1. In-Flight Emergencies Scott MacDonald MD, CCFP(EM)

2. Presenter Disclosure Faculty: Scott MacDonald Relationships with commercial interests:  None

3. Disclosure of Commercial Support This program has received NO COMMERCIAL financial support This program has received NO COMMERCIAL in-kind support

4. Objectives Case-based discussion of in-flight emergencies What to do What not to do Regulations/CMPA? Kit issues Environment issues

5. Case 1

6. Do I have to answer? You really want to see that movie… Legally obligated? NO (except Quebec) Ethically Obligated? YES o CMA Code of Ethics “Provide whatever appropriate assistance you can to any person with an urgent need for medical care”

7. Case 1 (cont’d) You feel the ethical pull to identify yourself…

8. Case 1 (cont’d) The flight attendant leads you to the front of the aircraft – a person in executive is suffering from acute SOB Hx Asthma/COPD and left their puffers in their checked bags You note significant increased work of breathing, and a significant increase in your personal sphincter tone

11. Please tell me this isn’t common… Varying stats: o ~1 in 600 flights o 1500 annually with Air Canada o 40,000+/year globally Minor complaints dominate: o nausea, fainting, adbominal pains Major issues: o Cardiac, Respiratory, Neuro o Low percentage occurrence with highest morbidity/mortality

13. Now what?... Identify yourself, qualifications Ask permission from patient, if feasible Ask Flight Attendants for medical equipment o And to hang with you Communicate with aircraft Captain Be a doctor…stay in your comfort zone and do your best for the patient

14. Am I Getting Sued? Falls under “Good Samaritan” precedent CMPA will defend you, regardless of where or who you treat Very unlikely to be successfully sued while providing Good Samaritan assistance Document the encounter Hand-over to pre-hospital or other qualified medical practitioners only

15. Back to the case…

16. Flight Medical Equipment

17. Don’t feel alone…. Flight attendants are trained Other passengers may be able to help o Trained medical personnel o Medications in carry-on Ground medical contact Captain

18. Asthma/COPD Exacerbation Open kit, use appropriate meds: o Ventolin MDI o Epi 1:1000 IM if severe If hypoxic, apply O2 o Ask Captain to descend to lower altitude if safe to do so (increase PO2) o Apply O2 (airline tank – 2-4L/min)

19. Case 2

20. The flight attendant leads you to the back of the aircraft A person is laying in the aisle, and a flight attendant is performing CPR

21. Do your best… Compression only CPR Use AED Consider IV drugs to your comfort level Remember survival likelihood is very low

22. When a patient dies… Ceasing efforts for an in-flight arrest is as difficult as in-hospital Once declared dead (or presumed dead) safest to restrain them in a seat Notify Captain

23. Case 3

24. The flight attendant leads you back a few rows Hx IHD and just began experiencing chest pain You note significant discomfort, diaphoresis and some tachypnea

25. Case 3 You are “old hat” at this now You take vitals, open kit, give ASA, and some nitro The patient is not improving

26. Diverting the aircraft… It is a judgement call made between you, ground medical support and the Captain Sick and not likely to improve = divert to nearest city with appropriate facility You are an advisor to the Captain o Captain has final say

28. What I Just Told You… Responding to “Is there a doctor on board” is an ethical obligation You are covered by CMPA and Good Samaritan precedent Be as calm as you can, do your best and stay in your comfort zone

29. What I Just Told You… Use the medical kit, personnel, ground support and Captain to your advantage Advise, using your best judgment, about diversion Skip the movie, seeing patients is more fun anyway… Said no one. Ever.