“If There’s a Doctor on Board, Please Ring Your Call Button”

Well, it happened again. Last Thursday evening, I was somewhere over Saskatchewan, returning from a lovely Mediterranean cruise, in that uncomfortable semi-conscious state that passes for sleep when you’re flying coach, when the airplane’s PA system rang out:

“If there’s a doctor on board, please ring your call button!”

If you’re old enough to remember the show “To Tell the Truth,” you know what happened next. In the show, four B-list celebrity judges guess which of three contestants holds a certain unusual job. Once the judges have made their guesses (guided by contestants’ answers to a series of questions), the real skunk breeder, or tea taster, or cemetery lot saleswoman is asked to stand. One contestant begins to rise, then checks herself and sits down. Then another. Finally the correct contestant stands. The audience lets out a collective “oooh.”

I’m guessing that the average packed Boeing 777 has at least a handful of doctor-passengers. When the call comes for a physician, I’m sure a few mutter, “no f-ing way” and go back to their Sudoku. But most, I think, respond like I do: we reach tentatively for our call button then, thinking better of it, stop, look around, start again, then finally push the damn thing. Even as we nobly hit the button, in our heart of hearts we hope that we’re number two – our guilt assuaged but our services unneeded.

And that’s what happened on Thursday. I waited a few seconds, heard another “Bing!,” breathed a sigh of relief, was elbowed in the ribs by my son Benjy, and then, shamed into it, hit the button. The flight attendant came over, thanked me, and told me that another doctor had already been selected. “I’m sorry,” I replied, which is weasel talk for “Whew!”

I settled back to “sleep,” but five minutes later she returned. “Perhaps you should come up.”

It is virtually always “come up,” since people with airplane medical illnesses seem to always be in business class. I don’t think business class actually causes folks to get sick on airplanes. Rather, as they taught us in Epi 101, this is an “association”: older wealthy people are both more likely to upgrade, and to get sick.

When I arrived, a very pleasant elderly American woman with asthma was panting like an overheated puppy, her concerned husband fretting next to her. The doctor already tending to her had not yet checked her vital signs, listened to her lungs, or administered a treatment other than oxygen. I wondered why, and then learned that the doctor was a radiologist (from Germany, as it happens). She seemed – what’s the word I’m looking for – yes, elated, to hand over the reins to me.

I opened the airplane’s medical kit, which used to contain virtually nothing but a stethoscope and a prayer, but is now stocked with a fairly complete array of medications (including epinephrine, Benadryl, atropine, Compazine, nitro, aspirin, and pain meds), as well as equipment for intubation and intravenous access. There’s also an automatic external defibrillator. Unfortunately for my colleague the radiologist, there’s no MRI or ultrasound.

This one was easy. I took a little history from the patient, listened to her lungs, and then recommended that she take a few extra puffs of her albuterol inhaler (she carried one but had been told to use it very infrequently, so she was waiting, patiently but mistakenly, until six hours were up to take another hit). Within 10 minutes, she was nearly back to normal. The flight attendants thanked me and I slouched back to my seat in coach.

I fly a lot (about 125,000 miles a year), and I’ve answered the “doctor on the plane” call about 15 times over the past two decades. (Once, I got called on both legs of an SFO-Philadelphia round trip!) Although the FAA estimates that there is one medical emergency for every thousand or so takeoffs, I must be getting on high risk flights or something, since I seem to average about one call a year, which would place the frequency at more like one in 50-100 flights.

In any case, this topic is one of the great sources of physician war stories (perhaps second only to municipal hospital ER horror stories during residency). So I’ll share a few of my experiences, in the hopes that some of you will share yours.

Standing in the Cockpit Soon After 9/11

I had to fly from SFO to Philly in late September 2001, just a few weeks after 9/11. I was scared to death. I noticed that no one dared fall asleep on the plane, and everybody had a look on his or her face that bespoke a fear of impending doom. The FAA had just announced its new restrictions on cockpit access and was in the process of hardening the doors; for now, someone approaching the cockpit too quickly would have been blocked by flight attendants and first-class passengers, and hit with weaponry consisting of serving carts and hot coffee.

About an hour into this US Airways flight, I got the call: a woman in seat 22A was having chest pain. I tried to figure out her risk factors and the quality of the pain, but made little headway since she didn’t speak much English (I think her primary language was Polish or Czech). The flight attendants found another passenger who spoke the language, or something close, and she joined us to translate.

With chest pain, as with many in-flight emergencies, the real issue is whether the pilot needs to land the plane early – there’s only so much you can do on board, and administering TPA or performing an emergent cath are not among your options. I tried to sort out the character of the chest pain and the patient’s risk factors, but between the language barrier and the lack of an ECG, the nature of the problem was really anybody’s guess.

