# Can you push ALS drugs based off an AED's decision to shock?



## exon111 (Dec 14, 2008)

The FAA requires larger commercial aircraft to carry ALS drugs like epi and lidocaine, but many of their AEDs don't display an ECG readout.  Hypothetically, if you are on a plane with a drug bag and an AED, could you push ALS drugs based on the AED's decision to shock or not?  If the AED says "shock advised", the patient must be in either v-fib or v-tach, so would it be alright to give epi after the first shock if AED recommends a second shock?


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## KEVD18 (Dec 14, 2008)

anybody who would treat based on a guess should have their ticket pulled the mintue the plane lands.


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## FF894 (Dec 14, 2008)

Wait, WHAT!?  Which ALS provider is going to be administering these drugs.  "Is there an ALCS certified person on the flight?  Please come to the front cabin"


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## traumateam1 (Dec 14, 2008)

KEVD18 said:


> anybody who would treat based on a guess should have their ticket pulled the mintue the plane lands.



Not that I disagree, because I don't.. but if this is the case, why does the FAA require ALS drugs to be on large commercial airplanes, if they only have AEDs w/o ECG screens?


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## VentMedic (Dec 14, 2008)

traumateam1 said:


> but if this is the case, why does the FAA require ALS drugs to be on large commercial airplanes, if they only have AEDs w/o ECG screens?


 
Interesting....

http://www.flightsafety.org/ccs/ccs_nov-dec01.pdf


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## FF894 (Dec 14, 2008)

Okay, I breezed through that and still don't see anything about an appropriate ACLS provider (and even more so for some of that) being on board to administer?  Did I miss it?


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## ffemt8978 (Dec 14, 2008)

VentMedic said:


> Interesting....
> 
> http://www.flightsafety.org/ccs/ccs_nov-dec01.pdf



Very interesting read...good find, Vent.


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## KEVD18 (Dec 14, 2008)

FF894 said:


> Okay, I breezed through that and still don't see anything about an appropriate ACLS provider (and even more so for some of that) being on board to administer? Did I miss it?


 
it does say that this gear is only to be used by a "qualified" person and goes on to specifically reference doctors and nurses.

what cracks me up about that is not every nurse would have the foggiest clue what to do with half of it(the same could be said for some doctors, but i digress).


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## VentMedic (Dec 14, 2008)

One more link:

http://rgl.faa.gov/Regulatory_and_G...fbaba1cf3e86256c2a004c7f3b/$FILE/AC121-33.pdf


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## traumateam1 (Dec 14, 2008)

Good article Vent, and thank you. But I still don't have an answer to my original question.

"Off duty" medics can now push ALS drugs when in the air based on an AED's interpretation of a heart arrhythmia?


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## traumateam1 (Dec 14, 2008)

KEVD18 said:


> *it does say that this gear is only to be used by a "qualified" person and goes on to specifically reference doctors and nurses.*
> what cracks me up about that is not every nurse would have the foggiest clue what to do with half of it(the same could be said for some doctors, but i digress).



Again, I don't disagree with you Kev.. but how do you know what rhythm if it's only an AED without an ECG screen?? Are they going off of the fact that a shock advised means is either two rhythms? v fib or v tach?


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## FF894 (Dec 14, 2008)

traumateam1 said:


> Good article Vent, and thank you. But I still don't have an answer to my original question.
> 
> "Off duty" medics can now push ALS drugs when in the air based on an AED's interpretation of a heart arrhythmia?



Technically, you are out of the state so do your protocols apply?  Even if you are NR, not all states fall under NR.  Anything beyond CPR and AED would open up some liability, no?


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## exon111 (Dec 14, 2008)

Most domestic airlines carry Medaire EMK kits: http://www.medaire.com/comm_kits.html

International carriers often have either Medaire enhanced-EMKs or Banyan Stat-kit 700 or 900s.  All of these kits are full of ACLS drugs, but the planes are only equiped with an AED.  The flight crew is not authorized to use drugs, they are supposed to ask if there is a medical professional on board who can assist.


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## ffemt8978 (Dec 14, 2008)

FF894 said:


> Technically, you are out of the state so do your protocols apply?  Even if you are NR, not all states fall under NR.  Anything beyond CPR and AED would open up some liability, no?



I believe the first article also mentioned something about contacting a ground based medical control.  Combine that with the FAA statement that the patient remains the responsibility of the crew, I would guess that you would follow their protocols as long as they were in your scope of practice.


