsgenossenschaft (sort of a public insurance for anything work-related). I'd expect that many jurisdictions have similar laws since that just makes sense from the view of the society.
No fault insurance is something that a lot of people would like to see in places where it's not. It allows for an environment where problems see the light of day and can be fixed. Germany commonly seems to get a lot of things right.
"no fault insurance" kinda sounds like what we have in New Zealand with ACC (Accident Compensation Corporation). Everyone contributes a bit into it through tax, but the flip side is that _everyone_ on New Zealand soil (not just citizens) is covered for accident related issues.
For example, I was hiking (or tramping as it's called in NZ) with a foreign friend visiting. They were unlucky and broke an ankle. We called the police, a helicopter was dispatched, picked her up, brought her to the hospital and fixed the ankle up. Zero cost to her.
One of the many upsides is that it's quite difficult to sue for personal injuries in NZ - as ACC basically covers the costs (or at least, that's my understanding anyway)
Sure there are downsides to any system, and some people do fall through the cracks of ACC, but on balance, I think it's one of the best things about NZ (besides the nice relaxed atmosphere and killer scenery)
I was reading about tort reform once and stumbled upon NZ's ACC concept and was staggered by its effectiveness. I suspect its success is due in part to NZ's population size, but any system that ensures all accident related issues are covered AND for the most part renders the civil courts redundant for personal injury claims is pretty phenomenal. I don't have a source for this, but I also remember reading that the ACC is now one of NZ's largest institutional investors with something like $30bn under management!
Does it cover loss of income and other consequential losses from the injury? If person A's negligence causes the loss of arm of person B, once person B is out of danger of dying and the acute injuries have healed, person B still has on-going harm from person A.
Suppose person B was a surgeon and lost their dominant arm/hand. Is that loss of income covered by ACC, via suing person A, or "too bad, so sad"?
I don't know the exact details, but yes, your income is covered up to some percentage, I'm not sure exactly what (80% springs to mind but I'm not certain - though Wikipedia suggests it's about right: https://en.wikipedia.org/wiki/Accident_Compensation_Corporat... )
Assuming no fault is something you want in a lot of places. For example the general rule for all emergency services (that is police, fire brigade etc.) is that unless you deliberately place a fake call, you're generally not held liable. The reasoning is that all emergency services would prefer to be notified earlier rather than later (for example for smoke rather than a full blown fire) and holding the caller liable for false alarms provides a strong incentive against that. So all in all, false alarms are considered something that the community/society needs to bear in return for peoples willingness to help/notify.
That nobody has been sued for this in the UK does appear to be a common belief amongst professional organisations.
"Despite the fact that no-one in the UK has been sued for providing first aid, it is a common fear that we’re regularly asked about." - Joe Mulligan, British Red Cross, 2015
"Although potential legal liability arising from good samaritan acts is something about which we're regularly asked by healthcare professionals, in practice we have never encountered a UK doctor, paramedic, nurse or other healthcare professional being sued after providing this kind of emergency assistance." - Shoosmiths, a major UK law firm that I have heard described as "Ambulance Chasers".
It seems to be common in the US for people to get sued for helping. Not so much in the UK, and following the 2105 SARAH act, which creates additional protections for such people, now even less likely.
Devon Air Ambulance used to tell a story, possibly apocryphal, about a callout to the middle of Dartmoor. In the course of treating a woman they had to cut off her cashmere top. After the incident they received a demand from the woman to pay for the damage done to her top, valued at several hundred pounds.
They replied that they would of course pay if she would reimburse them for the cost of the flight - enclosing a bill for £10,000. Answer came there none.
I do know that sometimes people do seek to start legal proceedings against emergency services. I worked with a fireman once who told me of a lady who wanted to start legal proceedings for some kind of assault based on how a fireman picked her up to carry her out of a building. Again, came to nothing.
In this day and age, if we cannot find any UK instance of someone being sued for providing first aid, I think we can label it "urban myth". Maybe some obsessive HN reader will find one for us :)
> There have been some cases in the UK where a claim has been brought against a ‘rescuer’, although there have been no reported cases in court where a casualty has successfully sued someone.
> • Out-of-court settlements are more common and go unreported, so it is likely that some claims against a rescuer have been ‘successful’, but these will have gone unreported.
> • It should be noted that even if a first aider is successful in defending himself against a claim, it is unlikely that he will be able to recover the full legal costs in defending himself. In civil litigation, it is unusual for a court to award the successful party more than 80% of their costs and it’s possible that an accusation can cost tens of thousands of pounds to defend.
> • In some instances it can be less expensive to settle a claim out of court than to defend it. It is not uncommon for insurers to settle claims even when the defendant was innocent, as this is the least expensive and least risky option.
This story took me a moment to process as an American, because here you'd get that bill regardless of whether you complained, and they wouldn't be joking about it!
In England and Wales all the air ambulances are charities, though receiving government funds. Much like the lifeboat provision by the RNLI it is a story of very different service provision than a purely state run institution would provide.
Pretty much. Their chances only get worse without intervention whilst waiting for the emergency services to turn up. I was told to expect broken ribs etc - which, apparently, aren't as grave an outcome as death.
The trainers on first aid courses I've attended have all said similar things. Yes, you are quite likely to break a casualty's ribs if you have to give them chest compressions. However, if you're a trained first aider and you're considering giving them chest compressions in the first place, presumably it's because you have ascertained that their heart isn't working properly and their life is therefore in immediate danger. Unless giving the compressions is getting in the way of something more important, like calling professional help as soon as possible or using an AED if one is available, it's practically impossible to make things worse for the casualty by trying.
One of my colleagues in the ambulance service got a formal complaint from a patient after a successful resus where the patient sustained two rib fractures. Fortunately the doc in charge of the ED stepped up and told the patient to stop being an ass.
That is a feature of US law, isn't it? Quite a few countries have laws that compel people to render first aid and at the same time offer protection from prosecution even if the first aid makes matters worse.
Both China and India have huge problems with citizens ignoring medical emergency to avoid being held responsible if the patient doesn't recover. The case of Wang Yue is famous enough that even most Americans have heard of it: https://en.wikipedia.org/wiki/Death_of_Wang_Yue
In Germany, every citizen is required to give first aid, as long as he doesn't endanger himself. If you don't help, you can get sued. And the law protects first aiders, so they can't usually get sued if they do something wrong.
