Qatar Airways Pilot dies mid-flight

[Boomerang_Butt]

Dealing with an incapacitated flight crew member is something that should be in every airline's SOPs. I am rather taken aback by the lack of a single contribution which starts "our airline's SOPs are to do ...."

It is. I briefly described mine, sorry I didn't specifically say it was the SOP.

4. Concerning the trope that only a registered medical doctor may determine death in England and Wales and the US and other countries, prima facie it rather misses the interesting point, which is: what do you do if it happens in your presence? It is a question which most people who put themselves out of quick access to medical services (for example, most people who go sailing, backpacking, trecking, rock-climbing, mountaineering, cross-country skiing, even hunting and angling) are wise to ask themselves, and indeed such guidance is available.

Generally, it's:

1. Secure incapacitated pilot away from controls.
2. If possible, remove pilot to other suitable area (usually the galley)
3. Page for onboard medical assistance while commencing first response
4. Purser or other crew to remain in flight deck to assist remaining pilot if only 2 crew operating
5. Contact outside assistance (for airlines that use Medlink)
6. Continue first response in consultation with outside advice & any onboard professionals
7. Assist travelling companions/family of the patient (if applicable)

CPR if conducted may only cease when:

a) Definbrillator advises to discontinue
b) Doctor onboard pronounces death
c) extreme danger to the crew performing CPR
d) On flights with only a few crew, the crew become too tired to continue
e) The flight lands and ground medical services take over
f) signs of life return

She says check pulse, breathing, maybe eyes (iris contraction), but that there is no single indication that someone is dead. Lack of iris contraction indicates brain damage of some sort, but one cannot thereby conclude that the victim is dead. She says that resuscitation must always be tried. But of course she operates in a relatively unconstrained situation.

As pointed out earlier we are legally unable to pronounce someone dead, even a doctor onboard can only pronounce death and not certify death. For this reason in my current outfit it's called "presumed death" and we are not allowed to fully cover the face of the deceased in case they are in fact under some other condition but not clinically dead.

Most large airlines do have equipment onboard to deal with a presumed death in flight (clean-up equipment, body bags, places to stow a deceased person, etc etc)
There are also procedures which deal with this but I won't go into them here; suffice to say we are going to treat the person with as much dignity as possible given the situation.

[SeenItAll]

While this was certainly an unfortunate event, one issue that has not been addressed fully is: why was the flight diverted to KUL? Examination of Great Circle Mapper suggests that the likely track would have been substantially to the north, and BKK, HAN or other airports would have been much closer.. See:
Great Circle Mapper

If the diversion was to KUL for ops convenience reasons (as suggested by A300Man), this would seem to imply that there was no question but that the pilot was verified to be completely dead.

[justforfun]

A guy died while operating the airplane...

Well done to QR for being able to summon an entire crew in KL and achieve a turn-round in under two hours.

A fellow crew member dies in flight and this is the BS that people post?

Having read the thread I am disgusted at the comments and all the BS about "operating the airplane" and so on...

What is more important, a colleague dying in flight... with all the "what if's"... because of "you know what"... the "what if's" just happened!

And there are people are on here talking about what can only be described as "crap"... your colleague just died in flight!!!! It IS a significant event.



JFF

[justforfun]

"SeenItAll" ... "Great circle mapper..."

Wow, this is a great piece of software... free to anyone in the world.

Amazing to think Jeppesen, Navtech etc went to all that trouble to develop bespoke software as opposed to what is is free on the internet.

KUL is and was the most beneficial / logical Intl Airport for them... given the fact the 330 comes in here, and pretty much always there is a crew here.

Get a grip!

JFF

[SeenItAll]

Justforfun: If you read my post, I did not suggest that QR made an incorrect decision. I only suggested that because KUL did not appear to be the closest airport to general flight track, QR's decision to go there suggests that it did not think that the shortened flight time would afford the pilot a greater chance of survival.

Now of course if you happen to know the actual flight track of that day's flight, or know that it is QR's procedure to think of operational convenience over the health of a still-living captain with a severe heart attack, please enlighten us.

[DownIn3Green]

Justfor "fun" or whatever you care to call yourself...Your profile does not state any pilot quals...and from your posts on this thread I understand why...

I don't know about training at other airlines other than where I have been, but in my experience NO ONE!!! ever "dies" onboard the A/C...Period...

They are deemed "seriously ill" or "medically inpaired" but never DEAD...

Reason being, what country are you over???...or "who" pronounced this "seriously ill" pax or crew passed into the ever for ever land??? Insurance, wills, liabelity concerns, etc...These are all things to think about...

Also, as has been stated on this thread...Who actually knows the person is "dead"...

