News Continued from page 1164
Pharmacists respond to inflight medical event, perhaps prevent flight diversion
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y responding to the overhead page for a doctor or nurse, a retired pharmacy director and a pharmacy resident aided a frequent flier in distress on a June 7 flight and perhaps prevented the aircraft from making an unscheduled landing. The 52-year-old passenger insisted his condition was merely diarrhea and dehydration caused by a “bug” he probably caught from his wife, said Jerry Siegel, a former pharmaceutical services director for The Ohio State University Med- Jerry Siegel ical Center in Columbus. But Siegel, now a vice president with Rhode Island–based Safe Medication Management, and University of Colorado Hospital postgraduate year 1 pharmacy resident Christopher Miller sus- Christopher Miller pected something more serious. Unexpected delay for passengers. Deep vein thrombosis was the pharmacists’ first concern because the aircraft’s departure from Minneapolis–Saint Paul International Airport had been delayed for two hours and no one had been allowed to stand, Siegel said. Just in time for the start of ASHP’s Summer Meetings in Denver, severe storms had hit the metropolitan area. The U.S. Weather Service’s Denver– Boulder station on June 7 forecasted the possibility for isolated severe storms later in the day. By evening, Denver International Airport had been closed to inbound aircraft because of the weather, said Siegel, who was on his way to the Summer Meetings. The Delta Air Lines aircraft backed out of its gate at Minneapolis–Saint Paul on time and waited about an hour and a half for permission to fly, he said. Then, while taxiing the aircraft to the runway, the cockpit crew discovered a computer problem that further delayed takeoff. An hour or so into the flight, which Delta reports normally lasts two hours 1166
and 10 minutes from gate to gate, the 52-year-old man sitting directly behind the first-class section and two rows in front of Siegel arose to use the restroom, he said. As the man waited his turn he passed out, Siegel said. An off-duty copilot in uniform happened to be standing behind the man and caught him. On awakening perhaps a minute later, the man said he needed to use the restroom because of diarrhea, Siegel overhead. Miller, seated further back on Delta flight 2109, said he heard only the last part of what turned out to be the flight attendants’ second overhead page for a doctor or nurse. He had been watching a movie and wearing a headset. When Miller looked up and saw other passengers craning their necks backward and forward along the aisle, he assumed that no physician or nurse had responded. Siegel arrived at the scene before Miller. “No one else came forward,” Siegel said. The pharmacists said they checked on the man in the unlocked restroom and wondered whether his efforts to restrain a bowel movement as he stood waiting to use the restroom had caused the syncopal episode. Diversions for medical reasons. Neurologic, syncopal, and cardiac episodes were the most frequent types of medical emergencies encountered inflight in 1991–93, the Federal Aviation Administration (FAA) reported in 1997. This conclusion was based on the experiences of nine major passenger carriers. The agency does not require the airlines to maintain records on inflight medical emergencies. That 1997 report is the most recent publicly available FAA report on the topic. Cardiac, neurologic, and respiratory episodes in passengers were the most frequent medical reasons for aircraft landings at airports other than the
Am J Health-Syst Pharm—Vol 72 Jul 15, 2015
scheduled destination in 1990–93, FAA determined; syncopal episodes came in fourth, with obstetric–gynecologic episodes in fifth. But obstetric–gynecologic episodes had the greatest diversion rate; one in five resulted in a change to the flight plan. Siegel and Miller described the events after the man emerged from the restroom as follows: He immediately had to sit and then lie down. As he lay on the cabin floor between the two front exits, the pharmacists obtained his medical history and learned that he had been on warfarin therapy because of earlier blood clots. His dosage had recently been increased to 5 mg/day in response to an International Normalized Ratio of 1.7. He denied any alcohol use. He reported flying to Denver every week and said he had never before passed out. They observed that he was sweating; his pulse was faint and slow; and he was not wearing thromboembolism-deterrent hose or a medical identification tag about his chronic condition. Not in the clear. The pharmacists said they then helped the man stand up, gave him four bottles of water to drink, and watched him return to his reserved seat. But when the man arose roughly 10 minutes later to use the restroom, he passed out a second time, Siegel and Miller said. This time they evaluated the man, who was lying on the floor, for signs of stroke and symptoms of myocardial infarction. He was sweating; his pulse was faint and very slow but detectable in all four extremities. He was coherent and had no trouble breathing. Eventually they elevated his feet. With just 20–30 minutes remaining in the flight, they asked the pilot to have paramedics attend to the man on arrival in Denver. Miller, who soon starts a postgraduate year 2 residency in critical care pharmacy at Ohio State, said he responded to many medical emergencies during the past residency year and completed a one-month rotation in the emergency department. But those experiences occurred in a highly controlled environment—nothing like “what Jerry and I had to do kind of on a whim” while inflight, he said.