In the US and probably the rest of the English speaking countries, typically only medical professionals and first responders are required to render aid, but the law does protect "good samaritans" from legal culpability if they do help.
At least in California, Good Samaritan laws will protect someone if and only if they are rendering medical aid that is in line with their training. Meaning if you know CPR and attempt to resuscitate someone who has no pulse and they die / have brain failure -> the law will protect you. If you know CPR and try to remove a bullet from someone's brain and they end up in a vegetative states (IANAL but) -> law probably won't protect you.
From my EMT course: The lawyer going after you would have to prove without doubt that the patient would clearly have survived if you didn't remove the bullet. In case of getting shot in the head, it's not very plausible that the patient would have survived anyways.
From a actual lawsuit: Someone without the proper training started an IV which later caused sepsis and death. Since the patient was admitted to an hospital it was not clear if an improply placed IV caused the death or an improper care in the hospital.
There have been recent situations here in Canada where very ill people were literally on the doorstep of the ER asking for help but were refused any help.
In nearly all the situations the staff in the building told the sick people outside to call 911 to get transported inside two feet inside the door.
The hospital workers and by that I mean nurses and doctors were unwilling to help even though the people outside were very ill.
So, the problem in Canada is that those policies are left up to each hospital or health unit to decide, and there doesn't appear to be a consensus (which is weird)
Yes sometimes it's a person literally on the doorstep of the ER in front of the doors. One time a news report said the person was in a passenger seat of a car. But usually right there at the ER in some state of distress.
I can understand some concerns of staff but to flat out refuse seems to go against the ethics of being in the medical trade.
I also suspect it's government bureaucracy and union rules, paperwork trumps life I guess.
Unless you have a "duty to respond", you are not required to act.
Even if you are a paramedic with the local fire department, in uniform and walking down the street, unless you are on-duty, you do not have to act. You'd be a massive dick if you didn't, but there is no legal requirement.
Correct. I was an EMT, and I would have been in no legal jeopardy for driving by an accident instead of responding, if I was off duty or outside my response area. (However, I always did stop and help if other responders were not yet on scene or looked like they could use more hands.)
OTOH, my EMT license meant I was not protected by good samaritan laws. As DINKDINK pointed out, if I "helped" beyond the scope of my training, I could have been sued.
Imagine you get to an emergency as a doctor and your patient has a blocked airway, so you perform an improvised tracheostomy, but because you're nervous you cut horizontally instead of vertically and kill the patient. I'm pretty sure as a doctor good intentions are not enough in cases like this.
Of course they are. If you are in that situation, then the patient would die (asphyxiate, probably, since they cannot breathe) without help. The doctor _tried_ to help, in non-optimal circumstances, so as long as the mistake was not intentional or due to negligence, the I believe the law will protect you in most countries.
Remember also that it's not enough to win, you also have to win quickly and cheaply. If that protection isn't reasonably assured, that will tend to bias people towards non-action.
Not that it matters now, but I appreciate you doing that in the face of indifference or outright criticism. If it were me or my family in need, you stepping up would be huge.
As an emergency physician, the first thing I would say if I ever met the doc would be 'well done' for volunteering - it's a hard thing to do. I'm also very glad that it seems the patient did ok.
However, in these kind of situations, I don't think it's in the patient's best interests to avoid diversion. The algorithm should be:
1) sick vs not sick - this person was clearly sick (when an ER docs say someone is 'sick', they usually mean there is a non-trivial probability that they could die in the next 24 hours)
2) Could a delay in critical care treatment lead to a worse outcome for the patient? If so, I would argue that you have to advise diversion to the nearest airport with the required standard of medical care.
That means that it might be ok to advise taking one hour to get to a major city, rather than taking 10 minutes to land at a rural airfield with a tiny hospital nearby - that's a judgement call. The only reason not to divert that I can think of is the cost to the airline, and passenger inconvenience: both of those looks like really bad reasons if the guys gets worse again and dies on the plane, when they might easily have been saved if they had diverted to a nearer airport + hospital.
I agree with another comment regarding the difficulty of IV's, particularly in shocked patient. Ideally, the airline kits would stock intra-osseous needles (needles with a screw that are screwed into the bone of the shin or upper arm using an electric dril). It sounds brutal,but is probably not much more painful than an IV, and takes seconds to do with training. The crew could be trained to use them as part of their first-aid training - the training takes less than an hour, and it would probably make more difference to patient outcome than having adrenaline on board would.
I totally agree about speaking to the pilot in person when you have a critically ill patient - they know (or can figure out) flight times to the various possible diversion airports, you (probably) know better what kind of care the patient needs, and the chances of finding that kind of care in a given city.
> It sounds brutal,but is probably not much more painful than an IV,
With due respect to a doctor, I've had an IV in my own arm and have seen an i-oss deployed on someone a few feet from me. The pain is not comparable, even when it is done by a expert. When it goes wrong and has to be repeated... The pain of i-oss needles has been much discussed in relation to the death penalty. They hurt.
My dentist told me about "pick a friend day" when they practiced injections deep into the jaw. Are there any med schools where students practice with i-oss needles on each other?
It seems trite to say, but the level of discomfort of an unnecessary procedure can greatly exceed that of a necessary one.
I've had a posterior shoulder dislocation, which requires one to be put under to reduce the dislocation. An on-site EMT attempted to reduce it not knowing it was posterior, and the pain (while excruciating) was nothing compared to unnecessary attempts on repeat injuries (anterior dislocations, which do not require anesthetic of any kind).
It's a great idea to introduce professionals to the experience of what their actions might feel like to patients. But they almost certainly are an approximation.
It's not that painful. I self-inserted an IO a few years ago to demonstrate the technique, and it's really comparable to the pain with an IV.
Some patients are so scared that they begin to cry even before the needle touches the skin, and they might subjectively be in great pain, but it's not due to the technique itself.
It will take much more than papers and doctors' testimony to convince me that jambing a piece of metal through a bone, with a drill, isn't painful. The guy beside me wasn't very happy, especially when they had to make that second attempt. Countless carpenters have put nails and staples through soft tissue, and occasionally through bone. That certainly hurts. I also cannot imagine pulling these things out is very fun. An IV can fall out unnoticed. A pin in a bone isn't going anywhere... which I guess is much of their purpose.
