NEW ORLEANS – Risk tolerance to current disease modifying therapies by patients with multiple sclerosis varies widely, results from a large national survey demonstrated.

“We have therapies available with a wide range of risks,” study author Sneha Natarajan, PhD, said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the risks are relatively minor like injection site reactions or flu-like symptoms and some are as bad as PML [progressive multifocal leukoencephalopathy], which can be fatal. We don’t know what kind of risks people tolerate.”

Doug Brunk/Frontline Medical News

[email protected]

NEW ORLEANS – Risk tolerance to current disease modifying therapies by patients with multiple sclerosis varies widely, results from a large national survey demonstrated.

“We have therapies available with a wide range of risks,” study author Sneha Natarajan, PhD, said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the risks are relatively minor like injection site reactions or flu-like symptoms and some are as bad as PML [progressive multifocal leukoencephalopathy], which can be fatal. We don’t know what kind of risks people tolerate.”

Doug Brunk/Frontline Medical News

[email protected]

NEW ORLEANS – Risk tolerance to current disease modifying therapies by patients with multiple sclerosis varies widely, results from a large national survey demonstrated.

“We have therapies available with a wide range of risks,” study author Sneha Natarajan, PhD, said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the risks are relatively minor like injection site reactions or flu-like symptoms and some are as bad as PML [progressive multifocal leukoencephalopathy], which can be fatal. We don’t know what kind of risks people tolerate.”

Doug Brunk/Frontline Medical News

[email protected]

Clinical Question: Do family reports of adverse events improve incident detection, compared with clinician reports and hospital incident reports?

Background: Hospital incident reports, which are voluntary and suffer from underreporting, capture only a fraction of errors and adverse events (defined as errors resulting in harm). Systematic, prospective surveillance by researchers is the gold standard but is time consuming and expensive. The authors hypothesized that family reports would improve error and adverse event detection.

Overall, error rates with family-reported errors were 15.5% higher (95% confidence interval, 9.0%-22.3%) than without. Adverse event rates with family reporting were 9.8% higher (95% CI, 3.1%-16.9%) than without. Family-reported error rates were 5 times higher (95% CI, 1.9-13.0) than hospital incident report rates.

The study showed that family-reported error and adverse event rates were significantly higher than voluntary, clinician-only hospital incident report rates. The study was limited to pediatric hospitals on general pediatric and subspecialty services, though findings potentially may be applicable more broadly (for example, adult and surgical services).

Bottom Line: Using a structured interview, families report significantly higher rates of errors and adverse events, compared with other sources.

Reference: Khan A, Coffey M, Litterer KP, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatrics. Published online Feb 27, 2017. doi: 10.1001/jamapediatrics.2016.4812.

Clinical Question: Do family reports of adverse events improve incident detection, compared with clinician reports and hospital incident reports?

Background: Hospital incident reports, which are voluntary and suffer from underreporting, capture only a fraction of errors and adverse events (defined as errors resulting in harm). Systematic, prospective surveillance by researchers is the gold standard but is time consuming and expensive. The authors hypothesized that family reports would improve error and adverse event detection.

Overall, error rates with family-reported errors were 15.5% higher (95% confidence interval, 9.0%-22.3%) than without. Adverse event rates with family reporting were 9.8% higher (95% CI, 3.1%-16.9%) than without. Family-reported error rates were 5 times higher (95% CI, 1.9-13.0) than hospital incident report rates.

The study showed that family-reported error and adverse event rates were significantly higher than voluntary, clinician-only hospital incident report rates. The study was limited to pediatric hospitals on general pediatric and subspecialty services, though findings potentially may be applicable more broadly (for example, adult and surgical services).

Bottom Line: Using a structured interview, families report significantly higher rates of errors and adverse events, compared with other sources.

Reference: Khan A, Coffey M, Litterer KP, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatrics. Published online Feb 27, 2017. doi: 10.1001/jamapediatrics.2016.4812.

Clinical Question: Do family reports of adverse events improve incident detection, compared with clinician reports and hospital incident reports?

Background: Hospital incident reports, which are voluntary and suffer from underreporting, capture only a fraction of errors and adverse events (defined as errors resulting in harm). Systematic, prospective surveillance by researchers is the gold standard but is time consuming and expensive. The authors hypothesized that family reports would improve error and adverse event detection.

Overall, error rates with family-reported errors were 15.5% higher (95% confidence interval, 9.0%-22.3%) than without. Adverse event rates with family reporting were 9.8% higher (95% CI, 3.1%-16.9%) than without. Family-reported error rates were 5 times higher (95% CI, 1.9-13.0) than hospital incident report rates.

The study showed that family-reported error and adverse event rates were significantly higher than voluntary, clinician-only hospital incident report rates. The study was limited to pediatric hospitals on general pediatric and subspecialty services, though findings potentially may be applicable more broadly (for example, adult and surgical services).

Bottom Line: Using a structured interview, families report significantly higher rates of errors and adverse events, compared with other sources.

Reference: Khan A, Coffey M, Litterer KP, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatrics. Published online Feb 27, 2017. doi: 10.1001/jamapediatrics.2016.4812.

SCOTTSDALE, ARIZ. – Linda L.M. Worley, MD, was stunned when a meeting she’d requested with her supervisor to address a shortage of beds turned into a rebuke.

“You’re on the tenure track, Linda. If you want to keep your job 6 years from now, you’d best pick up the pace. You need to see 20 private patients a week, and get moving on your research and publications,” Dr. Worley remembers the supervisor saying. At the time, she was a 32-year-old mother of two, wife, academic faculty physician, and sole attending running a general hospital consultation liaison psychiatry department and the college of medicine student mental health service. She also worked as the 24/7 on-call psychiatrist for a week at a time, said Dr. Worley, now a staff psychiatrist in the Fayetteville, Ark., Veterans Health Care System of the Ozarks and chief mental health officer for South Central VA Health Care Network.

• Care for your yacht, which is the body, including the brain. “You only get one, and if you’re going to have a chance of winning the regatta, you have to take care of it. This means getting good sleep, nutrition, exercise, preventive care, rest, and rejuvenation, including vacation,” Dr. Worley said.

• Chart your course; have a navigational plan that includes your life goals and aspirations. Identify and rely upon “landmarks,” such as being a good spouse, mother, physician, or friend for the most authentic definition of personal success. “These are like buoys that keep us sailing in the right direction,” she said.

• Reef in your sails, meaning mind the “winds that come at us from every side,” she said. This includes triaging tasks and not letting perfectionism get in the way. “Perfectionists take too long to tack; they don’t know when it’s time to turn in the other direction,” she said. “If you want to finish the race, you have to do the best you can in the time you have.” This was the lesson Dr. Worley said she learned that day when she was a young physician feeling overwhelmed.

• Empty your bilge, the nautical term for removing waste water from within the hull. Dr. Worley uses this as a metaphor for identifying and expressing negative emotions of fear, anxiety, sadness, and frustration. “These vital emotions are giving us important messages. It is important to recognize that they are present. Name and accept them, and understand what they are trying to tell us. Is it a symptom of an underlying illness that needs treatment? A conflict in a relationship? A need not being met? Are you living your deepest values? Express the emotions and sort through the best response,” she said. “It’s all part of emotional intelligence.”

• Keep an even keel, which is Dr. Worley’s way of stating the importance of being connected to love and to living your deepest values. “The keel is your character, your connection to meaning, a spiritual connection. In medicine, we shy away from that. I have only lately ventured into talking about this,” she said, noting that this connection can come in numerous ways, such as meditation, and being in nature or with animals. “It’s very personal. It’s hard to quantify, but I have witnessed it and its healing power within the therapeutic alliance.”

In break-out sessions during her well-attended talk at the meeting, Dr. Worley listened as psychiatrists of all levels of experience and responsibility, ranging from medical directors to those in private community practice, shared the kinds of concerns she said she often encounters in her role as a core faculty member of the Program for Distressed Physicians at the Vanderbilt Center for Professional Health.

“Changes in medicine have been so frustrating; physicians are at their wits’ end. We don’t recruit people into medicine because they have a skill set for expressing their emotions, or taking care of themselves, or dealing with conflict,” she said. “That’s okay. They can learn it.”

[email protected]

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – Linda L.M. Worley, MD, was stunned when a meeting she’d requested with her supervisor to address a shortage of beds turned into a rebuke.

“You’re on the tenure track, Linda. If you want to keep your job 6 years from now, you’d best pick up the pace. You need to see 20 private patients a week, and get moving on your research and publications,” Dr. Worley remembers the supervisor saying. At the time, she was a 32-year-old mother of two, wife, academic faculty physician, and sole attending running a general hospital consultation liaison psychiatry department and the college of medicine student mental health service. She also worked as the 24/7 on-call psychiatrist for a week at a time, said Dr. Worley, now a staff psychiatrist in the Fayetteville, Ark., Veterans Health Care System of the Ozarks and chief mental health officer for South Central VA Health Care Network.

• Care for your yacht, which is the body, including the brain. “You only get one, and if you’re going to have a chance of winning the regatta, you have to take care of it. This means getting good sleep, nutrition, exercise, preventive care, rest, and rejuvenation, including vacation,” Dr. Worley said.

• Chart your course; have a navigational plan that includes your life goals and aspirations. Identify and rely upon “landmarks,” such as being a good spouse, mother, physician, or friend for the most authentic definition of personal success. “These are like buoys that keep us sailing in the right direction,” she said.

• Reef in your sails, meaning mind the “winds that come at us from every side,” she said. This includes triaging tasks and not letting perfectionism get in the way. “Perfectionists take too long to tack; they don’t know when it’s time to turn in the other direction,” she said. “If you want to finish the race, you have to do the best you can in the time you have.” This was the lesson Dr. Worley said she learned that day when she was a young physician feeling overwhelmed.

• Empty your bilge, the nautical term for removing waste water from within the hull. Dr. Worley uses this as a metaphor for identifying and expressing negative emotions of fear, anxiety, sadness, and frustration. “These vital emotions are giving us important messages. It is important to recognize that they are present. Name and accept them, and understand what they are trying to tell us. Is it a symptom of an underlying illness that needs treatment? A conflict in a relationship? A need not being met? Are you living your deepest values? Express the emotions and sort through the best response,” she said. “It’s all part of emotional intelligence.”

• Keep an even keel, which is Dr. Worley’s way of stating the importance of being connected to love and to living your deepest values. “The keel is your character, your connection to meaning, a spiritual connection. In medicine, we shy away from that. I have only lately ventured into talking about this,” she said, noting that this connection can come in numerous ways, such as meditation, and being in nature or with animals. “It’s very personal. It’s hard to quantify, but I have witnessed it and its healing power within the therapeutic alliance.”

In break-out sessions during her well-attended talk at the meeting, Dr. Worley listened as psychiatrists of all levels of experience and responsibility, ranging from medical directors to those in private community practice, shared the kinds of concerns she said she often encounters in her role as a core faculty member of the Program for Distressed Physicians at the Vanderbilt Center for Professional Health.

“Changes in medicine have been so frustrating; physicians are at their wits’ end. We don’t recruit people into medicine because they have a skill set for expressing their emotions, or taking care of themselves, or dealing with conflict,” she said. “That’s okay. They can learn it.”

[email protected]

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – Linda L.M. Worley, MD, was stunned when a meeting she’d requested with her supervisor to address a shortage of beds turned into a rebuke.

“You’re on the tenure track, Linda. If you want to keep your job 6 years from now, you’d best pick up the pace. You need to see 20 private patients a week, and get moving on your research and publications,” Dr. Worley remembers the supervisor saying. At the time, she was a 32-year-old mother of two, wife, academic faculty physician, and sole attending running a general hospital consultation liaison psychiatry department and the college of medicine student mental health service. She also worked as the 24/7 on-call psychiatrist for a week at a time, said Dr. Worley, now a staff psychiatrist in the Fayetteville, Ark., Veterans Health Care System of the Ozarks and chief mental health officer for South Central VA Health Care Network.

• Care for your yacht, which is the body, including the brain. “You only get one, and if you’re going to have a chance of winning the regatta, you have to take care of it. This means getting good sleep, nutrition, exercise, preventive care, rest, and rejuvenation, including vacation,” Dr. Worley said.

• Chart your course; have a navigational plan that includes your life goals and aspirations. Identify and rely upon “landmarks,” such as being a good spouse, mother, physician, or friend for the most authentic definition of personal success. “These are like buoys that keep us sailing in the right direction,” she said.

• Reef in your sails, meaning mind the “winds that come at us from every side,” she said. This includes triaging tasks and not letting perfectionism get in the way. “Perfectionists take too long to tack; they don’t know when it’s time to turn in the other direction,” she said. “If you want to finish the race, you have to do the best you can in the time you have.” This was the lesson Dr. Worley said she learned that day when she was a young physician feeling overwhelmed.

• Empty your bilge, the nautical term for removing waste water from within the hull. Dr. Worley uses this as a metaphor for identifying and expressing negative emotions of fear, anxiety, sadness, and frustration. “These vital emotions are giving us important messages. It is important to recognize that they are present. Name and accept them, and understand what they are trying to tell us. Is it a symptom of an underlying illness that needs treatment? A conflict in a relationship? A need not being met? Are you living your deepest values? Express the emotions and sort through the best response,” she said. “It’s all part of emotional intelligence.”

• Keep an even keel, which is Dr. Worley’s way of stating the importance of being connected to love and to living your deepest values. “The keel is your character, your connection to meaning, a spiritual connection. In medicine, we shy away from that. I have only lately ventured into talking about this,” she said, noting that this connection can come in numerous ways, such as meditation, and being in nature or with animals. “It’s very personal. It’s hard to quantify, but I have witnessed it and its healing power within the therapeutic alliance.”

In break-out sessions during her well-attended talk at the meeting, Dr. Worley listened as psychiatrists of all levels of experience and responsibility, ranging from medical directors to those in private community practice, shared the kinds of concerns she said she often encounters in her role as a core faculty member of the Program for Distressed Physicians at the Vanderbilt Center for Professional Health.

“Changes in medicine have been so frustrating; physicians are at their wits’ end. We don’t recruit people into medicine because they have a skill set for expressing their emotions, or taking care of themselves, or dealing with conflict,” she said. “That’s okay. They can learn it.”