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## KEVD18 (Dec 14, 2008)

with out at least an aed that is capable of being unlocked/overridded to als mode, you would be pushing drugs blind.

as far as the liability, ask whoever it was that tried to tell me what my liability for practicing off duty in my own home state was.


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## traumateam1 (Dec 14, 2008)

Seems flawed to me lol. But I think I am missing something obvious here.. it just doesn't add up.

Here you go, have some ACLS drugs, that you aren't qualified to use. If there is someone qualified to use them, and willing to risk their ticket/license to use them, than it's a good thing you have them. And here is your AED.. just follow the voice prompts. You don't need a screen, just push the button when it tells you too, and if it doesn't.. just do CPR and use these here drugs.


I dunno, I don't really get this. Sorry.


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## exon111 (Dec 14, 2008)

FF894 said:


> Technically, you are out of the state so do your protocols apply?  Even if you are NR, not all states fall under NR.  Anything beyond CPR and AED would open up some liability, no?



If you make contact with the emergency phone number listed on the Medaire kits, you are released from all liability and it transfers to their physicians.

This explains it better: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1119072


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## exon111 (Dec 14, 2008)

traumateam1 said:


> Seems flawed to me lol. But I think I am missing something obvious here.. it just doesn't add up.
> 
> Here you go, have some ACLS drugs, that you aren't qualified to use. If there is someone qualified to use them, and willing to risk their ticket/license to use them, than it's a good thing you have them. And here is your AED.. just follow the voice prompts. You don't need a screen, just push the button when it tells you too, and if it doesn't.. just do CPR and use these here drugs.
> 
> ...



Neither do I, that's why I'm asking   I just can't figure out what you're supposed to do with all the drugs when all you have is an AED.  Some airlines are starting to put Philips FR2+ ECG equipped AEDs on their aircraft, but they are still a very small minority.  FAA requires an AED so they buy the cheap ones W/O ECG.


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## FF894 (Dec 14, 2008)

I agree with traumateam - doesnt make me feel real warm and fuzzy about it, even if I did call some number on the box and talk to some random doctor.  I would be reluctant to use the drugs, especially if i dont know what the heck I'm dealing with.  CPR is the only 100% proven to work therapy.  I'll do that and train people to do that while the pilot lands post-haste.


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## KEVD18 (Dec 14, 2008)

traumateam1 said:


> Seems flawed to me lol. But I think I am missing something obvious here.. it just doesn't add up.
> 
> Here you go, have some ACLS drugs, that you aren't qualified to use. If there is someone qualified to use them, and willing to risk their ticket/license to use them, than it's a good thing you have them. And here is your AED.. just follow the voice prompts. You don't need a screen, just push the button when it tells you too, and if it doesn't.. just do CPR and use these here drugs.
> 
> ...


 

heres the part your missing(altough you're not really missing it, since you said it yourself):

if theres a qualified person there who is willing to do it, then they are equipped. if not, then its just another item that the faa requires to be on board and the only interaction the crew has with it is seeing that its there and checking it off on the pre flight checklist.


further, its the faa. it doesnt matter if it makes sense. they put a committe together and came up with this and now its law.


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## VentMedic (Dec 14, 2008)

But, if the person is pulseless...dead....and you are on a TransAtlantic flight, how long to you think CPR will be effective? Until the next stop?


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## KEVD18 (Dec 14, 2008)

heres how it basically break out: if you code on an airplane, theres a really really really good chance you're going to remain dead. the drugs and the aeds and the rest of the crap are just there to make two groups of people feel better. the passengers, so they can think "if i have a problem, jet blue has mechanisms in place to help me. i feel all warm and fuzzy"; and the airlines so they can say "well, we did everything we could. the drugs and toys were there. if the passangers want to pay the fare increases, we can staf an er attending on every flight, but other than that this is all we can do".


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## marineman (Dec 14, 2008)

I can tell you I definitely wouldn't be the one risking my behind to do it but just wondering if you might be able to get away with thinking on the most basic terms. With either V-tach or V-fib our first line drug is Epi. So if the AED came back and said it was a shockable rhythm could you technically go ahead and push the drug blind. Also if a patient is PNB with a non-shockable rhythm both Atropine and Epi are indicated so if the AED came back and said no shock advised could you give the drugs?

Again before everyone jumps on me I will remain in my seat eating my peanuts and watching the movie but in a real MacGyver style pinch could that be efficient reasoning?


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## KEVD18 (Dec 14, 2008)

btw, look at the list of required gear again, this time focus on the quantities.

that amount of stuff would last long enough to get the medics there if the plane was still on the ground.


