Question for FT MD's on AA

 
Old Aug 22, 03, 12:03 am
  #1  
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Question for FT MD's on AA

Since there are so many FT MD's who fly AA, I ask this question. Does anyone know the liabilities one faces for treating a "patient" on an international flight? (specifically on AA from LHR to ORD)

This year has been a crazy year for me, as I've logged about 112,000 actual flight miles.

Many times I've heard them ask for a Doctor, and I usually hope someone else is willing. Every time until now, someone else has stepped up. This time, I guess I was the only Physician on the flight or no one else wanted to deal with it.

I guess my question is liability - does it matter where you are when you treat a patient? US vs. international airspace vs. UK airspace?

Here is what happened:

5 hours into the flight, approximately 50% of the way home, 50 year old caucasian woman in coach with history of hypertension, diabetes, obesity suffering from some sort of anxiety attack. (Yes, I assume psychological issues too, but I was going on what she told me.)

I did not have my stethoscope or BP cuff with me. I did have 10ml bottle of Diazepam (5mg/ml) for IV or deep IM use and Ambien 10mg.

Tried to calm her down, I am an ER doc so I should be able to do this effectively. No real luck. I think she was claustrophobic and she did not answer me when I asked her if this was the first time she flew internationally.

First thought was to sedate her and ask the crew to have an ambulance waiting. However, I was reluctant to do so without having vitals. I could have administered 5 to 10 mg of diazepam, and I believe this would have effectively sedated her. Nevertheless, I refused to provide any treatment to her besides verbal coaching.

To make a long story short, they had to restrain her with only an hour left to go in the flight. The FA was "pissed" at me for not sedating her.

If I had my stethoscope and BP cuff, I would have administered the diazepam. I did not, so I did not want to take any chances.

What did I do wrong? What did I do right? I surely didn't make any friends on the flight, passengers or crew.

Can anyone who works for AA pull up the after flight reports? I'm sure it's in there.

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Old Aug 22, 03, 12:12 am
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I for one am glad you used your best professional judgement and paid no heed to FAs who were "pissed" at you for not ignoring it. If they know better, they can administer the diazepam themselves.
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Old Aug 22, 03, 12:33 am
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I'm curious as to why you are carrying around diazepam? Isn't that a controlled substance? I know you can get a DEA license, but can't you get into big trouble? Why not give her the Ambien to put her to sleep if she was causing that much of a problem? This is the reason why it's always best to wait for the second call, "Is there a doctor on board?" The NEJM should do some kind of review article on this as it's something everyone seems to encounter. I think the expert on this would be fullfare, but I don't know if he's around here anymore.
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Old Aug 22, 03, 1:58 am
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CharlesMD, others: B'gosh, I don't perceive myself to be anything of an "expert" on this particular case. My field is trauma surgery and critical care (ICU) medicine. Nevertheless, it sounds like good judgment was rendered here. I, for one, don't carry any drugs around with me.

Reminds me of the old joke: A theatre patron faints and a physician races down to look at him/her. Takes one look and calls out, "Is there a doctor in the house?.

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Old Aug 22, 03, 2:11 am
  #5  
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I believe the laws collectively referred to as Good Sumaritan laws exempt you from most liability if you donated your time, money or resources in the interest of the recipient. For example, donating food to a shelter that results in sickness of someone will not expose the donor to liability. This holds true in most states, but there are certainly various laws and standards. I don't know much about how this applies to medical donations (including a physician's time).
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Old Aug 22, 03, 4:13 am
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Diazepam is a benzodiazepine, the original, I believe 40 years old now. I carry with it, and as a licensed Physician and Surgeon, I can carry pretty much whatever drugs I want with me on board.

Why did I have diazepam? Remember that crazy brit Richard Reid that tried to blow up a plane using a shoe bomb? They didn't get him fully restrained until they sedated him. If this was the case, then fine, I would have gladly sedated the guy until saliva ran down his chin.

As for the Ambien, again, a woman with unknown health problems. No way to take vitals. Ambien is not narcotic, but it is a controlled substance just like diazepam. Both are not class II and can be phoned in in Illinois. Anything class III and below can be phoned in to the pharmacy in Illinois.

Oh, and FYI - I'm traveling with U.N. Medical Services papers right now.


Just something I found.

Class I drugs are those with very high abuse potential and no therapeutic indication. These include compounds such as heroin and PCP. You may not write prescriptions for these drugs.

Class II drugs are used as narcotic stimulants and depressants. This class includes amphetamines, morphine, codeine, DronabinolTM, FentanylTM, hydromorphone (DilaudidTM), Meperidine (DemerolTM), methadone, RitalinTM, oxycodone (PercocetTM, PercodanTM, RoxicetTM, TyloxTM), rapidly acting barbituates (pentobarbitol, SeconalTM) and cocaine. All of thse drugs require a narcotic prescription. (Please check with the RNs for pads).

Class III are combination products containing a class II compound and a noncontrolled drug. This class includes VicodinTM, FiorinalTM (with codeine), TylenolTM number 2-4, testosterone (TestoDermTM patch), and hycodone (TussionexTM). These may be written on a standard prescription pad, but a DEA number should be included.

