Last week, a woman died suddenly on a flight from Haiti to New York. She reportedly began to feel lightheaded, thirsty, and short of breath midway through the flight; soon after, she collapsed. This story recalled my own experience trying to help a sick passenger on a cross-country overnight flight three years ago. The difficulties I encountered in trying to provide good care came down to an unglamorous but crucial concern: how medical equipment is organized in a setting where volunteers are working in an unfamiliar environment with limited supplies and no back up.
My wife and I are both physicians, and on this flight from Los Angeles to Pittsburgh, we responded to an announcement asking for medical assistance for a middle-aged man who had passed out. The passenger was awake but looked quite ill: He was breathing rapidly, with cool and clammy skin. He said that he felt very lightheaded. For a while, we observed him, at the same time coaxing him to drink some juice and checking and rechecking his heart rate. But his symptoms persisted: He continued to look pale and ashen, and we became increasingly worried. It was hard to assess the cause of his condition, but it certainly could have been life-threatening. I was particularly worried about the possibility of a blood clot in his lungs or a heart attack.
And so we asked for more help from the flight attendant. My wife wanted the plane's overhead lights turned on so we could see better. At first, she got nowhere: The flight staff didn't want to wake the passengers who were sleeping on the red-eye. Next, the flight attendant handed me a kit that had some, but not nearly enough, medical equipment: a blood pressure cuff, a stethoscope, a mask and tubing for oxygen, IV catheters, and a bag of saline fluid to administer intravenously. I asked for a glucometer to measure the patient's blood sugar level, and the flight attendant shook her head that she didn't have one. Another passenger, who was a diabetic, came forward with her own device, and I used that to confirm that the patient's glucose was normal. Finally, we were given a small oxygen tank that was close to empty.
The details about last week's Haiti-U.S. flight have yet to be completely reported. So far, the news reports include accusations of medical equipment that malfunctioned and airline staff who didn't respond to the passenger's requests for help. On our flight, mean attendants and broken equipment were not the problem. The flight attendants weren't uncaring, just slow to realize the seriousness of the situation. Once they understood that we were dealing with a potentially real emergency, as opposed to an anxious passenger (I recall my wife's less-than-subtle explanation), they were quick to help, including switching on the lights.
But the organization of the plane's medical equipment proved a major barrier. Unbeknownst to the flight attendant, there was a big kit of equipment in addition to the smaller one she had given me. But the big kit was stocked elsewhere in the plane—along with a second, and full, oxygen tank. In the end, it turned out that the plane had everything we really needed—such as a glucometer and lots of medications to use in emergencies. But the flight attendants didn't figure this out until we were landing, at least an hour after the patient became sick.
At the end of the flight, the attendant confessed she'd been confused because the last time she needed to access these kinds of supplies, she had been on a different type of plane where everything she needed was stocked together. In retrospect, I too was faked out, by the way the equipment was organized: The small medical kit I was given had just enough supplies (a mix of stuff for diagnosis and treatment) to convince me that this was all there was. If I had been given a bag with, perhaps, only Band-Aids and a gauze pad, I think I would have insisted on a search for more and better equipment. The deceptive way in which the supplies were packed and stored meant that I didn't have the right tools at the right time to take care of the sick passenger.
Efforts to improve patient safety in hospitals and other medical care settings have gained increased attention since the Institute of Medicine released its 1999 report outlining how common medical errors are. Organization of medical equipment is an important part of using the science of human-factors engineering to improve patient safety. Also called ergonomics, this science takes into account the design and organization of a particular environment to improve the way humans function within it. It borrows from aviation safety, which emphasizes standardization, checklists, cockpit design, and teamwork. I have written before about incorporating some of these processes into emergency care on ambulances. On airline flights, where medical emergencies are rarer and unexpected, the value of ergonomics may be even greater. The people using the equipment often cannot rely on their experience to overcome hurdles thrown up by poor design or organization like the ones my wife and I encountered.
Fortunately, the passenger whom I cared for improved without much help. I sat with him until we landed and an ambulance came to take him off the airplane. I suspect he fully recovered. But if he had deteriorated instead, I might not have been able to help him. The February 2008 edition of one of the airlines' in-flight magazines contains a letter from the CEO, bragging about the industry's widespread use of automated external defibrillators on airplanes. These machines can save a passenger or crew member whose heart suddenly stops beating. Stocking them is, doubtless, very important. But passenger safety depends on the next level of organization: Every plane should contain the same medical equipment, stocked in the same place, in the same way. Airline staff should, of course, be well-versed in what they have and where it all is. In addition, a card or a list, itemizing the available supplies, medications, and dosages, should be on board and automatically given to any doctor or nurse or EMT who offers to assist a sick passenger. I don't know if these rules would have saved the life of the woman on the plane from Haiti, but I have little doubt they could help many of the other passengers who get sick on airplanes every year.
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