If I were the FAA, rather than issue drills to flight attendants, I'd focus on perhaps preventing at-risk people from boarding aircraft in the first place. Or train cabin crews to identify situations before they need the in-flight crash cart.
That probably hurts a lot less than having someone else do it.
I used to take allergy shots as a child, and was greatly surprised to discover how much less it hurt to stick myself than to have a nurse do it - obviously not because of any better technique (I was eight), but rather because, controlling for noxious stimulus, you experience less pain when you're the one applying it to yourself.
I have no real idea why this is, but would guess it might be related on the one hand to having less bandwidth free to experience pain because you need to concentrate on what you're doing, and on the other hand being in control of what's going on to a greater extent than in the case where someone else is doing it to you. I also have no real idea of how to find studies corroborating the anecdote in a more systematic way, but I strongly suspect they exist and hope someone here will do a better job digging them out of PubMed than I have.
In any case, if it's a choice between having an intraosseous needle or dying, well, bring on the drill! I still have a few things left to do in this life. But I've had broken bones, too, and the pain from such an injury is unique and astonishing in a way that leaves me in no doubt of how unpleasant an intraosseous needle would be.
As an intravenous heroin user, I regularly inject into my veins and the pain, while not non-existent, is pretty minimal, unless I cannot access the vein due to thrombosis/collapse. This has always worried me, since it can take me half an hour to place a shot, and in hospital I have had multiple nurses and doctors try to insert a cannula over similar lengths of time. In a life threatening situation I have often wondered what would happen when the EMT could not get access. The existence of IO needles is interesting, therefore, since on IVDA patients they will still work - I just wonder how common a piece of kit they are in UK ambulances and A&E departments?
Off topic and this will come across as preachy - after all who is a random stranger to say how to live your life. But please think about quitting. Things will suck worse for a while but after some time life will get better.
The author says in the comments that they were over 2 hours from any airport, and given that this was halfway into a 17 hour flight, it's a fair guess they were somewhere over the Pacific -- the closest airport might have been on some little island.
I think you make a good point, but sounds like it was a tough call in this instance.
The nearest non-final destination for almost the entire flight is (a) pretty far away from the flight path anyway (b) probably not on anyones list of places they'd hope to end up in a severe medical emergency.
Wow, that path looks like it avoids any kind of land on purpose. Might make sense for legal issues, but I'd be much more comfortable if it went partly over South America or Africa (or close to the shore) in case of trouble with the plane.
That path is a great circle path, it's simply the shortest path across the face of the earth. It's not a flight plan or anything (but, being the shortest path, it's pretty close to what any given flight would follow).
There are actually regulations about how far an airplane can be from land - it's why so many flight paths are similar (US-Scotland overlaps US-Paris, for example).
You can use this website to see the true flight path for the Johannessburg flight: http://dl.fltmaps.com/en [enter Atlanta and Johannesburg as the endpoints]
Good point, I guess I was focussed on the use of adrenaline in cardiac arrest. Yes, it would certainly make a difference in that condition!
Funny, I even have a family member who carries an epipen, I had to give her a dose of adrenaline on a plane once when the chicken curry turned out (unexpectedly) to have nuts in it: we ended up using her own supply, but you're right, it should definitely be stocked!
In a flight that long that you arent that far into, landing early for a diversion requires dumping fuel (for up to an hour on larger aircraft) or risking the lives of the other passengers because the plane is over maximum landing weight.
So it very much is a case by case analysis of balancing the urgency for one passenger with the damage to the environment (dumped fuel) + risk to other passengers for a heavy landing + risks to other passengers from imposing a delay (e.g. Another passenger flying to a surgery).
I just read the wiki about fuel dumping. Based on that it seems less likely that most of the passenger flights have fuel dumping capabilities. Nice read though.
You can always dump it the hard way... fly slow, with the aircraft in a high drag configuration (e.g. flaps out, possibly gear down as well if the speeds allow it) and lots of throttle.
One item that doesn't seem to have entered into anyone's calculations, including the pilot's: the deposit of (ahem) raw sewage on the floor of the plane. If I were a passenger I think I would have wanted the pilot to divert even if the original patient was fully stabilized.
Depending on the choice of diversion locations and capabilities for flight continuation and accomodation, alternatives may have been worse than a carpeted stool sample which could be neutralised with a disinfecting cleanser -- alcohol or bleach, say.
I had a good experience on American Airlines. Volunteered when the announcement was made and had flight attendants that were attentive, helpful, and appreciative of my help. I didn't ask for anything but they thanked me as I left the plane - to my suprise, a couple of days later I got an email saying I was credited 25k points on my frequent flier account. I was quite far away from my seat and didn't realize they kept track of who I was. Was very pleasantly suprised and thought things went well.
304 comments
[ 2.6 ms ] story [ 290 ms ] threadCan you provide some examples of where the FAA is doing poorly due to regulatory capture in regard to safety?
Aside from that, the fact that disturbing other passengers was even remotely a concern in the case where a person is laying on the floor in a medical emergency is sickening.
IMO this suggestion is worth its weight in gold. Imagine what sort of a (valuable) resource could be created out of a databank of information culled from such incidences, growing with time.
Missing were:
- Aspirin
- Nitroglycerin
- Masks
- Fluid cleanup kits
- Airways
I'm assuming the latter three are one-time-use. I'm assuming the former two have expiration dates. Does anyone have info on how often these items might be used aboard flights and/or actually reach their expiration dates?
I'm asking specifically to see how much money is saved by not stocking up and simply assuming that the resulting lawsuits and fines are cheaper than keeping kit stocked. I simply can't attribute this kind of neglect to human error. Someone has to have done the math on this.
http://www.wsj.com/articles/SB954201508530067326
As far as trusting research, you can probably find a good solid reason to distrust any research. Whatever your politics you can probably find something you disagree with about any given funding agency. But in that case we should just revert to our Neanderthal selves and solve all of our problems with clubs. What you should be doing is thinking critically about the introduction and method section And comparing them to the results. If you're in the field, you should know the authors or at least something about them and their methods.
In medical use you don't use pure nitroglycerin; you typically dilute it with other stuff. For example https://en.wikipedia.org/wiki/Nitroglycerin_(drug)#/media/Fi... shows that the IV solution is 40mg of nitroglycerin per 100 mL of solution, or about .04% by mass. I doubt it's very explodey.
