5 ms·

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

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.

sandworm101 10y ago
> 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?
- eyelidlessness 10y ago
  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.
- paviva 10y ago
  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. You can read a little bit more about the pain here: http://sci-hub.cc/10.1177/1460408611430175 http://sci-hub.cc/10.1177/1460408611430175
  - sandworm101 10y ago
    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.
    - maxerickson 10y ago
      It sounds like your best bet for convincing yourself is doing like the GP poster and self-inserting one.
ScottBurson 10y ago
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.
- cperciva 10y ago
  The only flight Delta operates of this length is between Atlanta and Johannesburg, so they would have been over the Atlantic.
  - mseebach 10y ago
    http://www.gcmap.com/mapui?P=ATL-JNB http://www.gcmap.com/mapui?P=ATL-JNB 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.
    - lucb1e 10y ago
      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.
      - mseebach 10y ago
        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). http://www.gcmap.com/faq/intro#definegc 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.
      - ejstronge 10y ago
JupiterMoon 10y ago
On adrenaline. This is presumably in there for anaphylactic shock - in which case it will make a huge difference right?
- ghufran_syed 10y ago
  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!
hueving 10y ago
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).
- sitkack 10y ago
  https://en.wikipedia.org/wiki/Fuel_dumping https://en.wikipedia.org/wiki/Fuel_dumping
- gizmodo59 10y ago
  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.
  - TylerE 10y ago
    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.
lisper 10y ago
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.
- dredmorbius 10y ago
  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.

sandworm101 10y ago

> 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?

eyelidlessness 10y ago
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.
paviva 10y ago
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. You can read a little bit more about the pain here: http://sci-hub.cc/10.1177/1460408611430175 http://sci-hub.cc/10.1177/1460408611430175
- sandworm101 10y ago
  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.
  - maxerickson 10y ago
    It sounds like your best bet for convincing yourself is doing like the GP poster and self-inserting one.

ScottBurson 10y ago

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.

cperciva 10y ago
The only flight Delta operates of this length is between Atlanta and Johannesburg, so they would have been over the Atlantic.
- mseebach 10y ago
  http://www.gcmap.com/mapui?P=ATL-JNB http://www.gcmap.com/mapui?P=ATL-JNB 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.
  - lucb1e 10y ago
    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.
    - mseebach 10y ago
      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). http://www.gcmap.com/faq/intro#definegc 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.
    - ejstronge 10y ago

JupiterMoon 10y ago

On adrenaline. This is presumably in there for anaphylactic shock - in which case it will make a huge difference right?

ghufran_syed 10y ago
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!

hueving 10y ago

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).

sitkack 10y ago
https://en.wikipedia.org/wiki/Fuel_dumping https://en.wikipedia.org/wiki/Fuel_dumping
gizmodo59 10y ago
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.
- TylerE 10y ago
  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.

lisper 10y ago

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.

dredmorbius 10y ago
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.