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Fluids & Electrolytes
AS A NURSE on a progressive cardiac care unit of a Magnet(R) hospital, I've been trained to provide competent nursing care, respond to medical emergencies, and be a team player to ensure the best possible outcomes for my patients. I've often wondered, as many nurses do, if I'd ever be confronted with a medical emergency outside the safe confines of my hospital. What would the emergency be, where would it take place, and would I be able to use the skills I'd acquired under less than optimal conditions?
One day in January, at 30,000 feet in the air, I would learn the answers to my questions.
Returning home from visiting my sister in Arizona, I was waiting at the Phoenix airport along with 175 other passengers to board a flight to Detroit when an announcement informed us that our flight would be delayed. Knowing I'd miss my connection, I asked to be rebooked on another flight.
As I began walking through the terminal to my new assigned gate, I heard another announcement: "Would Carol Glover please return to the ticket counter?"
When I returned, the passengers were boarding. I told the ticket agent that I'd probably miss my connection and he replied, "The pilot has assured us that the delayed time will be made up in the sky." Reluctantly, I boarded the plane.
After reaching cruising altitude, I settled in for the 3½ hour flight. Soon I noticed a commotion about 10 rows in front of me. The flight attendants were gathering around a passenger and one of them was pouring something into his mouth. A voice came on overhead: "We have a medical emergency. Is there a doctor, nurse, or anyone with medical training on board?"
I got up from my seat and briskly walked toward the flight attendants. "My name is Carol, and I'm a cardiac nurse. What's the problem?" One of the flight attendants stepped back and a terrified young man held up his clenched and knotted fingers.
"I can't open my hands and my arms are cramping, too," he said. "What's wrong with me? I'm so scared-am I going to die?"
After asking his permission, I reached down to try and gently open his fingers, but I was unsuccessful. He was shaking and his anxiety was escalating. "What's your name?" I asked.
"I'm Andy. This has never happened to me before. What's wrong with me?"
"Andy, I'm not sure what's wrong, but I'm going to try and help you," I replied.
I turned to the flight attendant and asked what she was pouring into his mouth.
"Sugar," she replied.
"Did he have low blood sugar?," I asked.
"I don't know, he was just shaking and I thought it might be low."
I turned my attention back to Andy.
"Andy, do you have diabetes?"
"Have you ever had any seizures?"
"Is there anything else about your medical history you think I should know?"
I quickly took Andy's pulse and it was 110 and regular. He wasn't in respiratory distress, and his skin was warm and dry. The flight attendant asked whether I knew what was wrong. I looked at Andy, then down the aisle at all the faces watching me.
"I don't know what's wrong, but he needs medical attention."
First, I did a quick head-to-toe assessment. Andy was alert and oriented to time, place, and person; he had no facial droop, arm drift, or speech deficits, so I was pretty certain that he wasn't experiencing a transient ischemic attack or stroke. A flight attendant handed me a stethoscope and manual BP cuff. Andy's BP was 108/66. I listened to his heart. The cardiac rhythm was regular, but definitely tachycardic. Andy's eyes were wide with fear. His lips were dry and cracked, and his mucous membranes appeared dry. I squeezed his arm and told him he was doing great. I didn't believe this was a cardiac problem.
A flight attendant interrupted my thoughts and asked, "Can you use anything in here?" She unrolled onto the floor an emergency kit and handed me a laminated sheet with a list of the items in each compartment: atropine, epinephrine, nitroglycerin SL, first aid items, I.V. fluids, and supplies.
I asked Andy, "Do you have any allergies or did you take any medications before getting on this plane?" He replied, "I've been drinking alcohol."
"OK, how much?"
"I've been drinking a lot for four days and haven't eaten or had very much to drink besides alcohol."
This was starting to make sense. Immediately I suspected that he was experiencing tetany, or severe cramping as a result of dehydration and electrolyte imbalances. I knew that electrolyte imbalances, such as hypomagnesemia and hypocalcemia, put him at a higher risk for cardiac dysrhythmias, a potential medical emergency.