The pilot, communicating with his medical station on the ground (every major airline contracts with physicians who help them manage these situations), began sending messages back to me requesting details. The problem was that this quickly devolved into a bad game of “Telephone” – the ground doc posed a question to the pilot, who relayed it to the flight attendant, who ran it back to me, which sometimes prompted me to ask the patient through our passenger-translator. We weren’t making much progress, and in the post-9/11 environment, everybody was getting a bit twitchy.

Finally, I said to the flight attendant, “You know, this is silly. It really would be easier if I spoke to the doc on the ground myself.” “I’ll ask the pilot,” she said, and disappeared. “OK,” she said when she returned, “come up to talk to the doc and the pilot.”

Before I could fully process this, I soon found myself standing in the cockpit of an Airbus, right behind the pilot and co-pilot, about 3 weeks after 9/11. If I knew martial arts, I have no doubt that I could have taken the plane. And, it dawned on me that, if I were a terrorist, I could have staged the whole thing, with a partner playing the role of the “sick” passenger. The realization made the situation all the more surreal. I felt a bit ill myself.

Of course, nothing bad happened. We decided to treat the woman for indigestion (she had few cardiac risk factors), she improved, and we landed uneventfully a few hours later.

Peer Pressure – From the Pilot

Last year, I was flying back to San Francisco from Charlotte, and noticed an elderly woman and her middle-aged daughter across the aisle from my seat. The younger woman appeared to be blind and had the look of someone with a chronic illness. As the plane took off, she vomited. A flight attendant came over and asked, “Do you need to see a doctor, ma’am?” Please say no, I prayed to myself, but she said, “I think so.”

I had about 5 hours’ worth of work to do on this 5-hour flight, and I can’t say I relished the thought of spending the time rendering clinical care. But there I was. Despicably, I waited until they made the PA announcement before I leaned over to say, “I’m a doctor.”

I learned that the woman had hydrocephalus and a ventriculo-peritoneal shunt, and now suffered from nausea, a headache, and abdominal pain. This is a bad combination: it could mean that the shunt was malfunctioning or she had a serious infection. The idea of waiting nearly five hours for legitimate medical attention was troubling. I opened the airplane’s medical kit and began giving her anti-emetics and some pain meds. She improved for a short while, and then began to worsen. I told the flight attendant that we might need to divert the plane.

The pilot came out to speak to me – I was reassured that they were now enforcing the “no lay people in the cockpit” rule. “Doc,” he said, one pro to another, “I don’t want to tell you how to do your job, and you’re in charge here. If you say we need to land this bird, I’ll land it….”

I waited for the big “but.”

“But I need to let you know that when we took off, we had a full tank of gas, which will mostly burn off by the time we get to California. When you land a plane this heavy prematurely, you have to come in ‘hot.’” He explained that this meant landing at an unusually steep angle of descent while gunning the brakes to prevent the plane from overshooting the runway. “It’s not dangerous, really, but it’s a little scary, and we have to stay on the ground for a full inspection before we can take off again. It takes a few hours.”

“But really, doc, I don’t want to tell you how to do your business. It’s completely your call.”

If you’re a physician, remember that feeling you had during your residency, when you were admitting a patient to one of your pals, who was getting slammed upstairs? I don’t know the resident who didn’t factor the peer response into his or her decision-making. Most of us ultimately did the right thing, but it’s human nature to consider the “hurt” you’re causing to others even as you focus on your patient’s welfare.

Here, the “hurt” would be to about 300 people who would be delayed several hours – or perhaps even overnight – because of my decision. “Let’s give it another hour and see how she does,” I said.

If you’re not a physician, this might seem immoral, but I want to reassure you that I – and every physician I know – would find this to be an easy decision in a clear-cut emergency. But in cases like this, and what makes medicine so hard, is that we often don’t know what’s going on, and the chances are fairly good that waiting will be fine. In situations like this, it’s natural, and actually not inappropriate, to weigh all the consequences before rendering a judgment.

Luckily, this patient, like my 9/11 chest pain patient, did fine – or at least fine enough to make it until the paramedics could wheel her off the plane at the final destination.

Why Certain Kinds of Humor Aren’t Appropriate at 35,000 Feet

Leslie Neilsen as Dr. Rumack“Is there a doctor on the plane?” has been the source of Hollywood humor, as you might remember from this clip from the movie Airplane!, Here, Dr. Rumack, played memorably by Leslie Neilsen, answers the call, stethoscope helpfully already around his neck. But there is a time and place for humor and, well, this probably wasn’t it.

About 20 years ago, I was on a 747 flying to Chicago, as I recall. A flight attendant had passed out and was lying in plane’s rear galley.

By the time I arrived, she was already coming to. Her vital signs were OK (her heart rate was a bit slow, which is typical of this syndrome), and I was able to elicit the history of a tooth extraction the previous day and some lingering oral pain. So this was a clear case of vasovagal syncope; there was no need for worry.