[skol]

You certainly are wet behind the ears, you should stick to seafaring.
There's nothing in our SOP's about 'do not resuscitate'.

Is your ship 'dry'?

LOL

[telster]

Wetbehindear

I'm aware that this is an aviation forum, not a medical one, so don't want to go too far off topic.

Agree with what you've written about the limitations of CPR and agree that its main benefit is to keep the patient 'alive' until he can be defibbed. I've been to a few collapses where bystanders claim that CPR alone had revived the patient before our arrival but I'd be pretty certain they'd never arrested in the first place. Probably had to hold them down to do it!

Just bear in mind though, that sometimes defibbing does work and a 'do not resusc' policy will ensure that the arrested patient has no chance at all. I know of somebody who arrested mid sentence, was succesfully defibbed, and carried on talking where they left off with nothing more than 'wtf was that?!'.

I'd have thought that an aircraft with easy access to defibrillation would be one of the more likely places to have a successful outcome.

[Airclues]

justforfun

Thanks for biting. This is a forum for professional pilots not a condolences forum. I think that we are entitled to discuss "operating the airplane".

If, as has been reported, the incident took place an hour out of Manila and the aircraft then diverted to an airport where a crew was available rather than a closer destination, this would imply that the captain was declared dead with no hope of revival. It would be interesting to know who made this diagnosis.
Unfortunately these incidents will continue to happen and it is important that we learn as much as possible from the medical experts amongst us.

[A37575]

As a matter of interest was the first officer the only remaining pilot on the aircraft and what was his experience level.

[telster]

Do Not Resuscitate

Think this is getting off topic now, so this'll be my last post.

I can only speak for the UK, and I've been out of the ambulance service a few years now, but Do Not Resuscitate orders have no place in the pre-hospital environment. If you go into cardiac arrest, and an ambulance crew attends you, they will resuscitate despite the medallion, tattoo across your chest, wife begging you not to, whatever.

Legally, and morally, there is too much to lose by not resuscitating someone who might have benefited, and the legal minefield of ensuring that the patients wishes not to be resuscitated were made in sound mind, really were their wishes etc, is one to be picked across in a less time-critical situation than a cardiac arrest.

As for cockpit crew, realistically what are you going to do? Add your resusc preference to your pre-flight briefing, or have "DNR" embroidered onto your epaulettes??

[Boomerang_Butt]

Airclues,

On your mention of a decision to divert.... services such as Medlink, using qualified doctors, will advise for or against a diversion given the facts known at the time and available to them. In certain cases I believe they can pronounce death in which case they would probably advise continuing to a company port so that the affected crew can be stood down and supported by their colleagues and company personnel.

Of course, the captain/PIC always has the last decision but Medlink will give any and all necessary advice. They have legal liability to make decision on behalf of the cabin crew and cabin crew if following directions of Medlink are absolved of liability, given they follow said instructions to the letter.

Hope this helps clear it up a bit.

[topgas]

There is increasing evidence that the most important factor in the early stages of a cardiac arrest in adults is continuous chest compressions, to the extent that non trained personnel should not waste time trying to give "kiss of life". Even paramedics are not always very good at continuous compressions - they get distracted with airway, vascular access, etc. It would be nice if someone could lift the chin to open the airway so that there is air movement with the compressions, and of course the chances of survival also rely on rapid defibrillation using the Automatic External Defibrillator if it is a shockable rhythm. There's nothing to lose by trying, particularly in the pilot age group. Someone mentioned up to 10% survival - one in ten doesn't sound bad when the alternative - doing nothing - is pretty close to 0%

[SassyPilotsWife]

Let me give you a quick course in REALISTIC first aid. I am a 12 year US Paramedic with ACLS ( Advanced Cardiac Life Support and Instructor for 8 years. You may receive basic first aid course but its almost always with a dummy ( someone from ops or scheduling lol j/k) right there in front of you and not seated in a sim or actual cockpit or in the case of a passenger, seated or found in the bathroom ( you find alot of full arrest patients there, caught with their pants down literally). In the case of a flight deck crew member: Here ya go...

