Anesthesiologists have to be experts at crisis management. Fortunately, I was able to take a special course in Anesthesia Crisis Resource Management at Stanford over a year ago, before completing my residency. I have never been as grateful for this background as when I was called upon recently to resuscitate an elderly woman on an airplane. Perhaps my experience will be helpful to others.
I was flying from Salt Lake City to Atlanta on a Delta L-1011. We had a smooth take-off and had been in the air for about 30 minutes when a woman two seats in front of me called for help. The woman next to her had become apneic and had slumped in her seat. I found the woman pulseless, apneic and cyanotic. She had no medical alert bracelet and was traveling alone. With the help of the flight attendant, I dragged the woman from her seat, placed her in the aisle and began CPR. I asked for other volunteers who knew CPR. Five volunteers stepped forward, including an emergency room nurse. I assigned the passengers to perform CPR, the nurse to help with medications, and the flight attendants to act as “runners” for additional supplies. One flight attendant alerted the flight deck crew to the situation, and they began an emergency descent into Denver International Airport. I asked another flight attendant for supplemental oxygen and any available medical supplies.
The patient had a clear airway and was easy to ventilate with positive pressure delivered mouth to mouth. She made no spontaneous respiratory effort. I instructed the volunteers on effective CPR and turned over ventilation and chest compressions to them. A mask with a filter was provided for delivery of ventilation. I had to ask again for supplemental oxygen. (The emergency oxygen masks that appear automatically in case of cabin depressurization cannot be used for this purpose). The flight attendant brought me a nearly empty E-cylinder of oxygen and some oxygen tubing. I adjusted the flow to 15 liters, and placed the tubing in the corner of the woman’s mouth to provide an oxygen-enriched mixture of inspiratory gas. I asked for another oxygen tank which was provided in less than two minutes by the flight attendant. No defibrillator or Ambu bag for ventilation was available.
I monitored the adequacy of ventilation and chest compressions and had the CPR volunteers take turns, to avoid fatigue within the group. We were lucky that the patient had a clear airway and was easy to ventilate throughout. No mechanical suction devices were available.
A flight attendant brought the emergency medical kit (which is kept in the cockpit, is more advanced than the first aid kit kept in the cabin, and can only be used by a licensed physician) which contained two ampules of epinephrine but no other resuscitation medications. (The full contents of the first aid and emergency medical kits are described in Friedman AL: Emergency kits on airplanes. NEJM 330:439, 1994.) The ER nurse drew up the epinephrine in a three ml syringe. I considered my options for route of administration. There was no intravenous cannula or tubing, no flush solution, and no endotracheal tube. Because of the limited space in the aisle, I had limited access to the neck veins and I did not want to interfere with ventilation. I chose to give the drug via the right subclavian vein. The drug was quickly and easily administered. Colleagues have later suggested that other options might have been trans-tracheal administration via the cricothyroid membrane or injection into the tongue. Still, the patient was pulseless and there was no defibrillator.
After about 25 minutes of continuous resuscitation the plane landed. The paramedics boarded the plane with monitors, medications, a defibrillator, IV supplies and an endotracheal tube. The ECG tracing revealed coarse ventricular fibrillation. An IV was started and the patient was intubated while paddles were readied. The patient converted to sinus tachycardia with a palpable pulse after countershocks. The systolic pressure was greater than 100 mmHg. The patient then went into pulseless ventricular tachycardia, but was quickly countershocked again into sinus rhythm. A lidocaine bolus was given and a lidocaine infusion was started. The patient remained in sinus rhythm during transport to the helicopter. Prior to being loaded into the helicopter, she opened her eyes and reached for her endotracheal tube. The patient’s daughter called me several days later to thank me and to let me know that, although her mother was still critically ill, she was glad to have her alive. I do not know the long-term clinical outcome.
People have asked what Delta Airlines did for me for treating a major in-flight medical emergency and preventing an immediate death. Well, I arrived late to my final destination of Washington, D.C., and my bags were lost. Delta did send me a thank you note. Others have since reported to me having received a gift (for example, a bottle of champagne) from an airline for in-flight medical treatment. But, as it is with lots of things in anesthesia these days, the greatest reward I received is the satisfaction of a job well done. I’d like to thank to my mentors and teachers in crisis management from Stanford. I am glad you were there “with” me in spirit.
Phoebe Leith, M.D., Washington. D.C.