On Vacation - Would You Intervene?

[RobbiRN, RN]

While on vacation outside of the US a few days ago, I had two chances to intervene in medical situations. I'm curious what you would have done if you had been in my situation.

Case 1: In a southern coastal city in the UK, an elderly woman reportedly "just fainted and fell" while crossing a street. No one there knew her. Several bystanders were trying to help, including a man who identified himself as a "medic" and woman who worked at a pharmacy. The injured woman was obese, lying awkwardly on her right hip with her torso twisted, her upper chest on the pavement and her head twisted toward her left shoulder. Her head was lower than her body, and she was bleeding from a scalp laceration. The medic knelt beside her and held pressure on the scalp wound. She denied any pain and tried to get up several times, but they held her down even when she vomited, insisting that she should not move. Her breathing was heavy. EMS had been called, and I could hear a distant siren.

Case 2: Halfway between Amsterdam and New York, they paged overhead for a doctor to come to the back of the plane. No one moved. I went back and told the flight attendant I was an ER RN, not a doctor. Apparently, I was their best option.

He took me to an elderly man who was worried about moderate swelling and mild redness in his right lower leg and ankle. With his daughter translating, I learned the swelling had started during our flight, but he'd been on a plane for three hours prior to ours. He had a large scab on his lower right lower shin from a scrape three days ago but denied any pain. He was sitting on a jump seat with his leg propped up on a window well, straight and level with his hip. They were applying cool compresses.

I've second guessed myself a bit on one of these two. What would you have done?

[canadianedmurse]

such hard, complicated situations. I know many docs I work with in the ED are very hesitant to render aid in situations like this due to the legalities. International laws and good samaratian acts aren't always the same as what we are used to. It seems as though in Case 1 what you did was fine - help was on the way and there were people there, even if we disagree with their treatment. Watching and observing is fine, especially hearing sirens. No use in argueing with bystanders in regards to holding her down and such as long as she isn't aspirating. The most you could have done would be to ensure she isn't aspirating/log roll her into a recovery position. It is hard dealing with things like this when you are not working/have appropriate equipment to c-collar her, dress the wound, and transport. The legalities of preventing or not preventing someone with a suspicious spinal moi from moving is tricky when you are a provider internationally. I have yet to encounter a situation on a plane like the one you mentioned. That is a difficult situation. I'm not sure what I would do. Obviously you would be concerned about cellulitis vs DVT/VTE - but as an RN - especially internationally and without an MD around that is a call I would not make: if they were wondering about urgency. I'm curious, what did you do in that situation? Reccomend an urgent landing?

I tend to verge on the edge of caution when I am not working and people require assistance. If it is a non-complex situation or a situation that requires immediate intervention(cpr, anaphylaxis, ect.) then I am more than willing and wanting to help here in Canada. If everything seems under control or I am hesistant about legalities I tend to be a bit more conserved.

[CharleeFoxtrot, BSN, RN]

Scenario 1- nope.

Scenario 2 - nope.

Any scenario short of a full code I mind my own business.

[RobbiRN, RN]

2 hours ago, canadianedmurse said:

I'm curious, what did you do in that situation? Reccomend an urgent landing?

Thank you for your thoughts. Stay tuned. I wanted to start with an open-ended presentation to get other's ideas based on the situations before adding what I did and how it went. I will throw out the carrot that I did not simply observe in either situation.

[Orion81RN]

Scenario 1) I'd consider the amount of traffic on the street. I'd want the woman to stay put, so if no one is stopping cars from coming, I'd do something about that. I also don't like the way you describe her positioning while vomiting. If no one is keeping her from aspirating, even with medics on the way, I'd have to do something about that.

Scenario 2) ONLY bc nobody else responded, I'd say go for it. As far as what to do, many airlines utilize a service that has on call physicians. I'd utilize that and send a picture if possible. Get their recommendation and go from there. I'd have him elevate the leg as well.

I'm very curious now what you did. ?

[JKL33]

1: I would have recommended that the woman not be restrained if she was alert and oriented without pain or neuro (motor/sensory) deficits. I wouldn't have asserted myself any further than to make the recommendation and note that it is the current position of the relevant American colleges/committees (which may or may not be respected elsewhere).

