NORTHERN EVACUATIONS AND IN-FLIGHT EMERGENCIES

Gary Podolsky, M.D.

Learning Objectives:

MEDICAL EVACUATIONS

Often as clinicians we have to arrange evacuations for our patients when the local resources are unable to meet their needs. This can happen in almost any clinical situation but is more keenly felt in a wilderness environment. Important reasons for requesting evacuations include the evaluation of an illness or injury, whose definite care may not be managed locally, may require a specialist or a stable condition that may likely decline. The patient's best interests should also be balanced against the safety of rescue workers and other participants.

Other important considerations affecting decisions include cost (to patient, institution or insurance company), logistics (the feasibility of actual transport), adequate method of transport, and possible risk to those individuals with the evacuation. Once these issues have been decided on, planned evacuations may proceed.

In the Manitoban, North Medical evacuations are often necessary for transfer of patients. This may include routine transfer of stable care for definitive management in tertiary care centres such as Thompson or Winnipeg. It may also include urgent and emergent transfer in time sensitive conditions for life threatening conditions.

Physicians wishing to transfer their patients must have good communication with the receiving centre or doctor as well as the transporters (which may include the Air Evacuation company, ambulances to arrange transport to and from both airports). Different areas will have different protocols and it is important to have an understanding of the difficulties that may arise during transfer. Extrinsic problems such as weather delays, mechanical problems, and crew unavailability may slow down patient transfer. Intrinsic factors such as patient deterioration whether from there disease or injury or from the hyperbaric environment of the plane must be acknowledged.

COMMERCIAL TRAVEL AND MEDICAL PROBLEMS:

Unexpected emergencies occurring in commercial transport, particularly aircraft are different.

In-flight emergencies 1-4 for aircraft will be discussed. Many of these principles may also be generalized for other types of travel by train, small boats and cars where the resources are low and help is far away.

A physician bystander may become either the intended or accidental medical authority at the scene of an event with many unfamiliar people also involved. Other professionals present may include physicians (of all subspecialties), nurses, paramedics, lifeguards, sarteks (search and rescue technicians), pilots, police, firefighters, airline attendants and even holistic alternative practitioners. Unfortunately, it is impossible to know or verify everyone's qualifications and status (active, retired, or merely posing) and care must be taken.

It is always important to defer to the proper designated authority and not attempt to seize control but instead facilitate help in a nonconfrontational way if possible. If something is working well it may be best to leave it be as one of the Cardinal rules of Medicine is to "do no harm" . However, if someone unqualified attempts dangerous or unstable procedures, attempt to correct this as politically as possible. Good Samaritan status protects physicians rendering aid in good faith and it takes into consideration that limitations.

Case Study

On my First night in Paris I was strolling down a side street at the Champs Elysees and came across a crowd surrounding a young woman. Several obviously drunk men were trying to get her back in the bar. I approached her sober female friend and after identifying myself as a doctor I asked what was going on. She replied that her friend had suddenly collapsed. I asked if she was breathing and she said no so I made her to check and we at least confirmed respirations and pulse. During this several of the men were making their own suggestions- that we should just leave her to them and they would give her a few more beers to resuscitate her. I decided it would be very wrong for me to actually get to close to the young woman who it now appears was also underage but instead directed her friend to make sure she was breathing and distract the bar crowd from actually touching her. Eventually the ambulance came to take her away but in the meantime we had another man try to stick his fingers in his mouth and he dropped her head on the curb! After that was over her friend invited me for a drink but after hearing that another man had been knifed the previous week in that alley I decided to find someplace less colorful to stay.

In-flight Medical Kits may vary [see table] and may include a physician's kit (which is only to be used by someone qualified in the proper use).

Telemedicine is still in its early stages and will be used more and more in the future.

WARSAW-HAGUE PROTOCOL 5

In the early days of aviation there were no consensus on laws for transporting passengers and this led to uncertainty, which lawyers called "conflict of laws". Since passengers, cabin crew and air crew would be flying over different countries airspace it was difficult to establish jurisdiction.

Under the Warsaw convention (1929) the airline carriers' liability remained fault based, but fault would be assumed only with proof of damage and did not have to be established by the plaintiff. The carrier could escape liability only by proving that they and their servants or agents had taken all necessary measures to avoid liability and the burden of proof of that defence fell on the carrier. The amount of liability for damages was limited (1,000 British pounds in 1929 for death and injury) and, although a plaintiff could recover more if they could prove if there was reckless or intentional misconduct.

