Born to act... or at least learning how: My response to a mid-flight emergency 30,000 feet up8/22/2018 In December 2017, a few weeks after graduation from nursing school, I found myself on a Christmas Eve flight to Florida to spend the holiday with my in-laws. Being a poor recently graduated, unemployed prospective nurse, we booked a red eye flight out of Denver. I’m not usually one for sleeping on planes, its just not something that has ever come easy to me, so I read my book for the first hour of the flight. I’d like to say I was drilling flashcards or reviewing material for the NCLEX, which may in fact be true, but I honestly can’t remember at this point.
We had lucked out and got seats in an exit row on a Spirit flight, which for anyone who has ever been packed into a Spirit seat, knows is a godsend, and luckily nobody was seated in the row with us. I was seated in the window seat and decided I would try to get some sleep so I would be somewhat functional to celebrate Christmas when we arrived. I closed my eyes and leaned my head against the side of the plane attempting to drift off in the most unnatural sleeping position possible. It couldn’t have been more than five or ten minutes after I closed my eyes before I heard someone a few rows back shouting for help. “Please someone help, he’s not conscious! I don’t know what’s wrong!” These are not the most ideal choice of words anyone wants to be hearing traveling 500 miles per hour, 30,000 feet up in the sky. I’m not sure if it was machismo from just graduating nursing school or what, but I knew that I had to answer this call for help. In hindsight it could have helped that a couple weeks prior to this flight at my pinning ceremony, as I was seated in the front row, I watched as a fellow nursing student crossed the stage to be pinned. Meanwhile an elderly relative of hers crouched to take pictures in the aisle, when suddenly he began to struggle to get up and nearly fell over from a crouched position onto the floor. I just watched (and so did 35 other graduates in my cohort) as this elderly man wobbled. In my head I debated whether this was serious enough that I should take action, and worse callously thought about whether I should interrupt the ceremony to help. Finally our favorite professor and key note speaker decided he had seen enough and leapt into action jumping down from the stage and coming to this elderly man’s aide. I remember believing in that moment that Dr. Parker had waited as long as he could to see if any of us recent grads would rise to the call and only jumped into action when us newly minted nurse graduates failed to do so. For the record the old guy was fine, perhaps his knees were bad, or he was a little bit light headed and dizzy trying to stand up too quickly, but the point was I had let myself and Dr. Parker down. Answering the call for help isn’t always an easy thing to do. One of the simplest things I’ve learned since my pinning is that we can make that decision a non-decision by choosing in advance to help. This rule of thumb holds true coming to the aide of those outside of our job, as well as being quick to act when things start to go south or just don’t feel right about a patient when on duty at work. Then when the moment of truth comes we just have to act, we don’t need to deliberate about whether it is the right thing to do, we just need to get proximal to the event and do what we can to help. Back at 30,000 feet on Christmas Eve, I decided to act. I jumped out of my seat and moved a few rows back to find a couple seated in both of the aisle seats. The wife is on my left as I stand facing the back of the plane, and she is rightly hysterical about her husband seated to my right on the other side of the aisle. He is unresponsive with his head slumped onto his chest. I look up and down the plane and realize that no one else is coming to help, this is it, and it’s all on me. I, the recent nursing school graduate, have the most medical experience on this entire flight. What are the odds? No pressure right? The first thing I do is check my “patient” for a carotid pulse, which is absent or so weak I can’t palpate it. Now I’m thinking this guy is having a cardiac arrest, I’m literally going to have to do compressions on this flight. I release the man’s seat belt and try to arouse him by calling at him and asking if he is ok while squeezing his triceps. Now I am telling the passengers in the area that I need help moving this man to the exit row area where there is more room for me to work on this guy and we can start CPR. Nobody is moving; everyone is just looking at me, dear-in-the-headlights. “Seriously people, this is a freakin’ emergency!” I scream inside my head. Finally a woman seated directly behind my “patient” gets up to help me move him. As we start to grab him to move him out of his seat, the man’s eyelids open but his eyes are rolled back in his head. He begins to come to a little bit. As he becomes a bit more arousable I ask him if he is having chest pain or shortness of breath, which he denies. He states he has a headache and doesn’t feel right. He is lethargic and not all together with it. I decide to evaluate for a stroke, because it seems like a reasonable thing to do. So I have him smile for me, and raise his arms out in front of him. His speech is a little bit slurred and he is obviously confused about what is happening, but I don’t think he has had a stroke. At this point a flight attendant hands me a blood pressure cuff and a disposable stethoscope. I think I’ve been handling things pretty well up until this point, but I have a moment of panic with the blood pressure cuff and stethoscope in my hands. I absolutely hate using the disposable stethoscopes because you can’t hear anything. They are worthless, and I panic that I am not going to be able to get a reading on this guy’s pressure due to the subpar equipment. I decide that maybe he is dehydrated and simply passed out. This too seams reasonable. I recall a patient from my nursing practicum a month or two prior who had a similar look with his eyes rolled back in his head and no palpable pulse who collapsed in his chair when standing and pulling his pants up to be discharged. A vasovagal episode as we call it in healthcare which ultimately leads to fainting aka syncope. Maybe my current “patient’s” blood has been pooling in his legs from sitting so long during the flight and he is not getting good perfusion to his brain. I make a mistake, disengage, and drop the cuff and stethoscope to the floor and head down the aisle towards the galley to ask a flight attendant for some water or ginger ale. Looking back I think I fully intended to come back and check the “patient’s” pressure. I just was trying to buy myself some time and delaying the inevitable because I had already assumed I