Of course even if you want to explode stuff you normally don't use pure nitroglycerin either, because it's _too_ explodey. According to https://en.wikipedia.org/wiki/Dynamite#Form dynamite is 20-60% nitroglycerin nowadays. Still a lot more than 0.04%.
Even at my workplace, which is a much more tame environment, somebody goes around and checks the contents of the first aid kits that are located around the buildings, periodically.
I believe that's referred to as an 'ampoule.'
https://en.wikipedia.org/wiki/Ampoule
But the point remains: Delta initiated a 17h flight with a lethal head flight attendant and a half-stocked medical kit, and have failed to follow-up on the incident. I'd like to see the FAA's incident report.
Aspirin is easy to ask for from other passengers. Same with Nitro : either the patient IS known for angina, and usually has his own, or he's not, and I would not suggest giving nitro "just in case" with the disastrous side effects it can have.
Airways are mostly useless.
[1] https://www.law.cornell.edu/cfr/text/14/part-121/appendix-A
[2] http://www.faa.gov/documentLibrary/media/Advisory_Circular/A...
[3] http://www.sciencedirect.com/science/article/pii/S1477893910...
That being said, I've review your first link, and I'm not impressed.
* Sphygmonanometer = useless. You can't hear fuck. Just taking the pulse is accurate enough in life or death circumstances.
* Stethoscope = almost useless. You can't hear fuck. Might want to use to confirm a suspicion of pneumothorax.
* Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though
* CPR mask. If he's coding in the plane, he's dead.
* Saline solution, 500 cc. As good as two glasses of (holy) water by mouth.
* Protective nonpermeable gloves or equivalent. Good ! Should have at least four of those.
* Analgesic, non-narcotic, tablets, 325 mg = Tylenol. Who cares
* Antihistamine injectable, 50 mg. Why ??? Not more potent than any cheap oral antihistamine.
* Bronchodilator. Good
* Epi. Good. But they should not have two different concentrations to confuse people.
* Lidocaine. Have no idea why anyone would want that.
A systolic pressure is still a useful datapoint. If you want to get a diastolic pressure, see if you can't track down a paramedic (a modern widebody jet isn't much louder than the back of a rig).
> Stethoscope = almost useless. You can't hear fuck.
See above...
> Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though
Most people don't know how to use any of this stuff... That's why they page for a doctor...
> Saline solution, 500 cc. As good as two glasses of (holy) water by mouth.
That's enough to make a difference for a preload sensitive heart failure pt.
> Analgesic, non-narcotic, tablets, 325 mg = Tylenol. Who cares
Someone in pain?
> Lidocaine. Have no idea why anyone would want that.
As an antiarrhythmic, I'm sure. A "hail mary pass" at best, but worth a shot, I guess.
> Most people don't know how to use any of this stuff... That's why they page for a doctor...
In Australia we teach OPAs in Advanced First Aid (not the first aid certification that most people get, but it's a component of the training that workplace first aid officers at any large business must undertake). I'm not sure whether flight attendants are required to undergo that training but it would not be unreasonable to make them.
Of course, as you say, when you can page for a doctor...
Seems like a digital blood one would be fine?
> Antihistamine injectable, 50 mg. Why ??? Not more potent than any cheap oral antihistamine.
No more potent, but faster acting, no? Seems like a good idea for anaphylactic shock?
Not really. Even regular tablets begin to act in 20 min, even faster with the sublingual ones.
> Seems like a good idea for anaphylactic shock?
A very bad one, actually. Some people might want to give an antihistamine first (completely useless in anaphylaxis, by the way), and see what happens, instead of going straight to epi.
When you cannot know the provider's experience, its better to assume for the worse, and give one, and one only choice = EPI.
Anaphylaxis is only treatable with epi and fluids.
Most of the meds have an expiry date of at least a year. Most airlines contract with someone like Banyan who handles supplying and refilling/recertifying the medical kits.
[1] https://www.acep.org/Clinical---Practice-Management/Emergenc...
Given the general markup on anything certified for use in aviation, I suspect the cost is on the order of $1000 / year / plane; my guess is that the EMK had been used and not restocked rather than Delta deliberately understocking medical supplies.
Honestly if a flight is that tight to schedule they should just delay to make sure everything is right.
What other checks might have been missed? Fuel? Flap-setting? Doors are closed?
Cleaning and catering are not legal requirements to ensure the safety of the flight, unlike FAA-mandated equipment.
And maybe there's a periodic recheck, but not every rotation
And critically, before you take off. This is what checklists are for.
Checking for green M&Ms is a lot easier than individually inspecting grounding for all electrical work.
If the med kit's being shorted or overlooked, what else is?
There are well defined SOPs in healthcare for when a sealed kit is opened. It is taken out of service, restocked, QCd, and returned to service. There was no mention of O2 administration in this article but the oxygen kit also requires routine checks and maintenance.
Not sure about the jurisdictional issues given that it was an international flight.
Postscript: https://en.wikipedia.org/wiki/Wrongful_death_claim
After the flight, the airline gave her some duty free goodies on the spot, and a few days later, a one-way business class ticket (I guess to make up for the fact that she sat with this ailing passenger for most of that transoceanic flight).
The article didn't mention what airline. We were flying Singapore Airlines. Service does make a difference.
The article mentioned Delta's risk management folks further down. No worries though; I was wondering the same until I came across the conclusion.
Needless to say, I swore to never fly Delta again after that. As an aside, I had a lot of good experiences whenever I flew Southwest.
The difference in quality when comparing Delta to other airlines is stark enough to me that I will book with them, even if the flight is slightly more expensive or less convenient.
I've generally had better experiences with Southwest than other domestic airlines, and that includes spending the night in an airport because Southwest canceled my flight due to "snow" when nary a flake was seen at the destination.
Delta, I don't even know why they bother publishing a schedule. But I'm sure our relative experiences are completely dependent on specific airports and time of day.
(I have flown Singapore once and the actual flight service was fantastic. But I'm not going to drop my guard over one uneventful data point, and even they haven't pushed back against the molesters)
After taking the Singapore flight, I did joke about flying across the US via Asia just for the better service. But (thankfully) I still have no idea how they handle problems.
I want to believe that there are still businesses that believe in customer service and doing the right thing, and not just for customers who have paid an out-of-touch price. But part of me thinks it's just a matter of time until "market efficiency" gets to them as well.