In 1959, the original Warsaw agreement was modified with the Hague Protocol through agreements with passengers and airlines. There "special contracts" improved the fares of the passengers, liability and amount of damages recovered. To qualify for damages from the carrier, the passenger must have suffered death, wounding or body injury on board the aircraft in an accident caused by the carrier.

Airline personnel are trained in first aid but also must not act beyond their capabilities. Advice or assistance may be asked for from a medical practitioner either from a ground consult or onboard passenger. Doctor's may be asked to assist fellow passengers from either the passenger or by the crew. Airlines may have a protocol when the emergency kit may be opened for use by flight or cabin crew or a Good Samaritan.

The aircraft commander must authorize the use of this kit, especially since controlled substances may be inside. By providing and authorizing their drugs for use, the airline is involved in liability.

Samaritans may have to act on advice from a ground specialist and may receive instructions via a crewmember if unable to converse directly with the specialist.

Doctors acting as Samaritans, may be concerned with aspects of liability.

•  Duty of care of the physician

•  Liability of airline for the physician

Airline indemnity for Good Samaritans

A duty of care exists as soon as the doctor intervenes whether it is by their own initiative or that of the cabin or flight crew, or passenger. If recognizing his own inability to help he should step back. If acting negligently or incompetently he may be liable in common laws if the passenger suffers further harm. If his action were reckless resulting in serious harm, he may be criminally liable. An example would include someone without an active status as a physician and whose skills were not proficient to deal with the problem at hand. This includes being intoxicated when asked to see a patient. It is felt that if a physician knowing they are incapable of attending to another passenger would be at serious risk of liability especially in a bad outcome.

If a physician was sued directly by a patient, any insurance that protects the Good Samaritan Act may help, providing in cases of competence. Competent action will be supported. Physicians who have been given competent care have had lawsuits initiated against them by passengers (there is nothing that prevents someone from attempting a suit) but they have been protected. In cases where there was incompetence or obvious malpractice physicians are not protected.

If the doctor is contacted for helping in an emergency situation, he may become an agent of the airline. If a patient sues the airline as a result of malpractice in error, the airlines liability should be governed by the Warsaw system and the airlines insurance will cover this. But it is also possible that a doctor answering a request from the aircraft commander may be seen as wholly independent from the airline in any contractual sense. In this case the airline would only be liable if a legally defined "accident" was defined to have occurred. An "accident" is legally defined; any unintended and unexpected occurrence that produces hurt or loss." Problems arising from a preexisting state like arteriosclerosis leading to a myocardial infraction do not constitute an accident even if it may be argued that the hypoxic environment could be argued to be a precipitant.

A Good Samaritan may request from the airline commander a contractual indemnity in order that they may be a temporary agent for the airline. If this is refused the refusal by the commander this should be recorded in writing.

AVIATION MEDICAL ASSISTANCE ACT (1998, USA)

This act provides that in the USA an air carrier shall not be liable for the actions of the air carrier in obtaining the assistance of a passenger for an in-flight medical emergency. The provider shall also not be liable unless he is found guilty of gross negligence or unlawful misconduct.

The laws defining the Good Samaritan status of a physician attending to in flight emergencies attempt to make it easier for physicians to respond to in-flight emergencies without fear of lawsuit. It is in the best interests of the airline and passengers to have qualified medical attention in-flight, yet the airline and passengers have to be protected from the possibility of a charlatan or unqualified expert attending patients. The laws in place especially in US airspace attempt to allow good physicians to practice good medicine in a tough situation.

Suggestions for attending a fellow passenger as a Good Samaritan

•  Identify your skills and qualifications as a volunteer to the aircraft commander.

•  Seek a contract of indemnity from the Commander to act as an agent of the aircraft.

•  Advice of any ground-based consultant should be reviewed.

•  Make full notes on what happened aboard.

•  Speak to your insurer back home to notify them of what happened in the unlikely event of a future lawsuit being initiated.

•  It is strongly recommended that the physician not accept any substantial money or payment from the airline because it is felt that by doing so will undermine the Good Samaritan role.

•  If a patient appears unstable ask for an emergency landing if possible.

•  If a patient has a condition that might be aggravated by hypoxia have the aircrew pressurize the cabin might help stabilize some conditions such as pneumothorax.

