02 June 2006

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

"But Gee," I can hear you think, "Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory?" Well, yes. But. First of all, there is the performance anxiety thing. I'm used to working with a very small audience. In Economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room -- and I know they are very interested in what's going on. Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

So, on Olympic Air, somewhere over the mid-atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back. Great, I thought to myself, It's an Aortic Aneurysm. (see? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again . . . there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking somone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that. The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell.

As I stood up, I saw an elderly man about ten rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in. Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain.

I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane.

So I sat up in first class with him to keep an eye on him (The Wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be -- probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better.

And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.


  1. Wow, three in one flight. I have done two, but three is a record. My last one was a woman having an MI, and we actually did make an emergency landing. Chest pain?? I mean, really, I'm a pediatrician, somebody call a real doctor!!
    Amazingly, she lived to tell.

    So how was the TRIP???

  2. Very nicely done. I am reminded of a recent post (I'll try to look up the link for you) with a comment on how physicians are often the most effectively and commonly utilized medication themselves. In particular I'm thinking of your panick attack lady.
    Oopah to you, good sir! Hopefully from now on your luggage will be on a priority list and will actually arrive with you...

  3. Wow. In all the flights I've ever taken, I have NEVER heard the call go out for an MD! And you manage to get 4 in two flights! Lucky you!

    Nicely done with Panic Attack Lady!

    Welcome home! What'd ya buy me?!

  4. These are among my worst fears! SO far I have been lucky, but I always dread that call as well. Myabe once the others knew there was a doctor on board, it was "OK" to get sick. So did you actually put the HR of 150 guy on the defib monitor? Was he in SVT? A fib?

  5. Alas, the defibrillator was an "idiot-proof" model which did not have a monitor, so I could not get any useful information off of it. I only kept it handy in case he went out. Fortunately, I did not need it.

  6. Found you on Grand Rounds. Like your stories, look forward to reading you.

  7. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then.

    This made me weepy... it's just what she needed to hear! So sweet. :)

  8. Was a desire to be a hero any part of your decision to enter medicine, or to practice in the ER? I think the desire to be a hero really drove my decision to become a lawyer. And I think that is why I like it so much when people ask me for advice--although I have to be pretty careful not to give any.

    I read your post thinking it must feel pretty awesome to be the special type of person who can rush to the rescue of those in need. Like when you are the one person who can get a baby to stop crying, or figure out a piece of equipment, or say something that comforts another. And the fact that you can do it in a non-hospital setting without a cape seems all the more cool.

  9. I read your post thinking it must feel pretty awesome to be the special type of person who can rush to the rescue of those in need.

    Well, sort of. You see, outside of the ER I feel pretty damn helpless. What can I do without my huge armamentarium of meds and gadgets and of course without all those diagnostic test that we have in the ED? Not much. My CPR is probably better than yours, but that's about it. So during the in-flight emergencies, I felt scared and impotent. It was lucky that the sick guy had his cardiac meds on him, otherwise I wouldn't have been able to do anything except tell the pilot to land ASAP.

    Of course, there are a lot of things I can do. When we were sailing I brought along a substantial med kit, as I knew we were going to be a long way from civilization for a while, and I could reasonably forsee a number of medical problems -- lacerations, sprains and fractures, minor ailments etc. (like, say Sea Urchins in the foot!).

    Was a desire to be a hero any part of your decision to enter medicine, or to practice in the ER?

    Medicine, no, the ER, yes. Not exacttly to be a hero per se, but the adrenaline rush and the feeling of being a "real" doctor, to be sure.

  10. Yes, I did the same sinking thing behind a magazine once when the call for a MD went out on a DC to Denver flight. Until they called for somebody who knows about allergies - I'm an allergist. Little old lady with flushing, tachycardia, nausea and vomiting in 1st class. I was signing out the EPI kit, when a fellow allergist joined me. Bottom line, we noticed she was on Flagyl - and yes, young man, I did have a drink earlier in the flight...a disufiram reaction. We cut her off. Glad I asked first before causing dysrythmia in this senior at 30,000 ft.

  11. Whoa, doggie! You were one busy flying doctor! Unbelievable. It's like once they heard clinic was open, on the way over, they started lining up at the door!

    Excellent job with all four of them. Probably saved that last guy's life. Really. I hear you about feeling insecure outside your well-equipped ER, but look at your clinical skills - you don't need no steeenkin' ER!

    I really appreciate your honesty and eloquence about all the range of your feelings around this.

    (are you a metrosexual by any chance? JK!)

    Well done.

  12. Great stories!. Your descriptions and explanations are great. You sound like several ED docs I work with (I'm an ED RN). Keep up the great blogging.

