WEBVTT 00:00.031 --> 00:02.434 [SPEAKER_02]: We were flying back from Austria. 00:02.614 --> 00:05.938 [SPEAKER_02]: It was a nine hour flight we had settled in. 00:05.978 --> 00:08.281 [SPEAKER_02]: The flight was actually somewhat empty. 00:08.321 --> 00:13.828 [SPEAKER_02]: We were about to get lunch and I heard someone choking behind me or at least that's what I thought. 00:14.469 --> 00:28.806 [SPEAKER_02]: I looked behind me and actually the woman seated right behind me was having a seizure and she was blue and bleeding from the mouth and full tonic tonic seizure. 00:28.786 --> 00:32.591 [SPEAKER_02]: and actually was choking, she had vomited and was aspirating. 00:33.292 --> 00:35.695 [SPEAKER_02]: She's blue, and so I was trying to feel for a pulse. 00:36.075 --> 00:40.961 [SPEAKER_02]: And I couldn't feel a pulse, a cold for a doctor, and cold for help. 00:40.981 --> 00:43.024 [SPEAKER_02]: I didn't get the like, is there a doctor on board? 00:43.164 --> 00:44.906 [SPEAKER_02]: No, no, I did not. 00:45.107 --> 00:56.481 [SPEAKER_02]: Well, you know, obviously I am a doctor, which is great, but it was pretty clear to me, pretty early that 00:56.461 --> 01:05.252 [SPEAKER_02]: And at that point, everyone around is looking at us and I was trying to pull her into the aisle thinking I was going to need to start CPR in the aisles. 01:05.352 --> 01:08.676 [SPEAKER_02]: So again, just kind of sticking immediately, I need to help with this. 01:09.437 --> 01:16.326 [SPEAKER_02]: That did hurt me though, because the flight attendants came up with their actually really impressive 01:16.306 --> 01:22.054 [SPEAKER_02]: hack of medications, but also assumed I was not a doctor and tried to push the out of the way. 01:22.675 --> 01:27.842 [SPEAKER_02]: So at the point I had to clarify, I am in fact a doctor, I'm looking for more help. 01:27.862 --> 01:36.454 [SPEAKER_02]: And it was pretty lucky because another doctor on the flight was an emergency department physician and so she showed up to see what was going on. 01:36.474 --> 01:44.625 [SPEAKER_02]: And at this point, I still hadn't found a 01:45.668 --> 01:52.975 [SPEAKER_04]: Yes, thank goodness the patient's seizure broke and that was great news indeed, but the story did not end there. 01:53.315 --> 01:57.019 [SPEAKER_04]: Welcome to a special core I'm episode on In-flight emergencies. 01:57.679 --> 01:59.701 [SPEAKER_04]: I'm joined by the wonderful doctor Sophie Gomez. 02:00.542 --> 02:01.803 [SPEAKER_01]: I have everyone, I'm Sophie. 02:02.504 --> 02:14.815 [SPEAKER_01]: In-flight emergencies is a topic that I learned so much about talking to pilots from airlines about In-flight emergencies, people of built careers in osteoenvironments and of course doctors who have 02:15.908 --> 02:17.111 [SPEAKER_02]: Hi, I'm Aaron Truett. 02:17.612 --> 02:22.222 [SPEAKER_02]: I am a nocturnist at Beth Israel Deaconess Medical Center in Boston, Massachusetts. 02:23.265 --> 02:29.158 [SPEAKER_01]: And I thought the best way to go through the learning points would be to listen to Aaron's wild story and use it as a jumping off point. 02:29.763 --> 02:31.105 [SPEAKER_04]: Yes, it is so good. 02:31.125 --> 02:39.576 [SPEAKER_04]: I gotta say Sophie, thank you so much for doing this because I would always sweat when I'd hear is there a doctor on board and maybe after this, I will sweat a little bit less. 02:40.537 --> 02:41.738 [SPEAKER_04]: So back to our story. 02:41.758 --> 02:49.408 [SPEAKER_04]: So at this point, the woman sees your broke and then Erin has to think, what does she do now? 02:49.388 --> 02:51.252 [SPEAKER_04]: She was completely post-ictal. 02:51.393 --> 02:56.304 [SPEAKER_02]: I put my husband in charge of trying to talk to her because her brain cells weren't holding hands yet. 02:56.344 --> 03:05.946 [SPEAKER_02]: We were trying to find emergency contacts in her phone, and so me and this other doctor were trying to go through what can we do in this moment. 03:05.926 --> 03:27.013 [SPEAKER_02]: their pack of medications was great, but it was all in German, medications would say they're European brand name and then their generic name, but they weren't the standard medications that I was looking for, and I didn't recognize a lot of them and the, like, alpha, the tizing of them was very different because of the language. 