Edit: And this is what I get for checking HN before I've had my first cup of coffee. Of course you refer to TSA.
My delta flights are almost always on time and are usually a little early. The only big delays I've experienced are because of weather, which all airlines experience. The international meals are fine, as in, I wouldnt pay any more money to get a better meal.
Quality of the seats for delta is good for comfort+, which is in the same price range as regular economy for 'nice airlines'.
Choice of entertainment has been the in-flight system loaded with a bunch of new and popular movies for free, which is good enough for me.
Price is always in competition for the cheapest. There is a reason the airline is so large...
Not sure what you mean about flexibility of carry-on...
They've treated me with respect. They've changed flights for me to have a quicker flight. For the most part.. they've been a heck of a lot better than Delta. I liked NWA, not Delta.
You can see the analysis at http://projects.fivethirtyeight.com/flights/. The explanation, linked to at the top of that page, is at http://fivethirtyeight.com/features/how-we-found-the-fastest....
One of the Scoot flights had some sort of medical emergency. Who knows what happened, but from what I could tell the guy lived. The closest we got to a medical emergency on the United flights was the food.
It's all relative.
Just pray to god that something doesn't go wrong with the flight. If it does.. it's your fault.
With Air France, the breakpoint is making Gold Status in Flying Blue (their frequent flyer scheme). Irregular traveller or Silver or below? If there's a problem with your journey, you own it. Gold and above? If you encounter a hiccup, they own it, and if you show the folks in the business lounge your card they'll go out of their way to fix things for you.
(I was once flying economy on a Delta seat paid for by someone else, and the Delta flight was late enough coming in that I was going to miss my onward connection. But I had Gold Status to fall back on: AF picked up the ball, bumped me a class, and re-routed me on one of their own flights so that I got to my destination, a bit later than planned but the same day, rather than being dumped in Detroit overnight.)
Delta are the best of the "big three" US carriers in terms of customer service, and considerably better than American or United. On their intercontinental services they <em>try</em> to measure up to their non-US carrier alliance partners. Nevertheless, they're in third place relative to KLM or Air France as far as the passenger experience goes.
Relevant bit: I was on an AF trans-Atlantic flight a couple of years ago when a passenger a couple of rows behind me became unwell, and the passenger at the other side of my center aisle turned out to be a doctor on her way to a conference. Rubbernecking discreetly, I observed the cabin crew prioritizing the sick passenger's wellbeing and fetching the doctor the emergency kit and all the support she needed. Anecdata is not data and all that, but what I saw was what you'd hope to see in such a situation, not the fiasco described in the OP.
I will have flown ~100 sectors by the end of this year, to ~45 airports, about 2/3rds long-haul, and all but a handful in J or F. It's not an especially unusual year.
Service varies much more on flights with any one carrier much more than it varies between carriers. Seats vary depending on plane deployed by carrier as much as they vary between airlines. About the only constant is the amenity kits, food, and crew uniforms.
The best service I've had this year was on China Airlines (an ROC carrier, not a PRC carrier), and the worst by far was Asiana (out of South Korea). I have no trouble believing next year I'd have the complete opposite experience.
Service in any industry can be such a variable. I've sat in a restaurant and had outstanding service while watching the couple next to me get terrible service from the same server, culminating in that server accidentally crushing the reading glasses of one of the other diners. I got lucky, they didn't.
In short, in my experience: when booking flights, it's generally worth just ignoring any claims of service excellence or otherwise, and looking at the food and seats you'll get on the specific airplane you'll be flying on. I'd take the Vietnam Airlines 787 Dreamliner with the Zodiac Cirrus seats any day over a Singapore Airlines A330 with the 7811 seats, and if I was flying in Y, I'd be basing my decision purely on a combination of seat dimensions and how new the airframe was.
You have to ask, but I have noticed in recent years that they're quite open about the fact that the program exists, with posters all over most airports.
It can be tricky to get the airline to comply when they deny responsibility. So there are intermediary agencies that do the claim paperwork (and take the legal actions if necessary), taking a small percentage of the reward only if successful.
With the help of an intermediary, I successfully invoked Regulation 261/2004 against KLM after a flight was cancelled due to mechanical failure. The correct reward was ultimately transferred approximately one year after the original flight.
https://www.airhelp.com/en/know-your-rights
This Consumerist article [2] is out of date (2007), but it covers every airline's contract and I believe it remains mostly correct.
[1] https://en.wikipedia.org/wiki/Rule_240 [2] https://consumerist.com/2007/04/06/dont-fly-without-a-copy-o...
Probably worth noting two things here:
1.) In the United States disobeying any of flight crew (including flight attendants) is a federal crime.
2.) The pilot-in-command has the ultimate authority on the flight. If it is a life and death situation and you're getting static from someone, escalate to the PIC. You won't make any friends, but you may save a life.
https://www.reddit.com/r/medicine/comments/50q4fa/yes_there_...
> I'm going to share this story passed on to me by an anesthesiologist. He was on a trip from Canada to to Europe to visit family. He doesn't enjoy flying very much, even less so without anyone he knows to keep him distracted. So he purposefully got a late flight so he could sleep through it. Before boarding he took a few sleeping pills and downed a shot. He's an anesthesiologist, please don't try this at home. He boarded the plane almost last, did up his seat belt, and went nearly straight to sleep. Somewhere over the ocean he was half awake, in a lovely daze of drugs when he heard over the PA. "If there is a doctor on board the plane can they please identify themselves to the flight crew." He thinks about it for a minute, debating what to do and hoping someone else will say something before he has to. Finally he feels like he has no choice. He hits the call button on his seat arm and shortly after, a flight attendant comes to his row. He explains he's a Doctor and he'd like to help if possible. The flight attendant looks at him and says, "Sir, we called the Doctor for you, We've been unable to wake you for the past two hours, and we had to re-seat the passenger beside you because you were drooling on them."
Once, on an SD to NYC red eye in which I take a prescription sleeping pill, the person behind me took the same one and two shots. Scared me but I guess not fatal for him.
Though the bias of my heritage may be showing, I'd strongly suggest going with Qantas. ;)
Actually, no. That isn't what I meant. I flew Delta a month ago and won't be doing so again. Free TV shows and new planes don't compensate for being late or having unfriendly staff members. Never mind this tale...