•  Ensure adequate privacy and respect is given to passengers especially in intimate situations like childbirth.

SPECIFIC IN-FLIGHT EMERGENCIES

Many in-flight situations may develop requiring medical assistance. Some may be trivial and may require no specific intervention. Making a specific diagnosis and providing a definitive management may be delayed for ground consultation.

Other emergent conditions can be handled as best as possible but with a high degree.

The follow include some of the more common or at least important in-flight conditions that a practioner may be faced with

GYNECOLOGICAL AND OBSTETRIC PROBLEMS

Usually gestations greater than 32 weeks are not allowed to fly internationally but 36-week gestations may be permissible aboard domestic flights.

Women are encouraged to bring their antenatal care notes and medication with them. Pregnant women with complicated pregnancies such as severe anemia, evidence of intrauterine growth restriction or pre-eclampsia should not fly. A few cases of eclapmsia have occurred in flight. Treatment of choice is a lateral decubitus position, and keeping the airway clear. Magnesium sulfate is very unlikely to be available and Chamberlain 6 recommended using any sedative available to stop the seizure.

Eclampsia may be preceded by severe headache, itching of the mask area of the face, and right upper quadrant pains the fascia capsule of the liver is stretched. Make the patient as comfortable as possible and recommend emergent landing.

UNEXPECTED LABOR

First try to move the woman to a private area of the aircraft. Use blankets to make a curtain if necessary.

Check the blood pressure and perform an abdominal exam. In early labor, contractions may be 15 minutes apart and before full dilatation will occur every one to two minutes.

Do not rupture membrane. If skilled as a physician or midwife, do a vaginal exam to assess the cervical dilatation.

Normally labor will not proceed until l0 cm dilatation or when no cervix is palpated. A fetal heartbeat can be heard with a regular stethoscope but may difficult in a noisy plane. Adequate analgesia may not be available from either the medical kit or other passengers, so coaching the woman to take deep breaths in a slow controlled manner during contractions may help.

INEVITABLE DELIVERY

The doctor should prepare to be ready and clean the perineum with an antiseptic and put on gloves. If inexperienced with deliveries the clinician should not try to over intervene but should watch the delivery anticipating problems. The presence of a physician will at least calm many of the others involved.

There are many philosophies regarding different birthing techniques but I was taught to control the delivery of the head with gentle counter pressure to avoid expulsive delivery of the head. Attend the delivery within your own capabilities, and remember that in the vast majority of cases there are no complications. Episiotomies would be very unwise in an aircraft.

After the head is born, allow rotation of the shoulders to occur. If there is shoulder dystocia or failure of the delivery to proceed, try to press the head gently down to release the anterior shoulder. After the baby is delivered make sure it can be dried in a warm blanket. It should cry within 30 seconds, and if not, gently stimulation of the foot may help.

Clamping the placenta is next which prevents fetus to placenta shunting of blood. Allow for time for delivery of the placenta and do not tug on the cord. Suprapubic uterine massage may help contract the uterus. Examine the placenta to ensure it was delivered intact.

Suturing tears will have to wait but firm packing will decrease blood loss.

MOTHER

Ensure that the mother is ok and not having ongoing bleeding. Remove bloody pads and allow her to lie across three seats will make her comfortable.

Baby

Recording APGARS and observing the baby will be helpful. If no respirations have taken place in 60 seconds, try to gently inflate the lungs.

Obviously a low-tech approach will be needed, as no laryngoscope will be available. Place the baby on a flat surface with the head extended in a neutral position. Try two to three mouthfuls of breath (using your cheek pressure only) and watch for anterior chest movement. If there is no heartbeat, try chest compressions using two fingertips over the lower sternum at 2 cm depth. Use two compressions per second with mouth to mouth every third compression.

OTHER OBSTETRIC AND GYNECOLOGICAL SITUATIONS

Matzkel et al 7 have reported an increased risk of abruption placenta during plane landing possibly from the force of a seat belt across the abdomen. Gynecological emergencies like ectopic pregnancies or twisted ovarian cysts may occur. The rule of the physician here is to stabilize with I.V. fluids if available and advise immediate referral to a ground facility.