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## traumateam1 (Dec 14, 2008)

So it turns into a liability now? Lesser of a chance major airlines are going to get successfully sued over a person dying on their planes?

Well your honor, we did have ACLS drugs, and an AED on board.

I see. Thanks for clarifying it


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## exon111 (Dec 14, 2008)

marineman said:


> I can tell you I definitely wouldn't be the one risking my behind to do it but just wondering if you might be able to get away with thinking on the most basic terms. With either V-tach or V-fib our first line drug is Epi. So if the AED came back and said it was a shockable rhythm could you technically go ahead and push the drug blind. Also if a patient is PNB with a non-shockable rhythm both Atropine and Epi are indicated so if the AED came back and said no shock advised could you give the drugs?
> 
> Again before everyone jumps on me I will remain in my seat eating my peanuts and watching the movie but in a real MacGyver style pinch could that be efficient reasoning?



That's what I was thinking too.


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## traumateam1 (Dec 14, 2008)

KEVD18 said:


> btw, look at the list of required gear again, this time focus on the quantities.
> 
> that amount of stuff would last long enough to get the medics there if the plane was still on the ground.



Thats what I thought too Kev.. not a whole lot of supplies there, just enough to hopefully get the job done.


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## KEVD18 (Dec 14, 2008)

traumateam1 said:


> Thats what I thought too Kev.. not a whole lot of supplies there, just enough to hopefully get the job done.


 

nope. just enough to make it look like you could possibly get the job done while keeping it to a cost effective minimum.


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## traumateam1 (Dec 14, 2008)

So moral of the story:

Don't have "the big one" on an airplane.


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## FF894 (Dec 14, 2008)

In a hypothetical world I would say to the person next to me that has no idea who I am and could not identify my later as having anything to do with EMS so they can't go after me "I think you should push the one that says "Epinephrine" yeah that one, try 1mg - should be the full ampule.  Yeah just like that, I saw it on House once."  Okay, no shock advised? "OK, now try the one that says "Atropine" that might work..."  B)


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## FF894 (Dec 14, 2008)

traumateam1 said:


> So moral of the story:
> 
> Don't have "the big one" on an airplane.



True that...


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## TomB (Dec 15, 2008)

I worked a full arrest on a Delta jet on the tarmac at Savannah International Airport (SAV). It was an early morning flight and the plane was boarding when the patient coded. I used the AED (Philips HeartStart with monitor screen) and drug kit from the plane (I was impressed with the drugs in the box). The airway equipment was supplied by Crash Fire Rescue who seemed perfectly content to have me continue patient care until a ground EMS unit arrived on the scene. That took a long time. Apparently you can't just drive onto a major airport's tarmac without jumping through some hoops. I should add that there were several doctors and nurses on the plane also. In fact an anesthesiologist intubated. Having said that, I directed the code with the support of the other medical professionals on board the plane. By the time the ground unit showed up, the patient was bucking the tube, so when the local paramedic showed up and wanted to move the patient, we protested and suggested that he medicate the patient to maintain the tube first. I can't believe I was on the receiving end of this comment, but the paramedic gave me "that look" and said, "are you a doctor"? Before I could answer, one the doctors on the plane said (in his best "I'm about to bite your head off" voice) "I'm a doctor!" The paramedic left and returned a minute later with a prefilled syringe of Valium. It was passed down the line, and a nurse gave all 10 mg which calmed the patient down and helped maintain the tube. The paramedic looked at the doctor and said, "You'll need to come with us" at which time the doctor laughed directly in his face like he had just told a really funny joke. The paramedics loaded the patient on a long spine board with spider straps and carried the patient out from in front of the flight deck, out the side door of the plane, down the side stairs of the jetway, and away they went. The patient was awake and talking by arrival in the emergency department, but the flight left 45 minutes late because of the commontion and the fact that the pilot would not leave until the medical kit was restocked (no one seemed to know how to accomplish this). Needless to say, we all missed our connections.


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## TomB (Dec 15, 2008)

Oh yeah, all this to say, there are much MUCH worse places to have "the big one" than a commercial jet airliner! At home for example.


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## FF894 (Dec 15, 2008)

Strong work...  Dont worry- how do you know there's a doctor on the plane?  Oh, they'll tell ya!


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## KEVD18 (Dec 15, 2008)

the trick becomes seperating the dermatologists from the intensivists.