Lufthansa has a really great kit to deal with agitated passengers, but nothing to deal with pain. Air Canada's kit is pretty worthless. Most airlines fall in between.
That being said, I find the doctor's requirement a bit unrealistic.
Airways ? Common, good luck placing an airway in the cramped flight conditions. A BVM [1] would be more useful.
IVs ... Completely useless, too. First, unless you have a good nurse on board, you wont be able to open up a good vein. Second, you cannot expect airways companies to store enough of IV fluids to make a difference either way. Third, fluids don't save lives unless you have other medications coming in the next few minutes.
The lack of nitro might be a good thing too. Rarely useful, and most likely to result in the passenger passing out/dying than helping anyone.
IV access is useful for administration of several drugs that airlines (in the US anyway) are required to carry. While lots of docs haven't placed an IV since residency, it's not _that_ hard a skill, and it's more than just nurses who start a lot of IVs... A nurse wouldn't even be my first choice in that situation. I'd hope there was a paramedic (or ER nurse) aboard.
As far as IV fluids go... There are plenty of situations where a 250-500mL bolus can make a significant difference. Given the limited diagnostic tools available, I'd give fluids to anything that smelled like an MI (barring any contraindications). For all you know it's an inferior wall MI, and that boost to their preload will help tremendously.
1. Placing an IV in a sick, clamped patient IS difficult, even for experienced ER nurses.
If the patient is not sick, he doesn't need an IV. Its way easier to give drugs directly with a syringe than setting up an IV first.
2. In those situations, I'll just lift the patients legs up to give him that 500 mL bolus, which will take exactly 10 seconds, and not require any skills at all. Bonus points, if I realize he's not fluid-depleted, I'll just them back on floor -- et voilà!.
You're not going to buy 500 mLs by raising someone's legs... 250, maybe. And if they _do_ have a positive response, you'd still hold off on fluids?
I see it as more of a friendly discussion than an argument, but I'll certainly respect your wishes if you'd rather not...
I don't doubt you place IVs in sick patients, I only doubt those IVs make any difference. I am not very familiar with prehospital/EMT literature, and I don't know if any studies have been done, and I certainly don't have any hard data, but I do prefer when paramedics give aspirin, stick in a combi-tube, do basic stuff, and just rush the patient to the hospital instead of wasted time installing and IV on-site, giving fluids and what not. I've seen a great many "heart attacks" treated with fluids in full-blown congestive heart failure. This is anecdotal of course.
Again, for the 500 bolus, I am not aware of any literature to support it as a life-saving measure, and I do believe that if the patient is gonna code without a 500 bolus, he will code with a 500 bolus, too. We're talking of a previously healthy person suddenly dying here -- in those scenario fluid rarely makes a different unless its profuse bleeding, in which case 500 mL is not enough anyways.
The big problem I see with fluids, stethoscopes, IV benadryl, and the like, is that these things are DISTRACTIONS that make people waste their time trying to get a blood pressure when its obvious the patient's in shock (or equally obvious he isn't). A quick, focused history and exam + Epi + AED + Albuterol are the real life-savers and where the emphasis should be on.
I do think you're focusing too much on the dying/not dying distinction. There is a pretty wide range in the middle, and much can be done to help those patients (even if it's only to improve their comfort and reduce anxiety). There are a lot of patients who aren't going to die in the next couple hours who would still benefit from one or more of the interventions available on an aircraft (including a 500cc bolus).
"Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore. 500 mL may indeed be enough (if it's not enough, they're gonna bleed out anyway).
I agree 100% that any provider dealing with a medical emergency on an aircraft (or anywhere else) should be looking at the patient, first and foremost, and not rummaging through a medical kit...
Well, my point is that if they aren’t so bad, they don’t need IV fluids, and you can give them some juice with pretty much the same effect (I expect normal GI function).
> improve their comfort and reduce anxiety
The Lufthansa kit is great in that respect. Lots of Valium and Haldol to make plenty of passengers calm and happy.
> "Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore.
I know. That’s been the usual swinging pendulum through the years : give fluids, don’t give fluids, give just a little bit. I highly doubt all this matter except in a few situations in which the patients is pretty much assured to die on the plane: septic choc, severe bleeding, severe fluids loss (on flight cholera?).
Seriously, I’ve never seen an acutely sick patient who needed 500 of saline now. They either can wait till next week, or need 2L STAT. Now, the situation is completely different with the chronic/elderly patients slowly deteriorating during the course of many hours/days, and arriving in extremis, and being resuscitated with a little bolus. However, you don’t see those patients in planes because they don’t let them fly!
No idea why your posts are getting down-voted. This has been a mutually constructive discussion, in my opinion...
If it's a civil, informed, high level discussion of the topic by experts, I think it's a good discussion for HN. (Just have some sensibility to avoid or explain the very technical details.)
Borrowing a paragraph from the guidelines:
> On-Topic: Anything that good hackers would find interesting. That includes more than hacking and startups. If you had to reduce it to a sentence, the answer might be: anything that gratifies one's intellectual curiosity.
The article states that these items (airways, nitro, ...) were not just her requirements, but rather FAA mandated [1] items that did not appear in the flight's medical kit.
[1] http://www.faa.gov/documentLibrary/media/Advisory_Circular/A...
IV fluids are critical in dehydration--no drugs to follow.
Oh. I wrote the foregoing and then I re-read the part about "a good nurse...open up a good vein" and I realized you are a troll with no medical experience or qualifications. Good one.
If someone was able to walk on a plane, it's unlikely they are severely dehydrated... Plenty of other reasons to carry fluids though.
Unless you have a rare scenario where you've got an anesthesiologist/experienced paramedic, it is completely unrealistic to expect a random doctor to be able to use anything else.
[1] https://en.wikipedia.org/wiki/Combitube
That's not something AEDs can do... An AED can tell you whether or not the patient is in one of two very specific rhythms or not. If the heart is in ventricular fibrillation or ventricular tachycardia, the AED will advise a shock is necessary, otherwise it will report "no shock advised". There are all sorts of nasty cardiac rhythms that an AED will no shock, and there is way to differentiate that.
I remember a friend who became a paramedic. My home state brought in ambulances-for-everybody. If you wanted an ambulance, the dispatcher couldn't say no anymore, you got an ambulance. And for people on low-income cards, those ambulances were free. So my friend got called out to a lot of junk calls (his term: "coughs, colds, and sore holes"), and said that it was a problem for the paramedics because their skills rusted - some paramedics reported only seeing one heart attack in a year, and they have to pause and think what needs to be done again.