News
Siegel said the flight attendants arranged for him to sit next to the man, now upright in a first-class seat, for the remainder of the trip. The man passed out a third time as the aircraft was prepared for landing. Siegel raised the man’s legs and pushed back the seat. On arrival of the paramedics, Siegel said he provided a transition-of-care report and, with medical equipment in place, observed that the man had a heart rate of 52 beats/min and an abnormal electrocardiogram. He advised the man, who was conscious and thus would have to consent to further medical treatment, to seek care at the nearest hospital. That hospital is operated by the University of Colorado. Miller said he checked for the man at 6:30 a.m. on June 8 but did not find him in the emergency department or hospital. After checking a second time, on June 10, Miller said the absence of the man in the hospital’s census means he is likely “alive and well.” Siegel said that on several occasions he has been on a flight when a passenger had a medical emergency. “I usually wait and defer and see if there is a physician available and offer the physician assistance,” he said. As the only healthcare professionals to respond to the inflight medical emergency, the two pharmacists worked well as a team, Siegel said. —Cheryl A. Thompson DOI 10.2146/news150048
News Briefs • FDA on June 15 launched the database REMS@FDA. Accessible from www.fda.gov/rems, REMS@FDA provides a searchable and sortable table of current FDA-approved risk evaluation and mitigation strategy (REMS) programs. For each drug in the database, a “What do participants need to do?” link can be used to access information specific to dispensers and other accountable participants in a REMS program. There are links to a drug’s prescribing information and Medication Guide (at DailyMed), regulatory information (at Drugs@FDA), and REMS material. FDA said it designed REMS@FDA with pharmacists in mind. The “Contact Us” link at the database’s main Web page provides a means by which pharmacists can submit comments about REMS@FDA to the agency and ask questions. • Zomacton is the new FDA-approved brand name for the follow-on recombinant somatropin product originally marketed as Tev-tropin. Ferring Pharmaceuticals Inc. in December 2014 bought the U.S. rights to the product and a related needle-free injection device from Teva Pharmaceutical Industries Ltd. The labeling for Zomacton refers to the injection device as Zoma-Jet. Am J Health-Syst Pharm—Vol 72 Jul 15, 2015
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Pharmacists respond to inflight medical event, perhaps prevent flight diversion
B
y responding to the overhead page for a doctor or nurse, a retired pharmacy director and a pharmacy resident aided a frequent flier in distress on a June 7 flight and perhaps prevented the aircraft from making an unscheduled landing. The 52-year-old passenger insisted his condition was merely diarrhea and dehydration caused by a “bug” he probably caught from his wife, said Jerry Siegel, a former pharmaceutical services director for The Ohio State University Med- Jerry Siegel ical Center in Columbus. But Siegel, now a vice president with Rhode Island–based Safe Medication Management, and University of Colorado Hospital postgraduate year 1 pharmacy resident Christopher Miller sus- Christopher Miller pected something more serious. Unexpected delay for passengers. Deep vein thrombosis was the pharmacists’ first concern because the aircraft’s departure from Minneapolis–Saint Paul International Airport had been delayed for two hours and no one had been allowed to stand, Siegel said. Just in time for the start of ASHP’s Summer Meetings in Denver, severe storms had hit the metropolitan area. The U.S. Weather Service’s Denver– Boulder station on June 7 forecasted the possibility for isolated severe storms later in the day. By evening, Denver International Airport had been closed to inbound aircraft because of the weather, said Siegel, who was on his way to the Summer Meetings. The Delta Air Lines aircraft backed out of its gate at Minneapolis–Saint Paul on time and waited about an hour and a half for permission to fly, he said. Then, while taxiing the aircraft to the runway, the cockpit crew discovered a computer problem that further delayed takeoff. An hour or so into the flight, which Delta reports normally lasts two hours 1166
and 10 minutes from gate to gate, the 52-year-old man sitting directly behind the first-class section and two rows in front of Siegel arose to use the restroom, he said. As the man waited his turn he passed out, Siegel said. An off-duty copilot in uniform happened to be standing behind the man and caught him. On awakening perhaps a minute later, the man said he needed to use the restroom because of diarrhea, Siegel overhead. Miller, seated further back on Delta flight 2109, said he heard only the last part of what turned out to be the flight attendants’ second overhead page for a doctor or nurse. He had been watching a movie and wearing a headset. When Miller looked up and saw other passengers craning their necks backward and forward along the aisle, he assumed that no physician or nurse had responded. Siegel arrived at the scene before Miller. “No one else came forward,” Siegel said. The pharmacists said they checked on the man in the unlocked restroom and wondered whether his efforts to restrain a bowel movement as he stood waiting to use the restroom had caused the syncopal episode. Diversions for medical reasons. Neurologic, syncopal, and cardiac episodes were the most frequent types of medical emergencies encountered inflight in 1991–93, the Federal Aviation Administration (FAA) reported in 1997. This conclusion was based on the experiences of nine major passenger carriers. The agency does not require the airlines to maintain records on inflight medical emergencies. That 1997 report is the most recent publicly available FAA report on the topic. Cardiac, neurologic, and respiratory episodes in passengers were the most frequent medical reasons for aircraft landings at airports other than the