PEDIATRIC IN-FLIGHT EVENTS

In-flight medical emergencies for children are rare but conditions that may be aggravated by a hypoxemic environment include:

•  Chronic Lung Disease

•  Cystic fibrosis

•  Asthmas

•  Sleep related upper airway obstruction

•  Chest wall conditions

•  Muscle weakness (muscular dystrophy)

•  Restrictive lung disease (scoliosis)

•  Infections (upper and lower respiratory)

•  Blood (Sickle cell)

•  Cardiac Anomalies (heart defects, pulmonary hypertension, heart failure, cardiomyopathy, arrhythmias)

•  Neurological (seizure disorders, cerebral palsy, brainstem diseases, elevated intracranial pressure)

•  Usually parents will know a child's conditions and if severe will not fly on a commercial flight.

•  A condition may be undiagnosed and worsen in a hypoxic environment.

SPECIFIC PROBLEMS IN CHILDREN

Breathlessness should first be addressed with high flow oxygen.

Asthma may be treated with ventilation. If a spacer is unavailable an improvised one may be fashioned from a plastic or Styrofoam cup.

Children with ear pain on descent should be encouraged to try swallowing, using the Valsalva maneuver and drinking liquids.

Nasal decongestants may be used one to two hours before ascension and 30 minutes before descension.

Sickle cell crisis if suspected should be given oxygen and analgesia.

Anaphylaxis may be managed with adrenaline and antihistamines.

ADULT BREATHLESSNESS IN-FLIGHT

The different diagnosis of sudden dysphea includes Pulmonary embolism , Pulmonary edema , Pneumothorax and Asthma all of which must be rapidly assessed and treated. Other causes less common include pneumonia and ' café coronary ' - the sudden inhalation of a foreign body (typically a large lump of meat impacted in the larynx and expelled with the Heimlich maneuver).

Chest pain if sudden, must be evaluated by a careful history and physical.

Myocardial Infarction or unstable angina can not be excluded. A careful history and physical may exclude a chest wall pain and a pink lady (lidocaine and Maalox can exclude esophageal pain but in the absence of cardiac enzyme and EKG no one can rule out an MI with certainty.

Using onboard oxygen, ASP, mitrate and morphine is prudent unless contraindicated.

Other chronic conditions such as rupture of existing bullae may also occur. A pneumothorax may be partially managed in addition to the usual maneuver by requesting the aircraft to increase the pressure in the aircraft. This may help shrink the size of pneumothoraces. Treatment includes giving oxygen, hydration, and possible ASA to prevent platelets aggregation around obstructing gas bubbles.

One other consideration is an attack of decompression illness in scuba divers. Body tissues saturated with nitrogen may precipitate gas bubbles into parenchymal tissue. This most often occurs within 12-24 hours of diving but has occurred often-longer intervals. This may manifest as diffuse pain or neurological symptoms.

Case Study "Peter" a 32-year-old man recently learned to dive on a Mexican Resort through rudimentary instruction. He flew home to Winnipeg (elevation 200 ft above sea level) and developed diffuse neurological symptoms two days after his return. He responded to a Table 5 Decompression Treatment in the local hyperbaric chamber. In retrospect he had decompression illness precipitated by his plane ride. This is atypical of decompression illness in that presentation was delayed although the in-flight environment was responsible. Decompression illness can be very difficult to diagnose under the best of times when minor neurological lesions present. The key factor is suspicion and preparation for referral. In-flight oxygenation is important..

VENOUS THROMBOSIS

Long distance travel is associated with deep vein thrombosis and pulmonary embolism 9-12 . It has been described in both business class as well as economy class and suggestions have been made to relabel it 'traveller's thrombosis' rather than 'economy class syndrome'. There are also case reports of sinus and cerebral venous thrombosis although leg involvement is most common. It is rarely observed in flights less than 5 hrs long and more typical of flights over 12hrs in duration. Symptoms of thrombosis have been reported up to 2 weeks after flight although usually occur after 3 days post flight.

Prevention: In-flight leg exercises are very important for high-risk patients. Giangrande 9 recommends very simple exercises to flex extend and rotate the ankles as well as deep inspirations to assist venous return. Scurr et al 11 suggest that below knee stockings may reduce the risk of events. It is important that these fit correctly and do not constrict the popliteal fossa. Full-length stockings as used post surgery for venous prophylaxis are not appropriate in-flight since they are meant for recumbent patients. The Pulmonary Embolism Prevention Collaboration group found that ASA did prevent events. A physician may not see a DVT in evolution aboard but this is possible. Starting antiplatelet therapy with ASA therapy immediately and referring to ground for further follow up would be reasonable. Other types of anticoagulation are not feasible but ensure that hydration is maintained.

