Should There Be a Doctor On-Board?

I boarded the Boeing 767 United Airlines flight at Buenos, Aires, Ministro Pistarini International Airport, Ezeiza, for the 10-and-a-half hour overnight flight to Chicago with a quick layover in Newark. I had been on an extended trip through South America teaching, and it’s been a long trip. I’ve been out of the office too long and will head straight to the clinic when I land at 9:30 am the next morning. My flight plan is to eat a quick dinner and then get some sleep. Soon after I settle in, the flight attendants ask for our drink orders. “An Argentinian Malbec perhaps?” Just some sparkling water with lemon for me please. I know that wine on planes gives me headaches. What I don’t yet know is that this decision will prove impactful over the next four hours. Forty-five minutes into our flight we hit massive turbulence over Northern Argentina. As a thousand-mile frequent flier, I recognized this as uncharacteristically bumpy—enough so that I felt uneasy. The pilot commandingly announced, “Flight attendants take your seats immediately!” Passengers were noticeably uncomfortable and a mist of anxiety blanketed the cabin. I turned off the movie and switched to see the flight tracker in hopes of gaining some insight. I was likely just appeasing myself, as if I could get any information from the digital airplane icon that serves more as a hypnotic video sleep aid. I did notice we were over Paraguay and the plane’s course was zig-zagged rather than straight. Hmm…I’ve never seen that before. It’s a bit concerning, but maybe the captain is weaving the plane around turbulent pockets. I dismiss that rationalization when suddenly the co- captain dashes out of the cockpit and swiftly walks to the back of plane. That is unusual, and only to be further compounded when upon his return he tags the captain who comes out next. The flight attendant call tones sound, and I can see them getting on the phone and talking with seriousness. There is commotion, something is going on.

Then I hear that dreaded announcement: “Is there a doctor on board?”

These words are uttered on an estimated 44,000 flights per year—about one out of every 604.¹ And despite the moral tug of duty, the summoning is rarely welcomed by any of my professional kin. Even my colleagues in Emergency Medicine who are most qualified don’t welcome the responsibility when off-duty. These in-air medical situations are never well-controlled. The monitoring equipment is rudimentary at best and may be faulty.² And at 30,000 feet in a cramped, pressurized cabin where oxygen levels are equivalent to that of an altitude of 5000-8000 feet, even those with normal breathing and lung physiology can expect a 10 percent drop in the their blood oxygen levels.³ And those with chronic illness or who have undergone a recent surgery are at an even greater risk, especially on a longer transoceanic flight when the nearest strip of land may be hours away.⁴ A chaotic, uneasy situation is the norm. Physicians who accept the call are likely to have to act in a capacity different from that of their narrow specialties, and decisions are made without an expert to consult. Yet as takers of the Hippocratic oath, the beckoning transcends.

I hesitate for a few minutes but then decide to push my call button and announce myself as a doctor—the only one on the flight, it would turn out.

I am ushered to the back of the plane where I find an elderly woman in her seat slumped against the window. Clearly, she is in distress and appears to be losing consciousness. She is cold, clammy, and sweaty with labored breathing. The 71-year-old woman who speaks only Spanish is accompanied by her husband, who speaks broken English. He is nervous but unpanicked. I immediately recommend we get her out of her seat and lay her flat. A row of five middle seats is cleared, and with the help of three flight attendants we carry her listless body to the seats. I call for oxygen, which is put on her immediately by one of the flight attendants while I try to get a sense of her medical history. I am told by her husband that she started to feel sick, weak, and foggy soon after eating and during the turbulence. She told him she was going to faint. I asked about medicines she takes or other medical conditions. She has high blood pressure but he becomes unnerved trying to recall the name of the medicine she takes. She also took a metformin pill (a drug for non-insulin dependent diabetics) just prior to the flight, although he says she is not diabetic. “Anything else?” I ask. “No,” says the husband who is now leaning at her side caressing her face. She denies pain and any difficulty breathing.

The attendants are eager to help but in a clumsy way as they don’t really know what to do. One of them heads to the back to retrieve the medical “crash kit.” Many of the passengers now out of their seats are gathering around, some to see what is going on, others to try and be helpful. Most can’t do much, and the flight purser makes an announcement for them to clear the area. Not to mention the seat belt sign is still illuminated, as we are still experiencing massive turbulence. Funny how the turbulence,is no longer bothersome. A crisis has an interesting way of reducing a prior anxiety-provoking event to nothing more than a petty nuisance. The fastidious attendant brings me the medical kit while. Another brings me an AED. It’s at this moment that I wish I had paid more attention during my last biannual Advance Cardiac Life Support studies and exam, a previously seemingly useless requisite that is mandated for university staff privileges. I open up the kit and survey what is available. I take out some of the contents and lay them on the patient’s mid-section as there is not a lot of room to work. “Okay, there is an amp of epi, lidocaine, and atropine if there is a cardiac event,” I think to myself. I see glucose, blood sugar monitors, IV set up with two 500cc bags of normal saline, a stethoscope, and a host of other drugs from diphenhydramine to Lasix to promethazine.

