 So our second speaker today is CJ Calvo, our second-year retina fellow, and he has an interesting title. Is there a doctor on board? Thanks, Ryan. All right. Good morning, everyone. I'm CJ Calvo, one of the retina fellows, and I'm excited to give this talk to you about something that has absolutely nothing to do with ophthalmology, and I'm excited to give that to us because as ophthalmologists, I think we really need the help of all people. So the title, the title of my talk is Is there a doctor on board? And I'm going to be talking about something that we very often may encounter, or already have encountered, is the topic of in-flight medical emergencies, and there's going to be a time that you probably will get that overhead page on a plane and have to decide what to do. And so someone gave this talk to me when I was a resident, and I thought it was just really educational about what can you do on a plane? I don't know. You know, what tools are there? What, who can help you? So I think that this will be helpful for us because we are a very subspecialized field, and it's probably been a while since we dealt with a heart attack. How many people here would you say fly more than three times in a year? More than five times in a year? More than ten times in a year? Okay, so there's a lot of frequent flyers in this room. So worldwide, almost three billion people fly every year on a commercial flight. And so we know that in-flight medical emergencies actually pretty common. It's one in 600 flights, or there's about 44,000 in-flight medical emergencies worldwide every single year. Fortunately for patients, I think medical people are pretty well-traveled because in three quarters of all of these medical emergencies, there is a healthcare professional, like a physician or a nurse or an EMT or someone on board that's able to help them. So my objective for this talk is I want to better understand what's the nature of these emergencies, what you're likely to see, and I want to give you some education on what tools and resources are available for you when you respond to an emergency. And then we'll review some of the more common ones because like I said, it's been a while since we've dealt with these things as we're all ophthalmologists. Fortunately, most in-flight emergencies are simple problems. They're self-limited. The flight can go on to its normal journey without being disrupted. And a very serious illness is really rare. And death is particularly rare, you know, less than a point three percent of emergencies. Aircraft diversion, and what that means is say you're flying from New York to LA, diversion means that they need to change the path of that flight. They need to land in Kansas because there's a medical emergency that is time-sensitive and but that's a very rare occurrence. That means seven percent of all cases of medical emergencies have a flight diversion. So you can deal with most of these without diverting the plane. The types of problems that these people have, the majority of them are pre-existing problems. So someone already has COPD. They already have CHF and then they just have an exacerbation or an issue when they're on the plane. But there, you know, a quarter of them are new problems and some of them are even traumas, like someone, you know, overhead bag falls and hit someone in the head or someone gets a burn or they break their arm in a fall. But most of these are pre-existing problems. Medical problems are likely to happen in an airplane because of this interesting physiologic environment that you're in. So planes cruise at about 30 to 40,000 feet. The cabins are pressurized to about 5,000 or 8,000 feet. So about 11 PSI. So that's, you know, if you live in San Diego, you know, it's nothing for us. But if you live in San Diego, that's a big difference in in cabin pressure. And so the reduced partial pressure of oxygen in a healthy resting individual in an airplane is about 93 percent. So if you're someone that has CHF, COPD and then you get it and say you live in, you know, at sea level and then you get in an airplane, you're going to have a significantly decrease in your O2 saturation. And then this pressurization in the cabin is going to lead to expansion of closed gas spaces. So like your sinuses in your middle ear and that could lead to like a lot of discomfort and pain. And then as we know from retina surgery, non-physiologic gases will expand in that environment. Dehydration is a big issue that exacerbates problems in planes. The air is very dry in an airplane. So the airplane draws in air from the dry high altitude air and then it's dehumidified by cycling through the engine compartments. So it's very, very dry air. The recycled air also, you know, you're going to increase exposure to airborne illnesses and allergens. So that may trigger some respiratory diseases in the plane. And then as we know, we know about clotting and DBTs in planes, you know, so you have prolonged sitting, you have high poxemia. And then this may this may activate the systemic inflammation and platelets. And so in high risk individuals, they have a 5% risk of developing a lower limb thrombosis during a flight. So here's a list of there's a study that I'm that I am referencing a lot. It was published in New England Journal of Medicine last year where they looked at about 12,000 medical emergencies worldwide that came in through a call center. So it's like five international and domestic airlines. And you can see that the most common things are syncope, respiratory symptoms, nausea, vomiting and cardiac symptoms. OK, so we're going to talk a little bit about those later in the presentation. So what can we do when you get that overhead page? Is there a doctor on board? So what can we do? Well, the first thing you could do is do nothing. That is that is always a choice that you have. You could just do nothing at all. That is up to you. That is fine for you to do that. There's no legal obligation to assist on a flight. And I'll talk a little bit more about that. But you have to ask yourself, is there a moral and a professional