Critical Care at 33,000 Feet

As a part of the 50th anniversary of the BYU College of Nursing, a book was compiled called “The Healer’s Art: 50 stories for 50 years.” It has been 15 years since this book was first published and these stories were shared. We plan to regularly post selections from this book to help each of us remember and cherish the experiences of nursing and learning the Healer’s art. 

Critical Care at 33,000 Feet

Elaine Bond

On a return flight home from the Middle East, our plane was somewhere over the Atlantic. My fellow passengers were a varied ethnic group, mostly Arab, many East Indian, some Europeans, and a few Americans. Most of us had been on board for over nine hours, from our Amman, Jordan embarkation site and were tired and somewhat crotchety. Other passengers joined us during a refueling stop in Shannon, Ireland. We were about two hours out of Shannon when an overhead announcement asked if there was a doctor or a nurse aboard. I could tell by the tone of voice this was no ordinary request.

With my Critical Care senses kicking in, I pushed my call light, stood up, and started toward the front of the plane. A flight attendant hurriedly escorted me to the bulkhead, where a row of portable cribs hung, filled with babies, in front of their mothers’ seats. Another flight attendant handed me a large seven month old baby, Mohammed, who was in obvious distress. My senses were reeling, as I performed my initial assessment. Even as I noted he was seizing and not breathing, the smell of diarrhea and vomit assailed me, and the feel of hot, soiled clothing met my touch. Luckily, I could see his heart was still beating, as his pulse pounded in his throat.

As I stood in the aisle, surrounded by the baby’s young mother, Amal, and other concerned passengers, I tried to block out the confusion so I could function. “Baby, baby, are you all right?” I mechanically asked, extending his neck to assure an adequate airway. When he began to gasp for air, I quickly took stock of the surroundings and determined how to eliminate some of the confusion and get enough space in which to work. Since the plane was not full, I asked the flight attendants to move the other mothers and their babies to new seats. Amal hovered over me, worrying about her son, frantically asking questions in Arabic which I could not answer. Another nurse (Mary Peterson) arrived, saw someone was in charge, and began to return to her seat. Since my background is with adults, and though she was not a pediatric nurse either, I asked her to stay, knowing two heads were better than one, since we needed at least two pairs of hands and someone to communicate.

Mohammed drifted in and out of consciousness, sometimes able to focus on my face, alternating between no respirations and rapid respirations around 50 breaths per minute, with a heart rate of 160 to 180 beats per minute, sometimes seizing and sometimes lying limp. We unbundled him from his blankets and outer clothing. Now at least, we could see more easily whether he was breathing. He was clammy to the touch, leaving me wondering about his underlying problem. I knew he must be dehydrated due to the vomiting and diarrhea. Was he also hyperthermic? Did he have an infection? It was difficult to tell. My limited Arabic, “Marhaba, Kaef Halak? (hello: how are you?) was inadequate for the occasion.

One flight attendant served as a translator and brought the aircraft’s small first aid kit to us. Oh, for my emergency supplies and sterile gloves locked carefully away in the hold below! The first aid kit had a fever scan thermometer inside and we quickly checked Mohammed’s temperature. It was somewhere around 39 degrees, but we did not know whether it was accurate. A nearby grandmother handed us a rectal thermometer, which gave us a more precise reading of 41.2 degrees. We quickly asked for and received a container of ice, which we placed in strategic locations around Mohammed’s body, as we were getting his history from his mother.

She had taken him to see a doctor the day before the flight, when he would not nurse as usual, following several bouts of vomiting and diarrhea. The doctor had given her some acetaminophen suppositories to control his fever and Pedialyte to provide fluid, calories and electrolytes. Mohammed had not resumed nursing, would not drink the Pedialyte from a bottle, and Amal had not known what to do with the suppositories.

Since she had the Pedialyte and suppositories with her, we administered a suppository and mixed Pedialyte in a bottle to try to give him, should he become conscious enough to try to suck. We continued to cool him with cold wet cloths filled with ice. Because he was so dehydrated, his veins were so small. I could not have started an IV, even if I had the equipment and fluids.