As a plastic surgeon specializing in cosmetic surgery, I use few if any of these medicines and equipment, and it has been 20 years since I staffed an Emergency Room. A lot has changed. Regardless, I have declared myself in charge and have to act.

I give the kit back to the flight attendant who is in the row behind us handing me equipment. I ask for a blood pressure cuff and a pulse oximeter so I can get a sense of the ailing passenger’s vitals. I also ask for a glucose tab. The assisting attendant is confused. She doesn’t know what that is and it is not listed on the kit’s package insert. I ask for orange juice instead, but the reclined patient says she is too nauseated. Shen then she darts up and starts vomiting profusely. Fortunately, I get a bag to her mouth quickly enough to capture it. I look at it and see no blood. Okay, that’s a good sign. The lady slowly reclines and in the cramped space with all her movements the materials from the kit that I had pulled out are falling below and in between the seats. I manage to get a blood pressure: 109 over 67. Her heart rate is 88, and her respirations 12. I can’t get the temperature probe to work but she doesn’t appear febrile. I can’t find the pulse ox device, but eventually one of the attendants does place it on her left index finger, she is saturating at 92 percent with oxygen. I want to get her blood sugar levels, but I struggle to figure out how to use the monitor contained within the kit. I prick the patient’s fourth finger on her right hand twice and draw a little blood on to the monitor strip. Frustratingly, I can’t get a reading. Finally, a girl with brown eyes and long brown hair, wearing a red sweater ,and who couldn’t have been more than 14-years-old was at the right place at the right time. She was kneeling on the row of seats just in front of me, peering over cautiously. She has a diabetic family member and knew better than me how to use the monitor. She showed me. Her help proved instrumental. I was thankful. She was even more so, and I could tell she was happy to help and was greatly empowered to make a difference. It may have been one of those pivotal moments that sets a wide-open fertile mind into a career in medicine.

The flight’s purser appears, saying the captain would like an update on the patient. He is also trying to make contact with Medlink, as the protocol calls for a doctor consultant on the ground to make all the critical decisions based on what the doctor or volunteer medical provider in the air says. I report the vital signs to the attendant and mention I am still trying to make an assessment of the cause of the illness. Then the lady clonically jerks up and starts projectile vomiting on me and the surrounding seats. I now realize I need to start an IV and get her fluids. I ask for assistance as I struggle to get all the equipment and place it nearby me. I crouch down on the floor and attempt to maneuver within the allowed 31 inches between the economy seats. I find a large bore 18 gauge and a smaller 22g IV needle and catheter. I know that the 18g is better, but positioning is not great for insertion at the antecubital fossa. A vein in the woman’s right hand seems more ideal, so I decide to go with the smaller 22g needle.

Of course, I can’t find a tourniquet, so I use a glove to restrict the back blood flow, expanding the vessel lumen and allowing easier access. I ask one of the passengers to hold the IV tubing, an attendant to hold the IV bag, and request that another get tape and find an alcohol pad. Amazing how something so simple to do in a space where it is set up to be done, like putting in an IV in a pre-operative area, can be so difficult in a cramped space with no set up. How I wished I had a cart with supplies, lighting, a mayo stand and IV pole, not to mention a sharps box. I also need my glasses so I ask another attendant to get them from my bag. “Where is your bag she asks?” “At my seat in the overhead bin.” I respond. The other flight attendant hands me an alcohol pad and I pull the 22g IV catheter out of my pocket, unpackage it, stabilize the woman’s wrist and insert the IV needle. It goes in perfectly on the first stick. Thank goodness! I hook the tubing and a 500cc bag of normal saline and open it up wide. But before I can tape down securing the IV, the woman sits up again and starts to vomit. I hold my hand on the IV and do not allow her to use her right arm and hand as she keeps trying to cover her mouth. The lady who was sitting next to her volunteers helpful information mentioning seeing our distressed patient drink a beer before she got on the plane. Hmm..okay this is good information. Maybe we have something gastrointestinal and not cardiac or respiratory related. The captain comes by and asks me for a status report. He asks me if we should divert or keep going. He adds that we are over Bolivia and can’t land there and that terrible storms are hovering over Colombia, so next option may be to land in Caracas, Venezuela. Of course, that is not at all ideal and comes with a lot of complications. After Venezuela the next potential stop would be Miami but that is not for another three hours. He mentions he was unsuccessful at getting in touch with Medlink consultants, and it is my call whether or not we land. He then tells me I have just a few minutes to decide. The mesmerized teenager in red is looking at me, as is the husband, the flight attendants, and just about every other on-looking passenger. They are waiting to hear my response.

