An embolus in one but trauma in many at 30,000 feet

A middle-aged obese female with a past medical history of diabetes and congestive heart failure is in cardiac arrest after several hours of immobility on an airplane. What is the cause of her condition?

If this were a USMLE exam, my thoughts would race to Virchow’s triad: stasis, endothelial injury, hypercoagulability. But this wasn’t an exam. This was a few rows behind me on an airplane.

I sat only two rows behind her on the plane for a few hours. I barely noticed her and at the time, I wouldn’t have been able to pick her face out of a line-up. Yet, two hours into my flight, I was awoken by a woman’s scream and a frantic announcement over the speaker, “Are there any doctors, nurses, or any medical personnel on this flight? Please come to the rear plane immediately.” A woman had collapsed and was now unconscious in the back of the aircraft.

Being on a plane headed to a national medical conference, about twelve physicians and nurses, more than could actually fit in the back of the plane, suddenly rushed through the aisle.

For the next thirty minutes, I watched flight attendants run up and down the aisles, yelling, “I just checked my notes and she had two vodka drinks. I can’t find a coat hanger; does anyone have a coat hanger? I just found some medications in her purse, and she’s a diabetic! Does anyone have any other medications?”

She was given intravenous medications while physicians performed chest compressions. She was vomiting and they kept losing her pulse.

Children were shrieking; a flight attendant sobbed in the aisle; and several women reached for their bags to take pills themselves. The captain announced we were making an emergency landing in New Mexico in twelve minutes.

Sweat was pouring down one physician’s face as he pounded the woman’s chest and blew air into her mouth. Throughout our rough landing, the physician did not sit in his seat and buckle his seat belt — he continued on. Several minutes later, EMS boarded, and so did fire safety, the police, and crime scene investigation. The line of people on board the plane extended down the aisle, halfway down the entire plane on both sides.

The patient was immediately intubated and given more epinephrine. Vomit was suctioned from her mouth and nose. Her body was moved further down the aisle, away from the back of the plane to make more room for EMS. Whereas only a few people in the back of the plane could see her before, her limp body and intubation were now visible to half of the plane.

Twenty minutes later, her obese, bruised, totally naked body was brought off the plane. I’ll never forget her lifeless face and the difficulty with which EMS performed this task. A plastic sled wouldn’t fit in the aisle and there were no stairs to accommodate opening the back door of the aircraft. EMS had no other option. Over a hundred people, including very young children, saw her dragged off the plane in a scene resembling a lion struggling to drag his destroyed prey through the grass.

Fire safety removed the equipment from the plane, while a hazmat team cleaned her vomit from the floor. Police talked to the flight attendants, physicians, and passengers to piece together what happened during this woman’s last few hours. Crime scene took pictures of the aisle, her seat, and back of the plane. The flight attendants re-boarded the plane and went up and down the aisles talking to passengers saying, “She passed. Let’s all say a prayer for the poor woman.” The attending physician later told me she died in flight but EMS called the time of death on solid ground.

When I reached solid ground, it was difficult for me to digest what I had endured alongside every other passenger on the flight. A poor woman was happily sitting and drinking on her flight to the west coast only a few hours before a thrombus dislodged from the deep vein of her leg, propelling up through the vena cava and into the right ventricle, blocking blood flow to her legs. At least, that is what we think happened and true closure will never come.

Even with a plane staffed with more physicians than the average emergency room, when her heart stopped beating, her lungs stopped breathing, and her brain lacked the substance needed to survive, there was little anyone at 30,000 feet could do to heal this poor woman. In retrospect, maybe more could have been done to heal everyone else on that plane. On this flight, there was an embolus in one but trauma in many.

Melissa Stone is a medical student.  A case report discussing this event was published in the Journal of Travel Medicine.

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