The tragic story of the Continental pilot who died mid-flight, despite being attended by a cardiologist passenger armed with a defibrillator, leaves many people asking – but why couldn’t they save the pilot?
This is, in many ways, the story of sudden death – a medical term for when an otherwise healthy person, often without warning, collapses without a pulse, no longer breathing.
Details in the pilot’s case are – appropriately for the grieving family – few. Medically speaking, even if the plane could have landed immediately, or the pilot had, while visiting friends, collapsed in a hospital, there’s no way to predict what could have been. Studies show that sudden death is a generic name for a whole host of catastrophic medical conditions. But when a person collapses, with minimal or no symptoms, the first diagnosis that is assumed is that it’s caused by a heart attack – for good reason. Heart attacks make up the vast majority of cases of sudden death.
Most of us know that the words heart attack mean that a bit of the heart is, literally, dying because of blocked blood flow to that area. However, most lay people are unaware that, often, it is not the dying part of the heart that causes someone to collapse. After all, if only a small part is dying, shouldn’t the rest be able to keep squeezing blood along? When sudden death from a heart attack occurs, it is usually, instead, caused by the electrical misfiring of distressed cells. When even a small number of cells die within the heart, it disrupts the normal electrical charge of da-dum, da-dum, da-dum – a rhythm that is absolutely crucial to the forward flow of blood. Imagine, for example a galley crew – everyone pulling on their oars in synchronized strokes, movements sure and strong, propelling a massive entity forward. When a heart attack strikes, the galley crew becomes disorganized, some pulling against others, all forward momentum decreasing. Chaos can erupt – a condition called ventricular fibrillation, when the heart feels, literally, like a bag of worms, all the cells twitching and firing asynchronously.
A massive shock, delivered in that exact moment, can restart all the cells simultaneously – and the living, remaining rowers begin to pull together. It is for this reason that defibrillators are so very important to emergency protocols, and why they are now located in large gathering areas like our baseball stadiums.
So why didn’t a defibrillator work? That is a question no one may ever be able to answer. But autopsy results show many reasons why sudden death can be irreversible, even with all the high-tech equipment imaginable, even in the most skillful of hands. These reasons include the sudden death of a massive part of the heart – what doctors call, in medical gallows-jargon, “pump failure.” Sudden death, more rarely, can also be from the death of an absolutely crucial, but tiny, part of the heart – what doctors, in equally-gallows-jargon, call “bad luck.”
What would this tiny part be? Most people may not be aware that our heart valves are tethered by strings – imagine the ropes that hold a parachute as it fills and poofs up. Each of us has tough, fibrous strings that keep our valves from blowing inside-out (a situation that is evocatively called a “flail valve”). One end is attached to the valve and the other end is attached to tiny muscular finger-shapes inside your heart’s chamber. These “fingers,” called papillae, flex as the rest of the heart squeezes, as though they’re bracing themselves to hang onto the parasail of your valve-leaflet as it whips up in the turbulence of blood flowing past. If a person is unlucky enough to have a heart attack exactly in that tiny finger-muscle area of the heart, those valves “blow out” – and the blood, instead of flowing forward, sloshes back and forth, thrown up and falling back down, never getting to vital organs. This condition is known as an acute chordae tendinae rupture.
Moreover, sudden death can be mistaken for a heart attack, when the cause was always something no defibrillator could ever fix – things like the rupture of an aorta (the one massive blood vessel that carries oxygenated blood away from the heart), or a massive blood clot that wedges in a vessel, blocking as surely as a wine-cork all movement of blood to or from the heart. Other causes of sudden death will often have telltale symptoms that were missed or overlooked. For example, sudden death can be the rupture of a blood vessel in the brain – perhaps the person never mentioned the sudden, excruciating headache that hit moments before collapse.
The reason to grab the defibrillator and rush to shock a no-pulse/non-breathing person is because, if it might work, time is of the essence. Every second counts. It is as though the heart’s cells forget how to work together – individual cells become deranged, chemical signals dumped out, depleted and unrecoverable. Even the time it takes to ask “is there a doctor on board?” is crucial time lost – a Medscape physician-forum about doctors’ experiences giving aid on airplanes noted that some European airlines ask physicians to self-declare at check-in if they are willing to give aid during a flight – that way there are no overhead announcements. Instead the airline staff have a list and can approach a person rapidly and directly if an in-flight emergency occurs.
CPR is crucial during the moments the defibrillator is being located and used, whether a doctor is around or not. CPR buys time for the brain, and sometimes, even after prolonged minutes of CPR in a heart-attack patient, a defibrillator can still work. Few things are more amazing in medicine than actually seeing the person who lies pulseless and slack – clearly, visibly dead, and is shocked – who then begins to move and gasp and recover. The prompt laying-on of CPR-hands, the unpeeling of pads, the shout of clear - when it works, it is one of our most profound modern miracles.
But unlike what we see on TV, even that carefully orchestrated dance of professionals frequently doesn’t end well. For the grieving family of the Continental pilot, there may never be a clear answer to what happened – only the limited consolation of knowing that both a defibrillator and willing help was at hand in the moment of need.
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