[email protected]

On Twitter @whitneymcknight

To improve patient care and outcomes, leading dermatologists offered their recommendations on face scrubs. Consideration must be given to:

• Crystal Peel Microdermabrasion Exfoliating Face Crème
  Formulary for Physicians, Inc
  
  “This product is a highly effective facial scrub for patients with thick skin. Its exfoliating ingredient is corundum, another name for aluminum oxide, the crystal used by most microabrasion machines.”— Mark G. Rubin, MD, Beverly Hills, California
  
   
• Facial Fuel Energizing Scrub
  Kiehl’s
  
  Recommended by Gary Goldenberg, MD, New York, New York
  
   
• Olay Regenerist Regenerating Cream Cleanser
  Procter & Gamble
  
  “Oxygenated beads in the creamy formula help to gently exfoliate the skin without overdrying and stripping the skin’s outer layer, leaving the skin soft and fresh.”—Jeannette Graf, MD, New York, New York
  
   
• PRESCRIBEDsolutions: Starting Up/Face, Surface Improvement
  Biopelle, Inc
  
  “I use Starting Up/Face as my daily cleanser, as it contains salicylic acid and helps improve the overall texture plus minimize bumps from shaving, and Surface Improvement about every other day on my face in the shower.”—Joel L. Cohen, MD, Greenwood Village, Colorado
  
   
• St. Ives Apricot Blemish Control Scrub
  Unilever
  
  “It exfoliates and has salicylic acid. After exfoliating, I recommend allowing it to sit on the skin for 5 minutes before washing off.”—Anthony M. Rossi, MD, New York, New York

Cutis invites readers to send us their recommendations. Athlete’s foot treatments, cleansing devices, and redness-reducing products will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on face scrubs. Consideration must be given to:

• Crystal Peel Microdermabrasion Exfoliating Face Crème
  Formulary for Physicians, Inc
  
  “This product is a highly effective facial scrub for patients with thick skin. Its exfoliating ingredient is corundum, another name for aluminum oxide, the crystal used by most microabrasion machines.”— Mark G. Rubin, MD, Beverly Hills, California
  
   
• Facial Fuel Energizing Scrub
  Kiehl’s
  
  Recommended by Gary Goldenberg, MD, New York, New York
  
   
• Olay Regenerist Regenerating Cream Cleanser
  Procter & Gamble
  
  “Oxygenated beads in the creamy formula help to gently exfoliate the skin without overdrying and stripping the skin’s outer layer, leaving the skin soft and fresh.”—Jeannette Graf, MD, New York, New York
  
   
• PRESCRIBEDsolutions: Starting Up/Face, Surface Improvement
  Biopelle, Inc
  
  “I use Starting Up/Face as my daily cleanser, as it contains salicylic acid and helps improve the overall texture plus minimize bumps from shaving, and Surface Improvement about every other day on my face in the shower.”—Joel L. Cohen, MD, Greenwood Village, Colorado
  
   
• St. Ives Apricot Blemish Control Scrub
  Unilever
  
  “It exfoliates and has salicylic acid. After exfoliating, I recommend allowing it to sit on the skin for 5 minutes before washing off.”—Anthony M. Rossi, MD, New York, New York

Cutis invites readers to send us their recommendations. Athlete’s foot treatments, cleansing devices, and redness-reducing products will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on face scrubs. Consideration must be given to:

• Crystal Peel Microdermabrasion Exfoliating Face Crème
  Formulary for Physicians, Inc
  
  “This product is a highly effective facial scrub for patients with thick skin. Its exfoliating ingredient is corundum, another name for aluminum oxide, the crystal used by most microabrasion machines.”— Mark G. Rubin, MD, Beverly Hills, California
  
   
• Facial Fuel Energizing Scrub
  Kiehl’s
  
  Recommended by Gary Goldenberg, MD, New York, New York
  
   
• Olay Regenerist Regenerating Cream Cleanser
  Procter & Gamble
  
  “Oxygenated beads in the creamy formula help to gently exfoliate the skin without overdrying and stripping the skin’s outer layer, leaving the skin soft and fresh.”—Jeannette Graf, MD, New York, New York
  
   
• PRESCRIBEDsolutions: Starting Up/Face, Surface Improvement
  Biopelle, Inc
  
  “I use Starting Up/Face as my daily cleanser, as it contains salicylic acid and helps improve the overall texture plus minimize bumps from shaving, and Surface Improvement about every other day on my face in the shower.”—Joel L. Cohen, MD, Greenwood Village, Colorado
  
   
• St. Ives Apricot Blemish Control Scrub
  Unilever
  
  “It exfoliates and has salicylic acid. After exfoliating, I recommend allowing it to sit on the skin for 5 minutes before washing off.”—Anthony M. Rossi, MD, New York, New York

Cutis invites readers to send us their recommendations. Athlete’s foot treatments, cleansing devices, and redness-reducing products will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

The American Health Care Act, the House Republicans’ replacement for the Affordable Care Act, is currently viewed less favorably than its predecessor, according to a new poll by the Kaiser Family Foundation.

In the survey, 40% of respondents said that they had a “very unfavorable” opinion of the AHCA, compared with 29% for the ACA. The “very favorable” opinions also favored the ACA: 29% to 12%, according to a Kaiser report released May 31.

[email protected]

The American Health Care Act, the House Republicans’ replacement for the Affordable Care Act, is currently viewed less favorably than its predecessor, according to a new poll by the Kaiser Family Foundation.

In the survey, 40% of respondents said that they had a “very unfavorable” opinion of the AHCA, compared with 29% for the ACA. The “very favorable” opinions also favored the ACA: 29% to 12%, according to a Kaiser report released May 31.

[email protected]

The American Health Care Act, the House Republicans’ replacement for the Affordable Care Act, is currently viewed less favorably than its predecessor, according to a new poll by the Kaiser Family Foundation.

In the survey, 40% of respondents said that they had a “very unfavorable” opinion of the AHCA, compared with 29% for the ACA. The “very favorable” opinions also favored the ACA: 29% to 12%, according to a Kaiser report released May 31.

[email protected]

SAN FRANCISCO – A survey of public and private colleges and universities throughout the United States has revealed marked variation in the requirements for vaccination in the enrollment process and vaccine availability through on-campus student health.

The policies of the institutions usually reflected the policies of the particular state or district.

copyright luiscar/Thinkstock

© Ingram Publishing/Thinkstock

The sponsor of study was the Children’s Hospital of Philadelphia. The study was not funded. Dr. Feemster had no conflicts to disclose.

[email protected]

SAN FRANCISCO – A survey of public and private colleges and universities throughout the United States has revealed marked variation in the requirements for vaccination in the enrollment process and vaccine availability through on-campus student health.

The policies of the institutions usually reflected the policies of the particular state or district.

copyright luiscar/Thinkstock

© Ingram Publishing/Thinkstock

The sponsor of study was the Children’s Hospital of Philadelphia. The study was not funded. Dr. Feemster had no conflicts to disclose.

[email protected]

SAN FRANCISCO – A survey of public and private colleges and universities throughout the United States has revealed marked variation in the requirements for vaccination in the enrollment process and vaccine availability through on-campus student health.

The policies of the institutions usually reflected the policies of the particular state or district.

copyright luiscar/Thinkstock

© Ingram Publishing/Thinkstock

The sponsor of study was the Children’s Hospital of Philadelphia. The study was not funded. Dr. Feemster had no conflicts to disclose.

[email protected]

HM17 On Demand now available

Couldn’t make it to Las Vegas for SHM’s annual meeting, Hospital Medicine 2017? HM17 On Demand gives you access to over 80 online audio and slide recordings from the hottest tracks, including clinical updates, rapid fire, pediatrics, comanagement, quality, and high-value care.

Additionally, you can earn up to 70 American Medical Association Physician Recognition Award Category 1 Credit(s) and up to 30 American Board of Internal Medicine Maintenance of Certification credits. HM17 attendees can also benefit by earning additional credits on the sessions you missed out on.

To easily access content through SHM’s Learning Portal, visit shmlearningportal.org/hm17-demand to learn more.
 

Chapter Excellence Awards

SHM is proud to recognize outstanding chapters for the fourth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities.

View more at www.hospitalmedicine.org/chapterexcellence. Please join SHM in congratulating the following chapters on their success!

Silver Chapters

Boston Association of Academic Hospital Medicine (BAAHM)

Charlotte Metro Area

Houston

Kentucky

Los Angeles

Minnesota

North Jersey

Pacific Northwest

Philadelphia Tri-State

Rocky Mountain

San Francisco Bay

South Central PA

Gold Chapters

New Mexico

Wiregrass

Platinum Chapters

IowaMaryland

Michigan

NYC/Westchester

St. Louis

Outstanding Chapter of the Year

Michigan

Rising Star Chapter

Wiregrass
 

Student Hospitalist Scholar grant winners

SHM’s Student Hospitalist Scholar Grant provides funds with which medical students can conduct mentored scholarly projects related to quality improvement and patient safety in the field of hospital medicine. The program offers a summer and a longitudinal option.

Congratulations to the 2017-2018 Student Hospitalist Scholar Grant recipients:Summer Program

Anton Garazha

Rosalind Franklin University of Medicine and Science

“Effectiveness of Communication During ICU to Ward Transfer and Association with Medical ICU Readmission”

Cole Hirschfeld

Weill Cornell Medical College

“The Role of Diagnostic Bone Biopsies in the Management of Osteomyelitis”

Farah Hussain

University of Cincinnati College of Medicine

“Better Understanding Clinical Deterioration in a Children’s Hospital”

Longitudinal Program

Monisha Bhatia

Vanderbilt University School of Medicine

“Using Electronic Medical Record Phenotypic Data to Predict Discharge Destination”

Victor Ekuta

University of California, San Diego School of Medicine

“Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention”

Yun Li

Geisel School of Medicine at Dartmouth

“Developing and implementing clinical pathway(s) for hospitalized injection drug users due to injection-related infection sequelae”

Learn more about the Student Hospitalist Scholar Grant at hospitalmedicine.org/scholargrant.

SPARK ONE: A tool to teach residents

SPARK ONE is a comprehensive, online self-assessment tool created specifically for hospital medicine professionals. The activity contains 450+ vignette-style multiple-choice questions covering 100% of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine (FPHM) exam blueprint. This online tool can be utilized as a training mechanism for resident education on hospital medicine.

As a benefit of SHM membership, residents will receive a free subscription. SPARK ONE provides in-depth review of the following content areas:

• Cardiology
• Pulmonary Disease and Critical Care Medicine
• Gastroenterology and Hepatology
• Nephrology and Urology
• Endocrinology
• Hematology and Oncology
• Neurology
• Allergy, Immunology, Dermatology, Rheumatology and Transitions in Care
• Palliative Care, Medical Ethics and Decision-making
• Perioperative Medicine and Consultative Co-management
• Patient Safety
• Quality, Cost and Clinical Reasoning

“SPARK ONE provides a unique platform for academic institutions, engaging learners in directed learning sessions, reinforcing teaching points as we encounter specific conditions.” – Rachel E. Thompson, MD, MPH, SFHM

Visit hospitalmedicine.org/sparkone to learn more.
 

Sharpen your coding with the updated CODE-H

SHM’s Coding Optimally by Documenting Effectively for Hospitalists (CODE-H) has launched an updated program with all new content. It will now include eight recorded webinar sessions presented by expert faculty, downloadable resources, and an interactive discussion forum through the Hospital Medicine Exchange (HMX), enabling participants to ask questions and learn the most relevant best practices.

Following each webinar, learners will have the opportunity to complete an evaluation to redeem continuing medical education credits.

Webinars in the series include:
 

• E/M Basics Part I
• E/M Basics Part II
• Utilizing Other Providers in Your Practice
• EMR and Mitigating Risk
• Putting Time into Critical Care Documentation
• Time Based Services
• Navigating the Rules for Hospitalist Visits
• Challenges of Concurrent Care

To purchase CODE-H, visit hospitalmedicine.org/CODEH. If you have questions about the new program, please contact [email protected].
 

Set yourself apart as a Fellow in Hospital Medicine

The Fellow in Hospital Medicine (FHM) designation signals your commitment to the hospital medicine specialty and dedication to quality improvement and patient safety. This designation is available for hospital medicine practitioners, including practice administrators, nurse practitioners, and physician assistants. If you meet the prerequisites and complete the requirements, which are rooted in the Core Competencies in Hospital Medicine, you can apply for this prestigious designation and join more than 1,100 FHMs who are dedicated to the field of hospital medicine. Learn more and apply at hospitalmedicine.org/fellow.

New guide & modules on multimodal pain strategies for postoperative pain management

Pain management can pose multiple challenges in the acute care setting for hospitalists and front-line prescribers. While their first priority is to optimally manage pain in their patients, they also face the challenges of treating diverse patient populations, managing patient expectations, and considering how pain control and perceptions affect Hospital Consumer Assessment of Healthcare Providers and Systems scores. Furthermore, because of the ongoing opioid epidemic, prescribers must ensure that pain is managed responsibly and ethically.

To address these issues, SHM developed a guide to address how to work in an interdisciplinary team, identify impediments to implementation, and provide examples of appropriate pain management. In accompaniment with this Multimodal Pain Strategies Guide for Postoperative Pain Management, there are three modules presented by the authors which supplement the electronic guide.

To download the guide or view the modules, visit hospitalmedicine.org/pain.
 

Proven excellence through a unique education style: Academic Hospitalist Academy

Don’t miss the eighth annual Academic Hospitalist Academy (AHA), Sept. 25-28, 2017, at the Lakeway Resort and Spa in Austin, Texas. AHA attendees experience an energizing, interactive learning environment featuring didactics, small-group exercise and skill-building breakout sessions. Each full day of learning is facilitated by leading clinician-educators, hospitalist researchers, and clinical administrators in a 1 to 10 faculty to student ratio.

The Principal Goals of the Academy are to:

• Develop junior academic hospitalists as the premier teachers and educational leaders at their institutions
• Help academic hospitalists develop scholarly work and increase scholarly output
• Enhance awareness of the value of quality improvement and patient safety work
• Support academic promotion of all attendees

Don’t miss out on this unique, hands-on experience. Register before July 18, 2017, to receive the early-bird rates. Visit academichospitalist.org to learn more.
 

Choosing Wisely Case Study compendium now available

The Choosing Wisely Case Study Competition, hosted by SHM, sought submissions from hospitalists on innovative improvement initiatives implemented in their respective institutions. These initiatives reflect and promote movement toward reducing unnecessary medical tests and procedures and changing a culture that dictates, “More care is better care.”

Submissions were judged by the Choosing Wisely Subcommittee, a panel of SHM members, under adult and pediatric categories. One grand prize winner and three honorable mentions were selected from these categories. The compendium includes these case studies along with additional exemplary submissions.

View the Choosing Wisely Case Study Compendium at hospitalmedicine.org/choosingwisely.
 

Strengthen your interactions with the 5 Rs of Cultural Humility

Look inside this issue for your 5 Rs of Cultural Humility pocket card. It can be easily referenced on rounds and shared with colleagues. We hope to achieve heightened awareness of effective interactions. In addition to the definitions of each of the Rs, the card features questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.

For more information, visit hospitalmedicine.org/5Rs.

Brett Radler is communications specialist at the Society of Hospital Medicine.

HM17 On Demand now available

Couldn’t make it to Las Vegas for SHM’s annual meeting, Hospital Medicine 2017? HM17 On Demand gives you access to over 80 online audio and slide recordings from the hottest tracks, including clinical updates, rapid fire, pediatrics, comanagement, quality, and high-value care.

Additionally, you can earn up to 70 American Medical Association Physician Recognition Award Category 1 Credit(s) and up to 30 American Board of Internal Medicine Maintenance of Certification credits. HM17 attendees can also benefit by earning additional credits on the sessions you missed out on.

To easily access content through SHM’s Learning Portal, visit shmlearningportal.org/hm17-demand to learn more.
 

Chapter Excellence Awards

SHM is proud to recognize outstanding chapters for the fourth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities.

View more at www.hospitalmedicine.org/chapterexcellence. Please join SHM in congratulating the following chapters on their success!

Silver Chapters

Boston Association of Academic Hospital Medicine (BAAHM)

Charlotte Metro Area

Houston

Kentucky

Los Angeles

Minnesota

North Jersey

Pacific Northwest

Philadelphia Tri-State

Rocky Mountain

San Francisco Bay

South Central PA

Gold Chapters

New Mexico

Wiregrass

Platinum Chapters

IowaMaryland

Michigan

NYC/Westchester

St. Louis

Outstanding Chapter of the Year

Michigan

Rising Star Chapter

Wiregrass
 

Student Hospitalist Scholar grant winners

SHM’s Student Hospitalist Scholar Grant provides funds with which medical students can conduct mentored scholarly projects related to quality improvement and patient safety in the field of hospital medicine. The program offers a summer and a longitudinal option.

Congratulations to the 2017-2018 Student Hospitalist Scholar Grant recipients:Summer Program

Anton Garazha

Rosalind Franklin University of Medicine and Science

“Effectiveness of Communication During ICU to Ward Transfer and Association with Medical ICU Readmission”

Cole Hirschfeld

Weill Cornell Medical College

“The Role of Diagnostic Bone Biopsies in the Management of Osteomyelitis”

Farah Hussain

University of Cincinnati College of Medicine

“Better Understanding Clinical Deterioration in a Children’s Hospital”

Longitudinal Program

Monisha Bhatia

Vanderbilt University School of Medicine

“Using Electronic Medical Record Phenotypic Data to Predict Discharge Destination”

Victor Ekuta

University of California, San Diego School of Medicine

“Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention”

Yun Li

Geisel School of Medicine at Dartmouth

“Developing and implementing clinical pathway(s) for hospitalized injection drug users due to injection-related infection sequelae”

Learn more about the Student Hospitalist Scholar Grant at hospitalmedicine.org/scholargrant.

