We were still climbing from the airport tarmac, and the movie on my iPad, “Star Trek II: The Wrath of Khan,” was at an exciting point where Klingons are attacking the USS Enterprise when it came: “Is there a doctor on the plane?”
If you talk to your physician and healthcare colleagues who fly, you’ll hear about this scenario enough to know that it is not a rare event. Healthcare providers who fly routinely are more likely to tend to a sick airline passenger than they are to diagnose pheochromocytoma in their day jobs. Pheo is a two-in-a-million disease, but getting ill on a plane happens to one to two people in every 20,000. In fact, the sick airline passenger is relatively common, with an FAA study estimating 13 events per day in the 1990s (Anesthesiology. 2008;108(4):749-755). There have been a number of interesting articles written about the doctor-on-the-plane scenario. Our own Bob Wachter, MD, MHM, blogged about it in his usual humorous and insightful way a few years ago here, (http://community.the-hospitalist.org/2010/08/22/if-there-s-a-doctor-on-board-please-ring-your-call-button), and The New England Journal of Medicine published a perspective on it at www.nejm.org/doi/full/10.1056/NEJMp1006331?query=TOC (NEJM; 2010;363(21):1988-1989).
My most recent experience happened on a flight just before the New Year, and because many of us will be flying to and from the annual meeting in Las Vegas and it seems to fit naturally (in many cases) with what we do as hospitalists, I thought I’d put pen to paper regarding the sick airline passenger in flight.
Fasten Your Seatbelt
As I was walked up to the first row, the flight attendant said a passenger had almost passed out. A doctor was tending to the sick woman already, as were two very concerned flight attendants. I have been through this before, so I knew I couldn’t go back to my seat just yet. I asked the physician if everything was OK and if he needed help. In my previous experiences, the initial doctor was often a specialist, or retired, or both. They often were relieved to see a hospitalist and happily handed over the care of the airline patient once they heard I’m a hospitalist. Sound familiar from your day job?
This episode was no different: Although pleasant and concerned, the initial doctor was retired, and he made it clear this was outside of his area of expertise. He didn’t exactly sprint back to his seat, but you get the picture.
The patient was pale, looked ill, and was semi-conscious. She was about 70 (later confirmed at 73) and was sitting with her son, who worriedly showed me the auto-blood pressure cuff they had brought with her; it read 81/60. She denied chest pain or shortness of breath. Her pulse was 65, and her breathing was not labored.
For a hospitalist, attending to the ill airline passenger can be quite rewarding. Most diagnoses are those we see every day: syncope/pre-syncope, respiratory, and GI complaints make up more than half of the calls. Death is rare (0.3%), and other “big” decisions, like whether to force the plane to land early (landing a plane still full of fuel or at a smaller airport is not to be taken lightly), are uncommon (7.3%). Still, the illnesses can be real, and more than a quarter of aircraft patients are transported to a hospital upon landing (N Engl J Med. 2013;368(22):2075-2083). Our skills at diagnosis are undoubtedly valuable in the air.
Also, as Dr. Wachter said in his blog on the subject, tending to the ill airline passenger is “one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship. It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.”
We broke open the aircraft medical kit, which was surprisingly well supplied, complete with a manual BP cuff and medications any registered respiratory therapist or code responder would find familiar. Bronchodilators, epinephrine and lidocaine, the usual aspirin, even IV tubing and needles. The one thing I was shocked to find was that there is limited supplemental oxygen: only enough to supply a nasal cannula at 4L max, and that for only a few hours.
As with the vast majority of medical cases, a thorough history of my 73-year-old air traveler proved invaluable. She felt light-headed but never lost consciousness. She had no other symptoms. Her past medical history was significant for hypertension but no heart disease. Was there anything else? She had been discharged from a hospital three days before for severe hypertension. Her ACE inhibitor and beta-blocker doses had been doubled and HCTZ added (her hospitalist had done an excellent job educating her on her disease, her medication changes, and possible side effects).
Anything else? She had been traveling more than 12 hours with little to drink, but she had taken all of her meds just before boarding the flight. After some oral rehydration, leaning back, and elevating her feet, her blood pressure increased to 125/71. I checked on her frequently for the rest of the flight, and she was talking happily to neighbors and her son long before we deplaned. They were en route to Boston, where she was moving and had no doctor, but she had an appointment scheduled with a new one soon. I gave her my card and my cell number and instructed them to call me if there were any problems. She and her son were thankful (and her neighbors were too!), and I was glad to have helped.
The only thing left was the administrative paperwork for the airline. Would I please sign here? What was my license number (they were confused as to whether to take my NPI, my state license number, or DEA number, so I gave them all three), and where was I employed?
After getting home and recovering from my jet lag, I did some research on this topic. Colleagues of mine expressed concern over the legal liability of providing assistance in flight, but, compared to our day jobs, that concern seems to be unwarranted. The Aviation Medical Assistance Act of 1998 (www.gpo.gov) protects healthcare providers who render care in good faith.
As of the 2008 article by Ruskin, no physician providing care for an airline patient had been successfully sued. I learned that the medical kits are fairly well stocked and are set up for the physician/medical professional. I also learned that supplemental oxygen, so ubiquitous in the hospital, is more limited on an airplane. And, I found out that, while airlines contract with ground-based medical services, half of all emergencies are cared for by Good Samaritan doctors, licensed providers, nurses, and EMTs.
So, before my next flight, in addition to packing my iPad and thumb drive, boarding pass, and ID, I plan to pack those reference articles by Ruskin and Peterson.