Doctors Facing Medical Emergencies: What They Can and Cannot Do?

 

I received a comment and question in a WhatsApp chat group who asked me this:

 

 Dear Dr Lim,

 

I read with tremendous interest both your blog articles on AI vs human intelligence, Why the sky is dark at night, are we more intelligent than AI, the laws of robotics, is the Moon landing faked among other Thanks abundantly for your delightful efforts. 

But what I want to ask you is, you would be helpless as a doctor in a medical emergency in an aircraft without medical equipment, and you would prefer to leave the case to a first-aider to handle, especially flying in the airspace of another country where you are not registered to practice medicine.

Wouldn't that be against medical ethics? You also mentioned the Good Samaritan law. Wouldn’t that also protect you as well as a doctor? Maybe you should elaborate. 

Thank you. 

Jimmy Lee 

………………………………………………………….

Here's my answer to Mr Jimmy Lee:

 

Thank you, Jimmy, for your question.

I don’t actually mean doctors in an aircraft should not attend to a medical emergency, especially flying in the airspace of another country where they are not registered for practice.

Neither do I actually mean that their hands are tied with limited medical facilities onboard a passenger plane.

What I meant was, a doctor needs to be careful when flying through the airspace of another country where he is not licensed to practice medicine or to administer any medical treatment especially without the written consent of the patient or their relatives in critically ill patients inside an aircraft, even when requested by the pilot or cabin crew.

Of course, emergency childbirth in an aircraft or anywhere can easily be attended to by anyone, including cabin crew in an aircraft.

 So is choking using abdominal thrusts (Heimlich manoeuvre). Doctors are not required for many of these medical events. A first responder or a first-aider can handle these quite skillfully. 

But there are many medical emergencies in pre-hospital environments like in an aircraft where there is no facility, and little can be done even by doctors on board.

In such medical events, the patient needs to be transported to an appropriate (not nearest) hospital where there are facilities for aggressive medical or surgical interventions.

 For instance, there is nothing we can do in the event of massive internal bleeding such as the rupture of an aortic abdominal aneurysm (AAA). The patient may go into hypovolemic shock due to massive internal bleeding from the main artery – aorta. The patient may become hemodynamically unstable with AAA who presents with classic symptoms/signs such as hypotension, flank/back pain, pulsatile mass due to a sudden rapture of the aorta. He should be taken urgently to the operating room for immediate control of haemorrhage, resuscitation, and repair of the aneurysm.

 Immediate intervention prior to endovascular aneurysm repair (EVAR) to arrest internal bleeding is essential. In such events, we may consider giving IV access, initially by placing two large-bore IVs in place for rapid administration (bolus) of crystalloids, blood or medication.  

We may also consider plasma volume expanders (PVEs) intravenously to increase or retain the volume of fluid in the circulatory system. They are used to treat cardiogenic shock (a life-threatening condition in which the heart cannot pump enough blood that is needed by the body).

 But of course for external bleeding such as cuts and external injuries this is less of a problem where we can apply compressions with pads, cloth, gauzes, etc over the bleeding sites till bleeding stops through the body’s natural clotting mechanisms.

In acute myocardial infarction (AMI) – heart attack, the basic management we consider is ABC:

• Airway (does the patient have an open airway?)
• Breathing (is the patient breathing)
• Circulation (is there a detectable heartbeat)

• Appropriate ABC first aid techniques are given artificial respiration or cardiopulmonary resuscitation (CPR) followed by cardiac defibrillation if there is arrhythmia shown on ECE. Drugs like thrombolytic, vasodilators, antiplatelet and antithrombotic agents, ACE inhibitors, aspirin, etc, etc. may be indicated.

 Then there are also other events that are possible to passengers in an airplane

These may include allergic and hypersensitivity reactions such as anaphylaxis and asthma exacerbations may occur during air travel. Although the incidence of in-flight asthma and allergic emergencies may be rarer there may be other situations in the air that need immediate medical or surgical interventions.

