Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Up in the Air – Suspending Ethical Medical Practice I

In this week of holiday travel and the stress produced by the security theater of the TSA (Transportation Security Administration), it is reasonable to look at the stress that can be produced by medical theater.

An article in the New England Journal of Medicine describes a complication faced by five doctors in dealing with an in-flight cardiac arrest.

After 25 minutes of basic cardiac life support, there was still only pulseless electrical activity. The five physicians agreed that it was time to stop the code and declare the patient dead. But the flight attendant explained that if we stopped CPR, the airline’s protocol would require the cabin crew to continue it in our stead. “This is futile,” muttered the surgeon, and without discussion, he returned to his seat, leaving four of us facing a dilemma: If we turned the resuscitative efforts over to the crew, who would look after the passengers? But if we continued CPR, we would be treating a patient who had clearly been “overmastered” by his disease.[1]

There are a lot of comments in response to this. Two of the doctors continued CPR (CardioPulmonary Resuscitation), even though there was no good reason to continue CPR at this point.

The pilot announced that he was diverting the plane to a small airport. The crew calmed the passengers, addressed their other needs, and attended to landing preparations. As we descended steeply, the pilot ordered everyone to be seated. The anesthesiologist and oncologist complied. We were down to two physicians administering CPR. A flight attendant took over the use of the Ambu bag and required coaching on technique. I was instructed to hold onto my wife as she continued chest compressions, both of us half-strapped into stretched safety belts to allow us to continue CPR during the landing.[1]

Being transported in a car, a baby held in the arms of the baby’s mother is not considered restrained. The rapid deceleration from even 30 miles per hour is going to dramatically increase the weight of the baby to the point where the mother cannot hold onto the baby. The baby is no longer a baby. The baby is now a projectile.

Now, if a baby travelling at the speed of 30 MPH is too heavy for a mother to restrain, how much more futile will it be to attempt to restrain an adult travelling at several hundred MPH?

Futile CPR x futile attempts at restraint = Futile2?

I have never attempted to perform CPR during the landing of a plane, but I do not expect that it is any more effective than the ineffective CPR performed in a moving ambulance. The doctor and the flight attendant performing ineffective CPR were only endangering the other passengers and themselves. They are not just not restrained, but they are not even in seats that might act to partially restrain them.

Doesn’t the airline have a protocol requiring everyone, including flight attendants, to wear seat belts during take-off and landing?

Why does the ridiculous protocol trump the sensible protocol?

We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline’s protocol. CPR was going to go forward whatever we decided, and we chose to continue it ourselves so that the four flight attendants could attend to their duties during an emergency landing.[1]

How is endangering everyone in the cabin a practical concern?

On solid ground, I believe that medical policy and protocols should preclude such dilemmas. The responsibility for deciding to stop CPR should rest with a physician who is focused solely on the good of the patient.[1]

What if focusing solely on the good of the patient, in this case a clearly dead patient, endangers others who are not yet patients? The others may end up being patients due to the actions of the physician, or the others may end up so dead that no resuscitation is even attempted on them.

Terminating Resuscitative Efforts in Adult OHCA
Terminating Resuscitative Efforts in a BLS Out-of-Hospital System
Rescuers who start BLS should continue resuscitation until one of the following occurs:

  • Restoration of effective, spontaneous circulation
  • Care is transferred to a team providing advanced life support
  • The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met.
  • One set of reliable and valid criteria for termination of resuscitation is termed the “BLS termination of resuscitation rule” (see Figure 1).23 All 3 of the following criteria must be present before moving to the ambulance for transport, to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest: (1) arrest was not witnessed by EMS provider or first responder; (2) no return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis; and (3) no AED shocks were delivered.[2]

    During landing, continuation of the resuscitative efforts places others in jeopardy.

    Termination of Resuscitative Efforts and Transport Implications
    Field termination reduces unnecessary transport to the hospital by 60% with the BLS rule and 40% with the ALS rule,25 reducing associated road hazards34,35 that put the provider, patient, and public at risk. In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement.36-38 More importantly the quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital.39-41
    [2]

    In the absence of an effective restraint system that permits CPR in an airplane during landing, those who do not regain pulses should be pronounced dead.