Remember that this was a flight attendant on a jumbo jet, so I was surrounded by about 10 of her worried colleagues, as well as the co-pilot. “Do we have to land the plane, doc?” the chief purser asked. “No, I’m sure she’ll be fine,” I said. “She should rest, drink a little extra, and keep her legs elevated.”

Relieved, the group began to disperse to their stations. One of the other flight attendants walked up to me. “Thanks, doctor…. By the way, what kind of a doctor are you?”

“I have a PhD in English Literature,” I said, mischievously.

“Just kidding,” I quickly added, as I nearly scraped her off the ceiling.

I’ve now recognized that airplane emergencies are probably not the best time for jokes, though this seemed very funny at the time.

Why Do This?

In 2000, an elderly woman, traveling with her husband, passed out on my flight – this time in the back of the coach section. I don’t remember doing that much – mostly getting her some fluids, elevating her legs, and handholding. She perked up. As we parted, she and her husband asked for my card.

A few weeks later, I received this note from their daughter; I still have it taped to the back of my office door. It said,

I understand from my father and brother that we almost lost my mother. As her only daughter, I am indebted to you for helping her live a longer life….

Answering the “is there a doc on the plane?” call is one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship. We worry a bit about liability (though the protections under Good Samaritan laws are fairly robust). No money changes hands (the airlines sometimes credit you with a few thousand frequent flyer miles or give you a free drink), and there are no CT scanners or fancy consultants. It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.

That’s why, despite the angst and the time (all told, I’d estimate that I’ve spent more than 20 hours providing clinical care on airplanes), I answered that call on Thursday, and I’ll keep doing so in the future. I hope you will too.



***
I’d love to hear any stories you have about medical emergencies on airplanes – whether your role was as doctor, nurse, or patient.

29 Responses to ““If There’s a Doctor on Board, Please Ring Your Call Button””

  1. Brad Stephan August 22, 2010 at 5:25 pm #

    Nice stories! FYI – the television game show you describe is “To Tell The Truth,” with Bud Collyer.

  2. Bob Wachter August 22, 2010 at 8:19 pm #

    Brad — thanks so much, you’re absolutely right! The shows “What’s My Line?” and “To Tell the Truth” had morphed together in my mind, a senior moment indeed. I just spent the last hour reviewing old episodes of both shows… a nice stroll down memory lane.  

    I’ve changed the paragraph to reflect the truth: To Tell the Truth, that is. Thanks again.

  3. Dan in Seattle August 22, 2010 at 8:51 pm #

    My story was not on an airplane but did occur traveling. We were on Maui learning to surf with friends when one of 40 year old males in the group came to shore with “the worst headache of my life”. I found him sitting with his head down, eye closed in terrific pain. He described very abrupt onset of his HA while out on the water paddling aggressively (“like my head exploded”). He had no obvious neurologic physical findings but he was acting very much like a subarachnoid hemorrhage. I was very concerned but could not convince him to allow me to take him to an ED. As I was pressing the point with him and his wife, an elderly, homeless and leather faced local was sitting nearby and without speaking- stood up, slowly walked over to the man and began performing what appeared to be a manual massage/manipulation on his neck. Within 30 seconds the surfer had immediate and complete relief of his headache. The dark skinned elder, through a toothless grin then said “he has surfer neck.” Apparently rooky surfers will often develope muscle spasms in thier cervical muscles from cranking their necks back while paddling to catch waves.

    I tell the story to get laughs now but that moment, to those on that beach, I was pretty much worthless. As internists out in public and responding to these events, we need to be careful to recognize our bias and skill set and perhaps it is appropriate for others to step forward first. I am very comfortable with multisytem organ failure but should not expect myself to be competent with everything we stumble upon. Sometimes these people need a good RN, a medic, or even an Eagle Scout. In my case we needed a washed up elderly surfer dude.

  4. Dr. Amazon August 23, 2010 at 4:05 am #

    Hi Bob,

    Thanks for another informative and entertaining post. However, I feel obliged to notify you that you may have been shafted in the paltry compensation you’ve received for providing in-flight medical care: my buddy received a round-trip ticket when he responded to “If there’s a doctor on board…”!

  5. menoalittle August 23, 2010 at 4:11 am #

    Bob,

    From your eloquent description, you you made meaningful use of the airlines black bag but you undoubtedly need CDS (clinical decision support) to guide you through the ambiguity of watchful waiting v landing with a full tank; and the airlines’ flight attendants definitely need CER (comparative effectiveness research) to determine which nationality and specialty of physician is meaningfully suited for the emergency at 30.000 feet. The airlines should require CPOE (computerized physician ordering entry) on a handheld to enable the pilots to know what you are meaningfully doing, exactly, and what they should do, without having to get out of their seats. That is what meaningful air safety is all about.

