Saturday, August 29, 2009

First responder at 35,000 feet: The value of a good book

A few years back, I took a flight to Philadelphia to interview for the Safe Medication Management fellowship at the Institute for Safe Medication Practices. I was using the travel time to skim through "Medication Errors" (2nd edition), a book written by people I would meet the next day. Seated in an aisle seat, I had the iPod going full tilt, a distraction that both blocked airplane sounds and helped settle the butterflies in my stomach.

I may have been aware of some peripheral commotion but didn't really pay attention until a flight attendant, who had apparently noticed the title of the large textbook on my tray table, tapped me and asked, "Are you a medical professional? There's a gentleman on the plane who thinks he may be having a stroke. Are you willing to help him?"

I'm a perinatal nurse. Placentas. Labor. Birth. High-stakes vascular events in my clinical world are nearly always preceded by the diagnosis "pre-eclampsia," something a male simply cannot get. "Sure," I said, struggling to put on my shoes. "Stroke, stroke," I thought as I lumbered toward the designated seat. I think I should say something like, "What makes you think you are having a stroke, sir? Does something feel numb? Are you having trouble moving?"

When I reached the gentleman, however, talking was out of the question. He was cold, clammy, unresponsive, with a thready, bradycardic pulse. Where I live, people call this condition, "fixin' to die."

The flight attendants, working from a checklist, had notified the captain and sought help from medical personnel amongst the passengers. Communication with medical experts on the ground were being facilitated (loudly, with assessments and observations called from one flight attendant, stationed near our passenger-turned-patient, to another flight attendant, stationed at the now-open cock-pit door).

We apply oxygen by tight face mask. The first responders are three: me, an ex-Army corpsman, and someone who declines to be identified, although he is able to get oxygen flowing. (Something that's useful to know if you're a first responder while in flight: they don't drop the oxygen from the over-seat compartments. That's for emergencies that impact the oxygenation of everyone on the plane. Your team will be given a portable oxygen tank, and it may be helpful to remember "lefty-loosey, right-tighty" once you locate the on-off valve.)

"I have an AED, ma'am, I have an AED," the flight attendant repeated, rather persistently, pushing the box in my direction. Still feeling a pulse, but he's grayer, and the pulse rate is lowering. "Think, think," I thought. (The image of defibrillating a large man, mid-cabin just couldn't take hold in my mind. All I could picture was the impossibility of saying, "I'm clear, you're clear, we're all clear," when 5 rows of passengers are sitting in the metal chairs this man is going to touch if we lay him out here.)

Meanwhile, there's more flight attendant-to-cockpit communication (okay, yelling) as preparations for flight diversion are considered in light of the passenger's grave condition. "Does he have any medical conditions? Heart disease, diabetes,....." came the question as the flight attendant moved down the checklist. His traveling companion looks up, gasps, and says, "He has diabetes." Sweeter words had never been heard. This was something a perinatal nurse could do something with.

"Sugar," I said to the flight attendant. "Bring me sugar from your cart." The gentleman was unresponsive but the table sugar, which I applied (er, jammed) rather unceremoniously under his tongue and moistened with a few drops of water made him come around right quick. (Something else that's helpful to know if you're a mid-flight first responder is that flight attendants have a checklist and their efforts work in tandem with any assistance you can offer. The checklist helped to get useful facts, like this gentleman's diabetes, uncovered rapidly. This information would have been used by the medical professionals on the ground if I hadn't been able to put the pieces together and initiate corrective action. The take-away lesson? Help may not be as far away as it initially feels at 35,000 feet.)

It turned out that the passenger was a relatively new diabetic, and the day of traveling had put him off of his normal eating routine (although he had remembered to take his medications that morning). We continued on to Philly, with the gentleman refusing the EMS care that met him at the gate. I waved to him at the baggage claim area, and told his companions that he really should seek follow-up care immediately, something I very much doubt he did.

At my interview at ISMP the next day, I was asked if I had had a good flight. Of course, I told the story about the book and the in-flight interventions, at which point one of the staff members said to Mike Cohen, ISMP's president, now my mentor and friend, "See Mike, the book saved another life." Probably true. (I learned a great deal of life-saving information when I actually read the book, and I highly endorse it, both for its intended purpose and any adjunct benefit it affords the traveling public.)

May you always have a good book and fly the friendly skies!

Materials in this post first appeared on my Medscape blog, "On Your Meds: Straight Talk about Medication Safety" in April 2009.

1 comment:

WWWebb said...

At "the Grady's" this would have been known as a condition called "low sick", but I like your "fixin' to die" as well and am real surprised I've never heard it before.

I still amuse my Pennsylvania co-workers when I emit Southernisms like that.

And,on teleconferences, it allows me to think rings around those who do not know me and make the smug assumpion that a bit of a Southern drawl automatically infers slowness of mind.

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