The kit held a tantalizing, yet frustrating, array of options. Most of the commonly used resuscitation drugs were there, but we found only one IV kit, which a passenger opened and began trying to insert into a vein in our patient’s arm — no easy task on the now rapidly descending plane.
For an in-hospital arrest, once CPR is underway, someone needs to start thinking about treatable causes. For example, if we know that the patient has high potassium, we can treat that specifically instead of just following a one-size-fits-all protocol. Usually, that “someone” is one of the many professionals responding to the code, not the person leading it or doing chest compressions.
Nevertheless, I quickly went through the leading culprits in my head. Severely elevated acid levels, or severe imbalances in blood chemistry? Hard to see how that would happen during our flight, and I couldn’t test for or treat it with what I had on hand.
A massive blood clot? This can happen on a plane because of immobility (the “coach class syndrome”), but it’s pretty rare on a short flight.
A pneumothorax, when air collects between the lung and chest wall, can happen at altitude and cause cardiac arrest, but this usually pushes the windpipe to one side; our patient’s airway was perfectly centered.
Too little circulating blood volume? It could happen if someone were dehydrated or bleeding profusely — neither of which were obvious to me.
A medical chart might have provided clues, but of course none was on hand. But then I happened to see my patient’s wallet falling out of his pants pocket. Grabbing it, I almost immediately found what I was hoping for: a list of medications.
Another good medical aphorism is that 80 percent of diagnoses are made on history alone. This patient couldn’t speak, but his medication list spoke for him. Seeing several blood pressure medications and a blood thinner on the list, I inferred he had heart disease and high blood pressure.
Locked in an Upright Position
I thought about the narrow airplane seats, and about the position in which we found my patient: upright but unconscious. Perhaps his medications caused lower-than-normal blood pressure, and he had passed out. Unable to fall over, he’d remained upright, unnoticed, without enough blood flow to the brain, a situation that can lead to cardiac arrest.
Long before smartphones, this potentially lethal combination was known as “telephone booth syncope.” Falling over is the body’s way of protecting itself from low blood pressure because it allows whatever remaining blood pressure is present to work with gravity in getting blood to the brain. Passing out and being held upright, as in an old-style telephone booth, or in an airplane seat, or when well-meaning bystanders hold someone upright after they’ve fainted, can spur the central nervous system to shut down — in particular breathing, which is controlled by the brain stem.
If this patient had suffered telephone booth syncope, we needed to get as much blood to his brain as possible. Chest compressions helped, and we were preparing to give him IV medications. Now we lifted up his legs, too, to help restore central circulation.
As low-tech as this intervention is, while we did it the patient started to move, weakly. I felt a pulse, weak but steady, at his wrist. And a few seconds later, I felt a bump: The plane had touched down.
It had seemed like forever, but the pilot had found an airport and landed less than 30 minutes into our resuscitation efforts. A few minutes after we touched down, paramedical personnel were on board. I gave them a 30-second summary of what happened, and the patient was loaded onto a stretcher and gone. The captain called me to the front of the plane, and I told him what I thought had happened.
“Good work,” he said. “Now, what did you think of that emergency landing, eh?” I told him the truth: For once, worrying about the landing was the last thing on my mind.
I don’t know what happened to my patient; I never even learned his name. I have wondered about him in the years since this incident, however. The survival rate for cardiac arrests on an airplane is 1 in 7.
But long-term survival really depends on the cause of the event. And I’m optimistic that my diagnosis was right. Studies show that in-flight diagnoses are often borne out when patients reach the hospital. If the problem was telephone booth syncope, chances are good that he survived.
[This article originally appeared in print as "Up in the Air."]