September 05, 2011

Man Chokes to Death During Air Flight... Preventable?

Image courtesy of digitalart /
News media reported on Sept 5, 2011 about Robert Rippingale who choked to death during a flight from Singapore to New Zealand. He was with his girlfriend who noted he was shaking and turning blue after eating an in-flight meal. A doctor and two nurses attempted to save him though unsuccessfully.

The article reports that CPR was performed to try and save the man, but the obvious question is whether a Heimlich maneuver was done. Obviously, as long as an obstruction is present, doing CPR is bound to fail.

Assuming a Heimlich maneuver was performed and failed to remove the airway obstruction... what could have been done to save this man's life?

Let's assume best case scenario of having an experienced ENT surgeon was on board.

The surgeon could try to relieve the obstruction manually by looking down the throat using a laryngoscope and using instruments to remove the food obstruction from the airway.

If that fails, an emergency cricothyroidotomy would have saved this man's life. This emergency life-saving procedure is in essence making a hole in the neck directly into the airway. It is slightly different from a tracheostomy in terms of where anatomically this hole is made, but the end-result is the same.

Question is, EVEN if you had an experienced ENT on board, would an airplane even have a laryngoscope as well as instruments to remove a food impaction? Would an emergency cricothyroidotomy even be possible due to prohibition of sharp objects in airplanes? After all, you still need a knife of some sort to make the incision and to dissect down to the airway. Without a sharp instrument, this step would be impossible even if you have someone who knows what to do.

According to Appendix A to Part 121 of Title 14 of the Code of Federal Regulations (14 CFR 121), the specific requirements for US carriers regarding first aid and emergency aid kits are as follows:

For 0-50 seats, one kit is required; 51-150 seats, two kits are required; 151-250 seats require three; and more than 250 seats require 4 kits.

These kits must include, at a minimum:
  • 16 Adhesive bandage compresses, 1-inch
  • 20 Antiseptic swabs
  • 10 Ammonia inhalants
  • 8 Bandage compresses, 4-inch
  • 5 Triangular bandage compresses, 40-inch
  • 1 Arm splint, noninflatable
  • 1 Leg splint, noninflatable
  • 4 Roller bandage, 4-inch
  • 2 Adhesive tape, 1-inch standard roll
  • 1 Bandage scissors

Also, at least one approved medical kit must be on board that includes at a minimum:
  • 1 Sphygmonanometer
  • 1 Stethoscope
  • 3 Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent.
  • Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent).
  • CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent.
  • 1 IV Admin Set: Tubing w/ 2 Y connectors
  • 2 Alcohol sponges
  • 1 Adhesive tape, 1-inch standard roll adhesive.
  • 1 pair Tape scissors
  • 1 Tourniquet
  • 1 Saline solution, 500 cc
  • 1 pair Protective nonpermeable gloves or equivalent
  • 6 Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications).
  • 4 Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications).
  • 4 Analgesic, non-narcotic, tablets, 325 mg
  • 4 Antihistamine tablets, 25 mg
  • 2 Antihistamine injectable, 50 mg, (single dose ampule or equivalent).
  • 2 Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent).
  • 4 Aspirin tablets, 325 mg
  • 1 Bronchodilator, inhaled (metered dose inhaler or equivalent).
  • 1 Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent).
  • 2 Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent).
  • 2 Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent).
  • 2 Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent).
  • 10 Nitroglycerin tablets, 0.4 mg
  • 1 Basic instructions for use of the drugs in the kit.

It seems that there are airways of different sizes available, but no laryngoscope or other instruments to remove airway foreign objects.

Nowhere is a scalpel or knife listed either. You have needles and syringes which theoretically can be used to "poke" into the airway. However, though an 18 gauge needle might work for a chipmunk's airway, it is not sufficient for a full-grown man. It would be like breathing through a straw, but 50 times smaller and even more difficult to breath thru.

So it appears that in the event of an airway obstruction during an air-flight for which Heimlich fails, you can have the world's best surgeon present, and the man still would have died.

Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough "fabric" and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on.

Read the news article here.
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.


shadowfax said...

I imagine shouting out to the packed plane, "Does anyone have a penknife?" to dead silence because the TSA took all our sharps.

Seriously, the international carriers usually have much more comprehensive medical kits than domestic US carriers, and the Asian long-haul carriers are the industry leaders. They were the first to carry defibrillators (still not required in the US though now more or less standard) and their pursers all had EMT training. Still, I doubt that their kits extend to surgical trays...



Anonymous said...

Yeah, where is the requirement for an automatic defibrillator? Hello, NTSB?! They like to issue "recommendations" that the FAA may, or may not, adopt for 121 & 135 passenger service.

Dr Chang, in any case, forward this blog article to the NTSB Board Members, as what you are proposing is inexpensive, small, and lightweight.

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