 Let me give you just one or two examples, else we might need to write a textbook on the management of so many types of medical emergencies.  

Just to give you 1 or 2 examples will do here:

 

Let’ s take the first example on: 

 

1.   Acute neurological emergency like coma

The Management is:

50 ml of 50 % glucose IV infusion

Thiamine (vitamin B1) administered parenterally if coma probably due to acute alcoholism from over drinking on board a plane.

Seizure and infection must be treated.

Hypothermia, acid-base imbalance and metabolic disturbances must be corrected.

Reduction of ICP (intracranial pressure) may be lifesaving if instituted early. This can be done by forced by:

Hyperventilation to reduce arterial pCO2 to 30-35 mm Hg.

Intravenous infusion of mannitol of 200 ml of a 20 % solution 6 hourly

Dexamethasone (4- 6 mg 6 hourly) in cerebral oedema from intracranial tumours

Restriction of fluid intake

Neurosurgical referrals in some cases where a space -occupying lesion or hydrocephalus is found.

 

Let’s take a look at another example:

2.   Status Epilepticus

Monitor and restore vital function in ICU.

Any underlying cause or precipitating factor must be corrected.

Anticonvulsant therapy must be instituted immediately. Allergic and hypersensitivity reactions such as anaphylaxis and asthma exacerbations may occur during air travel. Although the exact incidence of in-flight asthma and allergic emergencies

First line drugs used are:

 IV Diazepam 10 mg (repeat if necessary) followed by IV Phenytoin 18 mg / kg body weight. Infused at a rate of no faster than 50 mg / min. Cardiac rhythm and blood pressure monitoring required in elderly casualty with ischemic heart disease.

Second line drug:

IV Phenobarbital 10 – 20 mg / kg body weight at rate no faster than 100 mg / min. Respiratory depression may necessitate assisted ventilation.

Third line drug

Seizures are considered refractory if third line drugs are required. Barbiturates induced coma under ECG guidance preferably in collaboration with a neurologist.

Please note:

The above are just two examples for academic interest information purposes only, and are not meant for self-treatment by using these drugs or methods normally used in hospitals.  All medical treatment, whether in a medical emergency or for chronic cases, must be administered by a medical doctor or a qualified healthcare professional except for simple non-pharmacological first aid.  The author of this blog discharges himself from all responsibilities if this advice and notifications are ignored.  

These are just two examples that cannot be managed inside a passenger plane flying at 10,000 metres over the earth’s surface. The plane has to make an emergency landing and the patient needs to be transported to a hospital immediately on landing.

 Then if a passenger goes into a shock which can be many types, ranging from hypovolaemic, septic, cardiogenic, anaphylactic, due to impeded blood flow, endocrinological condition, and neurogenic disorders we cannot treat all these inside a passenger plane what else can a doctor do? .

 A doctor confronted with these conditions in an airplane cannot do much except request for emergency landing with an ambulance waiting.

He can do some first aid to stabilize the patient of course in pre-hospital environments.   

Then there may be other emergencies and events  that can happen anywhere,  such as shock, cardiac emergencies, hypertensive emergency, acute respiratory emergency, acute gastrointestinal emergencies, acute metabolic emergencies, uraemic emergencies, acute neurological emergencies, haematological emergencies, thromboembolism, emergencies due to allergy, acute auto-immune emergencies, acute poisoning, acute life-threatening infections, near drowning, heat stroke,  brain attack (stroke), snake bites that can happen elsewhere in other environments

How do you expect a doctor, a paramedic, medical technician, first responder, first-aider or any other health-care profession manage all these medical emergencies in a pre-hospital environment such as in a passenger aircraft without any facility such as adjunct airways, intubation equipment drugs, defibrillator, oxygen, IV lines…etc.