03:27.574 --> 03:34.363 [SPEAKER_02]: So I'm looking through their packs and I asked them if they had Wi-Fi, they don't have Wi-Fi on this flight, 03:34.681 --> 03:40.849 [SPEAKER_02]: There's actually pretty comprehensive, but I couldn't find out of it, which is the first thing I was trying to look for. 03:40.910 --> 03:47.358 [SPEAKER_02]: So they had days of pant tablets, which I thought would be useful, but we couldn't find them. 03:47.919 --> 04:01.077 [SPEAKER_02]: Instead, what we could find was actually like rectal days of pant, just know, well, you know, there's like 20-something-year-old woman that I'm going to be like in the district rectal days of pant here on this airplane right now, unless it's, you know, 04:01.462 --> 04:02.364 [SPEAKER_02]: really dire. 04:02.384 --> 04:09.201 [SPEAKER_02]: I had decided with the rectal dies if he had like if she needed something, you know, it was just going to go under her time. 04:09.282 --> 04:14.374 [SPEAKER_02]: Like I, it was like figurative, it would absorb if I had to give it them. 04:14.936 --> 04:15.457 [SPEAKER_02]: That's a good word. 04:15.477 --> 04:16.079 [SPEAKER_02]: I'm using question. 04:16.139 --> 04:19.487 [SPEAKER_02]: Can you use would take something, rectal. 04:19.467 --> 04:22.511 [SPEAKER_02]: I mean, that makes it, it's like capillary beds. 04:22.531 --> 04:26.255 [SPEAKER_02]: I think I would milk the same assumption in the air without wife, I think. 04:26.275 --> 04:30.921 [SPEAKER_02]: Thinking right, like Lucas membrane, like I couldn't imagine how different it would be. 04:31.461 --> 04:37.008 [SPEAKER_02]: I'm trying to go through things like, okay, seizure, like, what are our ABCs? 04:37.589 --> 04:38.730 [SPEAKER_02]: Can't find a pulse ox. 04:38.750 --> 04:41.914 [SPEAKER_02]: I have no idea what she's oxygenating, but she was talking to us. 04:42.772 --> 04:47.296 [SPEAKER_04]: Okay, let's pause here and talk about one of the resources that all airlines carry. 04:47.316 --> 04:52.522 [SPEAKER_04]: This is what we would find in the emergency medical kit or you might hear the term EMK thrown around. 04:53.523 --> 05:03.252 [SPEAKER_01]: Yeah, so we sat down with Dr. Melissa Madison, who has gone through her own inflate medical emergencies and she's gone on to write about the EMK or emergency medical kit. 05:04.333 --> 05:06.135 [SPEAKER_03]: My name is Dr. Melissa Madison. 05:06.195 --> 05:11.260 [SPEAKER_03]: I'm the chief of hospital medicine at Massachusetts 05:11.662 --> 05:16.108 [SPEAKER_03]: The contents of the emergency medical kit are defined by the FAA. 05:16.148 --> 05:19.372 [SPEAKER_03]: And I don't think they have been defined or redefined since 2006. 05:19.593 --> 05:25.541 [SPEAKER_03]: So you will not find Narcan in the emergency medical kit. 05:26.402 --> 05:28.004 [SPEAKER_03]: You might say, why the heck not? 05:28.024 --> 05:29.346 [SPEAKER_03]: Like you can buy it over the counter. 05:29.406 --> 05:30.868 [SPEAKER_03]: Like why would we not have that there? 05:30.848 --> 05:33.131 [SPEAKER_03]: Well, 2006 was the different era. 05:33.511 --> 05:38.878 [SPEAKER_03]: Now, that's not to say that you know necessarily find Narcan on the plane. 05:39.419 --> 05:43.884 [SPEAKER_03]: So the airline is required to carry certain things. 05:44.605 --> 05:47.669 [SPEAKER_03]: That's the EMK, the emergency medical kit. 05:47.689 --> 05:53.516 [SPEAKER_03]: The airline then has up to its discretion, the ability to augment that kit. 05:54.297 --> 06:00.585 [SPEAKER_03]: And some airlines do very much augment the kit, 06:01.308 --> 06:21.683 [SPEAKER_03]: One of our colleagues years ago, I remember was flying Japan Airlines from Japan to Boston and had to respond to an emergency and the kit that Japan Airlines had had pressers, it had fluid, it had all kinds of stuff. 06:21.703 --> 06:24.868 [SPEAKER_04]: And there's quite a bit of variability on different airlines. 06:25.523 --> 06:28.748 [SPEAKER_01]: And that makes it hard to prepare for an inflied emergency from the ground. 06:29.409 --> 06:40.885 [SPEAKER_01]: If it's an American-based flight, you'll have at least a manual blood pressure cuff, one of those flimsy yellow-sethas-gopes, equipment for CPR, and just one IV-start kit. 06:41.606 --> 06:53.083 [SPEAKER_01]: Medication-wise, you'll have a 500-CC bullet, anti-histamines, an epipen, nitroglycerin, and aspirin for ACS, D50, and somehow 06:53.637 --> 07:00.571 [SPEAKER_01]: But again, these requirement minimums are for U.S. based flights only, and the kit organization is not standardized at all. 07:01.152 --> 07:03.297 [SPEAKER_04]: Yes, thank you for that, Rodin, of what to expect. 07:03.838 --> 07:11.173 [SPEAKER_04]: So back to our patient who had the seizure, now comes the next important question that makes most of us pause. 