SPARK ONE: A tool to teach residents

SPARK ONE is a comprehensive, online self-assessment tool created specifically for hospital medicine professionals. The activity contains 450+ vignette-style multiple-choice questions covering 100% of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine (FPHM) exam blueprint. This online tool can be utilized as a training mechanism for resident education on hospital medicine.

As a benefit of SHM membership, residents will receive a free subscription. SPARK ONE provides in-depth review of the following content areas:

• Cardiology
• Pulmonary Disease and Critical Care Medicine
• Gastroenterology and Hepatology
• Nephrology and Urology
• Endocrinology
• Hematology and Oncology
• Neurology
• Allergy, Immunology, Dermatology, Rheumatology and Transitions in Care
• Palliative Care, Medical Ethics and Decision-making
• Perioperative Medicine and Consultative Co-management
• Patient Safety
• Quality, Cost and Clinical Reasoning

“SPARK ONE provides a unique platform for academic institutions, engaging learners in directed learning sessions, reinforcing teaching points as we encounter specific conditions.” – Rachel E. Thompson, MD, MPH, SFHM

Visit hospitalmedicine.org/sparkone to learn more.
 

Sharpen your coding with the updated CODE-H

SHM’s Coding Optimally by Documenting Effectively for Hospitalists (CODE-H) has launched an updated program with all new content. It will now include eight recorded webinar sessions presented by expert faculty, downloadable resources, and an interactive discussion forum through the Hospital Medicine Exchange (HMX), enabling participants to ask questions and learn the most relevant best practices.

Following each webinar, learners will have the opportunity to complete an evaluation to redeem continuing medical education credits.

Webinars in the series include:
 

• E/M Basics Part I
• E/M Basics Part II
• Utilizing Other Providers in Your Practice
• EMR and Mitigating Risk
• Putting Time into Critical Care Documentation
• Time Based Services
• Navigating the Rules for Hospitalist Visits
• Challenges of Concurrent Care

To purchase CODE-H, visit hospitalmedicine.org/CODEH. If you have questions about the new program, please contact [email protected].
 

Set yourself apart as a Fellow in Hospital Medicine

The Fellow in Hospital Medicine (FHM) designation signals your commitment to the hospital medicine specialty and dedication to quality improvement and patient safety. This designation is available for hospital medicine practitioners, including practice administrators, nurse practitioners, and physician assistants. If you meet the prerequisites and complete the requirements, which are rooted in the Core Competencies in Hospital Medicine, you can apply for this prestigious designation and join more than 1,100 FHMs who are dedicated to the field of hospital medicine. Learn more and apply at hospitalmedicine.org/fellow.

New guide & modules on multimodal pain strategies for postoperative pain management

Pain management can pose multiple challenges in the acute care setting for hospitalists and front-line prescribers. While their first priority is to optimally manage pain in their patients, they also face the challenges of treating diverse patient populations, managing patient expectations, and considering how pain control and perceptions affect Hospital Consumer Assessment of Healthcare Providers and Systems scores. Furthermore, because of the ongoing opioid epidemic, prescribers must ensure that pain is managed responsibly and ethically.

To address these issues, SHM developed a guide to address how to work in an interdisciplinary team, identify impediments to implementation, and provide examples of appropriate pain management. In accompaniment with this Multimodal Pain Strategies Guide for Postoperative Pain Management, there are three modules presented by the authors which supplement the electronic guide.

To download the guide or view the modules, visit hospitalmedicine.org/pain.
 

Proven excellence through a unique education style: Academic Hospitalist Academy

Don’t miss the eighth annual Academic Hospitalist Academy (AHA), Sept. 25-28, 2017, at the Lakeway Resort and Spa in Austin, Texas. AHA attendees experience an energizing, interactive learning environment featuring didactics, small-group exercise and skill-building breakout sessions. Each full day of learning is facilitated by leading clinician-educators, hospitalist researchers, and clinical administrators in a 1 to 10 faculty to student ratio.

The Principal Goals of the Academy are to:

• Develop junior academic hospitalists as the premier teachers and educational leaders at their institutions
• Help academic hospitalists develop scholarly work and increase scholarly output
• Enhance awareness of the value of quality improvement and patient safety work
• Support academic promotion of all attendees

Don’t miss out on this unique, hands-on experience. Register before July 18, 2017, to receive the early-bird rates. Visit academichospitalist.org to learn more.
 

Choosing Wisely Case Study compendium now available

The Choosing Wisely Case Study Competition, hosted by SHM, sought submissions from hospitalists on innovative improvement initiatives implemented in their respective institutions. These initiatives reflect and promote movement toward reducing unnecessary medical tests and procedures and changing a culture that dictates, “More care is better care.”

Submissions were judged by the Choosing Wisely Subcommittee, a panel of SHM members, under adult and pediatric categories. One grand prize winner and three honorable mentions were selected from these categories. The compendium includes these case studies along with additional exemplary submissions.

View the Choosing Wisely Case Study Compendium at hospitalmedicine.org/choosingwisely.
 

Strengthen your interactions with the 5 Rs of Cultural Humility

Look inside this issue for your 5 Rs of Cultural Humility pocket card. It can be easily referenced on rounds and shared with colleagues. We hope to achieve heightened awareness of effective interactions. In addition to the definitions of each of the Rs, the card features questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.

For more information, visit hospitalmedicine.org/5Rs.

Brett Radler is communications specialist at the Society of Hospital Medicine.

HM17 On Demand now available

Couldn’t make it to Las Vegas for SHM’s annual meeting, Hospital Medicine 2017? HM17 On Demand gives you access to over 80 online audio and slide recordings from the hottest tracks, including clinical updates, rapid fire, pediatrics, comanagement, quality, and high-value care.

Additionally, you can earn up to 70 American Medical Association Physician Recognition Award Category 1 Credit(s) and up to 30 American Board of Internal Medicine Maintenance of Certification credits. HM17 attendees can also benefit by earning additional credits on the sessions you missed out on.

To easily access content through SHM’s Learning Portal, visit shmlearningportal.org/hm17-demand to learn more.
 

Chapter Excellence Awards

SHM is proud to recognize outstanding chapters for the fourth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities.

View more at www.hospitalmedicine.org/chapterexcellence. Please join SHM in congratulating the following chapters on their success!

Silver Chapters

Boston Association of Academic Hospital Medicine (BAAHM)

Charlotte Metro Area

Houston

Kentucky

Los Angeles

Minnesota

North Jersey

Pacific Northwest

Philadelphia Tri-State

Rocky Mountain

San Francisco Bay

South Central PA

Gold Chapters

New Mexico

Wiregrass

Platinum Chapters

IowaMaryland

Michigan

NYC/Westchester

St. Louis

Outstanding Chapter of the Year

Michigan

Rising Star Chapter

Wiregrass
 

Student Hospitalist Scholar grant winners

SHM’s Student Hospitalist Scholar Grant provides funds with which medical students can conduct mentored scholarly projects related to quality improvement and patient safety in the field of hospital medicine. The program offers a summer and a longitudinal option.

Congratulations to the 2017-2018 Student Hospitalist Scholar Grant recipients:Summer Program

Anton Garazha

Rosalind Franklin University of Medicine and Science

“Effectiveness of Communication During ICU to Ward Transfer and Association with Medical ICU Readmission”

Cole Hirschfeld

Weill Cornell Medical College

“The Role of Diagnostic Bone Biopsies in the Management of Osteomyelitis”

Farah Hussain

University of Cincinnati College of Medicine

“Better Understanding Clinical Deterioration in a Children’s Hospital”

Longitudinal Program

Monisha Bhatia

Vanderbilt University School of Medicine

“Using Electronic Medical Record Phenotypic Data to Predict Discharge Destination”

Victor Ekuta

University of California, San Diego School of Medicine

“Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention”

Yun Li

Geisel School of Medicine at Dartmouth

“Developing and implementing clinical pathway(s) for hospitalized injection drug users due to injection-related infection sequelae”

Learn more about the Student Hospitalist Scholar Grant at hospitalmedicine.org/scholargrant.

SPARK ONE: A tool to teach residents

SPARK ONE is a comprehensive, online self-assessment tool created specifically for hospital medicine professionals. The activity contains 450+ vignette-style multiple-choice questions covering 100% of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine (FPHM) exam blueprint. This online tool can be utilized as a training mechanism for resident education on hospital medicine.

As a benefit of SHM membership, residents will receive a free subscription. SPARK ONE provides in-depth review of the following content areas:

• Cardiology
• Pulmonary Disease and Critical Care Medicine
• Gastroenterology and Hepatology
• Nephrology and Urology
• Endocrinology
• Hematology and Oncology
• Neurology
• Allergy, Immunology, Dermatology, Rheumatology and Transitions in Care
• Palliative Care, Medical Ethics and Decision-making
• Perioperative Medicine and Consultative Co-management
• Patient Safety
• Quality, Cost and Clinical Reasoning

“SPARK ONE provides a unique platform for academic institutions, engaging learners in directed learning sessions, reinforcing teaching points as we encounter specific conditions.” – Rachel E. Thompson, MD, MPH, SFHM

Visit hospitalmedicine.org/sparkone to learn more.
 

Sharpen your coding with the updated CODE-H

SHM’s Coding Optimally by Documenting Effectively for Hospitalists (CODE-H) has launched an updated program with all new content. It will now include eight recorded webinar sessions presented by expert faculty, downloadable resources, and an interactive discussion forum through the Hospital Medicine Exchange (HMX), enabling participants to ask questions and learn the most relevant best practices.

Following each webinar, learners will have the opportunity to complete an evaluation to redeem continuing medical education credits.

Webinars in the series include:
 

• E/M Basics Part I
• E/M Basics Part II
• Utilizing Other Providers in Your Practice
• EMR and Mitigating Risk
• Putting Time into Critical Care Documentation
• Time Based Services
• Navigating the Rules for Hospitalist Visits
• Challenges of Concurrent Care

To purchase CODE-H, visit hospitalmedicine.org/CODEH. If you have questions about the new program, please contact [email protected].
 

Set yourself apart as a Fellow in Hospital Medicine

The Fellow in Hospital Medicine (FHM) designation signals your commitment to the hospital medicine specialty and dedication to quality improvement and patient safety. This designation is available for hospital medicine practitioners, including practice administrators, nurse practitioners, and physician assistants. If you meet the prerequisites and complete the requirements, which are rooted in the Core Competencies in Hospital Medicine, you can apply for this prestigious designation and join more than 1,100 FHMs who are dedicated to the field of hospital medicine. Learn more and apply at hospitalmedicine.org/fellow.

New guide & modules on multimodal pain strategies for postoperative pain management

Pain management can pose multiple challenges in the acute care setting for hospitalists and front-line prescribers. While their first priority is to optimally manage pain in their patients, they also face the challenges of treating diverse patient populations, managing patient expectations, and considering how pain control and perceptions affect Hospital Consumer Assessment of Healthcare Providers and Systems scores. Furthermore, because of the ongoing opioid epidemic, prescribers must ensure that pain is managed responsibly and ethically.

To address these issues, SHM developed a guide to address how to work in an interdisciplinary team, identify impediments to implementation, and provide examples of appropriate pain management. In accompaniment with this Multimodal Pain Strategies Guide for Postoperative Pain Management, there are three modules presented by the authors which supplement the electronic guide.

To download the guide or view the modules, visit hospitalmedicine.org/pain.
 

Proven excellence through a unique education style: Academic Hospitalist Academy

Don’t miss the eighth annual Academic Hospitalist Academy (AHA), Sept. 25-28, 2017, at the Lakeway Resort and Spa in Austin, Texas. AHA attendees experience an energizing, interactive learning environment featuring didactics, small-group exercise and skill-building breakout sessions. Each full day of learning is facilitated by leading clinician-educators, hospitalist researchers, and clinical administrators in a 1 to 10 faculty to student ratio.

The Principal Goals of the Academy are to:

• Develop junior academic hospitalists as the premier teachers and educational leaders at their institutions
• Help academic hospitalists develop scholarly work and increase scholarly output
• Enhance awareness of the value of quality improvement and patient safety work
• Support academic promotion of all attendees

Don’t miss out on this unique, hands-on experience. Register before July 18, 2017, to receive the early-bird rates. Visit academichospitalist.org to learn more.
 

Choosing Wisely Case Study compendium now available

The Choosing Wisely Case Study Competition, hosted by SHM, sought submissions from hospitalists on innovative improvement initiatives implemented in their respective institutions. These initiatives reflect and promote movement toward reducing unnecessary medical tests and procedures and changing a culture that dictates, “More care is better care.”

Submissions were judged by the Choosing Wisely Subcommittee, a panel of SHM members, under adult and pediatric categories. One grand prize winner and three honorable mentions were selected from these categories. The compendium includes these case studies along with additional exemplary submissions.

View the Choosing Wisely Case Study Compendium at hospitalmedicine.org/choosingwisely.
 

Strengthen your interactions with the 5 Rs of Cultural Humility

Look inside this issue for your 5 Rs of Cultural Humility pocket card. It can be easily referenced on rounds and shared with colleagues. We hope to achieve heightened awareness of effective interactions. In addition to the definitions of each of the Rs, the card features questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.

For more information, visit hospitalmedicine.org/5Rs.

Brett Radler is communications specialist at the Society of Hospital Medicine.

A 71-year-old man was referred to the gastroenterology department for evaluation of 9 months of progressive swallowing difficulties associated with epigastric and chest discomfort.

He was a previous smoker (17 pack-years), with a history of coronary artery disease, hypertension, and cervical spinal stenosis requiring decompressive laminectomy with a postoperative course complicated by episodes of aspiration.

DYSPHAGIA: OROPHARYNGEAL OR ESOPHAGEAL

Difficulty swallowing (dysphagia) can be caused by problems in the oropharynx or in the esophagus. Difficulty initiating a swallow can be thought of as oropharyngeal dysphagia, whereas the intermittent sensation of food stuck in the neck or chest is considered esophageal dysphagia.

Focused questioning can help differentiate oropharyngeal symptoms from esophageal symptoms. For example, difficulty clearing secretions or passing the food bolus beyond the mouth or frequent coughing spells while eating is consistent with oropharyngeal dysphagia and suggests a neurologic cause. Our patient, however, presented with a constellation of symptoms more suggestive of esophageal dysphagia.

When eliciting a history of esophageal symptoms, it is crucial to determine the progression of swallowing difficulty, as well as how it directly relates to eating solids or liquids, or both. Difficulty swallowing solid foods that has progressed over time to include liquids would raise concern for an obstruction such as a stricture, ring, or malignancy. On the other hand, abrupt onset of intermittent dysphagia to both solids and liquids would raise concern for a motility disorder of the esophagus. This patient presented with an abrupt onset of intermittent symptoms to both solids and liquids that was associated with substernal chest pain.

Once coronary disease was ruled out by cardiac biomarker testing, electrocardiography, and a pharmacologic stress test, our patient underwent upper endoscopy, which showed a normal esophageal mucosa without masses or obstruction and no evidence of peptic ulcer disease.

WHAT IS THE NEXT STEP?

When upper endoscopy is negative and cardiac causes and gastroesophageal reflux disease have been ruled out, an esophageal motility disorder should be considered.

1. After obstruction has been ruled out with upper endoscopy, which should be the next step in the investigation of esophageal dysphagia?