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## mycrofft (Dec 15, 2008)

*Or podiatrists (fell victim to that once)*

Back to original question.
No.
Even Welch Allyn, who makes super-duper VS monitors, says when you ask them directly that their machines are for monitoring, not directing care. (With an allowance for 10 mmHg in diastolic for their clinical machines as "acceptable", darn well better not be). The rudimentary scope on an AED and using two leads for your "ekg" can't help things along. I also don't think that their ratio of screen refresh to display may be a little high also.

If it was OK, they would be selling automated paramdics which would be placed on the chest and a bluetooth BP cuff put on the arm, the rest up to circuitboards.


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## FF894 (Dec 15, 2008)

mycrofft said:


> a bluetooth BP cuff



Now you are talking...


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## AlaskaEMT (Dec 17, 2008)

I would think you could run the V-fib/V-tach algorithm based on an AED's analysis.  You'll probably never need to, but if you had to...

Interesting topic.


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## reaper (Dec 17, 2008)

Lets look at it this way. If the pt has no pulse and not breathing, they are in arrest. Start normal CPR.

First drug in any rhythm is Epi, so why not push it. From there you would be blind on second drug. If the AED advises shock, then that would suggest VT/VF. So you could determine that Lido would be next. If no shock advised, then next would be Atropine.

I have talked with an FAA investigator about this very issue. If you are qualified to use the equipment and the ACLS drugs(ie-Paramedic,Rn,Dr,Rt), then you will not be held liable for their use. As long as you follow ACLS guidelines. I think you can justify the reason for your decision on Lido or Atropine in a case like this.

It is all up to what you as a provider feel comfortable doing!


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## MedicMeJJB (Dec 17, 2008)

:blink::blink:





KEVD18 said:


> anybody who would treat based on a guess should have their ticket pulled the mintue the plane lands.



Agreeeeeed!:blink:


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## KEVD18 (Dec 17, 2008)

reaper said:


> As long as you follow ACLS guidelines.


 

this is where the wheels fall off your argument. 

show me one acls document/reccomendation/protocol/rule/regulation from any organization having the authority and ability to produce such a document that states you should treat cardiac dysrhythmia blind. just one.


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## WuLabsWuTecH (Dec 17, 2008)

Don't get involved in this one...

While all US planes are considered part of the US even while over other countries, they aren't from the state you left or are going to and you'll have more issues than you can imagine!


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## reaper (Dec 17, 2008)

Never stated that I would produce a cert saying you can treat blind. I will follow the ACLS protocols for the rhythm I feel they are in. 

You need to be able to adapt in a situation like the one described. I would not have a problem treating this, if that is all you have to go off of. You can sit in your seat, that is your decision.


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## reaper (Dec 17, 2008)

WuLabsWuTecH said:


> Don't get involved in this one...
> 
> While all US planes are considered part of the US even while over other countries, they aren't from the state you left or are going to and you'll have more issues than you can imagine!



Do you realize how often a pt is treated in the air by a medic or Rn? According to the investigator I spoke with, there has never been a licensing or liability issue in any case. This was a case study I did years ago for a class. I had to research all of these issues and interview FAA personnel for the study.


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## Markhk (Dec 17, 2008)

Guys,

I think the question boils down to, "does an aircraft have ECG monitoring capability?" 

The answer is "maybe". Some airlines are extremely progressive with their telemedicine programs. Virgin Atlantic for instance purchased the Tempus 2000, which has 12-lead capability with transmission to Medaire, an aviation medical direction center. When I worked for another company, an airline was looking to purchase a product that Physio-Control used to distribute, the Biolog. It's a handheld EKG that is placed onto the chest directly which contacts three electrodes on the back.

See it here:
http://www.univie.ac.at/cga/courses/BE513/EKG/BiologInAction.jpg

A newer version of the Tempus unit is the Tempus IC, which can be seen here
http://www.tempusic.com/
That thing has more features than some of the Lifepaks I see around on CCTs. 

I will say that many airlines have gone with the Heartstart FR2 with ECG screen for the sole purpose of allowing medical professionals on board to see the screen. Heck, Philips even makes a special aviation battery specifically for the FR2. 

I would also add that despite the rather significant number of meds and equipment in the EMK, there are some rather dramatic oversights (in my opinion). For instance, a glucometer is not required on board. (Probably has to do with CLIA but Air Canada does carry it on board.) And how about something stronger for nausea? (Medaire stocks their Enhanced EMKs with Zofran now instead of promethazine...neither of which is required on board...Zofran to my understanding isn't great for motion-related vomiting).  And guess what about the aviation medical oxygen bottles? You aren't going to get anything more than 6lpm. So don't expect to use a non-rebreather on board. 