Am J Health-Syst Pharm—Vol 72 Jul 15, 2015
scheduled destination in 1990–93, FAA determined; syncopal episodes came in fourth, with obstetric–gynecologic episodes in fifth. But obstetric–gynecologic episodes had the greatest diversion rate; one in five resulted in a change to the flight plan. Siegel and Miller described the events after the man emerged from the restroom as follows: He immediately had to sit and then lie down. As he lay on the cabin floor between the two front exits, the pharmacists obtained his medical history and learned that he had been on warfarin therapy because of earlier blood clots. His dosage had recently been increased to 5 mg/day in response to an International Normalized Ratio of 1.7. He denied any alcohol use. He reported flying to Denver every week and said he had never before passed out. They observed that he was sweating; his pulse was faint and slow; and he was not wearing thromboembolism-deterrent hose or a medical identification tag about his chronic condition. Not in the clear. The pharmacists said they then helped the man stand up, gave him four bottles of water to drink, and watched him return to his reserved seat. But when the man arose roughly 10 minutes later to use the restroom, he passed out a second time, Siegel and Miller said. This time they evaluated the man, who was lying on the floor, for signs of stroke and symptoms of myocardial infarction. He was sweating; his pulse was faint and very slow but detectable in all four extremities. He was coherent and had no trouble breathing. Eventually they elevated his feet. With just 20–30 minutes remaining in the flight, they asked the pilot to have paramedics attend to the man on arrival in Denver. Miller, who soon starts a postgraduate year 2 residency in critical care pharmacy at Ohio State, said he responded to many medical emergencies during the past residency year and completed a one-month rotation in the emergency department. But those experiences occurred in a highly controlled environment—nothing like “what Jerry and I had to do kind of on a whim” while inflight, he said.
News
Siegel said the flight attendants arranged for him to sit next to the man, now upright in a first-class seat, for the remainder of the trip. The man passed out a third time as the aircraft was prepared for landing. Siegel raised the man’s legs and pushed back the seat. On arrival of the paramedics, Siegel said he provided a transition-of-care report and, with medical equipment in place, observed that the man had a heart rate of 52 beats/min and an abnormal electrocardiogram. He advised the man, who was conscious and thus would have to consent to further medical treatment, to seek care at the nearest hospital. That hospital is operated by the University of Colorado. Miller said he checked for the man at 6:30 a.m. on June 8 but did not find him in the emergency department or hospital. After checking a second time, on June 10, Miller said the absence of the man in the hospital’s census means he is likely “alive and well.” Siegel said that on several occasions he has been on a flight when a passenger had a medical emergency. “I usually wait and defer and see if there is a physician available and offer the physician assistance,” he said. As the only healthcare professionals to respond to the inflight medical emergency, the two pharmacists worked well as a team, Siegel said. —Cheryl A. Thompson DOI 10.2146/news150048
News Briefs • FDA on June 15 launched the database REMS@FDA. Accessible from www.fda.gov/rems, REMS@FDA provides a searchable and sortable table of current FDA-approved risk evaluation and mitigation strategy (REMS) programs. For each drug in the database, a “What do participants need to do?” link can be used to access information specific to dispensers and other accountable participants in a REMS program. There are links to a drug’s prescribing information and Medication Guide (at DailyMed), regulatory information (at Drugs@FDA), and REMS material. FDA said it designed REMS@FDA with pharmacists in mind. The “Contact Us” link at the database’s main Web page provides a means by which pharmacists can submit comments about REMS@FDA to the agency and ask questions. • Zomacton is the new FDA-approved brand name for the follow-on recombinant somatropin product originally marketed as Tev-tropin. Ferring Pharmaceuticals Inc. in December 2014 bought the U.S. rights to the product and a related needle-free injection device from Teva Pharmaceutical Industries Ltd. The labeling for Zomacton refers to the injection device as Zoma-Jet. Am J Health-Syst Pharm—Vol 72 Jul 15, 2015
1167