    Best regards,

    Menoalittle

  6. Maggie Mahar August 24, 2010 at 2:42 am #

    Bob-

    A wonderful post –illuminating and very funny., I’m linking to it on my blog

    Your candor about how you feel when answering these calls is great as well as your ultimate advice: “despite the angst and the time . . . .I answered that call on Thursday, and I’ll keep doing so in the future. I hope you will too.”

  7. Bill Randall, MS, RN August 24, 2010 at 7:56 am #

    Bob: very funny stories and so well written. I just found your “gem” “Understanding Patient Safety.” I’ve recommended it to all my colleagues. It’s a great, concise read. I saw you at the annual Beacon conference and became an instant fan. I love your matter of fact, straight forward, and practical delivery about somewhat complex and esoteric topics, not to mention your sense of humor. You make it real and bring us all back to earth. Thanks!

  8. Giri Venkatraman MD August 24, 2010 at 4:08 pm #

    Funny post…I am an ENT and had a flight attendant with epistaxis when going on vacation. Not often we get something right up our alley. Had to land the plane since I needed her to not work and sit and hold pressure. Apparently the FAA has some rules about attendant to passenger ratio and when we landed they had to get someone else to cover for her. The more interesting part of this story was that a few other passengers were inconvenienced and attempted to get freebies…
    BTW if you fly 125K miles a year why were you not in business class??

  9. Bob Wachter August 24, 2010 at 4:30 pm #

    Thanks for all the comments (particularly to Maggie, who posted a link on her terrific Health Beat blog).

    Giri, I wasn’t in business class because I used miles to “purchase” the tickets, which means you can’t upgrade. Two coach tickets to Europe will set you back 200K miles. Two business class tickets are something like 10 million. And, in my experience, even 1K folks are able to upgrade to business class only about 25% of the time, so I spend a lot of my life in coach. For some reason, the airlines seem to want to sell their business/first class seats if they can.

    I can’t leave the topic of business class vs. coach without a shout out to the classic Seinfeld episode, the one in which Jerry is in first class while Elaine is in coach. It is on my top five list of funniest Seinfeld clips – it’s well worth 8 minutes if you have it.


  10. Davis Liu, MD August 25, 2010 at 5:52 am #

    Great post and amazing stories. Only one time sitting at a window seat I heard the page for a doctor. Gotta be somebody else on the plane but me, right? I’m just a newly graduated family medicine resident. A second page. Rats.

    When flight attendant queries the older woman over in the aisle seat about her call button, she vigorously motions to me. That’s the culprit.

    Unlike Bob, my middle aged patient was in the last row, not in first class. Ashed face and breathing heavily, it was difficult to hear him let alone do any decent physical exam because of the engine noise. Medical kits are rudimentary with a cheap stethoscope.

    He perked up with oxygen. I made it up to the cockpit and chose not to land the plane (had to make a connection). Got lucky because the flight attendant used to be an ER nurse who helped as well.

    FYI – I grew up in Saskatchewan. Never thought I’d see that in a medical post!

  11. Rajani Bhat August 26, 2010 at 5:11 pm #

    Thank you for that wonderful article. You reminded me of countless occasions when i’ve responded to the doctor on board call.During my internal medicine residency and pulmonary and critical care fellowship, I travelled from NYC to my native city,Mumbai, every year and in 2008 ,weekend round trips almost every other month between NYC and London.I’d leave NYC Friday night and return Sunday midnight.My husband had decided to take an overseas assignment as i hardly saw him anyway during my critical care training. There have only been 2 transatlantic flights that i can recall when i wasnt paged. It was almost a pattern i grew accustomed to.The flight takes off, I’m dosing off ,happy to be away from my constant companion, my beeper and the request for a doctor on board goes off over the PA system. I’ve responded immediately to every call.
    I’ve had to treat people with bad gastroenteritis, alcohol withdrawal and DTs, heart failure and atrial fibrillation,hypoglycemia, severe back pain after lifting overweight baggage, diaper rash, colicky babies,migraines.I’ve had to deal with the dilemma of heartburn or heart attack??!!At times , I’ve reached into my own hand baggage or other passenger’s bags to find medications to treat people on board.I always carry my own steth so inever have to rely on their terrible stethoscopes which along with the sound of the airplane make auscultation impossible.Like you,I’ve discovered that the airlines emergency medications list has now expanded so you can actually treat some emergent conditions.x However ,I find their stock of syringes, needles ,IV equipment woefully inadequate. I’ve used their finest whisky from first class in place of alcohol swabs to give q 2 h benzo injections to a patient .In hindsight, maybe i should have just given the patient the whisky to drink.I’ve had to wait with patients until the ground medics team arrives and transports the patient and give signouts at the end of my long flights.I have found some airlines annoying in their insistence on not allowing me access to their emergency medication kits if I couldnt remember or provide them with my license or registration number.I’ve been fortunate that the only time I needed to ask the pilot to turn back was before the plan left the ground,while waiting in line behind 9 other planes for takeoff on the tarmac.
    I used to get exasperated earlier, but i’m used to it now.I am now familiar with the different goodies that different airlines give you for responding to the call. .I think my favourite has to be Virgin Atlantic, they gave me enough miles for me to get free tickets to visit my husband more often!
    I dont fly that much anymore, but i think i’ll be ready the next time I’m called