One thing I have consistently not seen on board -- and I think this is a good thing -- is intubation equipment. Auscultation next to the jet engines is difficult to say the least, with the need to move the patient during landing, tube extubation is a genuine concern. 

I've met a lot of flight attendants during training who have wonderfully varied backgrounds...surprisingly, quite a few are nurses, paramedics and EMTs themselves. So to echo what people have said, "Coding in an aircraft might not be as bad as one might think".


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## KEVD18 (Dec 17, 2008)

reaper said:


> I have talked with an *FAA investigator* about this very issue. If you are qualified to use the equipment and the ACLS drugs(ie-Paramedic,Rn,Dr,Rt), then you *will not be held liable for their use. As long as you follow ACLS guidelines*. I think you can justify the reason for your decision on Lido or Atropine in a case like this.


 

a quote from you, purportedly from an official with the faa, states that you are free from liability as long as you are properly trained and certified and you follow acls guidelines. your words, not mine.

so again, please direct me to a guidline that reccomends treating cardiac dysrhythmia blind.


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## KEVD18 (Dec 17, 2008)

Markhk said:


> Guys,
> 
> I think the question boils down to, "does an aircraft have ECG monitoring capability?"


 

im on board with everyhting you said after the above quote. unfortunatley, this scenario was posed as an aircraft without ekg monitoring capability and specifically revolves around guessing what rhythm they are in and treating accordingly.

if the plane has a aed that can be overridden then its a whole different ball game. you're no longer blindfolded


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## Markhk (Dec 17, 2008)

I agree with Kev's sentiment here...why do we feel, as advanced providers, the need to push cardiac meds in cardiac arrest? Even the OPALS study in Canada is showing that the most benefit for patients in cardiac arrest is early CPR and defibrillation, rather than ALS meds. And no anti-arrhythmic on the market has shown long term survival benefit. 

Also, let me echo again that the flight attendants on board don't just stand around looking cute during a code. One is usually designated the scribe, and documents what is going on the code. And the AED has a EKG card which is reviewed by the airline's medical director. (Yes, these airlines take it very seriously.) So if, for some reason, you give a patient a medication "blindly", the F/A will document "150 mg lidocaine given by Paramedic Passenger XYZ" and the doc can match it up on the event review summary from the AED. And if the docs sees you pushing lido in PEA (of course you wouldn't have known that with the screen-less AED), he might not be happy. You never know -- the airline doc could follow up with you or your employer. This has never happened to my knowledge, but you never know. Why risk giving a patient a med "in the blind"? 

Right medication, right patient, right dose, right route...RIGHT INDICATION.


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## reaper (Dec 17, 2008)

Markhk said:


> I agree with Kev's sentiment here...why do we feel, as advanced providers, the need to push cardiac meds in cardiac arrest? Even the OPALS study in Canada is showing that the most benefit for patients in cardiac arrest is early CPR and defibrillation, rather than ALS meds. And no anti-arrhythmic on the market has shown long term survival benefit.
> 
> *This may be beneficial when the pt will be transported right away. This is a whole different scenario we are dealing with here.*
> 
> ...



Again, You are dealing with a scenario that is outside the box. If the AED has a readout, then you would not be blind. This case was about using an older AED. This is a case where you are damned if you do or don't. If we are an hour out from landing and CPR and early defibrillation is not working, then I would try the drug route. At this point you have nothing to lose. They are dead, so Yes, I would go a head with them.


For everyone concerned with liability issues when dealing with any emergency on a flight. Here is a quote from the "U.S. Aviation Medical Emergency Act"

Quoted-(b) LIABILITY OF INDIVIDUALS.—An individual shall not be liable
for damages in any action brought in a Federal or State court
arising out of the acts or omissions of the individual in providing
or attempting to provide assistance in the case of an in-flight
medical emergency unless the individual, while rendering such
assistance, is guilty of gross negligence or willful misconduct.


Yes, you will argue gross negligence or misconduct. I would have no problem defending those issues, if all other options had failed. 

Plus, you would be on line with a MC MD. So you can run it past them too.


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## VentMedic (Dec 17, 2008)

> On-board medical assistance will continue
> to be discretionary and must be
> regarded as emergency treatment, *with*
> *no unrealistic expectations of favorable*
> ...


 
http://www.faa.gov/library/reports/medical/fasmb/media/F2004_1.pdf​ 

The drugs available for ACLS are Atropine, Epi and Lido.
I have a feeling they will have little note cards and even the basic description giving one an indication of when to use what. The flight attendants may be educated on how to follow the cards or at least be of some assistance to a licensed medical professional. If someone has some basic knowledge of ACLS, if they followed just the simplified instructions and the online MC, they may be able to get through a round. 

