In-flight surgery with a coat-hanger and silverware

If only we would leave more of these decisions to arm-chair bien-pensants, second guessing two seemingly highly competent medical professionals. I am sure the woman in question would also really have appreciated being settled with the likely ruinous debts resulting from a medically needless emergency landing.

The European rules for emergency medical kit (I guess FAA rules are very similar) also automatic defibrilators are increasingly being included in these kits:

CONTENT OF EMERGENCY MEDICAL KITS

(a) Emergency medical kits should be equipped with appropriate and sufficient medications and instrumentation. However, these kits should be supplemented by the operator according to the characteristics of the operation (scope of operation, flight duration, number and demographics of passengers, number of decks, etc.).

(b) The following should be included in the emergency medical kit:

(1) Equipment

(i) sphygmomanometer — electronic recommended;

(ii) stethoscope;

(iii) syringes and needles;

(iv) intravenous cannulae (a sufficient supply of intravenous cannulae should be available, subject to the amount of intravenous fluids carried on board);

(v) oropharyngeal airways (three sizes);

(v) tourniquet;

(vi) disposable gloves;

(vii) needle disposal box;

(viii) one or more urinary catheter(s), appropriate for either sex, and anaesthetic gel;

(ix) aspirator;

(x) blood glucose testing equipment;

(xi) scalpel.;

(xii) pulse oximeter; and

(xiii) pneumothorax set.

(2) Instructions: the instructions should contain a list of contents (medications in trade

names and generic names) in at least two languages (English and one other). This should

include information on the effects and side effects of medications carried. There should also be basic instructions for use of the medications in the kit and guidance for conversion

of units for the blood glucose test. The operator should make the instructions readily available. If an electronic format is available, then all instructions should be kept on the same device. If a paper format is used, then the instructions should be kept in the same

kit with the applicable equipment and medication.

(3) Medications

(i) coronary vasodilator e.g. glyceriltrinitrate-oral;

(ii) antispasmodic;

(iii) epinephrine/adrenaline 1:1 000;

(iv) adrenocorticoid;

(v) major analgesic;

(vi) diuretic — injectable;

(vii) antihistamine — oral and injectable (including paediatric form);

(viii) sedative/anticonvulsant — oral plus injectable and/or rectal sedative;

(ix) medication for hypoglycaemia (e.g. hypertonic glucose);

(x) antiemetic — injectable;

(xi) antibiotic — injectable form — Ceftriaxone or Cefotaxime;

(xii) bronchial dilator — inhaled (disposable collapsible spacer);

(xiii) IV fluids in appropriate quantity e.g. sodium chloride 0.9 % (minimum 250 ml); and

(xiv) acetylsalicylic acid — oral — for coronary use.

So i'm not an anaesthetist and therefore I claim no high ground with regard to this rusty attempt at respiratory and gas physiology -

When I read it initially I thought - that makes sense, but I just did the equations, and basically the thing you're worried about is that the pocket of air that is outside the lung is going to change volume significantly and lead to the worst case outcome, a tension pneumo.

But the volume of air outside the lung is going to be at cabin pressure, since that's where it developed. Cabin pressure is ~75kPa. Ground pressure is ~100kPa. The lung is going to exert more pressure than the gas so if you plug all that into boyle's law then you get a 75% reduction (or actually, you don't need to plug it into a calculator, because if you can't work out the percentage of 75/100 you're in trouble, so zero points to me). which would improve/stabilise. However maybe they were concerned the change in pressure could lead to a disequilibrium between lung pressure and potential space (of which there is always some due to breathing, and that sucking pressure into what should be a vacuum is what caused the pneumothorax - air leaking through a disruption in lung tissue) - and because the pressure differential is in favour of a flow into the low pressure zone, and that differential has increased, they're worrying about it shifting materially in a matter of minutes which could get bad quickly (particularly when you consider the potential for any leakage to become progressive, rather than, say, self-limiting)

I don't know enough of this sort of edge case medicine to make any sort of definitive statements but if that was the physiology, maybe they decided it was out of the question to risk it

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I just realised I didn't really answer your question - which relates to, i guess, basically being at cruising altitude as it develops. Because it's steady state (ie inspired air/atmospheric air is going to end up similar pressure to trapped air) basically not significant in terms of progression until you get to blood oxygenation thresholds - because there's a lower partial pressure of O2 in cabin air compared to on the ground, the decreased lung volume is going to cause these issues to become apparent more rapidly.

So it shouldn’t affect progression/growth of the pneumothorax, but it will exacerbate the physiological deterioration

Maybe she didn't have any kind of health insurance in any country except the one she was traveling to. So when the doctors told her she could endure the rest of the flight, she chose to do so instead of going bankrupt by the medical fees. It would be also insteresting to know if she hid her injuries before boarding for the same reason.

Presumably the patient had quite a high pain threshold, since she was already ignoring a broken arm and ribs in addition to the pneumothorax in order to make her flight.