• A 24-hour pH recording
• Barium esophagography
• Modified barium swallow
• Computed tomography of the chest

Barium esophagography is the optimal fluoroscopic study to evaluate the esophageal phase of the swallow. This study requires the patient to swallow a thick barium solution and a 13-mm barium pill under video analysis. It is useful early in the investigation of esophageal dysphagia because it can potentially reveal areas of esophageal luminal narrowing not detected endoscopically, as well as detail the rate of esophageal emptying.¹

The modified barium swallow, which is performed with the assistance of a speech pathologist, is similar but only shows the oropharynx as far as the cervical esophagus. Therefore, it would be the best fluoroscopic test to assess patients with possible aspiration or oropharyngeal dysphagia, whereas barium esophagography would be the test of choice in evaluating esophageal dysmotility or mechanical obstruction.

pH testing may be helpful in diagnosing gastroesophageal reflux disease but is less helpful in the evaluation of dysphagia.

Computed tomography of the chest may be useful to evaluate for extrinsic compression of the esophagus, but it is not the best next step in the evaluation of dysphagia.

Our patient underwent barium esophagography, which revealed tertiary contractions in the mid and distal esophagus with slight narrowing of the lower cervical esophagus (Figure 1). (Primary contractions are elicited when initiating a swallow that propels the food bolus through the esophagus, while secondary contractions follow in response to esophageal distention to move all remaining esophageal contents from the thoracic esophagus. Tertiary contractions are abnormal, nonpropulsive, spontaneous contractions of the esophageal body that are initiated without swallowing.²)

EOSINOPHILIC ESOPHAGITIS

Histologic study of biopsies of the mid and distal esophagus from our patient’s upper endoscopy revealed 5 eosinophils per high-power field.

2. Does this patient meet the criteria for the diagnosis of eosinophilic esophagitis?

• Yes
• No

No. Having eosinophils in the esophagus is not enough to diagnose eosinophilic esophagitis, as eosinophils are also common in patients with gastroesophageal reflux disease.

Eosinophilic esophagitis is defined as a chronic immune-mediated esophageal disease with histologically eosinophil-predominant inflammation (with more than 15 eosinophils per high-power field). The diagnosis is additionally based on symptoms and endoscopic appearance.³ When investigating possible eosinophilic esophagitis, it is recommended that 2 to 4 samples be obtained from at least 2 different locations in the esophagus (eg, proximal and distal), because the inflammatory changes can be patchy.

3. What is the likely cause of this patient’s dysphagia?

• Eosinophilic esophagitis
• Achalasia
• Esophageal spasm
• Extrinsic compression
• Esophageal malignancy

Eosinophilic esophagitis causes characteristic symptoms that include difficulty swallowing, chest pain that does not respond to antisecretory therapy, and regurgitation of undigested food. As we discussed above, this patient has only 5 eosinophils per high-power field and does not meet the histologic criteria for eosinophilic esophagitis.

Achalasia has a characteristic “bird’s beak” appearance on esophagography that results from distal tapering of the esophagus to the gastroesophageal junction,¹ and this is not apparent on our patient’s study.

Review of this patient’s esophagogram also does not reveal any extrinsic compression, esophageal malignancy, or distal tapering suggesting achalasia. In light of the abrupt onset of symptoms related to both solids and liquids associated with atypical chest pain, the primary concern should be for esophageal spasm.

ONE MORE TEST

4. What study would you order next to better elucidate the cause of this patient’s esophageal disorder?

• High-resolution esophageal manometry
• Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography
• 24-hour pH and impedance testing
• Wireless motility capsule

Esophageal manometry (Figure 2) is used to evaluate the function and coordination of the muscles of the esophagus, as in disorders of esophageal motility.

High-resolution manometry is the gold standard for evaluation of esophageal motility. It is appropriate in evaluating dysphagia or noncardiac chest pain without evidence of mechanical obstruction, ulceration, or inflammation.^4,5

High-resolution manometry differs from conventional manometry in that the catheter has more sensors to measure intraluminal pressure (36 rather than the usual 7 to 12). The data are translated into pressure topography plots (Figure 3).^6,7

Updated guidelines on how to interpret the findings of high-resolution manometry are known as the Chicago 3.0 criteria.⁴ According to this system, esophageal motility disorders are grouped on the basis of lower esophageal sphincter relaxation and then further subdivided based on the character of peristalsis.

EGD with endoscopic ultrasonography would not be appropriate at this time because there is little suspicion of an extraluminal mass that needs to be investigated.

A 24-hour pH and impedance study is helpful in determining the presence of esophageal acid exposure in patients presenting with gastroesophageal reflux disease. This patient does not have symptoms of heartburn or regurgitation; therefore, this investigation would not be of value.

A wireless motility capsule would help in investigating gastric and small-bowel motility and may be useful in the future for this patient, but at this point it would provide little additional utility.

ESOPHAGEAL SPASM

Our patient underwent high-resolution esophageal manometry. The results (Figure 4) revealed a normal resting pressure in the lower esophageal sphincter and complete relaxation in all swallows. The body of the esophagus demonstrated premature contractions in 90% of swallows. Overall, these findings were consistent with the diagnosis of distal esophageal spasm.

In addition to incorporating data obtained from endoscopy, esophagography, and manometry, it is crucial to identify the patient’s predominant symptom when planning treatment. For example, is the prevailing symptom dysphagia or chest pain? Additional consideration must be given to medical, surgical, and psychiatric comorbidities.

5. Which of the following is appropriate medical therapy for esophageal spasm?

• Calcium channel blockers
• Nitrates
• Hydralazine
• Phosphodiesterase 5 (PDE5) inhibitors
• All of the above

All of these have been used to treat distal esophageal spasm as well as other hypercontractile esophageal motility disorders.^8–20

Calcium channel blockers have proven to be effective in randomized controlled trials. Diltiazem has been shown to be beneficial at doses ranging from 60 to 90 mg, as has nifedipine 10 to 20 mg 3 times daily. Although different drugs of this class tend to relax the lower esophageal sphincter to different degrees, when choosing among them in patients with hypercontractile disorders there is little concern for potentially precipitating reflux.^8–13

Nitrates, hydralazine, and PDE5 inhibitors have been effective in uncontrolled studies but have not been studied in randomized trials.^14–17

Other treatments. Patients may also benefit from neuromodulators such as trazodone and imipramine for chest pain and optimization of antisecretory therapy if they have concomitant gastroesophageal reflux disease.^18–20

Patients who have documented esophageal hypercontractility along with reflux disease confirmed by an abnormal pH study show significant improvement in their chest pain symptoms with high doses of a proton pump inhibitor (PPI). As our patient presented with chest pain and dysphagia, a dedicated pH study was not needed, and we could progress straight to manometry and a trial of a PPI.

Our patient was started on a PPI and nifedipine but developed a pruritic rash. As rash does not preclude using another medication in the same class, his treatment was changed to diltiazem 30 mg by mouth 3 times a day, and his dysphagia improved. However, he continued to experience intermittent chest pain with swallowing. After discussion of neuromodulator therapy, he declined additional pharmacologic therapy.

A NONPHARMACOLOGIC TREATMENT?

6. Which of the following would you offer this patient as a nonpharmacologic alternative for his esophageal pain?

• St. John’s wort
• Ginkgo biloba
• Ginseng
• Peppermint extract
• Eucalyptus oil

In a small, open-label study in patients with esophageal spasm, the use of 5 drops of commercially available 11% peppermint extract in 10 mL of water significantly decreased simultaneous contractions and resolved chest pain.²¹ Esophageal manometry was performed 10 minutes after the peppermint solution was consumed, and the results showed improvement in esophageal spasm. While the authors of this study did not make any formal recommendations, the findings suggest that peppermint extract should be given 10 minutes before meals.

There is no evidence for or against the use of the other nonpharmacologic treatments mentioned here.

PAIN RELIEF

7. If a pharmacologic approach were chosen, which would be the best option for pain relief in this patient?

• Oxycodone 5 mg every 8 hours
• Acetaminophen 650 mg every 8 hours
• Ibuprofen 400 mg every evening at bedtime
• Trazodone 100 mg every evening at bedtime
• Imipramine 50 mg every evening at bedtime
• Aripiprazole 5 mg by mouth every day

Trazodone would be the most appropriate of these options. Doses of 100 mg to 150 mg every evening at bedtime have been shown to significantly improve global assessment scores of pain at 6 weeks.¹⁸

Imipramine 50 mg every evening at bedtime would be another option and also has been shown to reduce chest pain.¹⁹

Even though these were the doses that were investigated, in clinical practice it is common to start at lower doses (trazodone 50 mg or imipramine 10 mg) and to then titrate every 4 weeks based on the patient’s response.

Opiates (eg, oxycodone) should be avoided, as they can cause esophageal motility disorders such as spasm or achalasia.²²

Acetaminophen and aripiprazole have not been studied exclusively for their effect on chest pain related to esophageal spasm.

RECURRENT SYMPTOMS

The patient’s dysphagia initially decreased while he was taking diltiazem 30 mg 3 times a day, but it recurred after 6 months. The dosage was increased to 60 mg 3 times a day over the course of the next year, with minimal response. (The maximum dose is 90 mg 4 times a day, but because of side effects of lightheadedness and dizziness, out patient could not tolerate more than 60 mg 3 times a day).

8. What endoscopic therapies are appropriate for patients with esophageal spasm that does not respond to medication?

• Bougie dilation
• Balloon dilation
• Onabotulinum toxin injection
• Expandable mesh stent placement
• Mucosal sclerotherapy

Onabotulinum toxin injections have been shown to improve dysphagia when given in a linear pattern.²³

Endoscopic dilation has not been shown to be beneficial in this setting, as a study found no difference in efficacy between therapeutic (54-French) and sham (24-French) bougie dilation.²⁴

Our patient received 100 units of onabotulinum toxin (10 units every centimeter in the distal 10 cm of the esophagus). Afterward, he experienced resolution of dysphagia, with only mild intermittent chest pain, which was controlled by taking peppermint extract as needed. The symptoms returned approximately 1 year later but responded to repeat endoscopy with onabotulinum toxin injections.^23,25

Peroral endoscopic myotomy

Another relatively new endoscopic treatment for esophageal motility disorders is peroral endoscopic myotomy (Figure 5). During this procedure a tiny incision is made in the esophageal mucosa, permitting the endoscope to tunnel within the lining. The smooth muscle of the distal esophagus and lower esophageal sphincter is then cut, thereby freeing either the spastic muscle (in distal esophageal spasm) or the hyperactive lower esophageal sphincter (in achalasia).^26,27

In an open trial, after undergoing peroral endoscopic myotomy for esophageal spasm and hypercontractile esophagus, 89% of patients had complete relief of dysphagia, and 92% had palliation of chest pain.²⁸ Of note, the rate of relief of dysphagia was higher for patients with achalasia (98%) than for nonachalasia patients (71%).

A 71-year-old man was referred to the gastroenterology department for evaluation of 9 months of progressive swallowing difficulties associated with epigastric and chest discomfort.

He was a previous smoker (17 pack-years), with a history of coronary artery disease, hypertension, and cervical spinal stenosis requiring decompressive laminectomy with a postoperative course complicated by episodes of aspiration.

DYSPHAGIA: OROPHARYNGEAL OR ESOPHAGEAL

Difficulty swallowing (dysphagia) can be caused by problems in the oropharynx or in the esophagus. Difficulty initiating a swallow can be thought of as oropharyngeal dysphagia, whereas the intermittent sensation of food stuck in the neck or chest is considered esophageal dysphagia.

Focused questioning can help differentiate oropharyngeal symptoms from esophageal symptoms. For example, difficulty clearing secretions or passing the food bolus beyond the mouth or frequent coughing spells while eating is consistent with oropharyngeal dysphagia and suggests a neurologic cause. Our patient, however, presented with a constellation of symptoms more suggestive of esophageal dysphagia.

When eliciting a history of esophageal symptoms, it is crucial to determine the progression of swallowing difficulty, as well as how it directly relates to eating solids or liquids, or both. Difficulty swallowing solid foods that has progressed over time to include liquids would raise concern for an obstruction such as a stricture, ring, or malignancy. On the other hand, abrupt onset of intermittent dysphagia to both solids and liquids would raise concern for a motility disorder of the esophagus. This patient presented with an abrupt onset of intermittent symptoms to both solids and liquids that was associated with substernal chest pain.

Once coronary disease was ruled out by cardiac biomarker testing, electrocardiography, and a pharmacologic stress test, our patient underwent upper endoscopy, which showed a normal esophageal mucosa without masses or obstruction and no evidence of peptic ulcer disease.

WHAT IS THE NEXT STEP?

When upper endoscopy is negative and cardiac causes and gastroesophageal reflux disease have been ruled out, an esophageal motility disorder should be considered.

1. After obstruction has been ruled out with upper endoscopy, which should be the next step in the investigation of esophageal dysphagia?

• A 24-hour pH recording
• Barium esophagography
• Modified barium swallow
• Computed tomography of the chest

Barium esophagography is the optimal fluoroscopic study to evaluate the esophageal phase of the swallow. This study requires the patient to swallow a thick barium solution and a 13-mm barium pill under video analysis. It is useful early in the investigation of esophageal dysphagia because it can potentially reveal areas of esophageal luminal narrowing not detected endoscopically, as well as detail the rate of esophageal emptying.¹

The modified barium swallow, which is performed with the assistance of a speech pathologist, is similar but only shows the oropharynx as far as the cervical esophagus. Therefore, it would be the best fluoroscopic test to assess patients with possible aspiration or oropharyngeal dysphagia, whereas barium esophagography would be the test of choice in evaluating esophageal dysmotility or mechanical obstruction.

pH testing may be helpful in diagnosing gastroesophageal reflux disease but is less helpful in the evaluation of dysphagia.

Computed tomography of the chest may be useful to evaluate for extrinsic compression of the esophagus, but it is not the best next step in the evaluation of dysphagia.

Our patient underwent barium esophagography, which revealed tertiary contractions in the mid and distal esophagus with slight narrowing of the lower cervical esophagus (Figure 1). (Primary contractions are elicited when initiating a swallow that propels the food bolus through the esophagus, while secondary contractions follow in response to esophageal distention to move all remaining esophageal contents from the thoracic esophagus. Tertiary contractions are abnormal, nonpropulsive, spontaneous contractions of the esophageal body that are initiated without swallowing.²)

EOSINOPHILIC ESOPHAGITIS

Histologic study of biopsies of the mid and distal esophagus from our patient’s upper endoscopy revealed 5 eosinophils per high-power field.

2. Does this patient meet the criteria for the diagnosis of eosinophilic esophagitis?

• Yes
• No

No. Having eosinophils in the esophagus is not enough to diagnose eosinophilic esophagitis, as eosinophils are also common in patients with gastroesophageal reflux disease.

Eosinophilic esophagitis is defined as a chronic immune-mediated esophageal disease with histologically eosinophil-predominant inflammation (with more than 15 eosinophils per high-power field). The diagnosis is additionally based on symptoms and endoscopic appearance.³ When investigating possible eosinophilic esophagitis, it is recommended that 2 to 4 samples be obtained from at least 2 different locations in the esophagus (eg, proximal and distal), because the inflammatory changes can be patchy.

3. What is the likely cause of this patient’s dysphagia?

• Eosinophilic esophagitis
• Achalasia
• Esophageal spasm
• Extrinsic compression
• Esophageal malignancy

Eosinophilic esophagitis causes characteristic symptoms that include difficulty swallowing, chest pain that does not respond to antisecretory therapy, and regurgitation of undigested food. As we discussed above, this patient has only 5 eosinophils per high-power field and does not meet the histologic criteria for eosinophilic esophagitis.

Achalasia has a characteristic “bird’s beak” appearance on esophagography that results from distal tapering of the esophagus to the gastroesophageal junction,¹ and this is not apparent on our patient’s study.

Review of this patient’s esophagogram also does not reveal any extrinsic compression, esophageal malignancy, or distal tapering suggesting achalasia. In light of the abrupt onset of symptoms related to both solids and liquids associated with atypical chest pain, the primary concern should be for esophageal spasm.