The biggest stumbling block is not everyone will know what it means when the AED says "Not shockable". ​


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## reaper (Dec 18, 2008)

VentMedic said:


> http://www.faa.gov/library/reports/medical/fasmb/media/F2004_1.pdf​
> 
> The drugs available for ACLS are Atropine, Epi and Lido.
> I have a feeling they will have little note cards and even the basic description giving one an indication of when to use what. The flight attendants may be educated on how to follow the cards or at least be of some assistance to a licensed medical professional. If someone has some basic knowledge of ACLS, if they followed just the simplified instructions they may be able to get through a round. ​
> The biggest stumbling block is not everyone will know what it means when the AED says "Not shockable". ​



I agree with that one Vent. I was looking more at a Medic,Rn or Dr helping on this call. Someone that might have more knowledge in ACLS care.


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## VentMedic (Dec 18, 2008)

reaper said:


> I agree with that one Vent. I was looking more at a Medic,Rn or Dr helping on this call. Someone that might have more knowledge in ACLS care.


 
Not all Paramedics, RNs, RRTs, or MDs are created equal.


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## Markhk (Dec 18, 2008)

Hey Ventmedic,

The flight attendants I trained with were specifically told, "Do not open the EMK unless a medical professional shows a license", except for the BP cuff and stethoscope(kept in an exterior pouch). As such, the F/A are not suppose to do any skills outside the First Aid/CPR/AED/O2 route or even touch the meds...the protocol cards are suppose to be "strictly" for the medical professional rather than the F/A.  

As you can imagine, this sort of frustrated the flight attendant/ER nurse.


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## reaper (Dec 18, 2008)

VentMedic said:


> Not all Paramedics, RNs, RRTs, or MDs are created equal.



Their not? i thought that was the rule!B)


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## WuLabsWuTecH (Dec 18, 2008)

reaper said:


> Do you realize how often a pt is treated in the air by a medic or Rn? According to the investigator I spoke with, there has never been a licensing or liability issue in any case. This was a case study I did years ago for a class. I had to research all of these issues and interview FAA personnel for the study.



They should include something on the kit then that states that the user of the kit is protected under good Samaritan laws from claims of liability and the citation of the USC that contains that language.

Also, remind me again, do Good Samaritan Laws allow for the provider to stop at any time?  the other issue could become that once treatment is initiated, the provider would have to continue no matter what.


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## WuLabsWuTecH (Dec 18, 2008)

VentMedic said:


> http://www.faa.gov/library/reports/medical/fasmb/media/F2004_1.pdf​
> 
> The drugs available for ACLS are Atropine, Epi and Lido.
> I have a feeling they will have little note cards and even the basic description giving one an indication of when to use what. The flight attendants may be educated on how to follow the cards or at least be of some assistance to a licensed medical professional. If someone has some basic knowledge of ACLS, if they followed just the simplified instructions and the online MC, they may be able to get through a round.
> ...



Really?  Is it REALLY a good idea to train non-medical professionals (or anyone really) about how to push drugs using note cards?  This really worries me.

And I guess this explains teachers and professors allowing us a note card on exams.

"Professor?  If you're giving us a 3x5 note card for the exam, why not just make it an open book exam instead of us trying to cram everything onto the notecard or make it a closed not exam?"
"Well, in real life, if you were ever on an aircraft and someone coded, you don't have your textbook but you do get a 3x5 note card!"


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## VentMedic (Dec 18, 2008)

WuLabsWuTecH said:


> Also, remind me again, do Good Samaritan Laws allow for the provider to stop at any time? the other issue could become that once treatment is initiated, the provider would have to continue no matter what.


 
I think this quote I found earlier states "reasonable expectation". If there are no longer qualified or willing people to continue CPR for extended periods of time and the chances for survival rapidly decreases the longer CPR much be performed in less than an idea situation, reasonable expection of a favorable outcome can not be expected.

I did not say for Flight attendants to push meds. I stated to be of some assistance to the licensed medical professionals. They would know the kit and the needed instructions or emergency contact help. AHA ACLS publishes the little quick reference cards for all providers to use in the field or hospital.

I, myself, would even have a difficult time proving I am any type of medical professional since I do not carry my licenses if it is not a business trip.