obligation for you to help someone if there's no one else that's raising their hand? Or you can do something. So and we'll talk about those that want to do something and what's available for you. So this picture, I think is from the Moran flight to Hawaii and I is a popular one. So what equipment is available for you? There's an emergency medical kit available on almost every commercial flight that's regulated by the FAA. So if that airplane and then also if that airplane has at least one flight attendant, the FAA mandates that there is an automated external defibrillator. That's not the case in other places of the world, even in European airlines. It's not mandated for there to be an AED. So I want to go over this is the the minimum contents of the emergency medical kit. We're going to go through these. So blood pressure cuff, stethoscope, they have an airway like LMA, like a rinsial mask and for kids and adults. And they have a self inflating like a bag mask that's available as well. There's IV sets with tubing. You have protective gloves. There's needles for IVs or to administer medications. You have syringes to administer meds. You have analgesics. So they have acetaminophen and aspirin on the plane. They have an anesthesia, benadryl, oral and injectables. They have atropine, which is used for cardiac arrest. Aspirin, they have bronchodilator like albuterol inhaler. They have D50 dextrose solutions. And they have epinephrine, one dosage for like an epi-pin for anaphylaxis. And then another one for cardiac arrest like an ACLS scenario. Lidocaine as well. You have nitroglycerin tablets. You have normal saline. And then there's some basic instructions in the kit on how to administer this drugs. OK, so another thing that's really helpful and this isn't required. And it's not, you know, ubiquitous among all airlines. But the consulting physicians on the ground are becoming a big resource. And airlines are starting to use these more and more. And so, you know, you have to understand there's a big cost equation for the airline. And I'll talk about that later. And they don't want to divert the plane unless they absolutely have to. So they're going to consult with physicians on the ground that they do this all the time and they're going to be able to tell you what you should do. And so that could be a big resource for, you know, someone like me. I'd love to talk to another physician on the ground. So here's an example of this. This is a company called Medair. They are emergency room physicians that are located inside the emergency room of Vandergoot Samaritan in Phoenix and have ER physicians 24-7. And they are very experienced. You know, they're not just ER physicians that are getting thrown in there. Like they're trained specifically on what to do, you know, what signs and symptoms are is acceptable for you to manage, you need to divert. So they're really going to be helpful to you. So you're not going to have a phone to talk to them directly, but they're going to you're going to be able to communicate through the flight attendance and the pilot to the staff on the ground. Flight diversion, as I said, it's not common. It only happened in seven percent of flights, but it's a it's a really complicated thing. So they have to decide, are you going to save any time by, you know, diverting in Kansas or can we just book it another three hours and get to LA where we're going? If we stop in a small airfield in Kansas, are they going to have medical services nearby that are going to be able to take care of it? Is the weather safe? That's going to be another consideration for them. And then also like airplanes aren't always, you know, they may not be safe to land immediately after takeoff. If they have a large load of fuel, they may have to jettison this fuel to a fuel drop in order for the plane to be safe to land. And then it's a huge cost. So twenty thousand to three quarters of a million dollars for an airline to to vert a flight, because they have to now. Figure out this whole plane of people. We have to have them go somewhere. They have to get there if they have housing and then all the other flights down the down the line that that plane was going to go on. So it's a huge cost. So the airline definitely does not want to do that if they don't have to. Unfortunately, most people do fine without it. Liability is something that we think about a lot. And that's definitely, you know, it would be a concern of a volunteer health care provider and especially in a field that we're not very familiar with. And so there's no legal obligation to assist in the United States, Canada, England and Singapore. But in some countries like Australia and some European, it is required for you. So I don't know how they'd figure out that you were there. But apparently there have been legal precedent that that it is required. There's a 1998 Aviation Medical Assistance Act, which has a good Samaritan provision that protects passengers that offer medical assistance, you know, other than gross negligence or willful misconduct in. So in most states, you know, in the United States, you're not protected by the good Samaritan law. If you accept payment for your care. So, you know, if I, you know, see someone, but I bill for it, then you're no longer a good Samaritan. However, you know, it's very common for airlines that they want to give you points or they want to upgrade you or give you drink vouchers or something if you help. And it seems that that does not prevent you from being covered by the good Samaritan laws. However, the aviation experts say that that's something that makes you really nervous. Just avoid accepting any gratuities. And then you'll kind of eliminate that concern for you. There's only been one case in the United States where a physician has been sued for assisting in an in-flight emergency, but that case was dismissed. So it's a very, very low personal legal risk to assist in an in-flight emergency. And this practice is supported by experts in aviation medicine. So you really have a lot of people backing you up. And you only have to