Chest pain at FL370: five minutes, then a decision
Flight from Lagos to Nairobi (5 h 20 min), cruising at FL370, 178 passengers and 4 cabin crew. At seat 14D a 58-year-old man is grey and sweating, complaining of heavy central chest pain radiating to the left jaw that began 25 minutes ago. Pulse about 110 and irregular, breathing 24/min, skin cold and clammy. He is fully conscious and can speak only in short sentences. He has no medication with him and no medical escort. A nurse travelling as a passenger offers help. The nearest suitable airport is 55 minutes away, with a hospital 20 minutes beyond it; the destination is 3 h 10 min away. On board: two AEDs, first aid and doctor's kits, therapeutic oxygen with two masks, no pulse oximeter in the aft kit. One crew member is on rest break.
1. You are the first crew member at the seat. Set out your actions in order for the first five minutes and explain why each is done in that sequence.
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0–20 seconds: control the scene, not the patient.
- Delegate specifically and out loud: "You - AED and oxygen." "You - first aid kit and doctor's kit." "You - clear this aisle and get everyone back into their seats."
- Why: a single crew member treating a patient alone is the commonest failure in cabin medical events. Named instructions get results; "somebody get help" does not.
Next: primary assessment (DRABC). Danger, response, airway, breathing, circulation. He is conscious and speaking, so the airway is patent - now you are looking for the two immediate killers: cardiac arrest and hypoxia. Count the respiratory rate, take a pulse, look at colour, sweat and capillary refill. If he becomes unresponsive and stops breathing normally, stop everything else, start CPR and apply the AED - defibrillation in the first minutes is the only intervention that changes survival in a shockable rhythm.
Position. Do not lay him flat and do not walk him anywhere. Keep him seated, seat back reclined, collar and belt loosened. Why: sitting reduces the work of breathing in a failing heart; movement and exertion increase myocardial oxygen demand.
Oxygen. High-flow by mask, typically 2–4 L/min, titrated to effect under your operator's protocol. The mask also gives him something to concentrate on and signals that something is being done.
The nurse. Accept the offer, take her name and registration, and be explicit: cabin crew remain responsible, and she must not administer medication from the doctor's kit without the operator's ground medical advice.
Then: continuous presence, vitals every 5 minutes with times written down, and record the time of onset as he gave it.
2. The diversion is 55 minutes away and the destination 3 h 10 min away. What do you tell the flight deck, in what format, and what is your part in the decision? Include how you manage the oxygen supply.
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Report early, report in a structure, do not wait for a diagnosis. As soon as the primary assessment is done, call the flight deck:
- Who: 58-year-old male, seat 14D, travelling alone, no medical escort.
- What: central chest pain radiating to the jaw, onset 25 minutes ago, sweating, clammy, pulse ~110 irregular, resp 24, fully conscious.
- What has been done: oxygen at X L/min started at HH:MM, AED at the seat, nurse assisting, vitals log started.
- What you need: ground medical advice and a decision on diversion.
Facts first, then one line of interpretation - "suspected cardiac event, time-critical" - because that is the language medical advice and the commander need.
Your role in the decision. The captain decides. Your job is to make the decision possible quickly and to report deterioration immediately: loss of consciousness, loss of pulse, breathing that stops or becomes agonal, unrelieved pain, or a falling level of response. Do not lobby and do not express opinions to passengers about where you should be landing.
Oxygen maths. Duration = cylinder pressure × cylinder factor ÷ flow rate. Work it out on paper for the cylinders actually on board at the flow you are using. At 2–4 L/min a therapeutic cylinder is measured in tens of minutes, not hours. If the calculated supply is shorter than the 55-minute diversion, say so explicitly to the flight deck - it is a deciding fact. Conserve: lowest effective flow, one mask, no second mask for a companion, and ask the flight deck whether a spare cylinder or a cabin therapeutic outlet is available.
Clinical framing. Suspected acute coronary syndrome is time-critical. Fifty-five minutes to an airport with a hospital twenty minutes beyond it, against three hours ten to destination plus disembarkation and immigration, is usually the decisive comparison - but it is made by medical advice and the commander, not by the crew.
3. The captain diverts. Describe the cabin preparation and the handover you give to the paramedics.
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Cabin preparation
- Short, calm PA: medical emergency, we are diverting, remain seated, keep the aisle clear.
- Move the two adjacent passengers if seats are available; keep the row and aisle clear; stow loose items; secure the cabin for landing in the normal way.
- Keep oxygen running through descent and landing; do not let him walk off the aircraft.
- Brief the nurse on what will happen at the gate so she is not surprised when the door opens.
Documentation - write as you go, not afterwards
- Age/sex, time of onset, character and radiation of the pain, symptom trend.
- Vital signs with times (5-minute intervals).
- Every intervention: oxygen start time and flow changes, position, AED application if used (and keep the AED data).
- Who assisted and their registration; the passenger's own account; next-of-kin contact.
Handover to paramedics - structured, not narrative. Use your operator's format (for example ATMIST): age/sex, time of onset, presenting problem and history, signs and trend, treatment given and response, plus estimated time en route. Give the written record with it and keep a copy.
Afterwards. Complete the operator's medical incident report while it is fresh; the commander files the occurrence report. The record protects the passenger, the crew and the operator - and it is the first thing anyone asks for if the outcome is poor.