  13. Duano:

    I had a wise attending who taught me that he only gives epi to allergic reactions when he is reaching for the trach kit because he has failed intubation. So, believe it or not, I have never given epi in 9 years of clinical practice. Of course, there was just an article in AEM which implied that the risks of epi have been way exaggerated, so maybe I have been needlessly gun-shy.

    Though, wow. Two allergists on the same flight. I recall one time that three docs repsonded to a call: one was a radiologist, one a pediatric endocrinologist, and myself. Upon identifying myself as an ER doc, the other two vanished like a fart in the wind.

    dr peg:
    are you a metrosexual by any chance?

    This made me laugh out loud. My wife complains because given the choice, I would wear a gray T-shirt and jeans every day of my life. Until recently, I owned only one pair of non-athletic shoes. Not only have I never had anything waxed, I can barely remember to shave before a shift. No, definitely not a metrosexual.

    I am one damned handsome man, though.

  14. Wow, you just can't make stuff like that up! I wandered over to your blog via Grand Rounds: Good Stuff! I'll most definitely be back.

  15. "... What can I do without my huge armamentarium of meds and gadgets and of course without all those diagnostic test that we have in the ED? Not much.

    On the contrary -- as your own stories demonstrate. The gadgets and tests are useful tools -- but tools don't make a doctor. Knowledge, skills, and empathy do!

  16. Congrats on your transatlantic heroism! I did get a funny feeling reading the story though. I know it must be annoying to be singled out, especially amid the stresses of traveling. And as a non-doctor of course I can only imagine what it's like facing these situations. And I know that with a story like this where you practically need a triage center on the plane, grumbles about bad luck and inconvenience may be exaggerated for stylistic effect. Nevertheless, I can't help but be bothered by the cavalier tone. Put yourself in the shoes of the panicked woman, or the guy too short of breath to speak, and think about how you'd feel if possibly the only person on the plane who can help you is using iPod headphones to drown you out... Yeah, it must suck to be constantly "on call," but doesn't it kind of go with the territory? I always thought people wanted to become doctors because they were passionate about helping people.

  17. Anonymous,

    I wrote about this a few posts ago in this blog and I want you to know that your feelings about this are really shared, and to some degree inevitable. I know the author of this blog very well, and as I said before, knowing him and some of our other doctor friends was at first pretty unnerving. I've seen these people sick, angry, careless, drunk, goofy, mean, etc. At first I had that reaction of, "Are you really going to be handling people's lives and health?!?"

    Then you slowly come to see that their humanity is inevtibale, and even more, a benefit. As the author says in a later post, the divorce of his emotions from the job is survival to him. Would he do a better job were he emptionally invested in every case? That's hard to say, I wouldn't want him responsible for his own child's urgent care -- not that he wouldn't do a fine job applying atiseptic or even setting a broken arm, but if his child were really in serious shape, I couldn't imagine him having the clarity or dispassion he'd need to make the right decisions (necessarily). In the same sense you could argue that a big emotional investment might be counter productive. His job is to keep you alive, not keep you happy (he is an ER doc, obviously this is a different equation for a different kind of doctor).

    Even if we agree that he could do a slightly better job if he were emotionally invested, I would imagine his career would be limited to a few years and burnout. I burned out of a certain aspect of my job that was stressful, and I was dealing with issues costing companies about a million dollars a day -- I can't imagine the burnout potential of a job that could cost individuals the lives of their loved ones.

    So although I know how you feel, and I totally get your perspective, I have to respectfully disagree and continue to hope that doctors as skilled as our author can continue to defend themselves in whatever way possible to get the job done right.

    And he didn't address it, even in his follow up post, but I know him too well, he's not going to fail to answer the call.


  18. "I've seen these people sick, angry, careless, drunk, goofy, mean, etc. At first I had that reaction of, "Are you really going to be handling people's lives and health?!?"

    Matt - Oh so true! Although I am confident in my brother and Carlos' abilities, I had that same reaction in the beginning! :)

  19. Oh my gosh, this is my #1 worst fear since becoming a doctor. You're a better man than me.

  20. I hope you're just kidding about the ipod, because the poor sucker with congestive failure might get stuck with a NICU nurse who wouldn't be able to do anything but whine into the intercom for a physician. Believe me, I'd do it, too.

  21. I don't blame you. I'm a Mom. I wouldn't want to be on vacation away from my "job" and asked to change a diaper, watch a kid, make dinner, etc.

  22. I can relate to what your saying. It's some sort of a Catch-22 when you come to think of it. You're trying to do the right thing, but it gets back at ya'. Despite that, i'm glad you helped all the passengers the way you did.

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