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## Markhk (Dec 18, 2008)

I think, in particular, we have to keep in mind the international nature of some flights. The Aviation Medical Assistance Act does not specify if a US medical license is required, so you might have docs and nurses from other parts of the world (who call epi Adrenaline, and lidocaine Ligonocaine, and spell albuterol salbutamol), so those little cards may come in handy. 

Medaire, the aviation section of the Mayo Clinic, etc. solves a lot of the questions presented here, because you can just get orders from a physician on the radio.  

Interesting random fact: In a 10-year study, the FAA reported that there were no cases of fatal anaphylaxis on board US aircraft.


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## marineman (Dec 18, 2008)

VentMedic said:


> I, myself, would even have a difficult time proving I am any type of medical professional since I do not carry my licenses if it is not a business trip.



That's what I was thinking. I leave my first responder cert in my jump bag and my medic training permit on my clipboard that I bring on my ride alongs. I don't think I've ever carried a cert in my pocket other than maybe CPR.


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## VentMedic (Dec 18, 2008)

Another interesting link about Medaire and available equipment possibilities:

http://www.aviationweek.com/aw/gene...ca0907p2.xml&headline=The Doctor Is Always In


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## akflightmedic (Dec 18, 2008)

Interesting thread here.

Due to the amount of travel I do annually, I have had my fair share of experience with these scenarios. Some of you against working outside the box just do not seem to grasp the nature of air travel.

You can not just plop down anywhere as soon as an emergency on board arises. Even if flying over the US at a normal altitude of 30-35K feet, it will take 30 minutes or more to do an emergency landing. There are runway considerations, fuel issues, etc. Now with that time frame in mind and knowing the proven statistics of viability of a cardiac arrest patient outside of a hospital, what would you do?

I do a lot of international travel, meaning there are times where it could be HOURS before a landing is even possible. So go back through this scenario and ask yourself, would you provide ACLS medications without knowing what is on the screen? What if it were a family member? Would you still try?

The few times I have assisted on an IFE (In Flight Emergency), the attendants were extremely calm and quite selective in whom they allowed to assist the patient. My certs are always in my pocket and validating them (best as you can at 35K feet) is required before they even told me who the patient was. Basically they looked at them for appearance sake and checked the expiration date, which is fine because I do not imagine too many whackers travel with false credentials. I am sure it occurs but not that often.

I have worked one cardiac arrest, several syncopal episodes, abdominal pain, two chest pains and administered a patient's pain medication IM.

Except for the cardiac arrest as it was quite a few years ago, I had to show documentation of who I was and then after the flight attendant was comfortable with me, I was then allowed to assess the patient and determine if they needed any intervention and if the plane needed to divert. After my assessment, I was then placed on a phone with medical control whom I briefed on patient status and gave my opinion of whether or not we should land.

This is the tricky part!! It would be very easy for some overzealous, inexperienced or undereducated rescuer to say "we need to land now", when in all reality the patient will probably be fine. They do not want to hear those words unless it is absolutely necessary. Be prepared for medical control to question you quite extensively. If they are the attendant are dissatisfied with your answers, treatment or conduct, they will very quickly have you take a seat and make you sit on your hands.  (Seeing who read this far)

As far as legalities, we have covered that already with links to documentation supporting us so that we may render care, however I had indeed asked the same question when I offered my services. One of the airlines had me sign a document prior to rendering care that made me a temporary employee of the airline and thereby falling under the auspices of the airline's medical control physician. Since I was an employee, they have to compensate me, so I did receive an upgrade for a future flight and some Dom Perignon.

Not sure where I was going with all this, but I think I just want to stress that there are and will be times when you have to work outside your comfort zone. Some times within reason. extreme situation may call for an extreme action. Pushing medications on a cardiac arrest while in flight with no chance for landing instantly would be one of those times.


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## reaper (Dec 18, 2008)

Dang Ak, that was long!!!!!            j/k

But you wrapped up everything that has been discussed, perfectly.


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## Markhk (Dec 20, 2008)

That was a great post akflightmedic. 

I would just add a caveat though, in regards to the last part of your post for anyone who might be interested . While some airlines are generous enough to provide a "thank you" (it sounds like this particular air carrier had thought it through very well), other airlines will not provide compensation whatsoever. This is the norm, particularly in the United States, as there appears to be some belief amongst some legal departments that a "thank you" gift might void the protections given in the Aviation Medical Assistance Act. (I'm not a lawyer so I can't comment on how valid this logic is.) 