I look at the patient, I look at the captain. Time stops.

I am in my own head now and nobody else is there with me. My decision will affect all 350 passengers, and perhaps others waiting for this plane to land in Newark. If I decide to tell him to divert to Venezuela and land, what does that mean to the airline and to all these passengers? The cost and inconvenience would be enormous, plus any political or logistic difficulties, I would think. If we go forward toward North America and I am overlooking the early stages of a major event like a pulmonary embolism or cardiac ischemia, I would never forgive myself. Plus, I’d be inserting myself into a difficult medical situation to try to manage. Not to mention a potential liability even though the captain is quick to let me know it is not my liability and that Medlink makes the decision. But at the same time, he mentions not being able to get a hold of Medlink. For now it is my call, and at this moment in time, this lady’s health comes first.

I assess her quickly. She seems stable. Her vitals are good. I have IV access, and the fluids clearly are perking her up. I suggest we keep going, figuring she is better off being treated in Miami than Caracas. Besides, who knows what kind of international surprises would wait for us in Venezuela, a city that United Airlines no longer flies to because of safety issues. I now realize for the next three hours I will be the one taking responsibility for her. The captain says, “Carry on,” and returns to the cockpit. I continue to monitor the patient, start a second bag of saline.

I have a moment to talk to her husband who tells me their story. They are from Buenos Aires but have two grandchildren in New York. Sadly, their 7-year-old granddaughter has recurrent kidney cancer and is being treated at Sloan Kettering Hospital in New York. My heart is broken. Are they on their way to say good-bye to their granddaughter? I can’t even imagine the emotional toll. My somber pause is abruptly interrupted by an attendant who says they got a hold of Medlink and they are requesting my credentials and medical license number. At first, I can’t remember my license number or the last time I was asked for it, but somehow after a few minutes of dusting off my mental rolodex I remembered it!

It now appears we are past Venezuela and heading for the east coast of the US. Ninety minutes since the crisis started and the passenger has had 1 liter of saline, is no longer vomiting, and looks better. Things are stable, passengers return to their seats, and the attendants turn off the lights so others can sleep. I stay at the patient’s side. I don’t feel comfortable leaving her just yet. She still has an IV in her hand and her pressure is better but still a bit low. I decide to give her another 500cc of fluid and it is clearly helping. I finish up hearing more stories from the patient’s husband and the rotating flight attendant assigned to assist me. Two hours later, three and a half hours since I announced myself as a doctor, she is clearly better. I remove her IV and the monitoring equipment, bandage her hand, and then head to the lavatory to wash the dried vomit off my arms and sweater. I head back to my seat, clearly not going to sleep.

With a little under five hours left in the flight, I feel responsible for the passenger’s well-being. The grateful flight attendants keep coming up, thanking me, and asking me if they can do anything for me. Some water is all I request.

The flight’s purser mentions to me that as a token of the airline’s gratitude, he is authorized to give me 7,500 miles or a $150 voucher to use toward a flight. Which would I like? “Really!?” I think to myself. The attendant is visibly embarrassed making me the offer, as he too realizes it’s disproportionately absurd. I of course didn’t respond to the call for monetary gain, however, their offer is insulting. If they offered nothing instead it would be more gracious. Their meaningless hand-out perhaps provides insight into how the airlines feel about the medical profession. If I had made a recommendation to divert the flight and land elsewhere what would that have cost the airline? One study estimates upwards of $300-$900,000.^5,6 What if I wasn’t on the flight? Likely, they would have landed earlier and inconvenienced hundreds if not thousands of people, including one very dehydrated, physically sick, elderly woman with which to contend.

On flight 954 from EZE to EWR, I accepted that responsibility. Yes, was tugged by an ethical call to duty, and it necessitated I remain focused and taut the entire flight. And fortunately, all turned out well. However, it could have easily gone in a different direction, perhaps leading to a devastating outcome for one family and a public relations/financial morass for the airline. The least you would think the airline could offer is a flight to a destination comparable to what was purchased. I can’t imagine that would significantly impact their bottom line negatively. I told the attendant thank you and the airline for the miles and the voucher offer, feel free to choose for me, either is irrelevant.