07:12.267 --> 07:13.409 [SPEAKER_02]: her color was back. 07:13.469 --> 07:17.677 [SPEAKER_02]: She looked much better and eventually she was able to tell us she had a seizure disorder. 07:18.378 --> 07:28.055 [SPEAKER_02]: But her last seizure had been like four years ago, all in the context of drinking alcohol, which she hadn't had and she took limit delivery day and she had her pack of limit delivery. 07:28.075 --> 07:29.197 [SPEAKER_02]: We were able to find it. 07:29.698 --> 07:32.082 [SPEAKER_02]: We gave her an extra dose of it. 07:32.062 --> 07:35.209 [SPEAKER_02]: I was sitting there trying to use this glucometer that they had. 07:35.249 --> 07:39.578 [SPEAKER_02]: And I kept just getting error, you know, I just gave for a bunch of sugar packets. 07:39.699 --> 07:42.565 [SPEAKER_02]: It's like, it was like, well, I see that we're just going to fix that. 07:42.665 --> 07:44.088 [SPEAKER_02]: You know, I probably can't hurt her. 07:44.689 --> 07:50.121 [SPEAKER_02]: But what I just started to do at that point was collect everything that we might need. 07:50.101 --> 07:53.226 [SPEAKER_02]: Um, the pack of stuff was just, it's huge. 07:53.627 --> 07:54.649 [SPEAKER_02]: It's all over the place. 07:55.169 --> 07:59.437 [SPEAKER_02]: And while she was doing okay, you know, I'm like, okay, here are the sugar. 07:59.577 --> 08:06.188 [SPEAKER_02]: Here's the dies of Pam here's the I am dies of Pam here's the intubation kit IDs whatever just trying to put it all together. 08:06.248 --> 08:15.383 [SPEAKER_02]: So we could find it faster if we need it at then the flight attendants asked us, well, you know, do we land playing? 08:15.363 --> 08:21.068 [SPEAKER_02]: And that was a question that I knew was coming and also had no idea how to answer. 08:21.128 --> 08:28.614 [SPEAKER_02]: Like at this point, she was pretty aware of what had happened and was just in tears. 08:28.734 --> 08:30.556 [SPEAKER_02]: Home for her was the United States. 08:30.816 --> 08:35.740 [SPEAKER_02]: She did not want to be dropped off in Berlin to go to a hospital there. 08:35.760 --> 08:36.721 [SPEAKER_02]: She wanted to go home. 08:36.761 --> 08:44.948 [SPEAKER_02]: And everyone else on the airplane, just like staring, which also makes the whole situation very 08:44.928 --> 08:51.004 [SPEAKER_02]: I decided I was not going to make that decision and ask them to talk to their ground crew. 08:51.044 --> 08:53.450 [SPEAKER_02]: Wait, hold on. 08:53.771 --> 08:55.596 [SPEAKER_03]: What exactly is ground crew? 08:56.690 --> 09:17.466 [SPEAKER_03]: If you remember one thing from this podcast, I would suggest that you remember that every airline pretty much will have ground support that you can call every airline contracts with a company that has people on the ground who are physicians who are available 24 seven. 09:17.446 --> 09:26.855 [SPEAKER_03]: who they can call, and those physicians are trained to know what, how to respond to basically any emergency on a plane. 09:27.696 --> 09:35.583 [SPEAKER_03]: They know based upon what type of aircraft you're on, what type of emergency medical kit is available to you. 09:36.504 --> 09:44.331 [SPEAKER_03]: And they can tell you get the emergency medical kit. 09:45.256 --> 09:47.760 [SPEAKER_01]: And how the communication happens can take several different forms. 09:48.220 --> 09:55.350 [SPEAKER_01]: Because Erin's flight didn't have Wi-Fi, Erin basically was dictating a message to the flight attendants who were attempting to write it all down. 09:55.390 --> 10:01.198 [SPEAKER_01]: And then the pilots would radio down that message to the ground crew who was then communicating with a doctor. 10:01.719 --> 10:05.024 [SPEAKER_01]: And then that whole chain would be communicated back the other way. 10:05.745 --> 10:10.892 [SPEAKER_01]: If you have Wi-Fi, it's as simple as a phone call to a consulting doctor on the ground. 10:10.872 --> 10:17.748 [SPEAKER_01]: Whichever form you have, the ground support can be really helpful with the decision of whether to land the plan or not, especially if it's not a quick fix situation. 10:18.329 --> 10:26.709 [SPEAKER_04]: Yeah, I know for me, like my takeaway, it's like, okay, I'm going to get that communication type in the beginning or delegate that to someone else if it's going to take a lot of time. 10:27.992 --> 10:28.493 [SPEAKER_03]: Absolutely. 10:29.789 --> 10:45.233 [SPEAKER_03]: If you're on a flight and you're asked to respond to medical emergency and it's clear that it's a legit situation immediately asked the flight attendants to set up ground support. 