    The airline should have a protocol that specifically states this. Encouraging passengers or flight crew to endanger others, when CPR has not been effective, is endangering the passengers and the flight crew.

    This is irresponsible behavior by the airline.

    There are a lot of comments. Some provide good approaches to this. Others demonstrate that being a doctor and being sensible do not necessarily go together. I will address the comments in Up in the Air – Suspending Ethical Medical Practice II and later in Up in the Air – Suspending Ethical Medical Practice III

    Footnotes:

    [1] Up in the Air – Suspending Ethical Medical Practice.
    Shaner DM.
    N Engl J Med. 2010 Nov 18;363(21):1988-1989.
    PMID: 21083383 [PubMed – as supplied by publisher]

    Free Full Text Article from N Engl J Med with comments and links to Free Full Text PDF download

    [2] Terminating Resuscitative Efforts in Adult OHCA
    Part 3: Ethics
    2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Witholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital Cardiac Arrest (OHCA)
    Terminating Resuscitative Efforts in OHCA
    Free Full Text Article with links to Free Full Text PDF download

    .

    Comments

    1. To start off, thank you to those who volunteer to act not because you are legally obligated to but because you care. That being said, this article is a Pandora’s Box. For the most part the standard of care, protocol, and reporting that occurs is at the discretion the individual airlines. The FAA and the U.S. government have only regulated three major things with the Aviation Medical Assistance Act (AMAA) in April 1998. 1) Death while flying needs tracked and documented. 2) AED’s and minimum standards of medical supplies be available on flights, and the flight crew be trained in their use. 3) Neither the airline, nor the person providing assistance is liable for damages as long as the crew believes the passenger is “a medically qualified individual**” and the care is not grossly negligent or willful misconduct. Outside of this act standards are set by individual airlines for reporting medical emergencies and how those emergencies are handled. Essentially it’s a Good Samaritan Law for medical professionals while flying that supersedes jurisdictional and state boundaries.
      *the government definition includes Physician, PA, Nurse, Paramedic, & EMTs. Sorry for the emphasis on EMS staff I was just excited for the recognition of the professional qualifications EMS. Ok I’m off this Soap Box.

      The author was concerned that his practice as a physician was being impugned and infringed by the airlines when he wanted to declare the victim dead. “…as we continued administering CPR, we were acting less as physicians than as skilled passengers assisting a flight crew.” The AMAA law is only asking you to do just that. Act as a “medically qualified individual rendering ASSISTANCE” To declare a person dead is beyond assisting becomes practicing medicine. This could be seen as a class 1 felony in many states if you are not licensed to practice medicine within that state you make the declaration (Some states will allow it). There is a difference between declaring death and stopping CPR. RougeMedic lays out heavy list as to why to stop CPR, and unquestionably CPR has reasons to be stopped, particularly with regards to personal safety. I believe this entire event was a communication error between the flight crew and physicians caused by a stressful situation. The decision to make a divert landing for medical emergency is at the discretion of the pilot in most airlines. If the victim is dead the correctable phase of the emergency has passed. There is no longer a medical emergency. I know the physician is considering the good of the patient before the good of the community, but I was always told that when the patient dies that you should shift your focus from the patient who is gone to caring for those who are present. So what about considering these perspectives:

      -Should the pilot attempt an emergency landing at an airport that is not optimal for the aircraft, risking everyone on board, or should he continue to a better suited airport for a victim who’s outcome is death either way?

      -What effect would being in close proximity a declared dead person (social vs clinical death) have on the other passengers? Will seeing a dead person cause high anxiety for some and PTSD for others? In some cultures, even in the US, death is a major taboo.

      -A person who dies outside the hospital and unexpected will have to remain unmoved until a local coroner or medical investigator can document it. This would likely leave the aircraft, flight crew, and passengers displaced longer then transferring a patient to local EMS. In this case the person was in PEA, which is likely a rhythm local EMS protocol would require an ACLS resuscitation attempt before considering it futile.

      1) Was the situation in the article a result of a communication error needing clarification? Yes. 2) Do airlines need more clear and universal policies and protocols for in flight emergencies? Yes. 3) Should CPR be stopped, even if temporally, for safety reasons? Yes. Did everyone do what they felt they could given the situation? Yes. Did some of the original article commentators need reminded that their profession is not without boundaries? Yes

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