Medicine is very much a 'use it or lose it' discipline, at least when it comes to the details.
Hence needing to understand English.
1) This obviously physically incapable person was sitting in exit row initially
2) The F/A of negative utility (the physician probably should have escalated to the pilot, or at least the purser.) That has to be a combination of training and personal incompetence. (Actually, she sounds like the lead flight attendant, which means she should just be fired.)
3) The medical kit. wtf.
Ah -- appears to be Delta, which I'd never fly on a 17h international flight anyway.
Your other critiques are warranted; the lead FA shouldn't have acted the way the story portrays her to, and the medical kit was woefully understocked.
As an aside, do you think that because it's Delta it makes it worse? Why would American or United or Southwest or Allegiant or Silver or any other airline be intrinsically better? This was a lapse in judgement for not having the medical kit stocked, possibly a large one, but one particular organization isn't necessarily worse than any other.
I was also thinking of circumstances that may help explain her behavior. It's difficult, but here's what I came up with (this is merely speculation; I have no idea what may have been going through her mind): 1) She may have been afraid of getting fired if things weren't done exactly by the book, 2) she may have been afraid the airline would be liable for anything the doctor did (and perhaps, by extension, herself), 3) perhaps she knew something about the under-stocked medical supplies and fear or repercussions lead to her (re)actions, 4) she had zero empathy, or 5) simply distrusted the doctors.
In the case of #1, there's not much you can do outside rectifying the company's culture. If employees are so terrified of being fired for assisting, or allowing someone qualified to assist, in an emergency, there's something horribly wrong with that organization.
As for #2, the same may apply with #1, but if the airline is afraid of being liable for an in-flight emergency they shouldn't be in that business, and they certainly shouldn't place the burden of determining liability on the shoulders of a flight attendant when they can afford a legal team.
#3 is a bit of a stretch, but given the discussion above, it seems surprising to me that the medkit would be so sorely under-stocked. Possibly an extension of #2.
#4 is probably the real culprit, although your explanation of stress or life circumstances may be much more likely. Perhaps she was tired and cranky. (Still, not an excuse, but people do strange things when they're tired or ill.)
#5 is also a possibility, but if you're trapped in an aluminum cylinder tens of thousands of feet above the middle of an empty ocean, you really ought to reconsider your career choices if the only people who might be able to save a passenger's life are the very people you don't trust.
There's another point I read above that I agree with. If the flight attendants aren't letting you do what you can to help a passenger, perhaps getting the pilot-in-command to assess the situation might be a better option if time and circumstance allow. They likely don't want to be held responsible for someone dying on their aircraft, and they probably have experience with in-flight passenger-related emergencies. They can instruct the flight crew on an appropriate course of action, even if that action is to simply stay out of the way.
Oh, one other possibility is that the head flight attendant seemed overly preoccupied with other passengers' comfort. In a situation like that where someone might die, passenger's comfort probably shouldn't enter the equation. Sure, you don't want to endanger them, and maybe you don't want to inconvenience them (much), but if it's a life or death situation... give me a break!
Gosh, this post is a bit ranty. Sorry about that.
Though information-system-related service failures are generally increasing among carriers, if I'm recalling the coverage of Delta's outage correctly.
Still remains a good flag to raise.
"Delta, Delta, Delta, can I Help ya, help ya help ya?"
...
There was another doctor on the flight who volunteered his help. The two doctors liased and decided that my wife's training and skills were more relevant to the situation.
My wife was thanked and given symbolic remuneration ( which she will probably never bother to cash in ). She felt valued and will probably be willing to help again if in a similar situation with Singapore Airlines.
(My lifeguard certification has expired now)
For example, I was hiking (or tramping as it's called in NZ) with a foreign friend visiting. They were unlucky and broke an ankle. We called the police, a helicopter was dispatched, picked her up, brought her to the hospital and fixed the ankle up. Zero cost to her.
One of the many upsides is that it's quite difficult to sue for personal injuries in NZ - as ACC basically covers the costs (or at least, that's my understanding anyway)
Sure there are downsides to any system, and some people do fall through the cracks of ACC, but on balance, I think it's one of the best things about NZ (besides the nice relaxed atmosphere and killer scenery)
Suppose person B was a surgeon and lost their dominant arm/hand. Is that loss of income covered by ACC, via suing person A, or "too bad, so sad"?
There are also cities that charge fees for sending fire trucks to vehicle fires and accidents if non-residents are involved.
"Despite the fact that no-one in the UK has been sued for providing first aid, it is a common fear that we’re regularly asked about." - Joe Mulligan, British Red Cross, 2015
"Although potential legal liability arising from good samaritan acts is something about which we're regularly asked by healthcare professionals, in practice we have never encountered a UK doctor, paramedic, nurse or other healthcare professional being sued after providing this kind of emergency assistance." - Shoosmiths, a major UK law firm that I have heard described as "Ambulance Chasers".
It seems to be common in the US for people to get sued for helping. Not so much in the UK, and following the 2105 SARAH act, which creates additional protections for such people, now even less likely.
They replied that they would of course pay if she would reimburse them for the cost of the flight - enclosing a bill for £10,000. Answer came there none.
In this day and age, if we cannot find any UK instance of someone being sued for providing first aid, I think we can label it "urban myth". Maybe some obsessive HN reader will find one for us :)
> The most important thing to remember is that to date, no one in the UK has ever been sued for administering life-saving First Aid.
But also:
http://www.sa-cni.org.uk/uploads/4/9/5/4/4954631/the_legal_s...
> There have been some cases in the UK where a claim has been brought against a ‘rescuer’, although there have been no reported cases in court where a casualty has successfully sued someone.
> • Out-of-court settlements are more common and go unreported, so it is likely that some claims against a rescuer have been ‘successful’, but these will have gone unreported.
> • It should be noted that even if a first aider is successful in defending himself against a claim, it is unlikely that he will be able to recover the full legal costs in defending himself. In civil litigation, it is unusual for a court to award the successful party more than 80% of their costs and it’s possible that an accusation can cost tens of thousands of pounds to defend.