10:45.938 --> 10:52.686 [SPEAKER_02]: And so it took actually about an hour for that doctor to come back at the decision that it sounds like everything is fine. 10:52.706 --> 10:58.573 [SPEAKER_02]: I have wondered a lot about whether I should have done something differently here. 10:58.633 --> 11:04.360 [SPEAKER_02]: They told me initially, I'd have to make that decision within the next hour to hour and a half. 11:04.380 --> 11:06.963 [SPEAKER_02]: It took that doctor about an hour to get back to us. 11:07.003 --> 11:09.646 [SPEAKER_02]: So at that point, we were kind of running out of space. 11:10.047 --> 11:15.473 [SPEAKER_02]: And I think they said that they would land in Berlin, 11:15.453 --> 11:17.996 [SPEAKER_02]: that they could land in before we go across the Atlantic. 11:18.056 --> 11:25.004 [SPEAKER_02]: But that was really what they were trying to get me to decide is, do we land before we are over the ocean and then weren't a bad spot? 11:25.785 --> 11:36.617 [SPEAKER_02]: And at this point, you know, I was thinking to myself, this is a person with a known seizure disorder who just had a one-time seizure, came out of it without any intervention. 11:36.657 --> 11:41.983 [SPEAKER_02]: At first, looked pretty unwell, but then was pretty clearly like, 11:41.963 --> 11:43.265 [SPEAKER_02]: at this point she was with it. 11:43.365 --> 11:44.987 [SPEAKER_02]: Her neuro exam was normal. 11:45.087 --> 11:49.854 [SPEAKER_02]: You know by the time she had kind of woken up when we could do a full exam, she seemed well. 11:50.275 --> 11:53.880 [SPEAKER_02]: And she's telling us this story, she had been flying from Africa. 11:53.960 --> 11:56.143 [SPEAKER_02]: She hadn't slept for 24 hours. 11:56.203 --> 11:57.124 [SPEAKER_02]: She hadn't eaten. 11:57.264 --> 12:01.911 [SPEAKER_02]: She had gotten like stranded in an airport all night and hadn't been able to get any rest. 12:02.411 --> 12:11.464 [SPEAKER_02]: And so I guess I was just kind of imagining we gave her this extra full of mixed all like 12:11.444 --> 12:32.136 [SPEAKER_02]: Then we did go over the Atlantic and I left my seat and sat next to her because she was I think pretty understandably scared the other doctor there had told her and I didn't know this that you're more likely to have a seizure when you were falling asleep and waking up from sleep and 12:32.116 --> 12:35.081 [SPEAKER_02]: which I didn't know but apparently is true. 12:35.121 --> 12:41.992 [SPEAKER_02]: And this poor woman hadn't slept for, you know, day and a half and now was afraid to fall asleep. 12:42.773 --> 12:49.084 [SPEAKER_02]: And I was afraid that if she didn't sleep, the same reason that she got her first seizure is still there. 12:49.144 --> 12:55.434 [SPEAKER_02]: And so she's like trying not to sleep and trying to tell her I think she should just sleep if she needs to sleep. 12:56.015 --> 12:59.220 [SPEAKER_02]: There was also 12:59.200 --> 13:12.404 [SPEAKER_02]: And the other doctor, the emergency room doctor, I think very understandably was concerned about her having anything to eat or drink because if she had another seizure and needed to be intedated on the flight, that was going to be a problem. 13:13.365 --> 13:23.183 [SPEAKER_02]: But it led to this kind of place where I think the things that made it more likely for her to have a seizure weren't actually fixed. 13:23.872 --> 13:26.556 [SPEAKER_02]: So I'm if just it next to her for the flight. 13:26.896 --> 13:29.600 [SPEAKER_02]: And I like, I don't, it was pretty nerve wracking. 13:29.620 --> 13:33.806 [SPEAKER_02]: Like, I wouldn't put on my headphones sat there and like read a book really awkwardly. 13:33.846 --> 13:42.859 [SPEAKER_02]: Every time she would get up to go to the bathroom, you could just see like again, everyone in the cabin just like staring at the bathroom door is terrible. 13:42.839 --> 13:50.510 [SPEAKER_02]: And to impatient, well, it's about four hours after the first seizure, which put us right in the middle of the Atlantic. 13:51.271 --> 13:55.496 [SPEAKER_02]: And sure enough, I hear for breathing change, the look over just having a second seizure. 13:55.516 --> 13:55.576 [SPEAKER_02]: No. 13:58.420 --> 13:59.422 [SPEAKER_02]: The story was over. 13:59.482 --> 14:00.824 [SPEAKER_02]: It's not over. 14:01.284 --> 14:01.505 [SPEAKER_02]: No. 14:01.625 --> 14:03.567 [SPEAKER_02]: One of the flight attendant's very helpfully. 14:03.607 --> 14:05.150 [SPEAKER_02]: He's not real calm. 14:05.370 --> 14:12.019 [SPEAKER_02]: I was just like, just so you know, this is the worst place for this to happen. 14:12.877 --> 14:15.761 [SPEAKER_02]: It's two and a half hours one way and two and a half hours. 