ONE MORE TEST

4. What study would you order next to better elucidate the cause of this patient’s esophageal disorder?

• High-resolution esophageal manometry
• Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography
• 24-hour pH and impedance testing
• Wireless motility capsule

Esophageal manometry (Figure 2) is used to evaluate the function and coordination of the muscles of the esophagus, as in disorders of esophageal motility.

High-resolution manometry is the gold standard for evaluation of esophageal motility. It is appropriate in evaluating dysphagia or noncardiac chest pain without evidence of mechanical obstruction, ulceration, or inflammation.^4,5

High-resolution manometry differs from conventional manometry in that the catheter has more sensors to measure intraluminal pressure (36 rather than the usual 7 to 12). The data are translated into pressure topography plots (Figure 3).^6,7

Updated guidelines on how to interpret the findings of high-resolution manometry are known as the Chicago 3.0 criteria.⁴ According to this system, esophageal motility disorders are grouped on the basis of lower esophageal sphincter relaxation and then further subdivided based on the character of peristalsis.

EGD with endoscopic ultrasonography would not be appropriate at this time because there is little suspicion of an extraluminal mass that needs to be investigated.

A 24-hour pH and impedance study is helpful in determining the presence of esophageal acid exposure in patients presenting with gastroesophageal reflux disease. This patient does not have symptoms of heartburn or regurgitation; therefore, this investigation would not be of value.

A wireless motility capsule would help in investigating gastric and small-bowel motility and may be useful in the future for this patient, but at this point it would provide little additional utility.

ESOPHAGEAL SPASM

Our patient underwent high-resolution esophageal manometry. The results (Figure 4) revealed a normal resting pressure in the lower esophageal sphincter and complete relaxation in all swallows. The body of the esophagus demonstrated premature contractions in 90% of swallows. Overall, these findings were consistent with the diagnosis of distal esophageal spasm.

In addition to incorporating data obtained from endoscopy, esophagography, and manometry, it is crucial to identify the patient’s predominant symptom when planning treatment. For example, is the prevailing symptom dysphagia or chest pain? Additional consideration must be given to medical, surgical, and psychiatric comorbidities.

5. Which of the following is appropriate medical therapy for esophageal spasm?

• Calcium channel blockers
• Nitrates
• Hydralazine
• Phosphodiesterase 5 (PDE5) inhibitors
• All of the above

All of these have been used to treat distal esophageal spasm as well as other hypercontractile esophageal motility disorders.^8–20

Calcium channel blockers have proven to be effective in randomized controlled trials. Diltiazem has been shown to be beneficial at doses ranging from 60 to 90 mg, as has nifedipine 10 to 20 mg 3 times daily. Although different drugs of this class tend to relax the lower esophageal sphincter to different degrees, when choosing among them in patients with hypercontractile disorders there is little concern for potentially precipitating reflux.^8–13

Nitrates, hydralazine, and PDE5 inhibitors have been effective in uncontrolled studies but have not been studied in randomized trials.^14–17

Other treatments. Patients may also benefit from neuromodulators such as trazodone and imipramine for chest pain and optimization of antisecretory therapy if they have concomitant gastroesophageal reflux disease.^18–20

Patients who have documented esophageal hypercontractility along with reflux disease confirmed by an abnormal pH study show significant improvement in their chest pain symptoms with high doses of a proton pump inhibitor (PPI). As our patient presented with chest pain and dysphagia, a dedicated pH study was not needed, and we could progress straight to manometry and a trial of a PPI.

Our patient was started on a PPI and nifedipine but developed a pruritic rash. As rash does not preclude using another medication in the same class, his treatment was changed to diltiazem 30 mg by mouth 3 times a day, and his dysphagia improved. However, he continued to experience intermittent chest pain with swallowing. After discussion of neuromodulator therapy, he declined additional pharmacologic therapy.

A NONPHARMACOLOGIC TREATMENT?

6. Which of the following would you offer this patient as a nonpharmacologic alternative for his esophageal pain?

• St. John’s wort
• Ginkgo biloba
• Ginseng
• Peppermint extract
• Eucalyptus oil

In a small, open-label study in patients with esophageal spasm, the use of 5 drops of commercially available 11% peppermint extract in 10 mL of water significantly decreased simultaneous contractions and resolved chest pain.²¹ Esophageal manometry was performed 10 minutes after the peppermint solution was consumed, and the results showed improvement in esophageal spasm. While the authors of this study did not make any formal recommendations, the findings suggest that peppermint extract should be given 10 minutes before meals.

There is no evidence for or against the use of the other nonpharmacologic treatments mentioned here.

PAIN RELIEF

7. If a pharmacologic approach were chosen, which would be the best option for pain relief in this patient?

• Oxycodone 5 mg every 8 hours
• Acetaminophen 650 mg every 8 hours
• Ibuprofen 400 mg every evening at bedtime
• Trazodone 100 mg every evening at bedtime
• Imipramine 50 mg every evening at bedtime
• Aripiprazole 5 mg by mouth every day

Trazodone would be the most appropriate of these options. Doses of 100 mg to 150 mg every evening at bedtime have been shown to significantly improve global assessment scores of pain at 6 weeks.¹⁸

Imipramine 50 mg every evening at bedtime would be another option and also has been shown to reduce chest pain.¹⁹

Even though these were the doses that were investigated, in clinical practice it is common to start at lower doses (trazodone 50 mg or imipramine 10 mg) and to then titrate every 4 weeks based on the patient’s response.

Opiates (eg, oxycodone) should be avoided, as they can cause esophageal motility disorders such as spasm or achalasia.²²

Acetaminophen and aripiprazole have not been studied exclusively for their effect on chest pain related to esophageal spasm.

RECURRENT SYMPTOMS

The patient’s dysphagia initially decreased while he was taking diltiazem 30 mg 3 times a day, but it recurred after 6 months. The dosage was increased to 60 mg 3 times a day over the course of the next year, with minimal response. (The maximum dose is 90 mg 4 times a day, but because of side effects of lightheadedness and dizziness, out patient could not tolerate more than 60 mg 3 times a day).

8. What endoscopic therapies are appropriate for patients with esophageal spasm that does not respond to medication?

• Bougie dilation
• Balloon dilation
• Onabotulinum toxin injection
• Expandable mesh stent placement
• Mucosal sclerotherapy

Onabotulinum toxin injections have been shown to improve dysphagia when given in a linear pattern.²³

Endoscopic dilation has not been shown to be beneficial in this setting, as a study found no difference in efficacy between therapeutic (54-French) and sham (24-French) bougie dilation.²⁴

Our patient received 100 units of onabotulinum toxin (10 units every centimeter in the distal 10 cm of the esophagus). Afterward, he experienced resolution of dysphagia, with only mild intermittent chest pain, which was controlled by taking peppermint extract as needed. The symptoms returned approximately 1 year later but responded to repeat endoscopy with onabotulinum toxin injections.^23,25

Peroral endoscopic myotomy

Another relatively new endoscopic treatment for esophageal motility disorders is peroral endoscopic myotomy (Figure 5). During this procedure a tiny incision is made in the esophageal mucosa, permitting the endoscope to tunnel within the lining. The smooth muscle of the distal esophagus and lower esophageal sphincter is then cut, thereby freeing either the spastic muscle (in distal esophageal spasm) or the hyperactive lower esophageal sphincter (in achalasia).^26,27

In an open trial, after undergoing peroral endoscopic myotomy for esophageal spasm and hypercontractile esophagus, 89% of patients had complete relief of dysphagia, and 92% had palliation of chest pain.²⁸ Of note, the rate of relief of dysphagia was higher for patients with achalasia (98%) than for nonachalasia patients (71%).

A 71-year-old man was referred to the gastroenterology department for evaluation of 9 months of progressive swallowing difficulties associated with epigastric and chest discomfort.

He was a previous smoker (17 pack-years), with a history of coronary artery disease, hypertension, and cervical spinal stenosis requiring decompressive laminectomy with a postoperative course complicated by episodes of aspiration.

DYSPHAGIA: OROPHARYNGEAL OR ESOPHAGEAL

Difficulty swallowing (dysphagia) can be caused by problems in the oropharynx or in the esophagus. Difficulty initiating a swallow can be thought of as oropharyngeal dysphagia, whereas the intermittent sensation of food stuck in the neck or chest is considered esophageal dysphagia.

Focused questioning can help differentiate oropharyngeal symptoms from esophageal symptoms. For example, difficulty clearing secretions or passing the food bolus beyond the mouth or frequent coughing spells while eating is consistent with oropharyngeal dysphagia and suggests a neurologic cause. Our patient, however, presented with a constellation of symptoms more suggestive of esophageal dysphagia.

When eliciting a history of esophageal symptoms, it is crucial to determine the progression of swallowing difficulty, as well as how it directly relates to eating solids or liquids, or both. Difficulty swallowing solid foods that has progressed over time to include liquids would raise concern for an obstruction such as a stricture, ring, or malignancy. On the other hand, abrupt onset of intermittent dysphagia to both solids and liquids would raise concern for a motility disorder of the esophagus. This patient presented with an abrupt onset of intermittent symptoms to both solids and liquids that was associated with substernal chest pain.

Once coronary disease was ruled out by cardiac biomarker testing, electrocardiography, and a pharmacologic stress test, our patient underwent upper endoscopy, which showed a normal esophageal mucosa without masses or obstruction and no evidence of peptic ulcer disease.

WHAT IS THE NEXT STEP?

When upper endoscopy is negative and cardiac causes and gastroesophageal reflux disease have been ruled out, an esophageal motility disorder should be considered.

1. After obstruction has been ruled out with upper endoscopy, which should be the next step in the investigation of esophageal dysphagia?

• A 24-hour pH recording
• Barium esophagography
• Modified barium swallow
• Computed tomography of the chest

Barium esophagography is the optimal fluoroscopic study to evaluate the esophageal phase of the swallow. This study requires the patient to swallow a thick barium solution and a 13-mm barium pill under video analysis. It is useful early in the investigation of esophageal dysphagia because it can potentially reveal areas of esophageal luminal narrowing not detected endoscopically, as well as detail the rate of esophageal emptying.¹

The modified barium swallow, which is performed with the assistance of a speech pathologist, is similar but only shows the oropharynx as far as the cervical esophagus. Therefore, it would be the best fluoroscopic test to assess patients with possible aspiration or oropharyngeal dysphagia, whereas barium esophagography would be the test of choice in evaluating esophageal dysmotility or mechanical obstruction.

pH testing may be helpful in diagnosing gastroesophageal reflux disease but is less helpful in the evaluation of dysphagia.

Computed tomography of the chest may be useful to evaluate for extrinsic compression of the esophagus, but it is not the best next step in the evaluation of dysphagia.

Our patient underwent barium esophagography, which revealed tertiary contractions in the mid and distal esophagus with slight narrowing of the lower cervical esophagus (Figure 1). (Primary contractions are elicited when initiating a swallow that propels the food bolus through the esophagus, while secondary contractions follow in response to esophageal distention to move all remaining esophageal contents from the thoracic esophagus. Tertiary contractions are abnormal, nonpropulsive, spontaneous contractions of the esophageal body that are initiated without swallowing.²)

EOSINOPHILIC ESOPHAGITIS

Histologic study of biopsies of the mid and distal esophagus from our patient’s upper endoscopy revealed 5 eosinophils per high-power field.

2. Does this patient meet the criteria for the diagnosis of eosinophilic esophagitis?

• Yes
• No

No. Having eosinophils in the esophagus is not enough to diagnose eosinophilic esophagitis, as eosinophils are also common in patients with gastroesophageal reflux disease.

Eosinophilic esophagitis is defined as a chronic immune-mediated esophageal disease with histologically eosinophil-predominant inflammation (with more than 15 eosinophils per high-power field). The diagnosis is additionally based on symptoms and endoscopic appearance.³ When investigating possible eosinophilic esophagitis, it is recommended that 2 to 4 samples be obtained from at least 2 different locations in the esophagus (eg, proximal and distal), because the inflammatory changes can be patchy.

3. What is the likely cause of this patient’s dysphagia?

• Eosinophilic esophagitis
• Achalasia
• Esophageal spasm
• Extrinsic compression
• Esophageal malignancy

Eosinophilic esophagitis causes characteristic symptoms that include difficulty swallowing, chest pain that does not respond to antisecretory therapy, and regurgitation of undigested food. As we discussed above, this patient has only 5 eosinophils per high-power field and does not meet the histologic criteria for eosinophilic esophagitis.

Achalasia has a characteristic “bird’s beak” appearance on esophagography that results from distal tapering of the esophagus to the gastroesophageal junction,¹ and this is not apparent on our patient’s study.

Review of this patient’s esophagogram also does not reveal any extrinsic compression, esophageal malignancy, or distal tapering suggesting achalasia. In light of the abrupt onset of symptoms related to both solids and liquids associated with atypical chest pain, the primary concern should be for esophageal spasm.

ONE MORE TEST

4. What study would you order next to better elucidate the cause of this patient’s esophageal disorder?

• High-resolution esophageal manometry
• Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography
• 24-hour pH and impedance testing
• Wireless motility capsule

Esophageal manometry (Figure 2) is used to evaluate the function and coordination of the muscles of the esophagus, as in disorders of esophageal motility.

High-resolution manometry is the gold standard for evaluation of esophageal motility. It is appropriate in evaluating dysphagia or noncardiac chest pain without evidence of mechanical obstruction, ulceration, or inflammation.^4,5

High-resolution manometry differs from conventional manometry in that the catheter has more sensors to measure intraluminal pressure (36 rather than the usual 7 to 12). The data are translated into pressure topography plots (Figure 3).^6,7

Updated guidelines on how to interpret the findings of high-resolution manometry are known as the Chicago 3.0 criteria.⁴ According to this system, esophageal motility disorders are grouped on the basis of lower esophageal sphincter relaxation and then further subdivided based on the character of peristalsis.

EGD with endoscopic ultrasonography would not be appropriate at this time because there is little suspicion of an extraluminal mass that needs to be investigated.

A 24-hour pH and impedance study is helpful in determining the presence of esophageal acid exposure in patients presenting with gastroesophageal reflux disease. This patient does not have symptoms of heartburn or regurgitation; therefore, this investigation would not be of value.

A wireless motility capsule would help in investigating gastric and small-bowel motility and may be useful in the future for this patient, but at this point it would provide little additional utility.

ESOPHAGEAL SPASM

Our patient underwent high-resolution esophageal manometry. The results (Figure 4) revealed a normal resting pressure in the lower esophageal sphincter and complete relaxation in all swallows. The body of the esophagus demonstrated premature contractions in 90% of swallows. Overall, these findings were consistent with the diagnosis of distal esophageal spasm.

In addition to incorporating data obtained from endoscopy, esophagography, and manometry, it is crucial to identify the patient’s predominant symptom when planning treatment. For example, is the prevailing symptom dysphagia or chest pain? Additional consideration must be given to medical, surgical, and psychiatric comorbidities.

5. Which of the following is appropriate medical therapy for esophageal spasm?

• Calcium channel blockers
• Nitrates
• Hydralazine
• Phosphodiesterase 5 (PDE5) inhibitors
• All of the above

All of these have been used to treat distal esophageal spasm as well as other hypercontractile esophageal motility disorders.^8–20

Calcium channel blockers have proven to be effective in randomized controlled trials. Diltiazem has been shown to be beneficial at doses ranging from 60 to 90 mg, as has nifedipine 10 to 20 mg 3 times daily. Although different drugs of this class tend to relax the lower esophageal sphincter to different degrees, when choosing among them in patients with hypercontractile disorders there is little concern for potentially precipitating reflux.^8–13

Nitrates, hydralazine, and PDE5 inhibitors have been effective in uncontrolled studies but have not been studied in randomized trials.^14–17

Other treatments. Patients may also benefit from neuromodulators such as trazodone and imipramine for chest pain and optimization of antisecretory therapy if they have concomitant gastroesophageal reflux disease.^18–20

Patients who have documented esophageal hypercontractility along with reflux disease confirmed by an abnormal pH study show significant improvement in their chest pain symptoms with high doses of a proton pump inhibitor (PPI). As our patient presented with chest pain and dysphagia, a dedicated pH study was not needed, and we could progress straight to manometry and a trial of a PPI.

