Location, location, location

Wednesday, November 19, 2008

At 40,000 feet over the Atlantic, routine doesn’t exist for medical emergencies. Northwest flight 55 leaves Amsterdam at 320pm en route to Minneapolis. Halfway through the flight, I was half way through watching “A Good Year” starring Russell Crowe, when an announcement came overhead looking for some medical help in row 37. An ICU nurse from Minneapolis and I both responded to find a 53 year old women lying back in her seat looking rather ill. She was pale, sweaty and complaining of chest pain radiating down her left arm associated with shortness of breath.

The flight attendants had started to move. The woman had been given aspiring and an oxygen mask was on her face. Passengers nearby were relocated and two large medical equipment bags were already in the aisle.

First things first; the ABCs of resuscitation. She had a good airway and wasn’t laboring to breathe. Unfortunately, C for circulation was not so good; her blood pressure was low at 80/50. A handheld EKG machine showed that this lady was in the midst of a heart attack. On the ground, EMS and 911 would be activated, a trip to the ER would be followed by an even quicker trip for a heart catheterization to find the blocked artery, open it with a balloon and restore blood supply to heart muscle that was starving for oxygen. High tech, lab tests, x-rays don’t exist in the air. The pilot agreed to divert and the plane made its way to Bangor, Maine 30 minutes away.

Heart attack care tries to do a couple of things. First, nitroglycerin is used to dilate narrowed blood vessels and return some blood flow to the heart. Aspirin is used to make platelets less sticky so that blood can snake through narrowed arteries and oxygen is provided so that each red blood cell that makes it through a narrowed is packed with an oxygen molecule to deliver it to heart tissue. Heart and blood pressure monitors continually check the patient’s status and vital signs. On an airplane, the monitor was me checking the blood pressure and the nurse continuously feeling the pulse at the wrist.

Space was tight and the woman was laid flat across four seats. An IV was started and fluid was given to support her blood pressure. No IV poles; a flight attendant held the bag high. Nitroglycerin was sprayed under her tongue repeatedly making certain her blood pressure didn’t drop lower. An automatic defibrillator (AED) was attached just in case. Ventricular fibrillation, an abnormal heart rhythm that doesn’t support a normal heart beat is the most common cause of sudden death in the midst of a heart attack and the AED would be able to treat it by delivering an electrical shock.

As the plane touched down, the woman began to relax as her pain resolved and her blood pressure began to normalize. Within minutes, paramedics boarded and took over care. As they left for the hospital, I spoke with the emergency physician and the cath lab began to gear up for the patient to arrive. As I learned later, the woman underwent heart catheterization, balloon angioplasty to open a blocked vessel had a stent placed to keep it open and was resting comfortably in the CCU. From onset of pain to getting a heart attack fixed took a little over 2 hours. Not bad considering the situation.

For all the bad press that pilots and flight attendants get, I’m reminded that in times of need they do their job very well. The flight attendant mantra is that they are there for passenger safety. The Northwest crew performed like the pros they were. And for all the technology that exists in medicine, I am reminded that high touch at the bedside still has its role.

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