Risk Factors for Venous Thrombosis

DIABETIC TRAVELERS

Diabetics may be more prone to thrombosis and myocardial events.

Insulin dependant diabetics may become hypoglycemic. If no glucose monitoring is available treat all decreases in mentation as hypoglycemia, since this is an easily treatable condition. Giving extra sugar will do less harm than withholding it "better sweet than sour".

Diabetic ketoacidosis from a deficiency of insulin or other problem (sepsis etc) will be difficult to manage in flight but treatment should focus on the continuation of insulin. Extra boluses may be given as per a sliding scale if a glucometer is available. Even more importantly free sugar fluids should be pushed to prevent dehydration. Hyperosmolar non-ketosis in Type 2 diabetics should be managed similarly.

NEUROLOGICAL CONDITIONS

The in-flight atmosphere of a modern plane is pressurized to the equivalence of 5000-8000ft, which does lead to a significant lowering of the alveolar oxygen tension. For the majority of patients no neurological deficit will be noticed since cerebral blood flow is able to autoregulate under a variety of conditions 13 . Elderly people with sustained hypertension may show symptoms of cognitive impairment as will as those with sickle cell trait.

NEUROLOGICAL PROBLEMS IN FLIGHT

Syncope may occur in flight although rarely due to postural changes since everyone is sitting down but more likely from claustrophobia or stress although this should be considered after a very careful history and physical

EPILEPSY

In-flights seizures may occur in epileptics because of missed medication, time zone adjustments and sleep deprivation. Usually epileptics will have a medical alert bracelet and a companion with them to explain their illness.

In-flight, during a seizure the patient may be placed on their side in the aisle with attention to keep the airway free. After the seizure is over a careful assessment may be done. By this time the medical kit should be available and diazepam may be given I.V. 2 mg if another seizure is likely. If there is no second seizure hold the diazepam until after the assessment.

If a second seizure is ongoing phenytoin if available may be infused at 15 mg/kg as a slow infusion. At this stage the seizure is now more complicated and could proceed to status epilepticus if it remains uninterrupted and the aircraft should seek an emergency landing. A single uncomplicated seizure is less ominous and need not necessarily divert the trip.

ISCHEMIC ATTACKS AND STROKES

An alteration in consciousness must be treated as an impending ischemic event with oxygen and an adequate airway maintained.

If a patient has a relative minor deficit, which is more suggestive of an ischemic event it may be prudent to start on 600 mg ASA but this may be delayed if there is any suspicion of a hemorrhagic stroke.

Large neurological deficits are more likely hemorrhagic and ASA should be withheld. Steroids are not recommended in flights.

PSYCHIATRIC IN-FLIGHT PROBLEMS

Air flight has a tendency to increase anxiety in passengers, bring out the worst in personality disorders including air rage, and may be distressing for those with mental illnesses. Cabin crews are used to dealing with difficult people but sometimes a physician may be asked to provide a professional opinion. Somatization of a psychological ailment may come to play and a physician may be asked to assess an individual with symptoms.

On a recent trip out of Las Vegas a Flight Attendant whom I knew put out a call for a physician and I immediately responded. I was asked to see a middle aged woman with chest pain. She had a history of panic attacks and had recently been put on an SSRI uptake inhibitor only a few weeks earlier. She was hyperventilating and when I began to question her on the nature, position, intensity, and radiation of her pain she became easily distracted from her pain and calmed down. Luckily for me the airport paramedics arrived and I deferred all authority to them. She stayed in the airport and was assessed further. Often a physician may be asked for an opinion on whether a patient is fit to fly. They should decline to clear any patient and instead should refer to the local medical authority.

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In-flight a physician may be asked to speak with a distraught patient and through simple talking may be able to calm an anxious passenger. It is important not to write off symptoms as "supratentorial". If asked to see a patient organic illness should be considered through a good history and physical since many disease could mimic altered states (hypoglycemia, toxidromes, hypoglycemia among others).