2: I would have informed the crew that IMO there does not appear to be a particular intervention required on my part (meaning, nothing that needs to happen right this instant) and that they should report their findings to their med control for official advice.

Either the above or what @CharleeFoxtrot said.

[RobbiRN, RN]

59 minutes ago, Orion81RN said:

As far as what to do, many airlines utilize a service that has on call physicians.

I thought that was the case, but I asked the attendant if they used a service or had any doctor they could contact for direction if they failed to get help on board. He said no.

[canadianedmurse]

1 hour ago, JKL33 said:

1: I would have recommended that the woman not be restrained if she was alert and oriented without pain or neuro (motor/sensory) deficits. I wouldn't have asserted myself any further than to make the recommendation and note that it is the current position of the relevant American colleges/committees (which may or may not be respected elsewhere).

2: I would have informed the crew that IMO there does not appear to be a particular intervention required on my part (meaning, nothing that needs to happen right this instant) and that they should report their findings to their med control for official advice.

Either the above or what @CharleeFoxtrot said.

those are great interventions.

[RobbiRN, RN]

11 hours ago, JKL33 said:

1: I would have recommended that the woman not be restrained if she was alert and oriented without pain or neuro (motor/sensory) deficits. I wouldn't have asserted myself any further than to make the recommendation and note that it is the current position of the relevant American colleges/committees (which may or may not be respected elsewhere).

2: I would have informed the crew that IMO there does not appear to be a particular intervention required on my part (meaning, nothing that needs to happen right this instant) and that they should report their findings to their med control for official advice.

I like your answer because it pretty well backs what I did.

1. I watched for a couple of minutes to get a feel for what they were doing, then identified myself as an ER RN on holiday. I suggested that since she was alert and denying pain, allowing her to sit up would reduce intracranial pressure, reduce her work of breathing and the potential for aspiration. That's when the man identified himself as a "medic" and stated he wanted to maintain her c-spine until their EMS people got there. I chose not to assert myself further.

2. On the KLM flight, I told them I was not a doctor but I would give them my opinion that there was a high probability of cellulitis based on the appearance and history with a low possibility of a blood clot, neither of which required immediate intervention. I told them to stop the cool compresses which reduce blood flow, keep the leg warm, elevated, and to re-position it frequently. The fight attendant came by my seat later and gave me a $100 voucher for a discount on my next flight for my help. I initially declined, but he insisted "this is what we do."

Interesting side note. I checked later and most US based airlines do contract with an agency for in-flight direction if there are no volunteers who respond. Some airlines outside the US do not have medical backup on the ground, but licensed medical professionals on a plane in EU countries are required by law to respond to overhead pages.

[kp2016]

I am very very hesitant to intervene especially on planes when you often have no idea what you are volunteering to help with. If there is a problem later on you can bet your actions and any missed actions will be critiqued by people who have plenty of experience with the particular situation that was sprung on you. I’ve never given medical assistance on a KLM flight but on other flights the Lead Flight Attendant asked to see a copy of my RN license and sometimes even my BLS / ACLS cards and they made a note of it along with my name and seat assignment!

I’m amazed by the amount of really jacked up care I’ve seen first responders give to my patients over the last few years. I realize these people were trying to help but I’ve actually seen patients end up with some serious complications that were a direct result of inappropriate/ out dated or straight out wrong interventions. (But that’s a whole separate post)

To be clear I’m not suggesting that the OP was in anyway incorrect in their care. But I am saying please be mindful of your scope of practice. “I was trying to help” isn’t a justification for causing harm to a person.

[Wuzzie]

14 hours ago, JKL33 said:

I wouldn't have asserted myself any further than to make the recommendation and note that it is the current position of the relevant American colleges/committees (which may or may not be respected elsewhere).

I'm interested in hearing what they have to say. As far as I know C-spine precautions are still recommended with blunt force trauma (head laceration=head hit pavement=blunt force) but spinal traction and keeping patients on back-boards after admission to the ED is no longer SOP. As nurses is it within our scope to clear C-spines in the field? Not being snarky but, as a first responder as well as a nurse, this is the first I'm hearing that C-spine precautions have also gone the way of the Dodo.

[JKL33]

Hey Wuzzie. ? I'm definitely no expert about the pre-hospital side, I just know what I've been seeing/hearing on my end. This seems to confirm (?).