But there are situations I have confronted personally that require drugs, but I have none. So, what did I do? It concerns a young Malay girl who suffered an acute asthmatic attack - an extreme form of asthma exacerbation characterized by hypoxemia, hypercarbia, and secondary respiratory failure we call it status asthmaticus. So, what did my nurse and I do without drugs? Click to this link below:

“Ancient Medicine and Modern Medicine: My Personal Experience” published in my blog on Sunday, June 13, 2021

https://scientificlogic.blogspot.com/search?q=alternative+medicine

 

Once you get there, scroll down to the paragraph “Another Medical Emergency” to get the story.  

As far as your question about Good Samaritan laws (GSL) is concerned, this law offers legal protection to people even if not trained or qualified who give reasonable assistance to those who are, or whom they believe to be injured, ill, in peril. This is to encourage the public to render help in emergencies, especially in life-saving situations where otherwise they may be reluctant to offer help lest they may get sued if they make mistakes and make the situation worse because they are untrained and unqualified. This is why bystanders need to be legally protected else they may be unwilling to help.

It may not apply to doctors, paramedics or any healthcare professional who are trained and qualified but did a wrong or an unethical treatment that causes more harm to the patient in a medical emergency. So, doctors and healthcare professionals need to be very careful especially in a foreign country where a doctor is not registered to practice any form of medicine.

But I don’t think GSL gives protection to a doctor, paramedic who are supposed to be skilled but cause more harm to the patient or they give treatment without the consent of the patient or against his or her wishes.

Basically, there is nothing like learning first-aid. It does not require a license to practice. First-aiders only need to attend a 2- 3 days course, and for advanced first-aid course, they may need three or more weeks training with clinical skills stations available to practise their clinical skills such as cardiac defibrillation, intubation, IV infusion…oxygen administration and emergency drug administration, among others.

The purpose of first aid is to stabilize a patient in a medical event, and this can be extremely lifesaving. It might be surprising to know that not every doctor knows first-aid or how to treat a medical emergency. During their training they may not even be posted to the emergency department of a hospital. In their short stint of posting, they may not have any exposure in emergency medicine. They may only be posted to other areas of general medicine such as in ophthalmology, dermatology, general medicine and surgery, psychiatry, paediatrics, radiology departments etc that hardly require emergency care.

During my training in emergency medicine and trauma care at Kuala Lumpur Hospital, Selayang Hospital and at the University Hospital, National University of Malaysia (HUKM) as part of my voluntary service as a Regional Staff Officer for Training for St. John Ambulance Malaysia, we were told Malaysia may not have the Good Samaritan Law (GSL) to protect the public from rendering aid in medical emergencies. They suggested Parliament need to enact a Good Samaritan Bill ASAP (as soon as possible). Most countries, especially western countries and in the United States and Canada have the GSL.  

It might be surprising to know that not every doctor knows first-aid or how to treat a medical emergency. During their training they may not even be posted to the emergency department of a hospital. In their short stint of posting, they may not have any exposure in emergency medicine. They may only be posted to other areas such as ophthalmology, dermatology, general medicine and surgery, psychiatry, paediatrics, radiology, etc that hardly require emergency care.  

It might also be a surprise to everyone that a paramedic is a healthcare professional who undergoes a rigorous and structured 4-year training in emergency medicine in a university. He is far more qualified and professionally skilful than a doctor who undergoes a 5-year medical training in general medicine and surgery and may not be exposed to emergency and trauma care unlike a paramedic who specializes in this area for 4 years in a university together with clinical exposure in the emergency department of a hospital. A medical student takes 5 years to learn all sorts of medical disciplines - all mixed up, but a paramedical student takes 4 years to learn and specialize mainly in one medical discipline – medical emergency. So, we know their vast differences in clinical skills. I had stories told to me about their clinical skills when I was a trainer for St. John Ambulance Malaysia and also at University Hospital at the National University of Malaysia (HUKM)

I hope I have answered some aspects of emergency and trauma care. We can go on for days into months in this area of medicine, but I need to stop to attend to some housework and to rest.

Kind regards and thank you once again for your question.

Lim ju boo