  12. Ed Reategui August 26, 2010 at 10:42 pm #

    I was on a plane flight from Atlanta to Lima Peru when the PA announced if there was a Dr. in the plane. I waited for a while, but then the PA announced again (In a panic voice) Anyone with any medical experience please see the steward. I thought I guess that means me. I am an Emergency Room RN in my spare time. I was escorted to the back of the plane to find a young male passenger pale and diaphoretic. I had nothing to check his vitals, but my fingers to check for his pulse. He had a very weak radial pulse. I thought he may had vasovagal somehow. When I asked him how he felt, I found out that he only spoke French. I speak spanish, so I tried a mix of english and spanish and gathered that he was having abdominal pain. I decided then that he may be in some type of shock. We raised his legs and by this time the Steward brought an 02 tank, which we used on him. By this time his significant other next to him begins complaining of abdominal pain as well. She goes pale and diaphoretic too. I am like what the heck is going on. Am I on candid camera or what? I asked if there was any IV solutions or meds onboard which they replied no, and that the pilot wanted to know if we should land the plane. I asked them where we were. We were flying over Panama, about 3-4 hours from Lima. I checked my patient’s vitals (minus blood pressure) and found that the oxygen was helping. I could feel a bounding pulse on both of them. I said keep going we can make it. I kept coming back every so often to check on them and seemed to be OK. When we landed they walked out without any problems. Heck I guess they drank too much, who knows? The only complaint is that they got my info and never gave any frequent miles or a drink, sigh! Well maybe only Dr’s get offer that.

    Ed.

  13. Shadowfax August 27, 2010 at 3:53 pm #

    Great post.  I’ve had only a few “doctor calls, as I fly infrequently. I did, however, have a hellish NY-Athens round trip a couple of years ago with four separate patients. I blogged it over at my site, <a href=”http://allbleedingstops.blogspot.com/2006/06/rounding-at-37000-feet.html“>Movin‘ Meat</a>.

    Thanks for your great insights.

  14. Eric August 29, 2010 at 1:29 am #

    I liked your, “Why Certain Kinds of Humor Aren’t Appropriate at 35,000 Feet,” section joke, “I have a PhD in English Literature.” Actually, I thought you did? or with your prior post on medical writing, I thought you should. I enjoy reading these posts. Thank You.

  15. Chris Choukalas August 30, 2010 at 4:29 pm #

    Your story about peer pressure on the airplane really resonated with me. I’m a physician (also at UCSF, by the way, in anesthesiology and critical care) and attended to a patient on a 757 from DC to SFO about a year ago. It was difficult to decide whether to land or not; the potential inconvenience to other travlers, the aforementioned “coming in hot” aspect, etc., were on my mind, and the patient’s diagnosis was difficult to ascertain. This was compounded by the fact that we were over eastern Colorado and if I waited too long to decide, we’d be over the Rockies, which limited our landing options. In the end, I had the pilot land the plane. On the way down, the flight attendants continued to offer me food (which was for purchase to the other passengers), but I felt so guilty about landing the plane that, despite my ravenous appetite, I couldn’t accept it.

    Fortunately, the landing was smooth and we were able to depart and, ultimately, land at SFO without too much delay, but I’m sure I’ll remember that case for a long time.

  16. Painless September 2, 2010 at 7:02 pm #

    About 3 years ago I was on a trans Atlantic flight on my way to Scotland with my wife for her sisters wedding. We had just finished eating and were just settling down at the end of a very very long layover in New Jersy (we were flying from Florida) when the call came over. Being an ED Nurse I did respond to the call, then noticed that no one else had. After the flight attendant had looked at and documented every single piece of pertinant ID I had (nursing license, CPR, ACLS, etc… which for the life of me I still don’t know why she needed) they led me back about 5 row’s behind where I was sitting in coach. Apparently this frequent flier brittle diabetic had not eaten and they had a hard time arousing her for dinner. Her friends had traveled with her before and this had happened before, so they were in the process of giving her some glucose syrup under her tongue when I came up. She quickly woke up, I was able to get an accucheck (she had her own machine on carry on) and I was able to establish it was a tad low. After some juice and dinner, it came up rather nicely. I was asked the same question about turning around – this time it was before we got too far out into the Atlantic to be worth turning around. I made the decision to check her accuchecks fairly frequently and watch her closely, which I did. A couple of snacks later and a very long night for me (getting up every half hour, then hourly finally every couple of hours for nearly 8 hours) we made it to Scotland without further incident. I was never offered anything by the airlines… and for all that the person I was helping never said thanks either.
    Yes, despite all that I do think I’d do it again though.
    I can also relate my father having an episode of SVT on a plane, and thankfully there was a physician on board – the on ground MD wanted them to give my father nitro, but his heart rate was around 180 – 200 and he was pale, diaphoretic and had low blood pressure so the physician on the plane said… “eehhhh… NO!” to that request. Probably saved my fathers life to be honest. Thankfully Dad is doing very well, had ablation therapy and has never had that problem again.