Class IV drugs include benzodiazepine, phenobarbitol, propoxyphen/DarvonTM, MeridiaTM, AmbienTM and phentermine. In New York State, a narcotic prescription is required for all benzodiazepines. Please review the prescriptions with your supervising PIC. The drugs in this class like AmbienTM does not require a narcotic prescription, but a DEA number should be included on the prescription.

Class V drugs include cough syrup containing codeine and diphenoxylate (Lomotil). These may be written on a standard prescription pad, but a DEA number should be included.

Once you have a NYS license, you may apply to the DEA for a narcotics license and your own triplicate pads. This is rather expensive, and few residents choose to follow this route. (You must, however, have a DEA number in order to be accredited as an attending, so it is a good idea for those residents not doing fellowships to apply for one in April of your senior year. Otherwise your hospital appointments will be delayed). More commonly, residents use the AIM clinic narcotic pads, which are locked up in the nurses' offices. After you use the pads, it is important to return them to the locked cabinets.


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Old Aug 22, 03, 4:15 am
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<font face="Verdana, Arial, Helvetica, sans-serif" size="2">Originally posted by CharlesMD:
I'm curious as to why you are carrying around diazepam? Isn't that a controlled substance? I know you can get a DEA license, but can't you get into big trouble? Why not give her the Ambien to put her to sleep if she was causing that much of a problem? This is the reason why it's always best to wait for the second call, "Is there a doctor on board?" The NEJM should do some kind of review article on this as it's something everyone seems to encounter. I think the expert on this would be fullfare, but I don't know if he's around here anymore.</font>
Ambien is also a controlled substance. You don't put someone to sleep if you don't know if they are going to wake up. Moreover, as someone else here states in their sig, what if she had taken a laxative?

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Old Aug 22, 03, 6:42 am
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Without any real medical history, which this person was not really able to clearly give, any medication could cause problems, i.e., allergic reaction, interactions between medications, etc. Except for something like insulin shock or emergency athsma treatment which is life threatening, I believe caution should prevail and this was handled properly. JMHO
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Old Aug 22, 03, 6:55 am
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I am not a doctor at all - my opinion though is that the FA had a lot of nerve getting "pised off" about the way you handled it - and when did the FA graduate medical school?

What you did makes sense to me.
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Old Aug 22, 03, 7:19 am
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I had a similar experience recently. A pregnant FA fainted and I was the only physician on board. I was able to determine it was a vaso-vagal response but I kept on wondering what my liability was in this sitiuation and if the Good Samaritan rule came into play....
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Old Aug 22, 03, 9:37 am
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Sounds like you did the right thing. Imagine giving someone medication w/o any med history and them suffering adverse effects? Not just from a liability standpoint, but how would you feel as a person?

Me, I carry 10mg Valium (diazepam) for long flights to make me real happy if the Ambien don't knock me out. Never had it injected, it must be nice to get that "I don't care" feeling real fast...
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Old Aug 22, 03, 10:24 am
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<font face="Verdana, Arial, Helvetica, sans-serif" size="2">Originally posted by fredmartens:
Me, I carry 10mg Valium (diazepam) for long flights to make me real happy if the Ambien don't knock me out. Never had it injected, it must be nice to get that "I don't care" feeling real fast... </font>
From your profile, it doesn't look like you're a doctor. Did you just get a perscription from your doctor?

I've only had Valium once, and it was injected. That was lovely. Although, I tend to have a vasovagal response from injections, but the valium was enough to overcome the unpleasentness.

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Old Aug 22, 03, 10:47 am
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I'm not a doctor but my wife is a nurse who rarely flies, but in recent years she has been on three flights where they have asked for a doctor/nurse.

The first time she responded the FA asked her for her license to get the number for their log and she didn't have it. Now she always carries a copy with her. It happened again that they asked two weeks. One time she asked for the onboard oxygen and they brought her a cannister that wasn't even half-full. She was the one who was "piised". But I seemed to remember they carry BP cuffs now. Maybe I'm wrong.

Two weeks ago we were out over the Paciifc when a medical problem came up onboard the captain got on the radio to AA HQ and consulted with a doctor because none were on our flight. The doctor "suggested" we land ASAP and the next thing we know we were in LAX at 3 in the morning.

I think the airlines are totally worried, and probably with good reason, about liability. I think if any medical professional onboard suggested to the captain that a landing take place ASAP for medical reasons you would be on the ground sooner than you would think possible.
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Old Aug 22, 03, 10:50 am
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You gave it your best- So, did they upgrade you?
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Old Aug 22, 03, 10:51 am
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I wouldn't worry if the care I provided was emergency care to prevent loss of life or serious injury. The only time I was asked to assist on a flight, a woman had facial swelling from an antihypertensive medication (Vasotec), and injectable Benadryl was in the plane's first aid kit, and she asked me to administer it, so I did, and I really didn't worry about liability. The captain asked me if would should return to departure airport (SLC) or proceed to destination (SMF) and I told him to go on ahead. Boy, was he relieved!

I agree with the OP and others and would not have given this woman Valium or Ambien. Among other reasons, some people have paradoxical reactions to these drugs, producing disorientation.
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