Flying Safe - Medics Onboard Qantas

[artemis]

I'm sorry, that last sentence is just not true. Without going into the physics of laminar vs turbulent flow, almost all mechanical flow meters that are calibrated for sea level will under read at altitude due to the decreased density of the gas interacting with the bobbin or whatever flow sensing mechanism is there. Yes, the gas has also expanded but the net result is that your bottle will not last longer. In fact to keep the inspired oxygen partial pressure somewhere near where it was at sea level an increased flow rate may be required. There are ways around this, using pulsed electronic delivery systems but this is getting way OT.

My advice to anyone looking for medical advice re flying is: don't look for it on this thread. It may all be well meaning but is not always accurate.

Of some concern also is the "anti machinery" flavour of some recent posts. Clinical skills are to be applauded, but time after time it has been demonstrated that even in perfect light a pulse oximeter will detect subtle levels of cyanosis much more accurately than the most experienced clinician. And with the light available down the back of a 747, clinical assessment of cyanosis is just a guess. My advice to medicos who are called to assist is: put that damn oximeter on. It takes 2 seconds and you may discover something your excellent clinical skills have missed.

And your background is?

You talk of subtle cyanosis on a 747. What does one do to correct that on a 747? Put oxygen on? What does it matter what the sats are (especially if subtle) if you have given maximal therapy available to you? Sure I'll put it on, and preferably with an ECG - but again, how great is the info from that going to be? But subtle cyanosis? What next, an ABG? ECMO?

Please note that I raised the sats probe issue in relation to a patient with a broken leg. I'm pretty sure that if that patient had had some form of related respiratory compromise mid-flight, the sats probe and oxygen ain't gonna cut it. My point was to use the correct tool for the correct situation.

And fwiw, the Virgin trans-tasman flight - no sats probe. I was handed an oxygen cylinder, BP cuff and stethoscope (coughpy one). And this was prior to any iphone app too for O2 sats. I was told that if I wanted to defibrillate the patient I had to inform the Captain first. :-|

But perhaps you could stop putting down the "medicos" who are trying to provide some information to people who may be curious. No need to be nasty!

 

[RooFlyer]

Don't know why, but this thread made me think of this (Stan Cross, Smiths Weekly)

 

[AVC]

I'm sorry, that last sentence is just not true. Without going into the physics of laminar vs turbulent flow, almost all mechanical flow meters that are calibrated for sea level will under read at altitude due to the decreased density of the gas interacting with the bobbin or whatever flow sensing mechanism is there. Yes, the gas has also expanded but the net result is that your bottle will not last longer. In fact to keep the inspired oxygen partial pressure somewhere near where it was at sea level an increased flow rate may be required. There are ways around this, using pulsed electronic delivery systems but this is getting way OT.

My advice to anyone looking for medical advice re flying is: don't look for it on this thread. It may all be well meaning but is not always accurate.

Of some concern also is the "anti machinery" flavour of some recent posts. Clinical skills are to be applauded, but time after time it has been demonstrated that even in perfect light a pulse oximeter will detect subtle levels of cyanosis much more accurately than the most experienced clinician. And with the light available down the back of a 747, clinical assessment of cyanosis is just a guess. My advice to medicos who are called to assist is: put that damn oximeter on. It takes 2 seconds and you may discover something your excellent clinical skills have missed.

My SCUBA cylinder lasts longer at shallow depths. Same principle.
Doesn't necessarily mean that the patient will get better use out of it.

And don't get me wrong. I am not anti-machinery. I don't stick my ear on a patient's chest instead of reaching for the steth. But I have seen medicos staring at the Lifepak (which was clearly showing an electrical rhythm) and exclaiming that the patient "has an output". Err, no, you actually have to feel an output there guy.

One more thing:
A bottle is something you drink out of.
A tank is something you drive.
A cylinder is what is slung under the Oxyviva (or CABA, as the instructor said 20 odd years ago).

I was told that if I wanted to defibrillate the patient I had to inform the Captain first. :-|

:shock:

Ah yes, I'm sure those extra few minutes won't matter.... much.
IIRC it's about 10% less chance per 60 seconds lapsed.
I have done many resus' , and the only ones that ever talked again were the ones that went down right in front of me. Like literally.

 

[asg29e]

And your background is?

You talk of subtle cyanosis on a 747. What does one do to correct that on a 747? Put oxygen on? What does it matter what the sats are (especially if subtle) if you have given maximal therapy available to you? Sure I'll put it on, and preferably with an ECG - but again, how great is the info from that going to be? But subtle cyanosis? What next, an ABG? ECMO?

Please note that I raised the sats probe issue in relation to a patient with a broken leg. I'm pretty sure that if that patient had had some form of related respiratory compromise mid-flight, the sats probe and oxygen ain't gonna cut it. My point was to use the correct tool for the correct situation.

And fwiw, the Virgin trans-tasman flight - no sats probe. I was handed an oxygen cylinder, BP cuff and stethoscope (coughpy one). And this was prior to any iphone app too for O2 sats. I was told that if I wanted to defibrillate the patient I had to inform the Captain first. :-|

But perhaps you could stop putting down the "medicos" who are trying to provide some information to people who may be curious. No need to be nasty!