  17. Dick Sudmeier September 3, 2010 at 8:54 pm #

    It was truly a dark and stormy night flight from Amman to FRA in a plane packed with Chaldean refugees from Iraq. My wife and I were way it the back trying to sleep thru moderate to severe turbulence with headphones to drown out the crying babies when the PA call first in German came. No responses so then in English and my wife’s nudges moved me to get up. In the back galley was a young women lying on the floor retching. I quickly realized she was pregnant and that there was someone much more qualified than an internist available. Went back to my seat nudged my wife, a certified nurse midwife, and smirked “this one is for you”.
    She went back and did what ever you do in these cases. I was just about asleep when a second call came. This time in the front of the plane a lady had fainted. I figured I should handle this one. She came around nicely with positioning and tincture of time.
    It was actually quite rewarding as they clapped and let us off the plane first, no other compensation however. Also it was the first time I had heard the ancient Chaldean language spoken.

  18. Pedro September 8, 2010 at 6:21 pm #

    Great stories. I was on a flight from Puerto Rico to San Diego and had decided to upgrade to first class with miles I had built up over years. Nothing like a morning mimosa in first class. Unfortunately we had only been in the air for 20 mins before the gentleman next to me started to have a seizure in his sleep. No overhead call to try to avoid. So I gently placed a pillow between his head and the window and looked him over and told the attendant that I think the guy next to me is having a seizure. She asked if I was a doctor and I answered yes and she said “great” and moved on. Once his seizure was done she asked if I needed anything. All the attendants seemed happy to go about their business and check in every so often. Needless to say I never got that mimosa as I felt it would have looked bad to have a drink and be expected to monitor or treat him again if he had another seizure. The good news is that he was fine, has not had any further seizures and had a negative head CT 5 months later as he has emailed me and updated me.

  19. Jerod September 9, 2010 at 8:21 pm #

    On a tran-Pacific flight several years ago, I was sleeping soundly but my wife was awake. The flight attendant came down the aisle to get “Dr. XXXX” for a medical emergency. My wife interceded and said “you don’t want him – he is a PhD…..but I am a registered nurse and would be happy to help”. Believe it or not, the flight attendant asked her for a copy of her license – right there at 35,000′, in the middle of the Pacific and in the midst of an emergency. But, the fact that the passenger manifest happened to say “Dr. XXXX” was enough to convince her I was a physician. Oy.

  20. Barnice September 14, 2010 at 12:06 pm #

    Nice stories!

  21. Eric September 15, 2010 at 8:43 pm #

    I was flying home for Thanksgiving, wife (who is also a physician) and kids in tow. As we entered the terminal, a sherrif’s deputy darted in front of us, pulled an AED off the wall, and sprinted off. My wife and I looked at each other, and she said “OK, Mr Hospitalist… this one’s yours”. I followed the deputy all the way to baggage claim, where there was a man lying on the floor getting CPR (he had the good fortune to arrest in front of an off-duty EMT). We applied the AED and administered two shocks. Just as the paramedics stormed through the doors, the patient recoverd a pulse and began to breathe spontaneously. By the time they got him on the ambulance, he was talking to the medics. He survived his STEMI/arrest and is still alive and kicking. The most embarassing outcome was listening to my Jewish mother tell everyone over Thanksgiving dinner that her son the doctor saved someone’s life at the airport.

  22. scttjones231 September 18, 2010 at 3:33 am #

    Bob,

    From your eloquent description, you you made meaningful use of the airlines black bag but you undoubtedly need CDS (clinical decision support) to guide you through the ambiguity of watchful waiting v landing with a full tank; and the airlines’ flight attendants definitely need CER (comparative effectiveness research) to determine which nationality and specialty of physician is meaningfully suited for the emergency at 30.000 feet. The airlines should require CPOE (computerized physician ordering entry) on a handheld to enable the pilots to know what you are meaningfully doing, exactly, and what they should do, without having to get out of their seats. That is what meaningful air safety is all about.

    Best regards,

  23. Bob Wachter December 26, 2010 at 2:15 pm #

    I’m just catching up on back issues of the NEJM, so some of you may have already seen the “doc on the plane” article from last month’s Journal. An elderly man passed out in flight, and 5 physicians tended to him immediately. He was pulseless and apneic; they began CPR to no avail. After 25 minutes, they declare the man dead and prepared to stop their CPR efforts.