Unreponsive ? Remove the little bottle from his flight bag, delete girlfriends numbers from his cell phone THEN you Call for cabin crew. Ok all kidding aside :
If unresponsive check for pulse. No pulse ? Maintain your aircraft, notify CC then ATC and if able ( aircraft is maintained) start compressions regardless if pt is still seated until CC arrive. * BAD CPR IS BETTER THAN NO CPR*

ENTER CC who take over CPR

PILOT: 1. Before notifiying ops to be moved up on the seniority list, Notify ATC your emergency, ask them to get an ER doctor from the nearest hospital that can speak English ( if you're international) If this happens IN THE US: ASK ATC TO GET MED CONTROL if you do not have MEDLINK from the nearest city your closest to especially if diverting and patch them thru to you via SAT phone radio if possible or relay thru ATC There's your doc who can standby to assist or call time of death. Advise them you have a full arrest. This notification allows documentation of the time the patient was down and when CPR was started so that a doc can determine when to call time of death.
2. After you have requested MED CONTROL, ask if there is a PARAMEDIC on board, a NURSE 2nd and 3rd a DOCTOR. Why Paramedic first ? Because as Paramedics, we do this every day in the craziest of circumstances, places, environmental issues etc. and believe it or not, some of us travel with certain equipment ( ET roll kit, for intubation) I've done it while traveling to/from conventions, training courses, responding to/from emergency disasters. Also, we work under the direction of Med Control and MEDLINK and we can call time of death in the field under what is called standing orders. US that is, not sure about other countries.

CC: 1. Assuming you took over compressions, continue compressions, Give 2 rescue breaths and put pilot 02 mask on pt. Get pt out of his seat without manipulating flight controls. Get pt on flat hard surface OUT OF THE COCKPIT, attach AED if you defibrillate the pt in the cockpit and the only pilot left winds up getting shocked too, you then become fubar. Its too tight of quarters in there to take that chance. You can also cause an arch or get shocked yourselves. As Paramedics, we're even taught that our safety comes before patient safety. If we die, the patient definitely doesn't stand a chance. Keep CPR GOING! Realizing you can't take his o2 mask with you, follow current CPR guidlines for 2 persons CPR ( which just changed by the way) continue CPR while AED is attached to pt.
2. Follow AED instructions that are verbally given. Switch up compressions between CC's every 5 or so min. It is exhausting. If you have turned on your 02 tank, turn it off, save it in case you get him back because you're giving those rescue breaths. DO NOT STOP COMPRESSIONS unless to shock or change CC administering compressions.
3. If you dont have MEDLINK and the pilot has been able to make contact with MED CONTROL ( a doc at a hospital authorized to give instructions via phone/radio and even call time of death if indicated) he will ask you what access you have to certain meds. Clue: got an epi pen ? use it. Epinepherine is a first line drug used in ACLS and it is protocol for respiratory arrest. Pt isn't breathing right ? Never know he could have went into cardiac arrest due to anaphylactic shock which has probably caused edema to the airway and you need a patent airway ( open) to deliver oxygen to the lungs. Your working with what you've got. What are the chances of a passenger having one if you don't ? Ask. Here's something else you can do under the direction of that med control doc, Get a blood sugar on this pt. Is he a diabetic ? I have worked many full arrest on pt's who were diabetics and pushing D50 brought them back. You won't have D50 capabilities but at least the family and that pilot who witnessed this will know that if he had a blood sugar of 11, or even 40, he died because of that and there was nothing anyone could do. You can do this by asking if there is a passenger on board with a glucose testing machine ( they are pocket size)
The last 2 steps are only if there is enough crew to make sure that CPR is continuous and not interrupted.

When to stop CPR: The patient tells you your hurting him. ( its happened)
You have med control on the line telling you to stop
A doctor on board ( who has shown ID) tells you to
stop. Med Control doc supercedes doc on scene.
Obvious death: Rigor Mortis prevents you from CPR

Under no circumstances do you stop CPR to check pupils. Nor do you check pupils b4 starting CPR At this point, it's irrelevant.

Please remember this. People don't die from cardiac arrest persay.. They die from an underlying cause that then caused them to go into cardiac arrest. That is NOT always a heart problem. Especially at 43 years old. So you do have to treat the cardiac arrest and what I suspect with this Captain, was a PE aka Pulmonary Embolism. If he suffered a PE, there was nothing anyone could have done as once the PE moves from the lungs to the heart, thats it.. He has now earned his golden wings and is in a much better place.

This memo or reply to thread in no way is to take place of a well taught, industry specific first aid/ cpr/ aed course but it offers some helpful hints that aren't taught in the basic course that you may get or some of you haven't been able to get. So many instructors teach text book theory without real pt placement scenarios. If your SOP contraindicates any of this, just make sure you write down what was done in accordance with your SOP If its not in your SOP, then it needs to be.

Ahem. TOPGAS... like i stated above. Bad CPR is better than NO CPR. We are not God, it is not up to us to determine anyone's fate but I would hope you would give it a half ass chance and try. I'd rather know someone died despite ALL efforts than to know he/she died with NO efforts.

[lomapaseo]

Please remember this. People don't die from cardiac arrest persay

I would love to believe this since my heart and arteries, like many healty folks are in good shape except for V-tach possibly leading to V-Fib. or throwing a clot to lungs or brain. To me that is cardiac arrest and lights out.