14:15.841 --> 14:17.804 [SPEAKER_02]: The other way, what do you want to do? 14:17.824 --> 14:21.950 [SPEAKER_02]: It sounds like at this point, I may as well end up in Boston, you know. 14:22.531 --> 14:29.781 [SPEAKER_02]: But we did have them go ask the pilot, you know, if there were actual other emergency options in there. 14:30.021 --> 14:32.204 [SPEAKER_02]: And the pilot got back to us that there were. 14:32.224 --> 14:38.353 [SPEAKER_02]: We could land in like Newfoundland or or Halifax, or something like that. 14:38.413 --> 14:42.799 [SPEAKER_02]: If it came to it, which would save us maybe like an hour, hour to half. 14:42.779 --> 14:47.848 [SPEAKER_02]: You know, but by the way, where we were looking at, at least an hour and a half still in the flight. 14:48.088 --> 14:55.161 [SPEAKER_02]: This may be the hand emergency landing in the middle of nowhere, Canada, if we had to, and Europe is no longer an option. 14:56.142 --> 15:04.517 [SPEAKER_02]: And so, you know, at this point when she starts to seize the second time, like we did actually have our emergency kit ready, 15:04.649 --> 15:09.576 [SPEAKER_02]: I'm grateful to say I didn't have to use the days that they have at all, which was good. 15:10.136 --> 15:22.773 [SPEAKER_02]: She broke out of that one also spontaneously, but at this point, our level of worry was definitely increased because now we're looking at two seizures, is there a possibility of a third? 15:22.893 --> 15:30.083 [SPEAKER_02]: And so we kind of went from having a little bit of planning over worse case scenario to real planning. 15:30.535 --> 15:47.329 [SPEAKER_02]: at that point we're starting to like map out in the airplane where would we do the intubation what else do we need for that she's going through all of the intubation medications making sure she has an idea of the doses things like that and that's what we've realized to that neither of us had placed an IV and probably like 15:47.765 --> 15:51.069 [SPEAKER_02]: or knows seven years, 10 years, I'm not sure. 15:51.129 --> 15:55.774 [SPEAKER_02]: Maybe since I was like a resident in the ED, like during my rotation there. 15:55.855 --> 16:04.625 [SPEAKER_02]: But I do want it like probably, you know, I think I've done maybe a few lab draws since that time, but it was a real concern at that point. 16:06.287 --> 16:10.752 [SPEAKER_01]: And so they asked the flight attendant to make another announcement to see if there was a nurse on board. 16:11.018 --> 16:12.400 [SPEAKER_04]: Oh, so smart. 16:12.480 --> 16:18.490 [SPEAKER_04]: Man, I don't know if I would have thought about that, and like the panic to be that resource will be like, hey, is there a nurse? 16:18.550 --> 16:23.117 [SPEAKER_04]: Can someone else help with the IV versus kind of like feeling bad and kind of been seeing myself? 16:23.237 --> 16:24.118 [SPEAKER_04]: Okay, maybe I can do it. 16:24.138 --> 16:25.600 [SPEAKER_04]: I do that on that one time. 16:25.681 --> 16:35.676 [SPEAKER_04]: And I think Kudos all around for that smart thinking of knowing your own limits and that, yes, this is still a team support, even if you are so many thousand feet above ground. 16:35.656 --> 16:37.038 [SPEAKER_02]: Did you find a nurse? 16:37.058 --> 16:39.642 [SPEAKER_02]: We did find a nurse and what do we ask her? 16:39.702 --> 16:44.891 [SPEAKER_02]: She was the nurse who did outpatient IV vitamin and fuchsia. 16:45.491 --> 16:46.313 [SPEAKER_04]: Amazing. 16:46.473 --> 16:48.456 [SPEAKER_04]: Yes, she felt like you do this every day. 16:48.717 --> 16:52.863 [SPEAKER_02]: She was like, all I do is place IVs and people. 16:53.244 --> 16:54.686 [SPEAKER_02]: I could do this. 16:54.706 --> 16:57.130 [SPEAKER_02]: I can put one in, start if you need it. 16:57.430 --> 16:57.951 [SPEAKER_02]: Great. 16:57.931 --> 17:01.196 [SPEAKER_02]: So then we kind of talked through, do we put what it right now? 17:01.236 --> 17:06.245 [SPEAKER_02]: This is another moment where I kind of feel like in retrospect, I should have just said yes. 17:06.846 --> 17:13.577 [SPEAKER_02]: And then we would have had an IV, I could have done some fluids, you know, she was pretty unlucky at this point. 17:13.557 --> 17:23.290 [SPEAKER_02]: which I think was just, I think she was pretty dehydrated and she had broken out of the second seizure faster than the first one, which I found somewhat reassuring. 17:23.330 --> 17:29.959 [SPEAKER_02]: And so I think in retrospect, I would have asked for that IV, but we didn't. 17:30.540 --> 17:39.953 [SPEAKER_02]: And the discussion came back to her 17:40.388 --> 17:45.933 [SPEAKER_02]: because it showed us that she was like tacky, like 110s, 120s, and sometimes up to 130s. 17:46.554 --> 17:55.923 [SPEAKER_02]: And she was like borderline hypoxic, was sadting right around 88 to 93 with a few good breaths. 