    But the flight attendant tells them that airline rules are that CPR must continue until the plane is on the ground, even when several qualified physicians are prepared to pronounce the patient dead. Faced with the choice of handing over CPR to the flight attendants (all busy preparing for an emergency landing) vs. continuing it themselves, the physicians elected to continue the (futile) resuscitation. This article received nearly 100 comments, including from the patient’s wife (both the patient and his wife were retired physicians, as it happens).

    Sad story and fascinating stuff. And a foolish policy.

  24. Bob Wachter February 24, 2011 at 11:13 pm #

    This one from Geff McCarthy, who has a unique perspective on this as an MD and retired pilot:

    Bob, I’m a retired USAF fighter pilot, doc, and patient safety umm…expert. We met a few years back during my PS Fellowship.

    I empathized with your account(s) of evaluating sick passengers. I have done same multiple times, e.g., in Oct between Singapore and Perth. I particularly want to reinforce the Captain’s safety dilemma: Landing short of destination, especially heavy, imposes new, unplanned risks on pax and crew.  (I ignore the inconvenience and cost.) Any diversion is more challenging than the original plan; it diverts attention that is already taxed by the sick patient, and the ground reception and facilities may not be adequate.  

    In other words, the Captain has to balance the risk to the patient against the risks to the crew.  In an extreme case recounted in the NEJM, the airline required CPR to continue thru landing, despite all 4 docs – and the AED – certifying that the pax was dead.  This action jeopardized all aboard: The cabin crew continued CPR instead of being strapped in for landing. Wrong, and for spurious legal reasons. I pointed this out, and ASMA wrote a letter to NEJM in response.

    So: If you and readers volunteer to assist a sick passenger, consider that recommending diversion and/or immediate landing, especially when the outcome will not change for the patient, may be a misuse of the authority of your position.  Outline the decision tree — Risks, Benefits, and Alternatives is a familiar and useful framework – and let the Captain decide.

    Cheers.

  25. Julius R. Ivester Jr. MD March 18, 2011 at 2:29 pm #

    On a Medical meeting in Paris, my family and I were eating lunch in a sidewalk cafe. I heard a man behind me shouting “Mama, Mama”. I turned to find the elderly woman directly behind me slumped over her plate. I spun out of my chair, and pinched her shoulder with no response. Something made me think she had obstructed her airway. I got my arms around her upper abdomen and pulled in and up. Out popped an unchewed bite of fish.
    She woke up to find a strange American hugging her from behind sitting on the floor. The son thought I had attacked his mother. I found the fish on the floor and put it in his hand. He still didn’t get it.
    Paris EMS arrived en force, upset that they had been called to a false alarm.
    My french-speaking wife tried to explain to the gathering crowd what had happened, in vain.
    The crowd including those walking on the sidewalk was growing quickly.
    Things were not looking too good for me.
    Finally a proper Parisienne lady stepped up and talked with my wife in English. She turned to the son, restaurant owner and crowd and esplained that I had saved the woman’s life. She admonished the paramedics for taking so long to get there.
    The paramedics took the woman and son away for observation.
    She then turned to me and told me in excellent English, that I actually had assaulted the woman, because in France you must ask permission to help someone. She said that I probably would not be arrested, then turned and walked off down the street.
    My family and I left quickly, after paying the bill, to catch the bus for our afternoon tour of Paris. The bus driver held the bus for us, having heard about what had happened at the cafe.
    On a whim, we returned to the same cafe the next day for lunch and sat at the same table on the sidewalk. The owner came out, hugged my wife and me. We ordered pate and cheese off the menu, but were brought wine, steak frites, steamed veges, and desert, with no bill.
    Apparently having a customer die in your cafe is bad for business. All of the hullabaloo the day before was good for business.

    Paris EMS arrived, upset that they had been called to a “false alarm”.

  26. silvergirl, MD May 9, 2011 at 8:04 pm #

    Nice to read the comments above. I fly frequently for personal reasons, and have been the “MD responder” about half a dozen times. Most of the responses relate to vasovagal issues, e.g. poor hydration related to extended travel, GI distress from unusual foods: although the presentations are protean: epigastric pain, diaphoresis, syncope, or just dizziness. I have encountered a few diabetic issues which were quickly cleared up. Oftentimes I’ve called in Rx for patients at their destination, if needed. I’ve talked with collegues who have attended to onboard cardiac arrest and tension pneumothorax (glad it wasn’t me, now that we can’t carry on our swiss army knives!) The only patients that I don’t want to see are women with abdominal pain; the answer is never easily evident even in the clinical setting with an abundance of testing.

    I’m trained as an Emergency Physician, and attending to the great unknown is always a challenge that I relish. 15 yrs ago in medical school, I felt strongly that becoming an MD carried with it a certain civic duty; with this degree we have the responsibility and obligation to approach medical issues with a higher level of confidence than than the layperson. I feel that all people who carry this degree should be able to perform CPR, have a working knowledge of ACLS protocols and the accompanying equipment (e.g. AEDs onboard) and logically approach common medical problems. We should know “sick” from “worried well.”