My background relevant to this discussion is former RAAF aviation medicine instructor, currently anaesthetist and pilot of unpressurised high altitude aircraft.

Regarding subtle cyanosis; I was possibly being a little kind. Most people cannot spot cyanosis in good light until SaO2 is below 88%. In bad light? ??
How you deal with this information is up to the person on the spot. But it can't hurt to know.

I didn't think I was putting anyone down. Pot calling kettle black if I was, thinking about the way you described that nurse, who for all you know may have been merely following a company protocol regarding patient monitoring.

 

[asg29e]

My SCUBA cylinder lasts longer at shallow depths. Same principle.

Ah, now I see where you are coming from. It's an easy assumption to make but it really isn't the same. Your SCUBA is not a constant flow device. If you could somehow rig a conventional flow meter into the system downstream from the final regulator you would find that it read much higher during inspiration at, say, 30m depth than at sea level. Despite your lung volumes remaining unchanged. A slightly tricky concept, due to changes in gas density with pressure as I posted earlier.

 

[aliens]

I was speaking with a senior Qantas on board person recently and asked if they could tell the difference between a medical doctor and a PhD via the app. They can't.

I guess it's not really a philosophical question when the need arises. :mrgreen:

I am a PhD Dr (the real one ha ha) and have been approached a number of times to enquire if I am a medical doctor.

 

[Tassie]

I am a nurse. About twenty years ago I had just landed in Sydney on a QF flight from NZ. The woman across the aisle couldn’t wake her elderly husband. I got him on to the floor and started CPR (after appropriate checks of course.) Two doctors turned up to help shortly afterwards – one helpfully being a cardiothoracic surgeon. There was no room to kneel next to the body to do compression so I was hanging over the seat arm and had bruised ribs for weeks afterwards. It took 40 minutes for an airport emergency crew to show up and one hour for an ambulance to arrive! We worked on him for most of that time. The surgeon had a few goes at putting lines in him – but there was no sharps container. I went around and gathered them up later. I gave the attendant my boarding card – as I thought she would need to report who had attended. But despite being held up for all that time I did not get one word of thanks from Qantas – I often wonder if the doctors did. I even rang their OHS department to talk about the lack of sharps containers and was told – "oh they are on board, they obviously didn’t know where to look." There was no obvious concern about that. Still no thanks forthcoming.


Twice before that – coincidentally on flights to or from Perth – I have helped out with sick passengers, one had an anxiety attack and one was just exhausted and feeling dizzy. In both those cases I had effusive thanks from the crew – and offers of wine - even though I only really reassured the patients.

 

[coco50]

I am forever grateful to the unknown doctor who treated my daughter on a flight from LAX - SYD some years ago. She became very ill on the flight and he cared for her. When the flight arrived in SYD she was taken by ambulance to St Vincents where she had her appendix out.

 

[Supernanny56]

Having been the recipient of medical assistance on board a Air NZ many years ago I am forever grateful to the 4 (not 1) Dr's who put their hand up to assist. I was taken to hosp by ambulance directly off the plane. All organised whilst in the air. Customs and immigration boarded the rear of the plane and processed all our paperwork while we were still in our seats at the rear of the plane. Nothing but praise for everyone involved. Thanks to all the willing Dr's on any flight that help other passengers.

 

[Vjogia]

Hi, I was on a Qantas flight from Perth to Brisbane in August of 2014 when a fellow passenger was experiencing chest pain and shortness of breath. I attended to the patient. An ambulance was waiting for the patient on the tarmac. I was keen to have the plane diverted to Adelaide but was informed that the flight was too far away from there for the diversion. We were in the air for a further 3 hours before arrival at Brisbane airport. The patient had a pulmonary embolism. My services during the flight was not acknowledged by Qantas.

 

[prozac]

I'll acknowledge you Vjogia. Welcome to AFF.

 

[prozac]

Ah, now I see where you are coming from. It's an easy assumption to make but it really isn't the same. Your SCUBA is not a constant flow device. If you could somehow rig a conventional flow meter into the system downstream from the final regulator you would find that it read much higher during inspiration at, say, 30m depth than at sea level. Despite your lung volumes remaining unchanged. A slightly tricky concept, due to changes in gas density with pressure as I posted earlier.

What you two are discussing is Boyle's Law. Pressure and volume of a gas are inversely proportional assuming that temperature remains constant.

Around a decade ago I was flying JAL, seated in the rear 2 seats...yes whY class. A middle aged Japanese man wandered toward the rear of the aircraft and collapsed just behind where I was seated. The 2 FA's (one English, the other Japanese) just looked at him lying on his back and did nothing. This forced me to get up to offer assistance, checking the passenger's breathing and pulse and once satisfied placing him into recovery position and making sure he was comfortable. We then ascertained from his companion that he had had a few at the airport prior to boarding. My reason for relating this story is just to highlight that at least at that time JAL training for FA's was somehow lacking.

