Is There a Doctor on Board?
It finally happened - twice. Plus I share some practical tips for in-flight emergencies
“Is there a doctor on board?” — for those in the medical profession, this is a phrase that, not unlike death and taxes, is inevitable. It’s just a matter of when.
As a medical student, I often imagined how this would go — would I be the only doctor on the flight? Would I have to ground the plane because someone was having a heart attack? Would I have to do a needle decompression for a tension pneumothorax, which I diagnosed using only the most rudimentary of instruments, thus becoming an in-flight star?
Arrogant and self-important, maybe. But we all have our fantasies in which we are the hero.
Then I graduated from medical school, becoming an actual physician with a two extra letters to follow my name. And ever since then, I’ve been dreading it. While many physicians are concerned about the liability aspect, I have to confess that this has hardly crossed my mind. I’m more terrified that I won’t know what’s wrong, or how to fix it, and I’ll have to give up the right to my medical license (metaphorically, of course).
And then it happened twice in the span of two months.
Earlier this summer, I was on a flight to my best friend’s wedding, when I heard overhead (in Spanish) something that sounded like “medico” — I turned to the passenger to my right, hoping he spoke Spanish and would offer to translate. He confirmed what I had guessed from the pit in my stomach. Immediately a swarm of scenarios started running through my mind, and as I got out of my seat and started walking down the aisle, I had to think about how to take a history, reminding myself of basic symptoms and diagnostic tools as if I had never been to medical school.
I was in luck — an anesthesiologist and family medicine doctor were already at the patient’s side. Though I stayed in case my help was needed, I sighed in relief and mentally relaxed. There were grown-ups here. I wasn’t alone.
Luckily, the man’s condition wasn’t life-threatening, but he was in a lot of pain, which we unfortunately couldn’t address for hours due to how disorganized the communication was with the flight crew, and the lack of English-language medication packaging (which is a whole other story, for another time).
By this time in my journey, I had already been through one part of a disastrous travel day: a traffic-riddled ride to the airport, two separate waits in a security line (the TSA precheck sticker on my boarding pass “wasn’t valid”), and a take-off delayed by 2 hours, making me guaranteed to miss my connecting flight. And, to nobody’s surprise, staff and other passengers in JFK aren’t exactly polite. Airline staff and security personnel sassed me. Fellow passengers ignored me (for the record, I ignored them too).
As so many others do while flying, I felt subhuman by the time the overhead announcement aired.
But suddenly, as I walked back to my seat after helping the patient, it was as if I had entered a different world. People were looking at me, not through me. They watched me walk by with reverence, not disdain. Flight attendants thanked me profusely for what I saw as nothing, simply my duty. Strangers turned to me and asked with a smile, “Is everything okay? What happened?”
I smiled back. “He’ll be okay,” I said simply, reluctant to disclose patient information even 40,000 feet up in the sky.
What would the world be like if we all showed this kindness and respect to everyone, all the time? Particularly in moments of weakness, exhaustion, and frustration?
Because in a weird way, despite the frustrating experience I had just been through, helping someone and dusting off my rusty diagnostic skills actually made me feel better. Turns out, helping others puts you in a better mood.1
And then, barely a month later, it happened again. There must be something in the air this summer (both flights were red-eyes — is there some kind of correlation with flying time and in-flight emergencies?)
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On my way to a surgical conference, at nearly one in the morning, as I was listening to a podcast and trying to drift off to sleep, I heard an announcement overhead requesting a doctor. Barely did I have time to take out my noise-cancelling headphones and look around for a flight attendant when I saw a woman a few rows in front of me jump out of her seat, leap over her fellow passengers, and bound to the back of the plane.
I stared, looked back, and hastened to put my things away so I could get up.
Is there something wrong with my reaction time? Why was I so slow to respond? I reflexively reprimanded myself.
But no — never run to a code. The first pulse to take in an emergency is your own — I reassured myself.
But it still took me some time to orient myself. A woman had passed out in the aisle of the plane. Rather than think syncope and work down my differential diagnosis, I was immediately called back to a time that I myself fainted on a flight as a teenager. The flight attendant gave me water and a chocolate bar, and slowly brought to my feet. It was just dehydration, probably a vasovagal reaction brought on by my trip to the bathroom.
This woman was probably just dehydrated, too, I thought. She was groggy, but talking, which calmed some of my nerves. Awake and oriented. Maybe not alert, but she would come to.
The woman who had jumped out of her seat was taking charge, asking for a stethoscope and blood pressure cuff (which, if I’m being honest, I hadn’t immediately thought to request) — I learned later that she was a family medicine doctor, and I was happy for her to take the lead.
The patient’s heart rate and blood pressure were fine, but then her oxygen saturation was in the mid 80s. My dehydration hypothesis was debunked by that. Why would her O2 sat be low? I asked myself.
“Does she have any lung conditions, like asthma? Does she smoke?” I asked her companion, racking my brain for reasons why the O2 sat would fall below 90%.
She said no to both, and I was stumped.
“Why is her oxygen low?” the flight attendant asked the family medicine doctor.