And then you get the psychiatrist like this one:
http://www.bmj.com/cgi/content/full/317/7160/701


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## MMiz (Dec 20, 2008)

Markhk said:


> That was a great post akflightmedic.
> 
> I would just add a caveat though, in regards to the last part of your post for anyone who might be interested . While some airlines are generous enough to provide a "thank you" (it sounds like this particular air carrier had thought it through very well), other airlines will not provide compensation whatsoever. This is the norm, particularly in the United States, as there appears to be some belief amongst some legal departments that a "thank you" gift might void the protections given in the Aviation Medical Assistance Act. (I'm not a lawyer so I can't comment on how valid this logic is.)
> 
> ...


I got a thank you card, 5,000 frequent flyer miles, and a round of applause.


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## marineman (Dec 21, 2008)

MMiz said:


> I got a thank you card, 5,000 frequent flyer miles, and a round of applause.



Heck, I'd settle for a first class upgrade B)


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## TomB (Dec 21, 2008)

marineman said:


> Heck, I'd settle for a first class upgrade B)



Don't hold your breath.


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## piranah (Jan 8, 2009)

interesting situation.....i am ACLS/PALS intubation certified but licensed BLS in my state does the state cert count or my certifications......i would do BLS anyway im just wondering...


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## mikie (Jan 8, 2009)

*Great post AK!*



akflightmedic said:


> The few times I have assisted on an IFE (In Flight Emergency), the attendants were extremely calm and quite selective in whom they allowed to assist the patient.




Can you tell us what interventions you preformed on these patients with the limited supplies the airplane had?  

Thanks!


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## CH47Doc (Jan 12, 2009)

KEVD18 said:


> btw, look at the list of required gear again, this time focus on the quantities.
> 
> that amount of stuff would last long enough to get the medics there if the plane was still on the ground.




i was just going to say that.  theres also only .5 of atropine available, great for a first round pedi code.  I like how theres actually a sheet provided to tell the flight attendants what the drugs are for.  ya think they really care?  i like the 'non-narcotic pain relief' of 325mg of ASA as well.


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## mikeylikesit (Jan 12, 2009)

I wouldn't unless i got a readout first! Plus who am I covered by in case poo hits the fan and the drugs are bad or mislabeled?


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## reaper (Jan 13, 2009)

CH47Doc said:


> i was just going to say that.  theres also only .5 of atropine available, great for a first round pedi code.  I like how theres actually a sheet provided to tell the flight attendants what the drugs are for.  ya think they really care?  i like the 'non-narcotic pain relief' of 325mg of ASA as well.



Well, it is really 1 mg of atropine. So that is good for one round in adult code. I think the ASA is more likely for cardiac issues. They have tylenol, advil and aleve for pain. Hey, it is better then nothing!


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## CH47Doc (Jan 13, 2009)

my bad.  2 ampules of .5mg.  i never seen an 'ampule' of atropine.  i seen it in prefilled 1mg syringes though.


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## lizhiniatsos (Jan 13, 2009)

I've got a dead guy (or gal) in front of me...good CPR in progress...no status change in the patient....and a minimal tool box at hand....am I gonna take a chance and DO something....or just leave 'em lyin?....I'm thinkin'... I sure ain't gonna make 'em any deader by tryin' a few tricks...
           ....is it worth the risk? Each of us can only answer that for ourselves and act within' the bounds we feel are appropriate(all legal mumbo jumbo aside)...the answer will vary from one end of the spectrum to the other...

           for me, yes, the chance that I might help someone stick around to enjoy life awhile longer is one I would have to take...or live forever wondering "what if" and feeling horrible about it~


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## june125 (Jan 18, 2009)

This is a personal choice for each and everyone. I personally couldnt sit by and do nothing, I would want someone to help my family member.


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## daedalus (Jan 18, 2009)

I feel confident in pushing epinephrine in an arrest situation on an airline, even without EKG tracing. Dead is dead. The epi will probably make no difference in outcome but its worth a try huh?


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## rhan101277 (Jan 18, 2009)

FF894 said:


> Strong work...  Dont worry- how do you know there's a doctor on the plane?  Oh, they'll tell ya!



We have to ask for their credentials before they can begin care and once they start they are supposed to ride to the ambulance with you, since pt care is now their responsibility.  I don't know how reasonable that is in the field.


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## bonedog (Jan 19, 2009)

daedalus said:


> I feel confident in pushing epinephrine in an arrest situation on an airline, even without EKG tracing. Dead is dead. The epi will probably make no difference in outcome but its worth a try huh?



10-4, concurrance...


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