 

[drron]

Though to be fair my experience previously related on JAL was totally different.The CSM was most organised and an English speaking Japanese FA was assigned to me and the patient for the duration.She was a very good medical assistant as well.

 

[emcleod]

I've never felt the urge to post here before, but feel compelled to have a whinge about my experiences being called upon as a doctor on a number of flights. Qantas are pretty good and the cabin crew are generally grateful for assistance. On most long haul flights there are likely to be a number of specialists to choose from (I'm a general surgeon, so not so good on the more medical problems). Other airlines just seem to take it for granted that you will help - I remember a flight to Rome on Malaysian where I was woken and spent all night with a sick diabetic patient (which ruined my one day in Rome). The crew tossed a business class amenities kit at me toward the end of the flight - honestly, for the hours I'd put in I think they could have moved me forward for the rest of the flight. My tendency now is to slide down in my seat and hide and hope that someone else will put up their hand!

 

[prozac]

Welcome to AFF emcleod. I hope that you do not remain a lurker but will contribute to the forum if even spasmodically. It sounds like you have experience you could share with the rest of us.

For the contribution you made aboard that flight and unflagging effort I think an offer by the airline of a J return on another date of your choosing should not have been out of the question. After all the bad press resulting from a death on-board would not have been good publicity for the airline. But, then it was a Malaysian Airlines flight.

 

[VanDoc]

I was recently woken in the middle of the night on a trans-Pacific flight by a call for a medical doctor. When I identified myself as such, the flight attendant asked if I had any documents confirming that I was indeed a physician. As these were not readily to hand, my offer of assistance was declined.The flight was not diverted, and on our arrival, I noticed an elderly woman walking off the plane, escorted by a paramedic.
I am now wondering, is it routine for physicians to carry their credentials with them, and are flight attendants trained in the validation of such credentials? Are flight attendants required to find a credentialed family physician before a passenger can be further assessed and treated by a credentialed specialist? Or are flight attendants trained both in the assessment of medical credentials and the triage of medical emergencies, so they can seek the direct assistance of credentialed specialists themselves?
Should I now carry a certificate of professional conduct from my local licensing authority and wait for a call within my own area of specialist practice, or just roll over and go back to sleep?
What would you do?

 

[AVC]

Maybe medical doctors should carry one of those big framed certificates at all times.
But how is an FA going to tell the difference between say, a skin specialist and an ED reg?
Should nurses carry their "proof of qual"? Would an FA know the difference between an EN and an RN?
Paramedics? Firefighters? In some states the firefighters ARE the paramedics, in others they are just BLS first aiders.

It's not like a huge group of Medical Professionals are going to fight over who gets to treat.

And even if the best on-board medical help available was a first year medical student, that still has to be better than no treatment at all.

 

[legroom]

In this day and age of litigations, the next Q would be about the liability of the FAs and their airlines if harm occurs to patients as the result of such ID check (leading to offer of assistance declined) bearing in mind that medicos are not required to carry any IDs once they leave the gates of the hospitals.

Those few who choose to carry AHPRA cards do so out of their own initiative. I have not met anyone in person who does so.

The thinking behind ID check is flawed:

1) Medicos, as a rule, do not carry IDs (hospital lanyard is for .... hospital only... and in the best of times, only the junior ones wear them, conference ID is issued at registration and I always throw them in the bin before checking out of hotels).

2) Collaboration is ingrained into medicos who would know when to step back once a more relevant colleague is on the scene.

3) Incidence of medical assistance is low and therefore is unlikely to offer much chance of showing off from supposed pretenders who would be more likely to seek greener pastures elsewhere.

They would have to fly 604 times before they get one chance of putting their hands up (http://www.nejm.org/doi/full/10.1056/NEJMoa1212052).

4) Medicos are encouraged to step forward to be Good Samaritans, not because we seek extra work or fame. Imposing ID checks at times of emergency when no other help is at hand is quite myopic and potentially harmful to the patients.

5) Show me one case of fake medico causing harm to patient in flight, please.

 

[hedge]

I was recently woken in the middle of the night on a trans-Pacific flight by a call for a medical doctor. When I identified myself as such, the flight attendant asked if I had any documents confirming that I was indeed a physician. As these were not readily to hand, my offer of assistance was declined.The flight was not diverted, and on our arrival, I noticed an elderly woman walking off the plane, escorted by a paramedic.
I am now wondering, is it routine for physicians to carry their credentials with them, and are flight attendants trained in the validation of such credentials? Are flight attendants required to find a credentialed family physician before a passenger can be further assessed and treated by a credentialed specialist? Or are flight attendants trained both in the assessment of medical credentials and the triage of medical emergencies, so they can seek the direct assistance of credentialed specialists themselves?
Should I now carry a certificate of professional conduct from my local licensing authority and wait for a call within my own area of specialist practice, or just roll over and go back to sleep?
What would you do?

I think it's really unfortunate when the legal world causes a barrier to help someone in need.

 

[k_sheep]

On the lighter side I was flying domestic recently to the big annual pathology conference. I spotted at least 15 other pathologists or trainees on the flight. I had a giggle when I thought it there was an emergency, there'd be at least 20 medical doctors, but most of them quite useless