HICKAM AIR FORCE BASE, Hawaii -- (Editor’s note: This article is part one of a three-part series about in-flight medical support among Pacific Air Forces Surgeon General Team members.)
A night flight from Colorado to Hawaii nearly became tragic when a woman vomited and passed out near the lavatories in the back of an airplane.
Fortunately, Lt. Col. Ross Graham, Deputy Chief, Medical Readiness Division, PACAF Surgeon General, was also a passenger on that aircraft. He answered the call to step in, take lead, share his expertise, and render care.
“The flight attendants asked, ‘Is there anyone on the aircraft with medical training?’ and I got up and I went to the back,” chronicled Graham. “Another gentleman joined me, who happened to be a paramedic.”
Upon arrival, the passenger, who was a young woman in her mid-twenties, was just waking up, but minimally responsive.
“She was starting to make some noise and spontaneous movements, but wasn’t making eye contact or making sense,” described Graham. “So, we had the flight crew get various bags and medical equipment for us that is regulated to be carried on all aircraft flights by the Federal Aviation Administration.”
Graham typically carries a tourniquet on hand with him during deployments and overseas in case of emergencies. In contrast, for stateside flights, he remains well-read on how to utilize available in-flight medical equipment kits.
“There was a recent journal article about this that I serendipitously read a month prior to the incident that outlined some of the rules and the FAA-required equipment sets,” Graham said. “It was timely that I just read this article so I’m fresh on it.”
Graham is also an AF Emergency Room physician and explained how responding to a medical emergency mid-flight is different from medical emergencies on a military base or in an Emergency Department.
“In the worst-case scenario, you’re doing cardio-pulmonary resuscitation and you’re shocking someone to revive them,” Graham said. “Across the Department of Defense, there is a public access defibrillator program with defibrillators spread across the base. So, you’re generally covered on a base and a lot of civilian locations.”
In contrast to medical emergency responses on the ground which allow a vast range of resources in terms of personnel and equipment, impromptu in-flight care from a passenger who happens to be an off-duty medical provider is completely different.
Graham explained that unexpected scenarios such as in-flight emergencies require a prioritized focus on the fundamentals in terms of medical skills.
“Mental algorithms just kind of kick in and you start doing it subconsciously,” Graham said. “When we walk up and somebody is passed out, the number of things causing it can be vast. The number of things causing it that can be fatal is much more finite. ‘Did they have a stroke? Did they have one too many to drink? Are they diabetic and their blood sugar is wildly out of control? Did they just have a massive heart attack or a rupture of their aorta?’ There are serious and potentially deadly things that can cause someone to pass out.”
The diagnostic tools Graham could use in a hospital or from an ambulance were not available on the aircraft.
“You rely on your education, training, and experience in thinking through, ‘How do I reasonably assess that it’s not one of these bad things without actually having the tools?’” Graham explained. “While there are things you would do in a normal hospital or clinic environment, you recognize, ‘Well I can’t check this. I can’t get an electrocardiogram necessarily.’ I can’t do a lot of the more advanced things that I may do in a hospital type of environment.”
As FAA-regulated medical kits only provide so much, military members who respond to in-flight medical emergencies must think outside the box to save lives.
“Military training encourages innovation, which allows us military medics to be better prepared,” Graham continued. “It’s great to be able to use the skills and training that the Air Force has given us to help the civilian community as well, and not just the military.”
Regarding how Graham managed the emotional aspects of the situation, he not only had a civilian paramedic to assist him, but he also had a five-member team of flight attendants to keep the patient and other passengers calm.
“The flight attendants were very helpful,” Graham said. “We talked to the patient to establish that relationship, and I had one of the flight attendants hold the patient’s hand and provide a little bit of appropriate humor to build that rapport as the patient wasn’t fully cognizant to do what we needed her to do to maintain a safe situation for everyone.”
From Graham and the civilian paramedic’s expertise to the flight attendants’ and the pilot’s coordination, it was a group effort to resolve the situation and ensure medical services were available upon landing to Honolulu.
“There are many unknowns in medicine and the world around us,” Graham said. “Generally speaking, a team collaborative solution usually ensures the best solution.”
Overall, Graham’s leadership of an impromptu team helped mitigate the occurrence of the worst possible scenario during the mid-flight emergency.
“When you’re a trained medical professional, it’s your day-to-day job, and that’s how I approached the situation,” Graham said. “From both the military and emergency medicine standpoints, you identify the most likely thing going on and the worst thing that could be going on. You start at those places and then you make sure that you don’t end up in the worst possible spot as you work to ensure an optimal outcome.”