I wonder if the airline industry hubris may be short sighted. Considering that the number of passengers and transoceanic flights are increasing there are certain to be more in-air medical emergencies.⁷ A well-cited study found that 52 percent of the time an in-air medical emergency is announced a doctor is not on the flight or at least does not respond. Five to 25 percent of the time a nurse responds, 45 percent of the time it is a flight attendant alone.^1,6,8 Even if there is a doctor on-board, chances are he or she would be acting far outside their scope of expertise or perhaps may have clouded judgment after a glass of wine. Do we really want a compromised or less than ideal medical professional taking ownership of the situation? US doctors are not required to respond to such calls, by the way, whereas in other countries they may be legally obligated.⁹ However, the volunteer physicians who feel a sense of responsibility and accept the call to duty are being asked to make life and death judgment calls under poorly controlled situations.

Passengers are not required to disclose recent medical history when booking a flight but any of the following conditions may put a passenger at greater risk especially if on a long transoceanic flight when the nearest stop could be hours away.¹⁰

1. Recent post-intracranial or abdominal surgery within 14 days,

2. Recent chest or pulmonary surgery within 14 days

3. Pneumothorax 21 days before flight; 7–14 days allowed with medical escort

4. Any ear, nose, and throat procedure within the preceding 14 days

5. Cerebrovascular accident within the preceding 10 days

6. Acute psychotic mental illness

7. Gestation >36 weeks (<4 hours in flight); 32 weeks with twins

8. Post-delivery within the previous 7 days

9. Neonates under 1 week of age

10. Myocardial infarction within the previous 10 days

11. Unstable angina

12. Cardiac surgery within the previous 14 days (coronary artery bypass grafting)

13. Uncontrolled daytime epilepsy

14. Acutely infectious or communicable disease

15. Decompression syndrome 3–7 days before flight

They are clearly sacrificing the remainder of their flight, will likely be tired the next day, inevitably impacting their clinical schedules. And pledged physicians can’t help but to consider the looming liability. Although according to the 1998 Aviation Medical Assistance Act, a Good Samaritan provision protects passengers who offer medical assistance from liability, including doctors unless found to be acting with gross negligence or willful misconduct.¹ And while fatalities from medical emergencies are rare—36 out of 10,0001—it is meaningful if you or a loved one is one of the 36.

Maybe it is time to consider placing trained emergency health care professionals on long flights? Perhaps with the increasing number of airline travelers as well as an increased population of those living with chronic illness compounded by the addition of multiple transoceanic flights and the potential cost to diverting a flight such an initiative makes economic and fiduciary sense?

I sat back in my seat and clicked on the flight tracker. Four more hours to go, maybe, I’ll catch a movie. Just prior to touchdown in Newark I check on the patient one last time. She is pink, perky and has clearly improved. She is very thankful, as is her husband, who invites me to their house for carne asada. He says he is the best at making it. I graciously smile, knowing I’ll never see them again. But I am happy that I could have been part of their life in a positive way, even if so briefly. I realize while I may be a bit tired tomorrow, they will be met with much greater difficulties, their ailing granddaughter. I wish them well. As I disembark, I am thanked by many of the passengers including the teenage girl in red who looks at me with awe in her eyes. I head quickly for my connecting flight thankful that I have the skills and knowledge that allow me to help another when they need it most. There is no amount of award miles that could ever match that.

1. Peterson, DC et. al. Outcomes of Medical Emergencies on Commercial Airline Flights. N Engl J Med. 2013 May 30; 368(22): 2075–2083

2. Ruskin KJ, Hernandez KA, Barash PG. Management of in-flight medical emergencies. Anesthesiology 2008;108:749-55.

3. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med 2002;346:1067-73.

4. Shepherd B, Macpherson D, Edwards CM. In-flight emergencies: playing The Good Samaritan. J R Soc Med 2006;99:628-31

5. Kesapli M, Akyol C, Gungor F, et al. Inflight emergencies during eurasian flights. J Travel Med 2015;22:361-7.

6. Peterson, DC et. al. Outcomes of Medical Emergencies on Commercial Airline Flights. N Engl J Med. 2013 May 30; 368(22): 2075–2083

8. https://www.nytimes.com/2018/04/27/travel/american-airlines-brittany-oswell-death.html

9. David Kodama MD et. al. “Is there a doctor on board?”: Practical recommendations for managing in-flight medical emergencies. CMAJ 2018 February 26;190:E217-22

10. Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet. 2009;373(9680):2067–2077.

11. Ruskin KJ, Hernandez KA, Barash PG. Management of in-flight medical emergencies. Anesthesiology 2008;108:749-55.

12. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med 2002;346:1067-73.

13. Shepherd B, Macpherson D, Edwards CM. In-flight emergencies: playing The Good Samaritan. J R Soc Med 2006;99:628-31

14. Kesapli M, Akyol C, Gungor F, et al. Inflight emergencies during eurasian flights. J Travel Med 2015;22:361-7.

15. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

16 Verjee M. et al. Medical issues in flight and updating the emergency medical kit Open Access Emergency Medicine 2018:10 47–51