Syncope

Yesterday, I found myself standing at the end of a jet bridge at the airport. A group of firefighters with their fingers in their ears were standing with me, and we waited patiently as the airline staffer maneuvered the bridge to a recently-arrived aircraft. The jet bridge driver shut everything down, locked the bridge in place, and slapped the door of the airliner.  Someone inside popped it open almost immediately and a flight attendant looked around until she saw me. “Thirty-five charlie,” she told me.

Of course my patient was in 35C. Nobody ever needs help in the front of an airplane. If someone does need help at the front, the other people on the flight are apparently morally obligated to carry the ill party to the back of the plane. I smiled and boarded the aircraft. The other passengers were waiting in their seats for me to do my thing and get out of the way.  Some airlines de-board the plane, so the medics have to wait for everyone to get off before accessing the patient. This airline was being cool.

I like to be welcoming, so I grinned my most friendly grin and loudly welcomed everyone to Omaha. Most people got the joke and knew they were in Denver, but I always vaguely hope I give someone a reason to briefly worry about where they wound up.

I made my way to the back row and found a late-fifties female patient who looked to be completely well. There were three or four other people around her who appeared as though they were about to burst with the anticipation of telling me their story. I held eye contact with the patient, said hello, introduced myself, and asked her how she was feeling. She told me that she was completely fine; embarrassment seemed to be her only complaint. Asking around, I discovered that the patient had enjoyed a syncopal event without fall or seizure activity, but appeared to improve with time and oxygen. One of the firefighters had pushed an aisle chair* back to row 35, so I got the patient onto it, pretended to listen to her complaints that she could walk off the aircraft, and made a dumb joke about how she had to use the chair because it would be too much paperwork if she fainted again while I was standing around looking useless. I heard a more complete story from the nurses twitching with the excitement of delivering a handoff report and then followed the patient off the plane.

We moved up to the concourse so I could perform my job more fully. The patient was 59 years old, had no medical history, took no medications, and had no current complaints. She explained that she felt hot about an hour ago during the flight, so she stood to go to the bathroom. While heading to the john, she fainted. Something like this had never happened before, she reported neither recent trauma nor illness, and didn’t hurt herself when she fainted (someone caught and lowered her). She had a blood pressure of 128/72 and a regular pulse rate of 68.

Normally I have to be careful to preserve patient privacy when I write up a case study like this. I change details and make up parts of the call. This case study, though, combines dozens of patients with the same story into one tale. This call is one that I see at least once per shift at the airport. People faint on airplanes all the time. All. The. Time.

I bet someone is fainting on that plane right now... Source

The issue is that syncope can be a big deal. Most causes of syncope are benign, and it is one of the most difficult findings to diagnose even in emergency departments – let alone on an airport concourse. Some of the causes of syncope to consider include arrhythmia, ischemia, structural cardiac abnormalities, cardiac tamponade, pacemaker malfunction, occult trauma with hemorrhage, GI bleeding, ruptured AAA, ruptured ovarian cysts, ruptured ectopic pregnancy, pulmonary embolism, subarachnoid hemorrhage, neurocardiogenic syncope, carotid sinus hypersensitivity, orthostatic syncope, medication effects, TIA, CVA, subclavian steal syndrome, psychiatric syncope, transient hypoxia or hypoglycemia, vasovagal events, and so on.  The list is long. It is difficult to pare down, especially, as I said, on an airport concourse without the machine that goes ping.

My biggest goal when evaluating and managing the in-flight syncope patient is to not alter my normal practice. Patients deserve a full work-up, even when they are in a hurry to make a connecting flight and even when I will run the same call the next day. I try to evaluate everyone for ongoing symptoms, as well as concerning findings like seated syncope, syncope without prodromal symptoms, and alterations in physical exam and vital signs.

I offer transport to an emergency department for a complete evaluation, and am almost universally turned down. I have had some hysterically bad reasons for non-transport. One patient told me that she couldn’t be in medical danger because she had never had severe medical problems before. I pointed out that the fact that because people haven’t yet died doesn’t mean that they won’t eventually die.

Anyway, the in-flight syncope refusal is so common that I have a consistent speech that I give: “Listen, before I let you go, I need you to make your decision based on the information that I have. Fainting is caused by a long and illustrious list of problems. The most common reasons for fainting are usually less dangerous, but that doesn’t help us decide whether the cause of your event was life-threatening or benign. Your event could have been caused by a dangerous problem that could come back without warning. This event may be the only warning your body will give you before you suddenly die. It is unlikely, but a possibility that you need to plan for. I can’t tell you why you fainted. The safest thing for you to do is to go to the hospital.”

No no no no. No hospital.

“Okay, that’s your decision. You’re an adult and have been making decisions for a long time. I’m not going to take over for you now. There is one thing that I need you to understand, though. An airplane in flight is a really bad place to have a medical problem. A cruising altitude of thirty thousand feet is something like six miles. Being six miles above the ground isn’t like being six miles away from a hospital, however. If you have a medical problem in flight, you won’t be able get the help you need. What I will tell you is that if you don’t feel absolutely 100% normal in every way, the airline will reschedule you for free. Make sure you are feeling perfect before you get on the plane. Is that something you can agree with?”

Sign here.

*They make extra-narrow wheelchairs that fit down the center aisle of a modern airliner.