Our patient was started on a PPI and nifedipine but developed a pruritic rash. As rash does not preclude using another medication in the same class, his treatment was changed to diltiazem 30 mg by mouth 3 times a day, and his dysphagia improved. However, he continued to experience intermittent chest pain with swallowing. After discussion of neuromodulator therapy, he declined additional pharmacologic therapy.

A NONPHARMACOLOGIC TREATMENT?

6. Which of the following would you offer this patient as a nonpharmacologic alternative for his esophageal pain?

• St. John’s wort
• Ginkgo biloba
• Ginseng
• Peppermint extract
• Eucalyptus oil

In a small, open-label study in patients with esophageal spasm, the use of 5 drops of commercially available 11% peppermint extract in 10 mL of water significantly decreased simultaneous contractions and resolved chest pain.²¹ Esophageal manometry was performed 10 minutes after the peppermint solution was consumed, and the results showed improvement in esophageal spasm. While the authors of this study did not make any formal recommendations, the findings suggest that peppermint extract should be given 10 minutes before meals.

There is no evidence for or against the use of the other nonpharmacologic treatments mentioned here.

PAIN RELIEF

7. If a pharmacologic approach were chosen, which would be the best option for pain relief in this patient?

• Oxycodone 5 mg every 8 hours
• Acetaminophen 650 mg every 8 hours
• Ibuprofen 400 mg every evening at bedtime
• Trazodone 100 mg every evening at bedtime
• Imipramine 50 mg every evening at bedtime
• Aripiprazole 5 mg by mouth every day

Trazodone would be the most appropriate of these options. Doses of 100 mg to 150 mg every evening at bedtime have been shown to significantly improve global assessment scores of pain at 6 weeks.¹⁸

Imipramine 50 mg every evening at bedtime would be another option and also has been shown to reduce chest pain.¹⁹

Even though these were the doses that were investigated, in clinical practice it is common to start at lower doses (trazodone 50 mg or imipramine 10 mg) and to then titrate every 4 weeks based on the patient’s response.

Opiates (eg, oxycodone) should be avoided, as they can cause esophageal motility disorders such as spasm or achalasia.²²

Acetaminophen and aripiprazole have not been studied exclusively for their effect on chest pain related to esophageal spasm.

RECURRENT SYMPTOMS

The patient’s dysphagia initially decreased while he was taking diltiazem 30 mg 3 times a day, but it recurred after 6 months. The dosage was increased to 60 mg 3 times a day over the course of the next year, with minimal response. (The maximum dose is 90 mg 4 times a day, but because of side effects of lightheadedness and dizziness, out patient could not tolerate more than 60 mg 3 times a day).

8. What endoscopic therapies are appropriate for patients with esophageal spasm that does not respond to medication?

• Bougie dilation
• Balloon dilation
• Onabotulinum toxin injection
• Expandable mesh stent placement
• Mucosal sclerotherapy

Onabotulinum toxin injections have been shown to improve dysphagia when given in a linear pattern.²³

Endoscopic dilation has not been shown to be beneficial in this setting, as a study found no difference in efficacy between therapeutic (54-French) and sham (24-French) bougie dilation.²⁴

Our patient received 100 units of onabotulinum toxin (10 units every centimeter in the distal 10 cm of the esophagus). Afterward, he experienced resolution of dysphagia, with only mild intermittent chest pain, which was controlled by taking peppermint extract as needed. The symptoms returned approximately 1 year later but responded to repeat endoscopy with onabotulinum toxin injections.^23,25

Peroral endoscopic myotomy

Another relatively new endoscopic treatment for esophageal motility disorders is peroral endoscopic myotomy (Figure 5). During this procedure a tiny incision is made in the esophageal mucosa, permitting the endoscope to tunnel within the lining. The smooth muscle of the distal esophagus and lower esophageal sphincter is then cut, thereby freeing either the spastic muscle (in distal esophageal spasm) or the hyperactive lower esophageal sphincter (in achalasia).^26,27

In an open trial, after undergoing peroral endoscopic myotomy for esophageal spasm and hypercontractile esophagus, 89% of patients had complete relief of dysphagia, and 92% had palliation of chest pain.²⁸ Of note, the rate of relief of dysphagia was higher for patients with achalasia (98%) than for nonachalasia patients (71%).

More than 15 million patients in the United States have prescriptions for proton pump inhibitors (PPIs), in most cases for “heartburn,” reflux, and swallowing problems, and many more are taking over-the-counter PPIs or histamine 2 receptor antagonists.

Gastroesophageal reflux disease (GERD) seems to be the initial reflexive diagnosis given to most patients who complain of chest or epigastric burning or seemingly nonspecific swallowing difficulties. The prevalence of diagnosed GERD is high; in addition to causing “heartburn,” in my clinic it seems to be the most commonly attributed cause of chronic cough with a normal chest radiograph or hoarseness, and a frequent contributing comorbidity warranting treatment in patients with bronchospasm—diagnosed by my otolaryngology and pulmonary colleagues.

GERD is so common that it is no surprise that patients are increasingly diagnosed with it on the basis of a superficial history, or that patients diagnose and treat it themselves based on information they find on the Internet. Objective diagnostic tests are suggested when PPIs do not produce the expected response.

But long-term, high-dose PPI therapy may not be totally benign. Omeprazole, commonly prescribed and also available over the counter, may in some patients interfere with clopidogrel and increase the risk of coronary events, although this increase may actually be due to the underlying medical condition for which the PPI is prescribed—“confounding by indication.” PPI use is associated with decreased absorption of iron and vitamin B₁₂, perhaps contributing to anemia. The estimated risks of vertebral and hip osteoporosis, interstitial nephritis, and dementia are slightly increased. Patients with severe liver disease seem to be at far higher risk of bacterial peritonitis. Clostridium difficile infection and some pneumonias may also be increased in chronic PPI users. Therefore, we should think twice when making a clinical diagnosis of GERD, a diagnosis that often leads us to prescribe antacid therapy (usually a PPI) for a long time, sometimes unnecessarily.¹

Kichler and Gabbard, in this issue of the Journal, work through a clinical management scenario focusing on the evaluation of a patient with dysphagia, a common symptom described in many ways by patients who may have previously been diagnosed with GERD. The authors remind us of the value of a careful, focused, and detailed medical history, and provide updated information on the performance and utility of motility and endoscopic studies in diagnosing esophageal disorders.

More than 15 million patients in the United States have prescriptions for proton pump inhibitors (PPIs), in most cases for “heartburn,” reflux, and swallowing problems, and many more are taking over-the-counter PPIs or histamine 2 receptor antagonists.

Gastroesophageal reflux disease (GERD) seems to be the initial reflexive diagnosis given to most patients who complain of chest or epigastric burning or seemingly nonspecific swallowing difficulties. The prevalence of diagnosed GERD is high; in addition to causing “heartburn,” in my clinic it seems to be the most commonly attributed cause of chronic cough with a normal chest radiograph or hoarseness, and a frequent contributing comorbidity warranting treatment in patients with bronchospasm—diagnosed by my otolaryngology and pulmonary colleagues.

GERD is so common that it is no surprise that patients are increasingly diagnosed with it on the basis of a superficial history, or that patients diagnose and treat it themselves based on information they find on the Internet. Objective diagnostic tests are suggested when PPIs do not produce the expected response.

But long-term, high-dose PPI therapy may not be totally benign. Omeprazole, commonly prescribed and also available over the counter, may in some patients interfere with clopidogrel and increase the risk of coronary events, although this increase may actually be due to the underlying medical condition for which the PPI is prescribed—“confounding by indication.” PPI use is associated with decreased absorption of iron and vitamin B₁₂, perhaps contributing to anemia. The estimated risks of vertebral and hip osteoporosis, interstitial nephritis, and dementia are slightly increased. Patients with severe liver disease seem to be at far higher risk of bacterial peritonitis. Clostridium difficile infection and some pneumonias may also be increased in chronic PPI users. Therefore, we should think twice when making a clinical diagnosis of GERD, a diagnosis that often leads us to prescribe antacid therapy (usually a PPI) for a long time, sometimes unnecessarily.¹

Kichler and Gabbard, in this issue of the Journal, work through a clinical management scenario focusing on the evaluation of a patient with dysphagia, a common symptom described in many ways by patients who may have previously been diagnosed with GERD. The authors remind us of the value of a careful, focused, and detailed medical history, and provide updated information on the performance and utility of motility and endoscopic studies in diagnosing esophageal disorders.

More than 15 million patients in the United States have prescriptions for proton pump inhibitors (PPIs), in most cases for “heartburn,” reflux, and swallowing problems, and many more are taking over-the-counter PPIs or histamine 2 receptor antagonists.

Gastroesophageal reflux disease (GERD) seems to be the initial reflexive diagnosis given to most patients who complain of chest or epigastric burning or seemingly nonspecific swallowing difficulties. The prevalence of diagnosed GERD is high; in addition to causing “heartburn,” in my clinic it seems to be the most commonly attributed cause of chronic cough with a normal chest radiograph or hoarseness, and a frequent contributing comorbidity warranting treatment in patients with bronchospasm—diagnosed by my otolaryngology and pulmonary colleagues.

GERD is so common that it is no surprise that patients are increasingly diagnosed with it on the basis of a superficial history, or that patients diagnose and treat it themselves based on information they find on the Internet. Objective diagnostic tests are suggested when PPIs do not produce the expected response.

But long-term, high-dose PPI therapy may not be totally benign. Omeprazole, commonly prescribed and also available over the counter, may in some patients interfere with clopidogrel and increase the risk of coronary events, although this increase may actually be due to the underlying medical condition for which the PPI is prescribed—“confounding by indication.” PPI use is associated with decreased absorption of iron and vitamin B₁₂, perhaps contributing to anemia. The estimated risks of vertebral and hip osteoporosis, interstitial nephritis, and dementia are slightly increased. Patients with severe liver disease seem to be at far higher risk of bacterial peritonitis. Clostridium difficile infection and some pneumonias may also be increased in chronic PPI users. Therefore, we should think twice when making a clinical diagnosis of GERD, a diagnosis that often leads us to prescribe antacid therapy (usually a PPI) for a long time, sometimes unnecessarily.¹

Kichler and Gabbard, in this issue of the Journal, work through a clinical management scenario focusing on the evaluation of a patient with dysphagia, a common symptom described in many ways by patients who may have previously been diagnosed with GERD. The authors remind us of the value of a careful, focused, and detailed medical history, and provide updated information on the performance and utility of motility and endoscopic studies in diagnosing esophageal disorders.

It could happen. You are on a plane, perhaps on your way to a medical conference or a well-deserved vacation, when the flight attendant asks you to help a passenger experiencing an in-flight medical emergency. What is your role in this situation?

FLIGHT ATTENDANTS USED TO BE NURSES

Before World War II, nearly all American flight attendants were nurses, who could address most medical issues that arose during flights.¹ Airlines eliminated this preferential hiring practice to support the war effort. Traveling healthcare providers thereafter often volunteered to assist when in-flight medical issues arose, but aircraft carried minimal medical equipment and volunteers’ liability was uncertain.

In 1998, Congress passed the Aviation Medical Assistance Act (AMAA), which provides liability protection for on-board healthcare providers who render medical assistance. It also required the Federal Aviation Administration (FAA) to improve its standards for in-flight medical equipment.^2,3

HOW OFTEN DO EMERGENCIES ARISE?

How often medical events occur during flight is difficult to estimate because airlines are not mandated to report such issues.⁴ Based on data from a ground-based communications center that provides medical consultation service to airlines, medical events occur in approximately 1 in every 604 flights.⁵ This is likely an underestimate, as many medical events may be handled on board without involving a ground-based consultation center.

The most common emergencies are syncope or presyncope, representing 37.4% of consultations, followed by respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%).⁵ Very few in-flight medical emergencies progress to death; the reported mortality rate is 0.3%.⁵

CABIN PRESSURES ARE RELATIVELY LOW

The cabins of commercial airliners are pressurized, but the pressure is still lower than on the ground. The cabin pressure in flight is equivalent to that at an altitude of 6,000 to 8,000 feet,^6,7 ie, about 23 or 24 mm Hg, compared with about 30 mm Hg at sea level. At this pressure, passengers have a partial pressure of arterial oxygen (Pao₂) of 60 mm Hg (normal at sea level is > 80).⁸

This reduced oxygen pressure is typically not clinically meaningful in healthy people. However, people with underlying pulmonary or cardiac illness may be starting further to the left on the oxygen dissociation curve before gaining altitude, putting them at risk for acute exacerbations of underlying medical conditions. Many patients who rely on supplemental oxygen, such as those with chronic obstructive pulmonary disease, are advised to increase their oxygen support during flight.⁹

Boyle’s law says that the volume of a gas is inversely proportional to its pressure. As the pressure drops in the cabin after takeoff, air trapped in an enclosed space—eg, in some patient’s bodies—can increase in volume up to 30%,¹⁰ which can have medical ramifications. Clinically significant pneumothorax during flight has been reported.^11–13 Partially because of these volumetric changes, patients who have undergone abdominal surgery are advised to avoid flying for at least 2 weeks after their procedure.^10,14 Patients who have had recent ocular or intracranial surgery may also be at risk of in-flight complications.¹⁵

IN-FLIGHT MEDICAL RESOURCES

The limited medical supplies available on aircraft often challenge healthcare providers who offer to respond to in-flight medical events. However, several important medical resources are available.

Medical kits and defibrillators

FAA regulations require airlines based in the United States to carry basic first aid supplies such as bandages and splints.³ Airlines are also required to carry a medical kit containing the items listed in Table 1.

The FAA-mandated kit does not cover every circumstance that may arise. Although in-flight pediatric events occasionally occur,¹⁶ many of the available medications are inappropriate for young children. The FAA does not require sedative or antipsychotic agents, which could be useful for passengers who have acute psychiatric episodes. Obstetric supplies are absent. On international carriers, the contents of medical kits are highly variable,¹⁷ as are the names used for some medications.

The FAA requires at least 1 automated external defibrillator (AED) to be available on each commercial aircraft.³ The timely use of AEDs greatly improves survivability after out-of-hospital cardiac arrest.^18,19 One study involving a major US airline found a 40% survival rate to hospital discharge in patients who received in-flight defibrillation.²⁰ Without this intervention, very few of the patients would have been expected to survive. In addition to being clinically effective, placing AEDs aboard commercial aircraft is a cost-effective public health intervention.²¹

Most major airlines can contact ground-based medical consultation services during flight.¹⁰ These centers are staffed with healthcare providers who can provide flight crews with advice on how to handle medical events in real time. Healthcare providers can likewise discuss specific medical issues with these services if they respond to an in-flight medical event. Ground-based call centers can also communicate with prehospital providers should a flight need to be diverted.

Other on-board providers

Some medical events require the involvement of more than one medical provider. Other physicians, nurses, and prehospital providers are often also on board.²² Responding physicians can also request the assistance of these other healthcare providers. Flight attendants in the United States are required to be trained in cardiopulmonary resuscitation (CPR).²³

Flight diversion

Critically ill patients or those with time-sensitive medical emergencies may require the aircraft to divert from its intended destination. As may be expected, medical emergencies suspected to involve the cardiovascular, neurologic, or respiratory system have been shown to most likely result in aircraft diversion.^5,24 Approximately 7% of in-flight medical events in which a ground-based medical consultation service is contacted result in diversion.⁵

While an on-board responding physician can make a recommendation to divert based on the patient’s acute medical status, only the captain can make the ultimate decision.⁴ On-board healthcare providers should clearly state that a patient might benefit from an unscheduled landing if that is truly their assessment. In addition to communicating their clinical concerns with the flight crew, the responding physician may also be able to discuss the situation with the airline’s ground-based consultation service. On-board physicians can make important contributions to the assessment of illness severity and triage decisions.