was going to fail. I also wish in retrospect I would have asked for the gentleman’s name so I could have called for him with his name to arouse him instead of shaking, squeezing him, and basically yelling at him to wake up. When I come back up the aisle there is another women there who has picked up the stethoscope and BP cuff and is taking my patient’s” blood pressure. She is a nurse. She has lots of experience. She is an angel. I breathe a sigh of relief that I don’t have to manage this crisis anymore on my own, but I am also upset with myself that I shirked getting this man’s vitals and this nurse has, unbeknownst to her, had to step in for me. I will learn a lot from this nurse it turns out. She asks the wife for the husband’s name, and introduces herself to the patient. Brilliant! And such common sense! A few minutes later, he starts to get sick, and begins to vomit on his pants and on the cabin floor. The lady who was going to help me move him from his seat to the exit row uses a barf bag to catch what’s left. It turns out she is also a nurse. The older experienced angel nurse is in charge now. She is getting a history of events leading up to the flight from the wife. Brilliant! He’s taken Ambien before the flight; they ate dinner at a restaurant in the airport. They shared their food; the wife is not feeling sick at all. I don’t recall his vitals specifically at this point unfortunately; I think he may have been a bit febrile and perhaps tachycardic and a bit hypotensive. I am helping to get a new cycle of vitals. I assess his pulse rate. The older angel nurse comments on my apple watch display. She says I’m smart to have the second hand displayed on mine; she doesn’t have that on hers. This makes me feel good. Our patient continues to vomit or dry-heave sporadically. Another flight attendant asks us if we’d like some oxygen for our “patient”. It can’t hurt. He brings us a cylinder and mask. From somewhere a medical kit has showed up. It has emergency medicines and other supplies in it. I get the idea to test his blood sugar. He doesn’t have a history of diabetes, but I think it could be useful to rule out. My wife is a type-I diabetic I return to my row and get her glucometer and a new lancet. He surprisingly does have a high blood sugar, not grossly high, but high, perhaps undiagnosed type II or a stress response. His level of consciousness sporadically wanes and rebounds when we arouse him. He is lethargic, a likely effect of the Ambien, but possibly a sign of something else going on. The experienced nurse gets permission from ground control via the pilot to start an IV and administer a 500mL bolus of normal saline. It turns out even at 30,000 feet, under extreme circumstances we need permission from the powers-that-be to take any invasive action. Our goal is to get the fluid in him before we land in Florida. We let the flight staff know they don’t need to reroute the flight. They’ve been busy reshuffling passengers in close proximity to other seats on the plane, giving us more room to work, and freeing others from the trapped stench of emesis in the area. I am doing a good job reassuring the wife and educating her on what we have been doing and what we think might be going on. The experienced nurse nails the IV on the first try. I’m relieved she is here. I have no confidence in my ability to stick a needle in someone yet, much less in the middle of a semi-crisis, 6 miles up in the sky. She asks me to prime the IV tubing. “I can do that,” I say with a smile. There’s not much more we can do. We keep an eye on our “patient” and reassure the wife the rest of the flight. The bolus of normal saline fluid administered through the IV finishes as we taxi to the gate. Everyone is asked to remain seated so that medical staff from the airport can board the plane. They bring a specialized wheelchair just wide enough to squeeze down the aisle. We give report to the medical staff, who busily jot down their notes. They ask the wife a few questions and whisk our patient and his wife off the plane. Our in-flight medical team, returns to our seats. We collect our families and our bags. The rest of the passengers give us a round of applause as we head up the aisle to deboard the plane. Our little medical team and our families have short debrief after we get off the jet way and into the terminal to process our surreal Christmas Eve flight. Passengers departing the flight stream by our little group, telling us thank you and offering other encouraging words as they pass by. We separate from each other with hugs, no longer the strangers we began the flight as, but as a team bonded by our shared experience. I still don’t know much about nursing, but I now know a little bit more about functioning as a team during a crisis, and the underlying bond those of us in this profession share. I spend the next several days, maybe weeks, mulling over what I did well, and what I could have done better. I’m probably too hard on myself; after all I am not even a real nurse. Yet. I don’t need to handle emergencies and crises perfectly. Yet (or ever). I just need to pass the NCLEX, that’s my next goal in sight. Besides there’s always room to be better in nursing, there’s always room to grow and more to learn. Thankfully, there is no substitute for experience either, and this one has pushed me closer towards my goal of being a proficient critical care nurse, in spite of any ineptitude I have. Interestingly I will spot our “patient” and his wife in the ticketing line as we check in for our return flight home from Florida to Denver. I don’t know if they see me, but I also don’t make any effort to be seen or to ask them what the outcome was. For some reason it doesn’t feel appropriate to call out the events of our previous flight or inquire about his health in the sea of all these new strangers. I also run into my new friend the experienced angel nurse, the anchor of our team. She too is returning to Denver on the same flight my wife and I will be on. We catch up about our time in Florida and our return to Colorado. We both remark that it’s funny that we are all here together again, our patient and the two of us. She mentions that she said hi to them. I don’t push her for details, for some reason I prefer not to know. The concourse and ticketing counters are packed. From down the open room someone calls out for help. “Is there a doctor here? Please someone help!” The nurse and I look at each other and shake our heads. “Unbelievable. You’ve got to be kidding me”, I say. She laughs and replies, “Seriously again?” We share a quick chuckle; I turn to begin weaving through the crowded hall toward my next patient in need and just a little bit more prepared. “Born to act”, I tell myself, “or at least learning how.”
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