> • In some instances it can be less expensive to settle a claim out of court than to defend it. It is not uncommon for insurers to settle claims even when the defendant was innocent, as this is the least expensive and least risky option.
http://medicaleconomics.modernmedicine.com/medical-economics...
Source (only in German): https://de.wikipedia.org/wiki/Erste_Hilfe#Rechtliche_Situati...
From a actual lawsuit: Someone without the proper training started an IV which later caused sepsis and death. Since the patient was admitted to an hospital it was not clear if an improply placed IV caused the death or an improper care in the hospital.
In nearly all the situations the staff in the building told the sick people outside to call 911 to get transported inside two feet inside the door.
The hospital workers and by that I mean nurses and doctors were unwilling to help even though the people outside were very ill.
http://www.cbc.ca/news/health/hospital-er-call-help-1.368630...
I ask because I once walked my relative into an ER and they were attended to, no problem.
I can understand some concerns of staff but to flat out refuse seems to go against the ethics of being in the medical trade.
I also suspect it's government bureaucracy and union rules, paperwork trumps life I guess.
Even if you are a paramedic with the local fire department, in uniform and walking down the street, unless you are on-duty, you do not have to act. You'd be a massive dick if you didn't, but there is no legal requirement.
Therefore no normal law should be able to break your cover. As long as there's no doubt on your good intentions.
When you're lifeguarding you have that duty of care. When you're a passenger on a flight you don't.
(I think once you start providing assistance you need to keep doing it)
(Source: spend way too much time flying back and forth between Doha and the US)
However, in these kind of situations, I don't think it's in the patient's best interests to avoid diversion. The algorithm should be: 1) sick vs not sick - this person was clearly sick (when an ER docs say someone is 'sick', they usually mean there is a non-trivial probability that they could die in the next 24 hours) 2) Could a delay in critical care treatment lead to a worse outcome for the patient? If so, I would argue that you have to advise diversion to the nearest airport with the required standard of medical care.
That means that it might be ok to advise taking one hour to get to a major city, rather than taking 10 minutes to land at a rural airfield with a tiny hospital nearby - that's a judgement call. The only reason not to divert that I can think of is the cost to the airline, and passenger inconvenience: both of those looks like really bad reasons if the guys gets worse again and dies on the plane, when they might easily have been saved if they had diverted to a nearer airport + hospital.
I agree with another comment regarding the difficulty of IV's, particularly in shocked patient. Ideally, the airline kits would stock intra-osseous needles (needles with a screw that are screwed into the bone of the shin or upper arm using an electric dril). It sounds brutal,but is probably not much more painful than an IV, and takes seconds to do with training. The crew could be trained to use them as part of their first-aid training - the training takes less than an hour, and it would probably make more difference to patient outcome than having adrenaline on board would.
I totally agree about speaking to the pilot in person when you have a critically ill patient - they know (or can figure out) flight times to the various possible diversion airports, you (probably) know better what kind of care the patient needs, and the chances of finding that kind of care in a given city.
With due respect to a doctor, I've had an IV in my own arm and have seen an i-oss deployed on someone a few feet from me. The pain is not comparable, even when it is done by a expert. When it goes wrong and has to be repeated... The pain of i-oss needles has been much discussed in relation to the death penalty. They hurt.
My dentist told me about "pick a friend day" when they practiced injections deep into the jaw. Are there any med schools where students practice with i-oss needles on each other?
I've had a posterior shoulder dislocation, which requires one to be put under to reduce the dislocation. An on-site EMT attempted to reduce it not knowing it was posterior, and the pain (while excruciating) was nothing compared to unnecessary attempts on repeat injuries (anterior dislocations, which do not require anesthetic of any kind).
It's a great idea to introduce professionals to the experience of what their actions might feel like to patients. But they almost certainly are an approximation.
Some patients are so scared that they begin to cry even before the needle touches the skin, and they might subjectively be in great pain, but it's not due to the technique itself.
You can read a little bit more about the pain here: http://sci-hub.cc/10.1177/1460408611430175
If I were the FAA, rather than issue drills to flight attendants, I'd focus on perhaps preventing at-risk people from boarding aircraft in the first place. Or train cabin crews to identify situations before they need the in-flight crash cart.
I used to take allergy shots as a child, and was greatly surprised to discover how much less it hurt to stick myself than to have a nurse do it - obviously not because of any better technique (I was eight), but rather because, controlling for noxious stimulus, you experience less pain when you're the one applying it to yourself.
I have no real idea why this is, but would guess it might be related on the one hand to having less bandwidth free to experience pain because you need to concentrate on what you're doing, and on the other hand being in control of what's going on to a greater extent than in the case where someone else is doing it to you. I also have no real idea of how to find studies corroborating the anecdote in a more systematic way, but I strongly suspect they exist and hope someone here will do a better job digging them out of PubMed than I have.
In any case, if it's a choice between having an intraosseous needle or dying, well, bring on the drill! I still have a few things left to do in this life. But I've had broken bones, too, and the pain from such an injury is unique and astonishing in a way that leaves me in no doubt of how unpleasant an intraosseous needle would be.
I think you make a good point, but sounds like it was a tough call in this instance.
The nearest non-final destination for almost the entire flight is (a) pretty far away from the flight path anyway (b) probably not on anyones list of places they'd hope to end up in a severe medical emergency.
http://www.gcmap.com/faq/intro#definegc
Also, because it's so far from land, there are special procedures that need to be in place, see eg. ETOPS.
You can use this website to see the true flight path for the Johannessburg flight: http://dl.fltmaps.com/en [enter Atlanta and Johannesburg as the endpoints]
EDIT: Can't find an FAA source about distances to airport, but here's a related Wikipedia page. https://en.wikipedia.org/wiki/ETOPS
This is a true flight path, and it's much closer to the great circle: https://www.flightradar24.com/DAL200/ae190b1
Funny, I even have a family member who carries an epipen, I had to give her a dose of adrenaline on a plane once when the chicken curry turned out (unexpectedly) to have nuts in it: we ended up using her own supply, but you're right, it should definitely be stocked!
So it very much is a case by case analysis of balancing the urgency for one passenger with the damage to the environment (dumped fuel) + risk to other passengers for a heavy landing + risks to other passengers from imposing a delay (e.g. Another passenger flying to a surgery).
Lufthansa at least has a formal program to identify doctors between their passengers: http://www.lufthansa.com/us/en/Doctor-on-board