Wednesday, July 4, 2007

Do we land this plane or not? Part 2

When we left off we were considering the case of a woman who had just suffered an apparent in-flight tonic-clonic (grand mal) seizure; the flight crew needs an immediate decision on whether to make an emergency landing or not. At this point, most of the medical students in attendance at the talk said that they would not recommend diverting the flight.

In this case, the doctor decided to land. He said that the plane began descending almost immediately, and much faster than during a normal landing. As the descent started, the patient's condition was improving. She continued to improve during landing and taxiing, and wound up walking off the plane. The pilot thanked the doctor for his help, and the flight was turned around and airborne again in an hour, minimizing the inconvenience to the passengers. The doctor admitted that it was a little awkward to see the patient walk off the plane, but everyone was relieved that she was all right and that in the same situation again he would have made the same decision. (By the way, kudos to commenter Bethany for correctly diagnosing the patient's post-ictal state.)

At this point during the talk a resident spoke up to say that he had been in the same situation once. In this case a woman developed a severe headache, a symptom that could be relatively benign or could indicate a life-threatening condition. In this case the resident evaluated the woman and decided not to recommend a diversion. He also spoke with the woman's daughter (who he described as "hot" but denied that this had anything to do with his decision not to interrupt the flight).

A 2002 article in the journal Neurology concluded that "[n]eurologic symptoms are the most common medical complaint requiring air-to-ground medical support and are second only to cardiovascular problems for emergency diversions and their resultant costs to the US airline industry. Adding antiepileptic drugs to the onboard medical kit and greater emergency medical training for in-flight personnel could potentially reduce the number of diversions for in-flight neurologic incidents."

The Federal Aviation Administration states that "[c]ardiac emergencies account for the most diversions, followed in order by neurological, respiratory, and vasovagal cases. The diversion rate for cardiac cases is the highest, followed in order by neurological, obstetrical, vascular, and respiratory emergencies. Physicians responded to IMEs [inflight medical emergencies] approximately half of the time, while nurses respond about a third of the time. The medical kit was used in approximately half of IMEs. The stethoscope and sphygmomanometer were used over 700 of the time the kit was used, and nitroglycerin was used about five times as often as epinephrine or diphenhydramine."

Anecdotally, Paul Farmer once said that a request is made for a doctor on about one in every eighteen flights that he takes. Remind me to pack my stethoscope in my carry-on the next time I fly....


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