"Andy, I believe you're severely dehydrated and I'd like to start an I.V. to give you additional fluids. Is that okay?" He nodded yes. I looked into the emergency kit that the flight attendant had given me, opened the compartment labeled I.V. Start Kit and Fluids, and removed the supplies I needed. I spiked a bag of 0.9% sodium chloride solution.
Next, I inserted a venous access device in Andy's left hand and attached the tubing from the saline. I turned to the flight attendant and asked how we could hang the bag. She left and returned with a wire clothes hanger, then flipped open the overhead compartment. I inserted the bag over the neck of the hanger and hung it from a handle of a suitcase in the compartment. I opened the clamp on the tubing to run the solution.
I asked Andy how he was doing and he told me he was feeling lightheaded. I asked the flight attendant whether there was oxygen on board, and she returned with a portable tank. I attached the tubing and turned the knob to low. After I placed the mask over Andy's mouth, he began taking slow, deep breaths. "Relax," I told him. "Just breathe normally." I assured Andy that everything was going to be okay. I didn't know whom I was trying to reassure-him or me.
My mind was flying through all the possible interventions I could take to help him. No other team members were with me. No healthcare providers to call, no coworkers to help, no monitors to provide additional assessment data. I had to rely on my basic assessment skills.
I decided to check his blood glucose level, even though I knew it would probably be high from the packets of sugar he'd been given earlier. I looked for a glucometer in the emergency kit, but there wasn't one. I asked the flight attendant to ask the passengers for a glucometer. I was sure at least one of the 175 passengers on board had diabetes. The flight attendant made the announcement, "Attention passengers, please put on your call light if you have a glucometer." Lights and bells went off throughout the plane.
Glucometer in hand, I checked Andy's blood glucose level. It was 148, which was a little high. His heart rate was coming down and he wasn't shaking as badly.
I tried to calm Andy with questions about himself and his family. About 15 minutes later the flight attendant asked how he was doing. Andy pulled the oxygen mask away from his face and told me, "I've never been so scared in my life. I'm starting to feel better." Just then I realized something had changed.
"Andy, you just opened your hands," I said. He gently uncurled his knotted fingers. The flight attendant came by to check on us. With tears in his eyes, Andy held up his opened hands. I kept monitoring Andy's vital signs and fluids; his BP was coming up and his heart rate was coming down.
As I talked with Andy, he told me that this had become a life-changing experience. He realized the consequences of his actions affected not just himself, but every person on that plane. I listened empathetically and encouraged him to begin a new life without alcohol.
When we landed, the paramedics boarded and I gave them report. Tearfully Andy said, "I can never thank you enough for helping me." I gave him my phone number and asked him to call me and let me know how things turned out. As the passengers prepared to exit, a man seated across from me touched my arm. "You did a great job-thank you." His wife began to clap, and other passengers joined in. I smiled as we departed.
A few days later, Andy called and told me he'd gone to the hospital. His diagnosis: severe dehydration and electrolyte imbalance. He also shared that he's begun counseling for alcohol addiction.
This wasn't only a life-changing experience for Andy; it was for me, too. Through this experience, I renewed and confirmed my dedication to nursing and realized that I can make a difference any place, anywhere, at any time-in the air as well as on land.
Editor's note: Although starting an I.V. independent of a licensed prescriber isn't within the typical scope of an RN's practice, this action (as well as other actions) may be justified in certain life-threatening emergency situations, particularly when medical resources are lacking and the nurse judges the action(s) necessary to save a life. Many airlines do have medical kits that may be used by appropriately trained and qualified individuals. Some airlines even utilize a prearranged medical control system whereby a nurse or other healthcare provider in flight can contact a physician, apprise the physician of the situation, and receive treatment instructions, including advice and authorization for medication administration. If such a system is available during an onboard emergency, it should be requested and used by the nurse. In all cases, the nurse remains liable for any actions taken and is expected to use sound professional judgment. Whenever possible, the least invasive treatment options should be employed first.
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