realize if you're the only physician on board, some medical care is better than no medical care. I think that's been in the news quite a bit. There have been scenarios where there's an in-flight medical emergency, but there was a female physician, particularly females of color. And they asked for a doctor and you have like a female anesthesiologist or ER doctor and the flight attendants have bias and say, no, we don't want your help. We have like a male pharmacist. We'd rather him help us. And so these have been in the news. So I bring this up because you may consider caring with you. You're like hospital badge or I know many state medical licensees that give you like a wallet version to have in there. So if you want to help, you could have we bring a credential with you. And that can really allow you to get in there and help if the if the airline is giving you some resistance. So the most common in-flight emergencies, as we said, there's syncope, respiratory, GI and cardiac symptoms. I'm going to talk about some of them that I think may be the most difficult to deal with. We'll first talk about syncope. So when you first evaluate someone with syncope, and this is common in an airplane, people are dehydrated, you have altitude changes, people are nervous or cramped. It's just, you know, they may be hot, you know, so it really predisposes people to passing out. You know, when you're going to go and try to awake this patient, you have to understand that very often syncope patients are unresponsive. And when you check their vitals early on, they may be hypotensive as well. And so this should improve. So, you know, in most patients, they can improve just with oral treatments. They don't require IVs, but if they have persistent alter mental status, you need to start thinking about something else like an MI or a stroke. And so what you should do in these, confirm breathing impulse, move the patient to the aisle or the galley and then place the patient in a supine position, their legs raised and then provide oxygen for them. You're going to want to continue to check vital signs. As I said, patients are going to be hypotensive immediately after the episode. If the patient has diabetes or if you're concerned, check the blood sugars either with the kid or fine one on the plane. And then most patients, if it's just syncope, they're going to respond in a couple of minutes spontaneously. And if the patient, for some reason, cannot take oral fluids, you know, you need to consider doing an IV and giving them the normal saline. Cardiac symptoms, you know, these are the ones that are probably some of the scariest on the airplane. But thankfully, with aspirin, nitrates and oxygen, you can really manage most of these yourself without diversion. In most cases where an MI or if you're if you're suspecting an MI or an arrhythmia, the AED would be a really helpful tool. You can put the AED pads on the patient and they have an analysis mode. And that can tell you, you know, some may actually show you a strip. Most of them won't. But it will tell you the patients in, you know, ventricular tachycardia, ventricular fibrillation, and that will give you a sense of what the patient's kind of disposition is. Are they in normal sinus rhythm? If so, AED will tell you do not shock. And if it tells you they should shock, then this is a lot more severe than you thought it was. So you can use AED as a monitoring device. The survival rate of cardiac arrests on airplanes is, you know, very different, you know, Carrie Fisher, the actress she died from a cardiac arrest on an airplane, but about half of these, the flight actually did not diverted in this series of the 12,000 flights or 12,000 emergencies over two years. None of the 920 non-arrest cardiac cases resulted in death. So like I said, you could manage these patients pretty well. And then they use the AED or they apply the AED to 137 patients, but only five of them, thank you, only five of them received a shock so you can see how it's helpful to use the AED as a monitoring tool. So you're going to want to check vital signs. You're going to want to provide oxygen to them. If your history suggests that the chest pain is cardiac in origin and consider giving them aspirin, nitroglycerin, sublingual nitroglycerin can be given every five minutes, but you want to make sure the patient's systemic blood pressure is greater than 100 to prevent them from getting hypotensive with that dose. You want to check their blood pressure after everyone. We talked about using the AED for its monitoring capabilities. And then, you know, ground-based consultation is very helpful with these. So there's a paper that also talks about this in JAMA and they have these cards that are in the paper. And so, you know, GI, stroke, seizure, obstetric emergencies, they have these like quick reference cards. So I think I'm going to probably take like a screenshot of this and keep it in my phone in that event. But if any of you guys are interested in having it, just let me know and I'll email you the paper. I think it could be a good thing to keep in like the photos of your phone to have like a reference sheet if you needed to have some help. So in conclusion, you know, it's a pretty common thing. So a lot of people here fly, if you fly more than 10 times over a year throughout your life, you know, there's a high likelihood that you're going to have a medical emergency. So I think that we should all be prepared in these scenarios. We are ophthalmologists, but we are physicians and people are going to expect you to your physician. You know, you need to be able to have some basic physician knowledge and medical service. You can't just say, you know, let me know when they need a desec or something, you know. Thankfully, most of these in-flight emergencies are self-limited. The plane will proceed on its normal journey. And then there is minimal personal liability and offering assistance. And like I said earlier, if you were the only physician on board, some medical care is better than no medical care. Any questions? All right, thanks everyone.