Air Rage is defined by Lucas 14 as shouting, irritability, combativeness, anger, provocative stances and verbal insults escalating to anti-social behavior by a passenger towards others or the crew. This can be an emergency and danger to the air flight. Confrontation should be done by those skilled enough in mediation and are able to present self-assertion without aggression. It is important to communicate calmly to the person without patronizing and attempt to identify the outburst trigger. If the mediator can identify the trigger and acknowledge the feelings, emotions, and sensibilities of the trigger they may be able to avert a crisis. 14 . Physical restraint is justified when attempts to manage behavior have not helped. Diazepam 10mg po or injectable by physician may be required to chemically restrain the individual.

RESCUE HELICOPTERS

Helicopters are limited to a ceiling altitude for rescue of 8,000 to 10,000 ft (2,400-3,000 in) 15 although some jet helicopters have gone to above 20,000 ft (6,100 m). Cold air is denser so a helicopter can go higher at lower air temperatures. Conversely warmer air temperatures can reduce its ceiling by several thousand feet.

Helicopters do not usually make absolute vertical or horizontal take offs and this should be remembered when considering their approach.

Preparing an area for a helicopter landing by marking the prevailing wind with a make shift air sock, smoke or even an arrow pointing to the direction of the wind may help. The downward thrust from the copter can produce intense winds. It is suggested to protect eyes and clear area of clutter when anticipating a landing. Fires should be extinguished to reduce the danger of spread embers. There are international symbols to signal aircraft but when dealing with people who are unfamiliar with these it is best to keep symbols simple.

The blades of a helicopter may be unnoticed when spun so always crouch when approaching the copter and from the front where the pilot can see you. Wind can also alter the path of the blades causing them to bend down further.

Nepalese Helicopter Evacuation

While on a medical mission in Nepal our Trip Leader and Director had guided us to an area where there had been large amounts of fights and thefts from the underground Maoist Communist Party. Several of the villages we passed through were noticeably shook up and after some discourse our Leader decided to call for a helicopter, as he felt the group was now in danger. We had planned to evacuate at a town four hours away and went off marching towards this village. When we arrived we were puzzled as to why no help arrived. We later learned that our contact in Katmandu had not been paying attention to the phone and had not arranged one until the following morning. Ironically we were now in the very town that all these self-titled Maoists were purported to be gathering around. We passed the evening sleeping outside the police station. Some of our group heard screams from the villagers in the valley below us.

The next day the helicopter came but was too small to carry our whole group so we would have to travel twice. We approached the copter properly and wore hearing ear pads due to the roar. The proposed one and a half day hike out now only took 25 minutes. On departing from the helicopter I forgot to adopt the habitual duck as leaving but was cautioned a few feet after leaving the copter. After the second group arrived, most of our group was poised to leave immediately as our guide insisted Katmandu itself was too dangerous to stay. At this point I was now in a position where I could verify him and phoned the local Canadian Embassy to verify if anything I had heard in the last few days was true. While I phoned the remainder of my group left for the airport without saying good-bye. I stayed during the next planned day of protests and marches and very little happened. I believe there was a shoot out at the near the village where we had previously stayed. I also discovered that the remainder of the medicine I had brought for free distribution had been sold on the black market by our Medical Leader.

PLANNED ELECTIVE EMERGENCY MEDICAL EVACUATIONS

Planned evacuations use pressurized aircraft with special adaptations for carrying oxygen and medical supplies. The commercial company I work for has several Lear jets that are able to take patients with specialized needs. Patients are first selected whether they are well enough to travel and this is first brokered through an insurance company who underwrites the considerable expense in repatriating injured travelers. It is indeed cheaper for the company to repatriate someone who is stable back to their home country t\rather than pay foreign medical bills.

In transporting elective returns we have the luxury of knowing their past medical history and the cooperation of the receiving and transferring facilities. Medications are supplied. The main goal is to transfer the patient speedily and make sure their current status is kept the same. Accurate dosing of medications is important across time zones is important as well as documenting vital signs. During the talk I will present several case studies of transfers

Case 1# Gerard a 47yr unstable angina returning home via commercial plane with myself as a medical attendant

Case 2# 34y UN worker, victim of a bombing attack in Iraq, post double craniotomy from shrapnel damage.

Case 3# 72 yr Finnish woman with BOOP.

Case 4# 52 yr Englishman returning home after a mi.

Appendix 1: Abandoning a Helicopter ( Suggestions by Craighead and Craighead 17 )

Appendix 2 . Being Rescued by a Helicopter 17