17:55.943 --> 18:10.277 [SPEAKER_02]: So then the question from the ED doctor who seen this a few times was, could this be a PE from her travel that has caused hypoxia that has caused 18:10.477 --> 18:19.488 [SPEAKER_02]: And she was wondering about whether, at this point, we actually consider full-on anti-corrigulation, like we found lovin' ox-shots in their kit. 18:20.749 --> 18:29.640 [SPEAKER_02]: But you start to realize, like, well, I don't know, because the other possibility is the seizure is from something in the brain, or is probably not related at all. 18:29.760 --> 18:36.248 [SPEAKER_02]: My thought was, this is Laura's seizure threshold, and someone with the seizure disorder, and we just haven't fixed that problem. 18:36.397 --> 18:46.488 [SPEAKER_02]: But you realize how limited you are when you can't just go and get a scan and answer this question, you know, and so find we like diligently take the low of an ox out, we put it to the side. 18:46.848 --> 18:48.670 [SPEAKER_02]: That's the color stitch effort. 18:48.690 --> 18:53.315 [SPEAKER_02]: Like if something happens and we're coding her then that is anything we may use. 18:53.555 --> 18:54.917 [SPEAKER_02]: Find every foot that aside. 18:55.597 --> 18:59.041 [SPEAKER_02]: But these discussions become really interesting when you just have no info. 18:59.822 --> 19:04.767 [SPEAKER_01]: Was there any discussion about like what is a normal 19:04.932 --> 19:08.659 [SPEAKER_02]: Yes, so I knew that it was lower than typical. 19:08.820 --> 19:15.673 [SPEAKER_02]: And in fact, I put the pulsox on myself to test it first and I was adding around 96 to 97%. 19:16.194 --> 19:19.240 [SPEAKER_02]: So I figured that that was robably normal. 19:19.341 --> 19:25.152 [SPEAKER_02]: And so this was still probably lower than what that would be smart. 19:25.857 --> 19:27.765 [SPEAKER_04]: Ah, another good place to pause. 19:27.965 --> 19:28.688 [SPEAKER_04]: Poll sucks. 19:29.431 --> 19:33.527 [SPEAKER_04]: All right, how much do we pull our hair out that the patient is actually hypoxic? 19:33.668 --> 19:36.238 [SPEAKER_04]: Is she sitting at that like 88, 93%. 19:37.163 --> 19:37.644 [SPEAKER_01]: Yeah. 19:37.664 --> 19:41.948 [SPEAKER_01]: So in a plane, you're flying at 35,000 feet above the ground. 19:42.549 --> 19:46.213 [SPEAKER_01]: However, the cabin is pressurized to about 68,000 feet. 19:46.814 --> 19:51.299 [SPEAKER_01]: So being in an airplane is equivalent to being at the top of a relatively tall mountain. 19:51.399 --> 19:54.182 [SPEAKER_01]: Think top of a ski resort or top of a hike. 19:54.783 --> 20:03.272 [SPEAKER_01]: So your oxygen would reasonably be a little bit lower than what's expected for a healthy long at sea level. 20:03.775 --> 20:16.738 [SPEAKER_01]: But someone who is lung disease with their oxygen curve already shifted to the left, you could have significant hypoxia develop, which is why COPD patients, for example, are sometimes recommended to use oxygen one flying. 20:17.022 --> 20:17.904 [SPEAKER_04]: Yeah, no fair. 20:18.505 --> 20:22.714 [SPEAKER_04]: But you know, our lady, she doesn't have one Caesar, not that we know of, right? 20:22.915 --> 20:27.224 [SPEAKER_04]: She's two seizures in and her O2 is sitting at 88 to 93%. 20:27.685 --> 20:29.770 [SPEAKER_04]: So that is lower than what we'd expect. 20:29.850 --> 20:34.440 [SPEAKER_04]: And so I guess we're dealing with a mild degree of hypoxia to add to the equation. 20:35.703 --> 21:04.022 [SPEAKER_02]: At this point, it was like, can we actually just get her some sort of benzo to last these last few hours, and someone in the cabin was overhearing this discussion and was like, hey, I have a Xanx and we're like, okay, you know, she holds this tissue out of her pocket. 21:04.593 --> 21:12.146 [SPEAKER_02]: I'm pretty sure it's a Zadex, you know, it's from her sister because she gets scared on flights and it's like, do you know the dose? 21:12.326 --> 21:15.431 [SPEAKER_02]: I think it was one million grams and so this is half of that. 21:16.072 --> 21:18.737 [SPEAKER_02]: And at that point, we just decided, good enough. 21:19.979 --> 21:22.023 [SPEAKER_02]: We had her take the Zadex. 