PHM 2024 Sesson Recap
For hospitalists who are accustomed to caring for sick patients, encountering emergencies outside of the hospital is far beyond our comfort zones. To quell anxieties and prevent panic, Y. Katharine Change, MD, John P. Schmidt, MD, and Julie E. Barrett, MD, MPH provided an overview of how to respond as the first person on the scene of an emergency or when someone asks that feared question, “Is there a doctor in the house?”
Dr. Chang kicked off the mini plenary by addressing different laws that protect bystanders who provide help in an emergency. Various acts exist including the Good Samaritan Law, Volunteer Protection Act, and Duty to Assist Legislation. While the details and protections may vary from state to state, the common thread between each is to provide reasonable assistance (at minimum calling 911) and stay until a higher level of care arrives, or until it is no longer safe for you. Throughout her portion, Dr. Chang stressed multiple times that while you do have a duty to help, you won’t be able to help if you become injured so ensuring your own safety is of utmost importance.
Dr. Chang then went on to discuss providing care to victims of motor vehicle accidents, particularly motorcycle accidents. Dr. Chang reviewed the anatomy of a motorcycle, including the location of the fuel tank (in the middle), brake on the right, clutch on the left, exhaust pipes on the side, and that most motorcycles have a kill switch. This knowledge comes in handy when the bike has fallen onto the victim and needs to be moved away to prevent further injury, if it’s possible to do so safely. When removing helmets, be mindful of the potential for cervical spine injury. It may be safer to secure their airway with a jaw thrust rather than the head tilt and chin lift. Regarding children in car accidents, if they are still in a car seat, Dr. Chang advised leaving the child in the car seat, which not only provides ongoing immobilization but is also their safe place. It is not necessary to place a child back into their car seat if they have been ejected, but additional measures need to be undertaken to physically stabilize them.
Transitioning from the land to the air, Dr. Schmidt discussed what to do when an emergency is encountered on a plane. Like Dr. Chang, Dr. Schmidt also addressed laws in place that protect those assisting in emergencies which become unclear when traveling, particularly when traveling internationally. In summary, the Aviation Medical Assistance Act is essentially the Good Samaritan Law of the sky. Also, proof of medical qualification may be requested by the airline, though acceptable proof differs between airlines. When on an international flight, Dr. Schmidt noted that each plane should be viewed as a “little hunk” of the country operating the airline and as such, that country’s laws will apply, some of which (specifically Germany, France, and Australia, to name a few), mandate that any physician present must provide assistance. And while the supplies in the physician kit may differ from plane to plane and country to country, one resource remains constant—a ground-based physician who anecdotally tends to be Australian.
What medical emergencies are physicians most likely to encounter on a flight? Dr. Schmidt discussed several studies, noting that the most common complaints among ages included syncope or presyncope, respiratory symptoms, or gastroesophageal symptoms. One study detailed the incidence of injuries incurred among the pediatric population, most commonly burns (from soup or hot beverages), contusions, lacerations, and closed head injuries. About 7% of in-flight emergencies end with a diversion of the flight, which interestingly differed when broken down by the type of health care practitioner involved. A majority of diverted flights involved physicians and EMS responders compared to those with a nurse or flight crew only. And what happens when the on-board physician and on-ground physician disagree about diversion? The captain decides.
Finally, Dr. Barrett brought the session to a close by discussing delivering a baby. Thankfully, because it has likely been many years since most of us have even thought about the stages of parturition, Dr. Barrett reviewed the three stages of labor: dilation of the cervix, the descent of the head and delivery of the infant, and delivery of the placenta. In the moment, while you are trying not to panic, determining which stage of labor your patient is in, and likely remembering that one time in medical school when you were allowed to catch the baby, you should also try to gather supplies. The first supply you need is EMS—call 911. Next, though a bulb syringe and chux pads would be ideal, you may not be so lucky. At a minimum, gloves, clean blankets or towels, and possibly a clean piece of string to tie off the umbilical cord will do. Immediately putting baby to breast and applying fundal massage will encourage cessation of bleeding and delivery of the placenta. Hopefully, if they haven’t already, EMS will soon arrive to safely transport the mother, baby, and placenta off to the nearest hospital.
While some of us will be lucky enough never to hear that dreaded call or be the first on the scene, many of us will be in situations where we are asked to triage an emergency using knowledge and skills we haven’t used in a while. The most important takeaways from this session are don’t panic, remember your ABCs, determine what resources you have, and call 911 (or the airline equivalent, who might just greet you with a very pleasant accent).
Key Takeaways
- Don’t panic. Remember your ABCs. Call 911, or if on a plane, the ground-based physician.
- Take inventory of your resources. That may include the people around you.
- Don’t forget about your own safety. You can’t help others if you become incapacitated.
Dr. Nelson is a first-year pediatric hospital medicine fellow at the University of Pittsburgh Medical Center in Pittsburgh, a recent graduate from the University of Louisville’s internal medicine and pediatrics residency program in Louisville, Ky., and a former trainee member of The Hospitalist’s editorial board.