MEDICOLEGAL ISSUES

No legal duty to assist

US healthcare providers are not legally required to respond to on-board medical emergencies on US-based airlines. Canada and the United Kingdom also do not require providers to render assistance. But the General Medical Council (the regulatory body for UK doctors) states that doctors have an ethical duty to respond in the event of a medical emergency, including one on board an aircraft. Other countries, notably Australia and some in the European Union, require healthcare professionals to respond to on-board medical emergencies.¹⁰

Regardless of potential legal duties to assist, healthcare providers are arguably ethically obliged to render assistance if they can.

Aviation Medical Assistance Act

The extent of an American healthcare provider’s liability risk for assisting in a medical emergency on a plane registered in the United States is limited by statute. The 1998 AMAA provides liability protection for on-board medical providers who are asked to assist during an in-flight medical emergency. This statute covers all US-certified air carriers on domestic flights and would likely be held to apply to US aircraft in foreign airspace because of the general rule that the law of the country where the air carrier is registered applies to in-flight events.

Under the AMAA, providers asked to assist with in-flight medical emergencies are not liable for malpractice as long as their actions are not “grossly” negligent or intended to cause the patient harm.²⁵ This is distinguishable from a standard malpractice liability scenario, in which the plaintiff only needs to show ordinary negligence. In a traditional healthcare setting, a provider has to act within the “standard of care” when assessing and treating a patient. If the provider deviates from the standard of care, such as by making an error in judgment or diagnosis, the provider is legally negligent. Under traditional malpractice law, even if a provider is minimally negligent, he or she is liable for any damages resulting from that negligence. Under a gross negligence standard, providers are protected from liability unless they demonstrate flagrant disregard for the patient’s health and safety.

Postflight issues

A provider who undertakes care should continue to provide care until it is no longer necessary, either because the patient recovers or the responsibility has been transferred to another provider. At the point of transfer, the healthcare provider’s relationship with the patient terminates.

The provider should document the encounter, typically using airline-specific documentation. The responding physician needs to be mindful of the patient’s privacy, refraining from discussing the event with others without the patient’s authorization.²⁶

Healthcare providers who wish to respond to in-flight medical emergencies must first determine if they are sufficiently capable of providing care. During a flight, providers do not expect to be on duty and so may have consumed alcoholic beverages to an extent that would potentially render them unsuitable to respond. When it is appropriate to become involved in a medical emergency during flight, the healthcare provider should state his or her qualifications to the passenger and to flight personnel.

If circumstances allow, the volunteer provider should obtain the patient’s consent for evaluation and treatment.¹⁰ Additionally, with the multilingual nature of commercial air travel, especially on international flights, the provider may need to enlist a translator’s assistance.

Providers may find it preferable to treat passengers in their seats.²⁷ Given the confined space in an aircraft, keeping ill passengers out of the aisle allows others to move about the cabin. If it becomes necessary to move the patient, a location should be sought that minimally interferes with other passengers’ needs.

If a passenger has critical medical needs, in-flight medical volunteers can recommend flight diversion, which should also be discussed with ground-based medical staff. However, as emphasized earlier, the captain makes the ultimate decision to divert, taking into account other operational factors that affect the safety of the aircraft and its occupants. In-flight medical care providers should perform only the treatments they are qualified to provide and should operate within their scope of training.

After the aircraft lands, if the passenger must be transported to a hospital, providers should supply prehospital personnel with a requisite transfer-of-care communication. In-flight medical providers who have performed a significant medical intervention might find it appropriate to accompany the patient to the hospital.

SPECIFIC CONDITIONS

The list of possible acute medical issues that occur aboard aircraft is extensive. Here are a few of them.

Trauma

Passengers may experience injuries during flight, for example during periods of heavy air turbulence. Responding physicians should assess for potential life-threatening injuries, keeping in mind that some passengers may be at higher risk. For example, if a passenger on anticoagulation experiences a blunt head injury, this would raise suspicion for possible intracranial hemorrhage, and frequent reassessment of neurologic status may be necessary. If an extremity fracture is suspected, the physician should splint the affected limb. Analgesia may be provided from the medical kit, if appropriate.

Gastrointestinal issues

Acute gastrointestinal issues such as nausea and vomiting are often reported to ground-based medical consultation services.⁵ Responding on-board providers must consider if the passenger is simply experiencing gastrointestinal upset from a benign condition such as gastroenteritis or has a more serious condition. For some patients, vomiting may be a symptom of a myocardial infarction.²⁸ Bilious emesis with abdominal distention may be associated with small-bowel obstruction. While antiemetics are not included in the FAA-mandated medical kit, providers can initiate intravenous fluid therapy for passengers who show signs of hypovolemia.

Cardiac arrest

Although cardiac arrest during flight is rare,⁵ medical providers should nonetheless be prepared to handle it. Upon recognition of cardiac arrest, the provider should immediately begin cardiopulmonary resuscitation and use the on-board AED to defibrillate a potentially shockable rhythm. Flight attendants are trained in cardiopulmonary resuscitation and therefore may assist with resuscitation efforts. If the patient is resuscitated, the responding physician should recommend diversion of the flight.

In the event of a severe life-threatening allergic reaction, the FAA-mandated emergency medical kit contains both diphenhydramine and epinephrine. For an adult experiencing anaphylaxis, a responding on-board physician can administer diphenhydramine 50 mg and epinephrine 0.3 mg (using the 1:1000 formulation), both intramuscularly. For patients with bronchospasm, a metered-dose inhaler of albuterol can be given. As anaphylaxis is an acute and potentially lethal condition, diversion of the aircraft would also be appropriate.²⁹

Myocardial infarction

When acute myocardial infarction is suspected, it is appropriate for the provider to give aspirin, with important exceptions for patients who are experiencing an acute hemorrhage or who have an aspirin allergy.³⁰ Supplemental oxygen should likewise be provided if the responding physician suspects compromised oxygenation. As acute myocardial infarction is also a time-sensitive condition, the clinician who suspects this diagnosis should recommend diversion of the aircraft.

Acute psychiatric issues

While approximately 2.4% of on-board medical events are attributed to psychiatric issues,⁵ there are few tools at the clinician’s disposal in the FAA-mandated emergency medical kit. Antipsychotics and sedatives are not included. The responding physician may need to attempt verbal de-escalation of aggressive behavior. If the safety of the flight is compromised, the application of improvised physical restraints may be appropriate.

Altered mental status

The differential diagnosis for altered mental status is extensive. The on-board physician should try to identify reversible and potentially lethal conditions and determine the potential need for aircraft diversion.

If possible, a blood sugar level should be measured (although the FAA-mandated kit does not contain a glucometer). It may be appropriate to empirically give intravenous dextrose to patients strongly suspected of having hypoglycemia.

If respiratory or cerebrovascular compromise is suspected, supplemental oxygen should be provided.

Unless a reversible cause of altered mental status is identified and treated successfully, it will likely be appropriate to recommend diversion of the aircraft.

Acknowledgment: The authors acknowledge Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine University of Maryland School of Medicine, for her contributions as copy editor of a previous version of this manuscript.

It could happen. You are on a plane, perhaps on your way to a medical conference or a well-deserved vacation, when the flight attendant asks you to help a passenger experiencing an in-flight medical emergency. What is your role in this situation?

FLIGHT ATTENDANTS USED TO BE NURSES

Before World War II, nearly all American flight attendants were nurses, who could address most medical issues that arose during flights.¹ Airlines eliminated this preferential hiring practice to support the war effort. Traveling healthcare providers thereafter often volunteered to assist when in-flight medical issues arose, but aircraft carried minimal medical equipment and volunteers’ liability was uncertain.

In 1998, Congress passed the Aviation Medical Assistance Act (AMAA), which provides liability protection for on-board healthcare providers who render medical assistance. It also required the Federal Aviation Administration (FAA) to improve its standards for in-flight medical equipment.^2,3

HOW OFTEN DO EMERGENCIES ARISE?

How often medical events occur during flight is difficult to estimate because airlines are not mandated to report such issues.⁴ Based on data from a ground-based communications center that provides medical consultation service to airlines, medical events occur in approximately 1 in every 604 flights.⁵ This is likely an underestimate, as many medical events may be handled on board without involving a ground-based consultation center.

The most common emergencies are syncope or presyncope, representing 37.4% of consultations, followed by respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%).⁵ Very few in-flight medical emergencies progress to death; the reported mortality rate is 0.3%.⁵

CABIN PRESSURES ARE RELATIVELY LOW

The cabins of commercial airliners are pressurized, but the pressure is still lower than on the ground. The cabin pressure in flight is equivalent to that at an altitude of 6,000 to 8,000 feet,^6,7 ie, about 23 or 24 mm Hg, compared with about 30 mm Hg at sea level. At this pressure, passengers have a partial pressure of arterial oxygen (Pao₂) of 60 mm Hg (normal at sea level is > 80).⁸

This reduced oxygen pressure is typically not clinically meaningful in healthy people. However, people with underlying pulmonary or cardiac illness may be starting further to the left on the oxygen dissociation curve before gaining altitude, putting them at risk for acute exacerbations of underlying medical conditions. Many patients who rely on supplemental oxygen, such as those with chronic obstructive pulmonary disease, are advised to increase their oxygen support during flight.⁹

Boyle’s law says that the volume of a gas is inversely proportional to its pressure. As the pressure drops in the cabin after takeoff, air trapped in an enclosed space—eg, in some patient’s bodies—can increase in volume up to 30%,¹⁰ which can have medical ramifications. Clinically significant pneumothorax during flight has been reported.^11–13 Partially because of these volumetric changes, patients who have undergone abdominal surgery are advised to avoid flying for at least 2 weeks after their procedure.^10,14 Patients who have had recent ocular or intracranial surgery may also be at risk of in-flight complications.¹⁵

IN-FLIGHT MEDICAL RESOURCES

The limited medical supplies available on aircraft often challenge healthcare providers who offer to respond to in-flight medical events. However, several important medical resources are available.

Medical kits and defibrillators

FAA regulations require airlines based in the United States to carry basic first aid supplies such as bandages and splints.³ Airlines are also required to carry a medical kit containing the items listed in Table 1.

The FAA-mandated kit does not cover every circumstance that may arise. Although in-flight pediatric events occasionally occur,¹⁶ many of the available medications are inappropriate for young children. The FAA does not require sedative or antipsychotic agents, which could be useful for passengers who have acute psychiatric episodes. Obstetric supplies are absent. On international carriers, the contents of medical kits are highly variable,¹⁷ as are the names used for some medications.

The FAA requires at least 1 automated external defibrillator (AED) to be available on each commercial aircraft.³ The timely use of AEDs greatly improves survivability after out-of-hospital cardiac arrest.^18,19 One study involving a major US airline found a 40% survival rate to hospital discharge in patients who received in-flight defibrillation.²⁰ Without this intervention, very few of the patients would have been expected to survive. In addition to being clinically effective, placing AEDs aboard commercial aircraft is a cost-effective public health intervention.²¹

Most major airlines can contact ground-based medical consultation services during flight.¹⁰ These centers are staffed with healthcare providers who can provide flight crews with advice on how to handle medical events in real time. Healthcare providers can likewise discuss specific medical issues with these services if they respond to an in-flight medical event. Ground-based call centers can also communicate with prehospital providers should a flight need to be diverted.

Other on-board providers

Some medical events require the involvement of more than one medical provider. Other physicians, nurses, and prehospital providers are often also on board.²² Responding physicians can also request the assistance of these other healthcare providers. Flight attendants in the United States are required to be trained in cardiopulmonary resuscitation (CPR).²³

Flight diversion

Critically ill patients or those with time-sensitive medical emergencies may require the aircraft to divert from its intended destination. As may be expected, medical emergencies suspected to involve the cardiovascular, neurologic, or respiratory system have been shown to most likely result in aircraft diversion.^5,24 Approximately 7% of in-flight medical events in which a ground-based medical consultation service is contacted result in diversion.⁵

While an on-board responding physician can make a recommendation to divert based on the patient’s acute medical status, only the captain can make the ultimate decision.⁴ On-board healthcare providers should clearly state that a patient might benefit from an unscheduled landing if that is truly their assessment. In addition to communicating their clinical concerns with the flight crew, the responding physician may also be able to discuss the situation with the airline’s ground-based consultation service. On-board physicians can make important contributions to the assessment of illness severity and triage decisions.

MEDICOLEGAL ISSUES

No legal duty to assist

US healthcare providers are not legally required to respond to on-board medical emergencies on US-based airlines. Canada and the United Kingdom also do not require providers to render assistance. But the General Medical Council (the regulatory body for UK doctors) states that doctors have an ethical duty to respond in the event of a medical emergency, including one on board an aircraft. Other countries, notably Australia and some in the European Union, require healthcare professionals to respond to on-board medical emergencies.¹⁰

Regardless of potential legal duties to assist, healthcare providers are arguably ethically obliged to render assistance if they can.

Aviation Medical Assistance Act

The extent of an American healthcare provider’s liability risk for assisting in a medical emergency on a plane registered in the United States is limited by statute. The 1998 AMAA provides liability protection for on-board medical providers who are asked to assist during an in-flight medical emergency. This statute covers all US-certified air carriers on domestic flights and would likely be held to apply to US aircraft in foreign airspace because of the general rule that the law of the country where the air carrier is registered applies to in-flight events.

Under the AMAA, providers asked to assist with in-flight medical emergencies are not liable for malpractice as long as their actions are not “grossly” negligent or intended to cause the patient harm.²⁵ This is distinguishable from a standard malpractice liability scenario, in which the plaintiff only needs to show ordinary negligence. In a traditional healthcare setting, a provider has to act within the “standard of care” when assessing and treating a patient. If the provider deviates from the standard of care, such as by making an error in judgment or diagnosis, the provider is legally negligent. Under traditional malpractice law, even if a provider is minimally negligent, he or she is liable for any damages resulting from that negligence. Under a gross negligence standard, providers are protected from liability unless they demonstrate flagrant disregard for the patient’s health and safety.

Postflight issues

A provider who undertakes care should continue to provide care until it is no longer necessary, either because the patient recovers or the responsibility has been transferred to another provider. At the point of transfer, the healthcare provider’s relationship with the patient terminates.

The provider should document the encounter, typically using airline-specific documentation. The responding physician needs to be mindful of the patient’s privacy, refraining from discussing the event with others without the patient’s authorization.²⁶

Healthcare providers who wish to respond to in-flight medical emergencies must first determine if they are sufficiently capable of providing care. During a flight, providers do not expect to be on duty and so may have consumed alcoholic beverages to an extent that would potentially render them unsuitable to respond. When it is appropriate to become involved in a medical emergency during flight, the healthcare provider should state his or her qualifications to the passenger and to flight personnel.

If circumstances allow, the volunteer provider should obtain the patient’s consent for evaluation and treatment.¹⁰ Additionally, with the multilingual nature of commercial air travel, especially on international flights, the provider may need to enlist a translator’s assistance.

Providers may find it preferable to treat passengers in their seats.²⁷ Given the confined space in an aircraft, keeping ill passengers out of the aisle allows others to move about the cabin. If it becomes necessary to move the patient, a location should be sought that minimally interferes with other passengers’ needs.

If a passenger has critical medical needs, in-flight medical volunteers can recommend flight diversion, which should also be discussed with ground-based medical staff. However, as emphasized earlier, the captain makes the ultimate decision to divert, taking into account other operational factors that affect the safety of the aircraft and its occupants. In-flight medical care providers should perform only the treatments they are qualified to provide and should operate within their scope of training.

After the aircraft lands, if the passenger must be transported to a hospital, providers should supply prehospital personnel with a requisite transfer-of-care communication. In-flight medical providers who have performed a significant medical intervention might find it appropriate to accompany the patient to the hospital.