21:23.064 --> 21:25.268 [SPEAKER_02]: We did make it across the whole way. 21:25.687 --> 21:35.282 [SPEAKER_02]: As we were getting closer to landing, I had talked to the flight attendance about, can we get the emergency medical people to come on the flight to take her off? 21:35.322 --> 21:43.155 [SPEAKER_02]: Because at this point, she's still kind of like border line hypoxic and I just really felt like she should be seeing in an emergency department. 21:43.540 --> 21:48.666 [SPEAKER_02]: So they take her off and everyone else on the plane, it's just this big sigh of relief. 21:48.726 --> 21:51.750 [SPEAKER_02]: But as we're leaving, the pilot came out. 21:51.770 --> 21:53.732 [SPEAKER_02]: It was just kind of this odd experience. 21:53.752 --> 22:01.401 [SPEAKER_02]: He shook my hand and shook my husband's hand and says something really kind of over the top about your thank you for saving our flight. 22:02.382 --> 22:07.708 [SPEAKER_02]: And then you get out that you just wait an hour for your baggage. 22:08.279 --> 22:10.481 [SPEAKER_04]: and what a story. 22:10.501 --> 22:15.125 [SPEAKER_04]: It is amazing to me how resourceful you have to be. 22:15.746 --> 22:21.351 [SPEAKER_04]: I am so glad for a good ending, but I do wonder if things hadn't gone well. 22:21.731 --> 22:24.253 [SPEAKER_04]: What if she'd aspirated more after a second seizure? 22:24.313 --> 22:28.137 [SPEAKER_04]: Maybe it's worse case being going into a P.A. 22:28.197 --> 22:29.618 [SPEAKER_04]: rest even passing away. 22:29.798 --> 22:31.580 [SPEAKER_04]: That is so awful to think about. 22:31.760 --> 22:38.286 [SPEAKER_04]: I also imagine that a lot of the reasons why people don't 22:38.266 --> 22:40.379 [SPEAKER_01]: Yeah, that's a great question. 22:40.922 --> 22:45.188 [SPEAKER_01]: So I sat down with a pilot from one of the major airlines Zachary Trouplet. 22:46.012 --> 23:01.279 [SPEAKER_00]: So in 1998, the Aviation Medical Assistance Act, the AMAA, was basically passed and what that does is that ensures that any medical volunteers on the aircraft, including physicians, are, you're not held responsible. 23:01.299 --> 23:09.454 [SPEAKER_00]: You can't be held responsible in federal or state court for anything that happens on board an aircraft outside of like gross negligence in a situation. 23:09.434 --> 23:16.845 [SPEAKER_00]: So any time you volunteer, you don't have to be nervous that you're going to be held responsible for the outcome of the situation because you did it in good faith. 23:18.267 --> 23:19.088 [SPEAKER_04]: Ah, for you. 23:19.409 --> 23:21.132 [SPEAKER_04]: And that is such a relief to hear. 23:21.192 --> 23:27.521 [SPEAKER_04]: And so be that last point about the pulse ox also think about like they couldn't actually find a pulse ox initially, right? 23:27.561 --> 23:28.202 [SPEAKER_04]: And that story. 23:28.342 --> 23:32.589 [SPEAKER_04]: And so a big question like what should we be bringing with us? 23:32.689 --> 23:34.151 [SPEAKER_04]: And you've thought about this so much. 23:34.171 --> 23:36.775 [SPEAKER_04]: So what are you bringing on your played these days? 23:37.177 --> 23:38.158 [SPEAKER_01]: taking a step back. 23:38.278 --> 23:42.563 [SPEAKER_01]: I start by thinking about what are the most common chief concerns on an airplane. 23:43.164 --> 23:51.112 [SPEAKER_01]: And in order, those are syncopy, shortness of breath, GI stuff, so nausea, vomiting, diarrhea, and then finally chest pain. 23:51.893 --> 23:55.938 [SPEAKER_01]: Syncopy and chest pain, we actually have a quite a bit in the MK for those already. 23:56.338 --> 24:04.467 [SPEAKER_01]: We have nitroglycerin, aspirin, a 500cc bullis, dextrose, so I mostly focus on the 24:04.447 --> 24:14.624 [SPEAKER_01]: So I'll bring a modium, zo-friend, for GI complaints, and then potentially oral steroids for a COPD exacerbation, and ideally, you would also have Narcan and Piran inhalers. 24:14.884 --> 24:18.810 [SPEAKER_01]: But a lot of those, you can actually find from other passengers. 24:19.331 --> 24:21.034 [SPEAKER_04]: Yeah, that's a smart list. 24:21.375 --> 24:25.982 [SPEAKER_04]: So if you do a shake, prescribe this yourself before a flight or how do you actually go about getting Lisa's? 24:26.266 --> 24:28.990 [SPEAKER_01]: Yeah, in theory you can, that makes me a little nervous. 24:29.231 --> 24:31.594 [SPEAKER_01]: So I just got my PCP to prescribe them for me. 24:31.614 --> 24:34.639 [SPEAKER_01]: And I just tell her that it's for my first aid kit. 24:35.360 --> 24:38.685 [SPEAKER_01]: And after hearing Erin story, maybe I'll start carrying a pulse ox too. 24:39.266 --> 24:43.733 [SPEAKER_04]: Yeah, I feel like the pulse ox for me is doable since I have one at home and would be easy grab. 24:43.813 --> 24:49.823 [SPEAKER_04]: I don't know if I would have all my ducks in the road to prescribe it for myself before a flight or get someone else to do it for me. 24:49.863 --> 24:51.345 [SPEAKER_04]: Might forget those things. 