    I feel sad when I see physicians approach an ill patient with a “doe in the headlights” look. Step back, remember your training and forget where you are for a second. Usually the answer is right in front of you.

    I’m the first person on that button when the call for help comes. I hope to see you all there as well!

  27. silvergirl, MD May 9, 2011 at 9:09 pm #

    addendum, re: NEJM article and Geff McCarthy comments above.

    1) Dead is dead. I personally would not continue CPR/ACLS after medically futile point reached, although this decision much easier to defend in retrospect with several physicians in consensus.

    2) Decision to continue/land. I agree that cost and inconvenience should not be a factor, but consideration of safety for all is paramount. If the patient is unstable, and not responding to agressive measures, one should discuss with Captain/First Mate about landing. I would not divert a plane for gastroenteritis or even suspected appendicitis, but would for progressive respiratory difficulty, persistent hypotension, probable cardiac event, status epilepticus, unstable CVA with declining mental status, etc. It would be good to have a peer-reviewed guideline for the airlines, also reviewed by Pilot’s Association.

    Hmmm…I smell a project!

    • Debi Wong August 23, 2011 at 2:12 am #

      I am a family nurse practitioner.

      Last year I was on a Boston to Portland (Oregon) flight and a call for medical assistance was announced. A newly diagnosed diabetic 60ish male passenger had “gone grey” and passed out.

      I checked him out , got him supine across the seat row, had the flight attendants give him O2. The flight attendants put me on a headphone set-up to speak with the captain as they asked me if I thought it was necessary to land. They then explained that the airline has a fixed number of oxygen canisters that are mainly for the crew in the case of loss of cabin pressure.

      My thought in that moment was “you want me to make that decision???!!!”

      Due to the noise, was unable to obtain a normal blood pressure, but got at least the systolic by palp. I decided to put him on the defibrillator to at least see what his heart may be doing.

      I was then patched through a physician at Med/Aire and again was asked about his condition. I had obtained more hx from his family who were flying with him. Again, they asked me if I thought they needed to land. By that time, he was awake, albeit exhausted, and the color had returned to his face. We decided to put an IV in him and give him NS. We used the on-board glucometer and his blood sugar was 120. The Med/Aire physician initially wanted me to bolus him with dextrose 5 and when I told him about his diabetic state, we changed it to plain normal saline. Luckily, a critical care nurse was seated in the row in back of him and placed the IV in his hand.

      I ended up going through the med kit and it was pretty well equipped. I only wished they had nasal cannulas instead of this rebreather mask and a O2 flow rate fixed at 4 liters.

      We landed in Portland and the ambulance was waiting for him. I was unable to obtain his final disposition, but I suspect a little bit of hypoglycemia and altitude sickness was likely the culprit.

      I was initially scheduled to sit in first class, and was bumped because of a plane malfunction and subsequent change. As soon as things stabilized for the patient, the flight crew provided me with a free meal rather than charging me for it. I later received a letter thanking me for my assistance and was given some extra air miles for my efforts (I
      declined cash). I continue to see the same crew and we are on a first name basis now.

      One of the things I did find out, was that there are only a limited number of O2 tanks for the crew in the case of an air pressure change in the cabin and that the tanks can only be depleted to a certain level and if they reach that level, the pilot is required to land. With a fixed fairly high airflow, it can get used up pretty quickly.

  28. Robert Benak May 30, 2013 at 2:29 am #

    I would guess I have taken roughly 200 flights in my life and have heard the call on a plane only once. I (IM trained Hospitalist) and another physician I did not know arrived at the passengers seat simultaneously from opposite ends of couch (one thing I infer from this thread is that physicians tend to fly couch). We were both relieved to find a 65 year old nice lady with what seemed very likely to be benign syncope from dehydration.

    Perhaps more amusing (and certainly a little humbling for me) is my attempt to tender medical care half way up from the Grand Canyon floor to the rim. I was hiking by myself that day very soon after finishing my residency. i was pretty comfortable with multi-organ system failure in the MICU, but (due to our surgery dept at my training program insistence upon seeing all abdominal pain), I had almost no experience with abd pain

    Ihad fallen in with a group of 5 other hikers. We were enjoying the inconceivably great scenery and interesting conversation when one of the other hikers developed abdominal pain over perhaps 15 minutes. Just before she started to flex her spine, I began to ask her if she was alright. She kept insisting she was fine, and was obviously embarrassed by my inquiries.

    However, when she finally sat down, I began trying to convince her to let me take an H&P. with a good deal of anger, she whispered in my ear that she was sensing a return of the diarrhea she had suffered in the early morning before starting her hike. Once she found a discrete side trail and some donated toilet paper, she was fine; and my concerns regarding peritonitis vs pancreatitis were proven foolish

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