SPECIFIC CONDITIONS

The list of possible acute medical issues that occur aboard aircraft is extensive. Here are a few of them.

Trauma

Passengers may experience injuries during flight, for example during periods of heavy air turbulence. Responding physicians should assess for potential life-threatening injuries, keeping in mind that some passengers may be at higher risk. For example, if a passenger on anticoagulation experiences a blunt head injury, this would raise suspicion for possible intracranial hemorrhage, and frequent reassessment of neurologic status may be necessary. If an extremity fracture is suspected, the physician should splint the affected limb. Analgesia may be provided from the medical kit, if appropriate.

Gastrointestinal issues

Acute gastrointestinal issues such as nausea and vomiting are often reported to ground-based medical consultation services.⁵ Responding on-board providers must consider if the passenger is simply experiencing gastrointestinal upset from a benign condition such as gastroenteritis or has a more serious condition. For some patients, vomiting may be a symptom of a myocardial infarction.²⁸ Bilious emesis with abdominal distention may be associated with small-bowel obstruction. While antiemetics are not included in the FAA-mandated medical kit, providers can initiate intravenous fluid therapy for passengers who show signs of hypovolemia.

Cardiac arrest

Although cardiac arrest during flight is rare,⁵ medical providers should nonetheless be prepared to handle it. Upon recognition of cardiac arrest, the provider should immediately begin cardiopulmonary resuscitation and use the on-board AED to defibrillate a potentially shockable rhythm. Flight attendants are trained in cardiopulmonary resuscitation and therefore may assist with resuscitation efforts. If the patient is resuscitated, the responding physician should recommend diversion of the flight.

In the event of a severe life-threatening allergic reaction, the FAA-mandated emergency medical kit contains both diphenhydramine and epinephrine. For an adult experiencing anaphylaxis, a responding on-board physician can administer diphenhydramine 50 mg and epinephrine 0.3 mg (using the 1:1000 formulation), both intramuscularly. For patients with bronchospasm, a metered-dose inhaler of albuterol can be given. As anaphylaxis is an acute and potentially lethal condition, diversion of the aircraft would also be appropriate.²⁹

Myocardial infarction

When acute myocardial infarction is suspected, it is appropriate for the provider to give aspirin, with important exceptions for patients who are experiencing an acute hemorrhage or who have an aspirin allergy.³⁰ Supplemental oxygen should likewise be provided if the responding physician suspects compromised oxygenation. As acute myocardial infarction is also a time-sensitive condition, the clinician who suspects this diagnosis should recommend diversion of the aircraft.

Acute psychiatric issues

While approximately 2.4% of on-board medical events are attributed to psychiatric issues,⁵ there are few tools at the clinician’s disposal in the FAA-mandated emergency medical kit. Antipsychotics and sedatives are not included. The responding physician may need to attempt verbal de-escalation of aggressive behavior. If the safety of the flight is compromised, the application of improvised physical restraints may be appropriate.

Altered mental status

The differential diagnosis for altered mental status is extensive. The on-board physician should try to identify reversible and potentially lethal conditions and determine the potential need for aircraft diversion.

If possible, a blood sugar level should be measured (although the FAA-mandated kit does not contain a glucometer). It may be appropriate to empirically give intravenous dextrose to patients strongly suspected of having hypoglycemia.

If respiratory or cerebrovascular compromise is suspected, supplemental oxygen should be provided.

Unless a reversible cause of altered mental status is identified and treated successfully, it will likely be appropriate to recommend diversion of the aircraft.

Acknowledgment: The authors acknowledge Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine University of Maryland School of Medicine, for her contributions as copy editor of a previous version of this manuscript.

It could happen. You are on a plane, perhaps on your way to a medical conference or a well-deserved vacation, when the flight attendant asks you to help a passenger experiencing an in-flight medical emergency. What is your role in this situation?

FLIGHT ATTENDANTS USED TO BE NURSES

Before World War II, nearly all American flight attendants were nurses, who could address most medical issues that arose during flights.¹ Airlines eliminated this preferential hiring practice to support the war effort. Traveling healthcare providers thereafter often volunteered to assist when in-flight medical issues arose, but aircraft carried minimal medical equipment and volunteers’ liability was uncertain.

In 1998, Congress passed the Aviation Medical Assistance Act (AMAA), which provides liability protection for on-board healthcare providers who render medical assistance. It also required the Federal Aviation Administration (FAA) to improve its standards for in-flight medical equipment.^2,3

HOW OFTEN DO EMERGENCIES ARISE?

How often medical events occur during flight is difficult to estimate because airlines are not mandated to report such issues.⁴ Based on data from a ground-based communications center that provides medical consultation service to airlines, medical events occur in approximately 1 in every 604 flights.⁵ This is likely an underestimate, as many medical events may be handled on board without involving a ground-based consultation center.

The most common emergencies are syncope or presyncope, representing 37.4% of consultations, followed by respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%).⁵ Very few in-flight medical emergencies progress to death; the reported mortality rate is 0.3%.⁵

CABIN PRESSURES ARE RELATIVELY LOW

The cabins of commercial airliners are pressurized, but the pressure is still lower than on the ground. The cabin pressure in flight is equivalent to that at an altitude of 6,000 to 8,000 feet,^6,7 ie, about 23 or 24 mm Hg, compared with about 30 mm Hg at sea level. At this pressure, passengers have a partial pressure of arterial oxygen (Pao₂) of 60 mm Hg (normal at sea level is > 80).⁸

This reduced oxygen pressure is typically not clinically meaningful in healthy people. However, people with underlying pulmonary or cardiac illness may be starting further to the left on the oxygen dissociation curve before gaining altitude, putting them at risk for acute exacerbations of underlying medical conditions. Many patients who rely on supplemental oxygen, such as those with chronic obstructive pulmonary disease, are advised to increase their oxygen support during flight.⁹

Boyle’s law says that the volume of a gas is inversely proportional to its pressure. As the pressure drops in the cabin after takeoff, air trapped in an enclosed space—eg, in some patient’s bodies—can increase in volume up to 30%,¹⁰ which can have medical ramifications. Clinically significant pneumothorax during flight has been reported.^11–13 Partially because of these volumetric changes, patients who have undergone abdominal surgery are advised to avoid flying for at least 2 weeks after their procedure.^10,14 Patients who have had recent ocular or intracranial surgery may also be at risk of in-flight complications.¹⁵

IN-FLIGHT MEDICAL RESOURCES

The limited medical supplies available on aircraft often challenge healthcare providers who offer to respond to in-flight medical events. However, several important medical resources are available.

Medical kits and defibrillators

FAA regulations require airlines based in the United States to carry basic first aid supplies such as bandages and splints.³ Airlines are also required to carry a medical kit containing the items listed in Table 1.

The FAA-mandated kit does not cover every circumstance that may arise. Although in-flight pediatric events occasionally occur,¹⁶ many of the available medications are inappropriate for young children. The FAA does not require sedative or antipsychotic agents, which could be useful for passengers who have acute psychiatric episodes. Obstetric supplies are absent. On international carriers, the contents of medical kits are highly variable,¹⁷ as are the names used for some medications.

The FAA requires at least 1 automated external defibrillator (AED) to be available on each commercial aircraft.³ The timely use of AEDs greatly improves survivability after out-of-hospital cardiac arrest.^18,19 One study involving a major US airline found a 40% survival rate to hospital discharge in patients who received in-flight defibrillation.²⁰ Without this intervention, very few of the patients would have been expected to survive. In addition to being clinically effective, placing AEDs aboard commercial aircraft is a cost-effective public health intervention.²¹

Most major airlines can contact ground-based medical consultation services during flight.¹⁰ These centers are staffed with healthcare providers who can provide flight crews with advice on how to handle medical events in real time. Healthcare providers can likewise discuss specific medical issues with these services if they respond to an in-flight medical event. Ground-based call centers can also communicate with prehospital providers should a flight need to be diverted.

Other on-board providers

Some medical events require the involvement of more than one medical provider. Other physicians, nurses, and prehospital providers are often also on board.²² Responding physicians can also request the assistance of these other healthcare providers. Flight attendants in the United States are required to be trained in cardiopulmonary resuscitation (CPR).²³

Flight diversion

Critically ill patients or those with time-sensitive medical emergencies may require the aircraft to divert from its intended destination. As may be expected, medical emergencies suspected to involve the cardiovascular, neurologic, or respiratory system have been shown to most likely result in aircraft diversion.^5,24 Approximately 7% of in-flight medical events in which a ground-based medical consultation service is contacted result in diversion.⁵

While an on-board responding physician can make a recommendation to divert based on the patient’s acute medical status, only the captain can make the ultimate decision.⁴ On-board healthcare providers should clearly state that a patient might benefit from an unscheduled landing if that is truly their assessment. In addition to communicating their clinical concerns with the flight crew, the responding physician may also be able to discuss the situation with the airline’s ground-based consultation service. On-board physicians can make important contributions to the assessment of illness severity and triage decisions.

MEDICOLEGAL ISSUES

No legal duty to assist

US healthcare providers are not legally required to respond to on-board medical emergencies on US-based airlines. Canada and the United Kingdom also do not require providers to render assistance. But the General Medical Council (the regulatory body for UK doctors) states that doctors have an ethical duty to respond in the event of a medical emergency, including one on board an aircraft. Other countries, notably Australia and some in the European Union, require healthcare professionals to respond to on-board medical emergencies.¹⁰

Regardless of potential legal duties to assist, healthcare providers are arguably ethically obliged to render assistance if they can.

Aviation Medical Assistance Act

The extent of an American healthcare provider’s liability risk for assisting in a medical emergency on a plane registered in the United States is limited by statute. The 1998 AMAA provides liability protection for on-board medical providers who are asked to assist during an in-flight medical emergency. This statute covers all US-certified air carriers on domestic flights and would likely be held to apply to US aircraft in foreign airspace because of the general rule that the law of the country where the air carrier is registered applies to in-flight events.

Under the AMAA, providers asked to assist with in-flight medical emergencies are not liable for malpractice as long as their actions are not “grossly” negligent or intended to cause the patient harm.²⁵ This is distinguishable from a standard malpractice liability scenario, in which the plaintiff only needs to show ordinary negligence. In a traditional healthcare setting, a provider has to act within the “standard of care” when assessing and treating a patient. If the provider deviates from the standard of care, such as by making an error in judgment or diagnosis, the provider is legally negligent. Under traditional malpractice law, even if a provider is minimally negligent, he or she is liable for any damages resulting from that negligence. Under a gross negligence standard, providers are protected from liability unless they demonstrate flagrant disregard for the patient’s health and safety.

Postflight issues

A provider who undertakes care should continue to provide care until it is no longer necessary, either because the patient recovers or the responsibility has been transferred to another provider. At the point of transfer, the healthcare provider’s relationship with the patient terminates.

The provider should document the encounter, typically using airline-specific documentation. The responding physician needs to be mindful of the patient’s privacy, refraining from discussing the event with others without the patient’s authorization.²⁶

Healthcare providers who wish to respond to in-flight medical emergencies must first determine if they are sufficiently capable of providing care. During a flight, providers do not expect to be on duty and so may have consumed alcoholic beverages to an extent that would potentially render them unsuitable to respond. When it is appropriate to become involved in a medical emergency during flight, the healthcare provider should state his or her qualifications to the passenger and to flight personnel.

If circumstances allow, the volunteer provider should obtain the patient’s consent for evaluation and treatment.¹⁰ Additionally, with the multilingual nature of commercial air travel, especially on international flights, the provider may need to enlist a translator’s assistance.

Providers may find it preferable to treat passengers in their seats.²⁷ Given the confined space in an aircraft, keeping ill passengers out of the aisle allows others to move about the cabin. If it becomes necessary to move the patient, a location should be sought that minimally interferes with other passengers’ needs.

If a passenger has critical medical needs, in-flight medical volunteers can recommend flight diversion, which should also be discussed with ground-based medical staff. However, as emphasized earlier, the captain makes the ultimate decision to divert, taking into account other operational factors that affect the safety of the aircraft and its occupants. In-flight medical care providers should perform only the treatments they are qualified to provide and should operate within their scope of training.

After the aircraft lands, if the passenger must be transported to a hospital, providers should supply prehospital personnel with a requisite transfer-of-care communication. In-flight medical providers who have performed a significant medical intervention might find it appropriate to accompany the patient to the hospital.

SPECIFIC CONDITIONS

The list of possible acute medical issues that occur aboard aircraft is extensive. Here are a few of them.

Trauma

Passengers may experience injuries during flight, for example during periods of heavy air turbulence. Responding physicians should assess for potential life-threatening injuries, keeping in mind that some passengers may be at higher risk. For example, if a passenger on anticoagulation experiences a blunt head injury, this would raise suspicion for possible intracranial hemorrhage, and frequent reassessment of neurologic status may be necessary. If an extremity fracture is suspected, the physician should splint the affected limb. Analgesia may be provided from the medical kit, if appropriate.

Gastrointestinal issues

Acute gastrointestinal issues such as nausea and vomiting are often reported to ground-based medical consultation services.⁵ Responding on-board providers must consider if the passenger is simply experiencing gastrointestinal upset from a benign condition such as gastroenteritis or has a more serious condition. For some patients, vomiting may be a symptom of a myocardial infarction.²⁸ Bilious emesis with abdominal distention may be associated with small-bowel obstruction. While antiemetics are not included in the FAA-mandated medical kit, providers can initiate intravenous fluid therapy for passengers who show signs of hypovolemia.

Cardiac arrest

Although cardiac arrest during flight is rare,⁵ medical providers should nonetheless be prepared to handle it. Upon recognition of cardiac arrest, the provider should immediately begin cardiopulmonary resuscitation and use the on-board AED to defibrillate a potentially shockable rhythm. Flight attendants are trained in cardiopulmonary resuscitation and therefore may assist with resuscitation efforts. If the patient is resuscitated, the responding physician should recommend diversion of the flight.

In the event of a severe life-threatening allergic reaction, the FAA-mandated emergency medical kit contains both diphenhydramine and epinephrine. For an adult experiencing anaphylaxis, a responding on-board physician can administer diphenhydramine 50 mg and epinephrine 0.3 mg (using the 1:1000 formulation), both intramuscularly. For patients with bronchospasm, a metered-dose inhaler of albuterol can be given. As anaphylaxis is an acute and potentially lethal condition, diversion of the aircraft would also be appropriate.²⁹

Myocardial infarction

When acute myocardial infarction is suspected, it is appropriate for the provider to give aspirin, with important exceptions for patients who are experiencing an acute hemorrhage or who have an aspirin allergy.³⁰ Supplemental oxygen should likewise be provided if the responding physician suspects compromised oxygenation. As acute myocardial infarction is also a time-sensitive condition, the clinician who suspects this diagnosis should recommend diversion of the aircraft.

Acute psychiatric issues

While approximately 2.4% of on-board medical events are attributed to psychiatric issues,⁵ there are few tools at the clinician’s disposal in the FAA-mandated emergency medical kit. Antipsychotics and sedatives are not included. The responding physician may need to attempt verbal de-escalation of aggressive behavior. If the safety of the flight is compromised, the application of improvised physical restraints may be appropriate.

Altered mental status

The differential diagnosis for altered mental status is extensive. The on-board physician should try to identify reversible and potentially lethal conditions and determine the potential need for aircraft diversion.

If possible, a blood sugar level should be measured (although the FAA-mandated kit does not contain a glucometer). It may be appropriate to empirically give intravenous dextrose to patients strongly suspected of having hypoglycemia.

If respiratory or cerebrovascular compromise is suspected, supplemental oxygen should be provided.

Unless a reversible cause of altered mental status is identified and treated successfully, it will likely be appropriate to recommend diversion of the aircraft.

Acknowledgment: The authors acknowledge Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine University of Maryland School of Medicine, for her contributions as copy editor of a previous version of this manuscript.