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

[KEVD18]

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.

 

[WuLabsWuTecH]

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!

 

[reaper]

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.

 

[reaper]

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.

 

[Markhk]

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A newer version of the Tempus unit is the Tempus IC, which can be seen here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".

 

[KEVD18]

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.

 

[KEVD18]

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

 

[Markhk]

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.

 

[reaper]

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.

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.

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.

 

[VentMedic]

On-board medical assistance will continue
to be discretionary and must be
regarded as emergency treatment, with
no unrealistic expectations of favorable
outcomes for passengers experiencing
medical distress in flight. For this reason,
it is likely that the Aviation Medical
Assistance Act provides a "Good Samaritan"
clause that limits "non-employee
passenger liability." This means that
persons, such as passenger physicians,
who are not employed by the airline
and who, in good faith, offer their assistance,
will not be held liable unless
the assistance is "grossly negligent" or
is "willful misconduct."​

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". ​

 

[reaper]

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.

 

[VentMedic]

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.

 

[Markhk]

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.

 

[reaper]

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

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

 

[WuLabsWuTecH]

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.

 

[WuLabsWuTecH]

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". ​

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!"

 

[VentMedic]

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.

 

[Markhk]

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.

 

[marineman]

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.

 

[VentMedic]

Another interesting link about Medaire and available equipment possibilities:

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