Sometime during the confusion, the airplane’s co-pilot came to ask us what we needed to do. I said, “We have two choices: return to Shannon, Ireland or land at the first available airport in North America. This baby will not live until we reach JFK airport in New York.” After conferring with the captain and radioing for additional instructions, the co-pilot returned and reported we had passed the point-of-no-return and must continue forward.

The next two hours were a blur as we sped over the Atlantic to our new destination, racing against time. We continued to cool Mohammed, worrying that we would cool him too rapidly, or that we couldn’t cool him enough. His temperature slowly dropped; down to 39.9 degrees, then 39.4, on to 38.9, down to 38, then into the 37s. We removed the ice and wet cloths and placed him in a clean dry blanket.

The flight attendant brought us a small, partially full oxygen cylinder with an adult face mask. We had to estimate the flow of oxygen and I had to help others understand we couldn’t place the mask completely over Mohammed’s face; we didn’t know how much flow we had and we incurred the risk of having him rebreathe his own carbon dioxide. He soon regained some color in his face and his capillary refill time returned to normal.

He seemed to be awake and we tried to give him the Pedialyte, but he was too weak to swallow. His dark eyes were huge as he tried to fathom what was going on around him. We gave him to his mother to hold, hoping it would provide some comfort and a sense of security for both of them. She was very frightened– on her way to a foreign land to meet her husband, unable to speak the local language, and not knowing whether her baby would be dead or alive in the next minute.

I didn’t pay attention to how hot it was in the plane: I thought I was hot because I was working so fast and because of the stress of the moment. However, the heat came back to haunt us later.

The pilot, co-pilot, and chief flight attendant gave regular updates to the passengers about our diversion to Gander, New Foundland, and about Mohammed’s condition. From what I could hear and see, the passengers were understanding and quiet. The mothers and grandmothers in our vicinity gave words of encouragement to Amal and to us, which the flight attendant translated for us. I suggested some Muslim, Hindu, and Christian prayers might be in order as well! The pilot was able to locate Mohammed’s father in New York and get him on a plane to Gander to meet us.

At last, we landed in Gander, where there was an ambulance waiting for us. We hustled Mohammed into the ambulance where they could get an IV started, get some fluid into him, and give him the correct amount of oxygen.

While I was helping with paperwork, both for the ambulance and the emigration officials, one of the flight attendants came to me reporting an elderly male patient was not responding well and asked if I would look at him. When I got to the man, he was slumped in his seat, grey, totally unresponsive, chin on his chest and not breathing! As I lifted his head, I thought, “Oh no! This cannot happen twice on the same plane!” He began breathing and his color began to improve. His initial blood pressure was 60/40 mm Hg and his pulse was 30 beats a minute. I tried to analyze whether his rate was really that slow or whether he was in bigeminy or trigeminy. I could only feel a pulse every second or third beat.

Getting an adult into Trendelenburg in a cramped airplane is no small task! However, Nurse Peterson was creative in getting people out of enough center seats so she could get space for him to lie down. Once again, we needed an interpreter and a spokesman for the gentleman, who was East Indian. We discovered he had taken his Beta Blocker (Atenolol) shortly before the problem arose for Mohammed. Our analysis told us the heat in the plane and the excitement of the emergency landing had exacerbated his normal response; he vasodilated and bradied down.

His blood pressure slowly equalized and his heart rate returned to normal. As he became more alert, he was able to converse with us. He refused to get off the plane and said his daughter could take him to a doctor when we got to New York. Nurse Peterson stayed with him as I finished the paperwork for Mohammed so the ambulance could leave. We periodically checked on the gentleman during our flight to JFK and he experienced no further difficulty.

As I walked off  the plane, five hours late, I thought, “This is just like any routine day in ICU. When the shift starts, you have no idea what care you will need to provide. When a trauma patient arrives, you stabilize, assess, stabilize more, assess more, send the patient off to surgery, deal with psychosocial concerns, get an interpreter for families, save lives, then walk out the door. No one out there can possibly understand the drama behind the work we do. You smile when your significant other asks how your day went, and you answer, ‘It was just a routine critical care day.’ ”

 

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