24:52.068 --> 24:52.409 [SPEAKER_01]: Yeah. 24:52.669 --> 24:54.333 [SPEAKER_01]: And if you forget, it's all good. 24:54.653 --> 24:56.056 [SPEAKER_01]: Use the crowd to be resourceful. 24:56.537 --> 25:00.605 [SPEAKER_01]: I mean, looking at Erin's story, she had other passengers organizing medications. 25:01.126 --> 25:02.549 [SPEAKER_01]: She asked for an IV nurse. 25:03.050 --> 25:04.153 [SPEAKER_01]: She was ground control. 25:04.353 --> 25:06.297 [SPEAKER_01]: And she used meds from other passengers. 25:06.580 --> 25:22.817 [SPEAKER_04]: Yeah, that's a great point because I gave it in the beginning as for like I was just impressed that she even asked for hey, is there another doctor on board, even though she herself was doctor, she's just like new, hey, I need more hands and I love that about her and I think that really lends into some final words of wisdom that Dr. Melissa Matsen had for us. 25:23.962 --> 25:26.405 [SPEAKER_03]: I think you want to try to stay within your scope. 25:26.485 --> 25:28.087 [SPEAKER_03]: I think you don't want to do something you're not. 25:28.107 --> 25:33.312 [SPEAKER_03]: So, familiar with, I've heard about people trying to do all sorts of heroic things. 25:33.473 --> 25:36.096 [SPEAKER_03]: And I'm not sure that is it going to work. 25:36.536 --> 25:41.221 [SPEAKER_03]: What we did when we responded to that case that I told you about was not heroic. 25:41.241 --> 25:49.731 [SPEAKER_03]: I've heard of people on airlines where they've tried to mix up pressures like they had an FB and an FB pen and they had some fluids. 25:49.771 --> 25:51.673 [SPEAKER_03]: They're trying to make an FB drip. 25:51.653 --> 25:58.922 [SPEAKER_03]: What are you talking about, you know, so just I would just say like use caution, use good judgment. 26:00.124 --> 26:04.689 [SPEAKER_01]: So don't feel like you have to do something heroic because you're the doctor on board. 26:04.910 --> 26:07.753 [SPEAKER_01]: And at the same time, no, that we can all have a role. 26:08.895 --> 26:10.437 [SPEAKER_03]: I've heard of medical students. 26:10.537 --> 26:13.601 [SPEAKER_03]: I've heard of residents feeling like, I'm not worthy enough. 26:13.681 --> 26:14.282 [SPEAKER_03]: I'm not enough. 26:14.422 --> 26:19.348 [SPEAKER_03]: I mean, if there's no one else on the plane, 26:20.071 --> 26:25.666 [SPEAKER_03]: And if an emergency medicine physician goes out, they'd be way more qualified than I would, right? 26:25.686 --> 26:27.611 [SPEAKER_03]: Because I'm an internal medicine hospitalist. 26:27.631 --> 26:33.287 [SPEAKER_03]: And yes, I'm not like unqualified, but I'm at the most qualified person to respond to an inflammatory medical emergency. 26:34.189 --> 26:34.570 [SPEAKER_03]: But 26:35.107 --> 26:37.713 [SPEAKER_03]: say an emergency medicine physician responds. 26:38.474 --> 26:41.301 [SPEAKER_03]: And then I say, well, they don't need me, well, you know, right? 26:41.321 --> 26:43.265 [SPEAKER_03]: Like, you could actually go and be helpful. 26:43.906 --> 26:53.908 [SPEAKER_03]: So do what you feel comfortable doing, but don't feel like you're not necessarily going to be a helper because you might actually be a helper. 26:54.766 --> 27:00.600 [SPEAKER_01]: So practicing in an Austria environment is inherently uncomfortable because we're not where we usually practice medicine. 27:01.102 --> 27:07.778 [SPEAKER_01]: And so I think it's all about finding that balance between what's within our scope and being resourceful to apply our scope. 27:07.798 --> 27:09.703 [SPEAKER_04]: Yeah, very, very well put. 27:10.088 --> 27:12.733 [SPEAKER_04]: Thank you so much Sophie, and that is a wrap for today. 27:12.793 --> 27:25.680 [SPEAKER_04]: If you found this episode helpful, or ask us to please share it with one other colleague, your team, or someone who may be going on a flight sometimes soon, as always, opinions express our own and do not forget the opinions of any affiliated institutions. 27:25.920 --> 27:26.341 [SPEAKER_04]: Take care. 27:28.686 --> 27:31.371 [SPEAKER_01]: But somewhere between 23 to 26%. 27:31.773 --> 27:35.080 [SPEAKER_04]: So, do you think you said 23 or 23, you said, you mean 93? 27:35.581 --> 27:41.673 [SPEAKER_04]: No, he says, I was like, oh, I was like, that's pretty bad. 27:41.713 --> 27:45.400 [SPEAKER_01]: You're like, that doesn't seem right. 27:45.661 --> 27:46.362 [SPEAKER_04]: Oh, I love you. 27:46.723 --> 27:48.887 [SPEAKER_04]: You can convince me of things now.