Is there a doctor on board?

November 11, 2014

Dr. Afshar recounts an experience with assisting a patient with a medical emergency while on a transatlantic flight.

 

Inbox: “0 unread messages.” EMR in-basket: “0.” The 24-hour-call before vacation had been quite productive: emails were responded to, charts were completed, and phone calls made. The service was running smoothly and as such, sign-out was brief. Vacation was at my fingertips. I would plan on going straight to the airport. My backpack was already in the trunk. I would not dare waste a minute and had anticipated my standard back-seat wardrobe-changing routine and light, no-check-in bag.

Six hours into our transatlantic flight, deep in REM sleep, with no worry but a week of agenda-less frolicking, I thought I heard my pager. Impossible. I did not have one on. Again, there it was: “Attention, ladies and gentlemen, please identify yourself if you are a physician,” I heard on the overhead speaker.

Back in row 47, where I was wedged in a non-reclining middle seat (tough luck when you check in 40 minutes before the flight), I stood up to scour the aisles, hoping somebody would respond. Nothing. Please let there be an internist on board, I thought to myself. Could I be lucky enough for a precipitous delivery? Nope. I started running codes in my head and imagining trauma-level hypothetical situations. I hoped treatment algorithms were stored somewhere in my brain. A-B-Cs, I reminded myself, ACLS, chest pain, an approach to aortic dissections. Please no. I walked to where the flight attendant was standing and thought to myself, “Ob/gyn residency sure does lack in general medicine training.” No time to think about my desire to revamp medical education now. I began visualizing the pages out of Pocket Medicine as a shower of horrific situations went through my head. The flight attendant smiled and I identified myself as an ob/gyn resident physician who might be able to give a hand.

In seat 5A, I met my patient. He* was a lovely 68-year-old gentleman who had become light-headed and felt like he was going to pass out when coming back from the restroom.

According to the International Civil Aviation Organization (ICAO), there are 2.75 billion airline passengers annually worldwide and that number continues to increase. During those flights, there are 11,920 in-flight medical emergencies-one medical emergency per 604 flights or 44,000 medical emergencies annually.1 Luckily for us ob/gyns and our patients, in-flight obstetrical emergencies are rare, confirming that air travel is safe during pregnancy, generally until about 36 weeks’ gestation.2

 

 

* The last time I had a male patient was medical school. The physiology should be the same, right?

 

A large, prospective study published in May 2013 in the New England Journal of Medicine characterized these in-flight emergencies over a 3-year period and demonstrated that physician passengers provide medical assistance in 48.1% of these cases and air-flight diversion happens in only 7.3% of these cases.1 The most common in-flight emergencies are syncope (37%), respiratory symptoms (12%), and nausea or vomiting (9.5%). The good news is that these are complaints that any physician, of any specialty, should generally be able to deal with.

While I was taking his history, my patient realized that he had accidently tripled his dose of diuretic that morning. He confused his “little pills.” This turned out to be a simple case of orthostatic hypotension. His vitals improved with volume repletion and saltines. I sure can say, that was the only time I have placed intravenous access in somebody while over 35,000 feet above the ocean. Obviously, he did fine.

When we got out of the plane at Charles de Gaulle, we were met by an on-ground medical team (which I learned is the standard of care for any non-diverted in-flight emergency). As my co-passenger (now patient) went off with the medical team, he smiled and gave me a hearty hug, saying, “Merci, médecin.” I really had not done much, but I told him it was a pleasure and a privilege. I also let him know that I usually spend my days taking care of women as an ob/gyn. He laughed and said, “Don’t forget, we’re all just humans anyway.” His words stuck with me.

As physicians in training, we feel invincible and the thought of medical liability while helping this gentleman never crossed my mind. It turns out, just remembering the lifelong commitment to the health of others around you and the basis of the Hippocratic oath usually keeps you safe. In 1998, the Aviation Medical Assistance Act included a Good Samaritan provision, a protection for passengers who offer in-flight medical assistance. This provision protects us from liability, except in cases of gross negligence and willful misconduct.

I’d say day one of my vacation was a perfect start. Luckily for my patient, he was not very sick and did fine. Luckily for me, I got another beautiful life lesson that reminded me that medicine is a way of life, not a job. Medicine is an endless commitment to learning and a call for duty. Medicine is humanism, whether on the ground or in the air.

 

References

1. Peterson DC, et al. Outcomes of medical emergencies on commercial airline flights.New Engl J Med. 2013;368(22):2075–2083.

2. Air travel during pregnancy. ACOG Committee Opinion Number 443, October 2009.