“It’s probably due to the altitude, let’s just give her some supplemental oxygen.”
Oh. Of course, I thought, immediately accepting the other physician’s authority. No, not of course — a second later I wondered if she was right. I have no idea how altitude impacts vitals, but I didn’t know why the oxygen saturation would drop so low in a healthy person. I made a mental note to look it up.2
The flight attendant got on the phone with the pilot and I heard her say, “yeah, the nurses here say she’ll be okay. They don’t think we need to ground the plane.”
Even here, after responding to a request for a doctor on board, I was assumed to be a nurse. I stifled the urge to roll my eyes.
We stayed by the patient’s side for some time and made sure her O2 saturation recovered. There was no glucometer on board, so I asked her to drink juice just in case.
All’s well that ends well, I thought, though I had gotten no sleep during that four hour red-eye and I had to present at a conference the next day. Oh well, I thought, I’ve done more on less sleep.
But in both instances, it could have been much, much worse.
I’m still not sure that I could adequately respond to an in-flight emergency — a true emergency. It is bound to happen again, I know, and I’m not sure how to be better prepared.
Can I familiarize myself with on-board equipment? Not really. Turns out, the medical kits widely vary airline to airline, and are even less standardized on international airlines.3
Can I practice taking a history and physical in an unknown situation? Perhaps, but I have lost some of these muscles as a surgical resident, now only taking focused histories and physicals in pre-specified situations (rule out cholecystitis, cold leg in a vasculopath, consult for a trach in a bedbound ICU patient).
Can I carry basic medications with me? Yes — I often do. Though aspirin and Tylenol won’t do much in a true emergency.
Like most situations in life, I don’t think there’s a magic button. For the most part, I’ll just have to trust my instincts, get into medical mode as quickly as possible, and pray that there’s a more grown-up doctor on board.
Practical Information for Medical Professionals Confronted with Flight Emergencies:
While one can’t predict what might happen in an in-flight emergency, it never hurts to be prepared. Just like Hermione when confronted with an unfamiliar situation, I hit the (online) stacks to find out more.
First, a disclaimer — I have no specific training in occupational or aerospace medicine, nor do I have any expertise on in-flight emergencies. Nothing I say in this post should be construed as medical advice. Below are simply some resources and information for healthcare professionals that might help in an emergency situation.
One study of commercial flights in North America over a two-year period found that in-flight emergencies occur approximately once per 604 flights.
This same study also found that the most common problems were: syncope or presyncope (37.4% of cases), respiratory symptoms (12.1%), and nausea or vomiting (9.5%).
Aircraft cabins are pressurized to maintain an effective altitude of 8,000 feet. The flow rate of supplemental oxygen on board is between 4 and 8L/min — for more details on pressurization, humidity, infection disease spread, and oxygen availability, see The Aircraft Cabin Environment in Travel Medicine.
At 8,000 feet, the partial pressure of oxygen is 108mmHg, compared to 148mmHg at sea level. This is equivalent to breathing 15.1% oxygen at sea level, resulting in most healthy passengers having a lowered oxygen saturation of 90-93% — from The effect of high altitude commercial air travel on oxygen saturation in Anaesthesia
The most common etiology for in-flight syncope is orthostatic vasovagal hypotension. It is especially pronounced in patients with underlying autonomic dysfunction including diabetes, alcoholism, and in the setting of beta-blocker and benzodiazepine usage. — Demystifying airline syncope in World Journal of Cardiology
Pediatric patients make up 9.3% of in-flight emergencies. In children, the most common issues were found to be infectious (27%), neurological (15%), and respiratory (13%) — in A Systematic Review of Pediatric and Adult In-Flight Medical Emergencies in International Journal of Pediatrics
Given that air within the cabin is at a lower pressure than air at sea level, volume expansion of closed gas-containing compartments in the body can occur. Expand volumes of air in the paranasal and frontal sinuses, and Eustachian tube can cause ear pain; however, this can also occur in other body spaces. As a result, travel should be delayed after procedures or surgery, including colonoscopies (at least 24 hours), neurosurgical interventions (one week), major abdominal surgery (at least ten days) — Is There a Doctor Onboard? Medical Emergencies at 40,000 Feet in Emergency Medicine Clinics of North America
Further reading: In-flight Medical Emergencies in American Family Physician
Previous Essays in Brief Op Notes
When Heuristics Cause Harm
Light sarcasm. Of course I know this, but it can be easy to forget.
It turns out that a normal oxygen saturation at an altitude of 8,000 feet is about 90%. Airplane cabins are pressurized, so the cabin air composition at 40,000 feet ends up being the same as a regular altitude of 5,000-8,000 feet. Domestic flights rarely fly this high. So my doubts were not unfounded — the altitude alone should not have caused a healthy person’s saturation to drop to 86%. However: this particular patient had been drinking, which likely impaired the breathing reflexes that would have compensated for this change in atmospheric pressure.
In the United States, the Federal Aviation Association mandates certain medications and equipment be kept on board. Click here for more information.