[olster]

SPW -thank you for taking the time to post -very interesting and very good info.

[JEM60]

SPW
Excellent post. Whilst no longer involved as a First Responder, I believe that there is a lot of discussion in UK as to whether or not the two rescue breaths are worth while, and that continous CPR is the answer. No decision yet, but I think the breaths will go.

[riverfish]

Hello.
I have no aviation knowledge specifically. I have dropped in as a doctor, doing a repat flight yesterday, to see if there was anything to cause the go around and hold at DUB yesterday due to a blocked runway.!!


If I may just make a few points.

1) The real thing is very different from 'training' No matter how well you train..you are never completely prepared, though to think through what you need to do will help you work more efficiently and safely through the situation. Though of course in the aviation industry, lots of your training is for situations that you hope will not occur in real life.
2) If the pilot has arrested, his chance of survival outside a hospital setting is very small. Effective management and treatment will increase his survival odds, but they are still small.
It is therefore imperative that the other healthy individuals on the plane are not jeapordised by trying to extracate from the seat. Do not underestimate how awkward heavy and difficult corpses/unconscious people are to move. You will need one person to protect the head/neck, and others to move the trunk. They will need lying somewhere eg the galley.If there is any risk whatsoever of risking the safety of the others on the plane DO NOT DO IT!!!

I have never had to do rescussitation on a plane, but my impression is that it would be very difficult because of the cramped conditions and noise.They would need lying down on a firm surface, I suppose in the galley.

3) You need to get effective cpr (cardiac massage ) as soon as possible, and if you have an automatic defib on the plane get it connected, and get a reading as quickly as possible to see if there is something that would benefit from a shock. These things are really good and idiot proof these days, and you cannot do any damage with them!!
worth a couple of mins of your time having a look at it if you havnt.

4) \You are right that the guidelines have changed recently...or they are doing in 2011.. http://www.resus.org.uk/pages/guidesum.pdf


5) In the resuscitation council guidelines, 'call for help' is number one on the list...even for people who supposedly know what they are doing....so you should too.
Nurse doctor paramedic, ask for them all. An ER nurse is going to be more use than an ophthalmologist, but find out who you have on board. You might have someone like me going to do a medical retrieval, with a defib in my hand luggage!!!! If you dont ask you may never know.

6) Speed in getting effective cpr under way is crucial.
We had a lady in the er a couple of weeks ago all monitored, with something completely different , when all of a sudden she had a cardiac arrest!!!! Defibbed within 10 seconds, and virtually carried on with the conversation where she left off!!!
I was at a concert, and an old guy became ill and was led outside, I and a collegue, a consultant anaesthetist administered effective cpr for half an hour from the moment he collapsed. By the time the ambulance appeared 45 mins later, he had come round. Though we will never know what happened for sure, the likelihood is that the guy must have developed an abnormal heart rhythm that did not give him a pulse. we kept him going till his heart clicked back into a rhythm with a pulse. ...so it is worth giving it a good go, but he was lucky to be right by two experienced docs.



7) I wouldnt get too involved in discussions about pupil size any more than I would get involved in discussions about wind shear!!

I hope this is useful, and I hope it never happens!!

[topgas]

SPW - great post
I would only take issue with you about Pulmonary Embolus, clot which moves from the legs(usually) through the heart and lodges in the lung vessels, blocking the blood flow. Chest compressions can break up the clot and distribute it to the smaller vessels, allowing more blood to flow through the lungs and pick up oxygen. No disrepect intended on paramedic CPR - they are still better than most, and the good are very good. I've had the honour to fly missions with some of the best.

WBE
latest changes are

1. When obtaining help, ask for an automated external defibrillator (AED), if one is available.
2. Compress the chest to a depth of 5-6 cm and at a rate of 100-120 min-1.
3. Give each rescue breath over 1 s rather than 2 s.
4. Do not stop to check the victim or discontinue CPR unless the victim starts to
show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally.
5. Teach CPR to laypeople with an emphasis on chest compression, but include ventilation as the standard, particularly for those with a duty of care.
In addition, advice has been added on the use of oxygen, and how to manage a victim who regurgitates stomach contents during resuscitation.

The whole lot are here

Just remember the five Ps

[BRE]

Riverfish: "By the time the ambulance appeared 45 mins later, he had come round."

What kind of concert was that? All concerts I'm familiar with (not counting local bands in a pub that accomodates 50 guests) have an ambulance on the premises. The only exception to this are opera houses / concert halls, which will have staff paramedics and are in a central urban setting where you can reasonably expect an ambulance or helicopter to arrive within 5 minutes.