“If there is any medical doctor on board, please make yourself known to cabin crew as soon as possible.”
I knew this day would come. Three years from graduation with an MBBS behind my name and many flights later, I have heard of many heroic and horror stories of flight emergencies. Fortunately, I had never once encountered them personally. Now, 13 hours from the John F. Kennedy airport and barely 3 hours till my transit destination, the time had come. I had mentally prepared for it before, the
NEJM review paper was pretty helpful. Still, that did not stop the thought of sliding low into my chair and disappearing into thin air from popping up in my mind. I stopped my movie (No Reservations, great show), and hesitated.
“I haven't practiced for 5 months. Am I covered by practicing insurance? What can I possibly do on an aircraft? What if I do something wrong?”
Also, of all the flights in my life, I had opted to wear pyjamas (track pants) on one of the longest flights I've ever taken. No one is going to believe I'm a doctor in this attire! I thought. Excuses, one after another.
After about 30 seconds, I knew that if I didn't respond, I would live to regret it for the rest of my life. I unbuckled my seat belt and stood up, shuffling slowly to the aircraft galley to look for some crew, but there was no one there. Looking around, everyone seemed to be hurrying towards an elderly Chinese gentleman some 10 rows behind me in the next seating section. Cabin crew of higher authority were gathered (could tell from their more distinguished uniform). There were another two gentlemen there as well, probably doctors who were more prompt in identifying themselves as medical doctors.
I walked gingerly along the dark aisle towards the commotion.
“Did anyone page for a doctor?” I asked one of the senior stewardesses.
“Oh there is one already there attending to the patient. You are...?”
“I'm also a doctor. Alright, if you need additional assistance please let me know. I'm seated at 45G.” The stewardess took down my seat number.
Heng ah, I thought to myself, walking away. No point crowding around an already very congested walkway with two doctors readily available. Looking back at the commotion again, one of the two doctors had a stethoscope swung around his next. Well prepared, I thought. The other Asian doctor in a neat collared shirt and pants was sort of hovering around, not doing much. They both looked far older than me.
“They probably have more than enough years of experience, hands and brains”, I thought. As I comfortably settled myself back into my movie, I saw them wheeling the patient from his chair to one of the cabin stowaway areas. He looked pale, dazed and didn't seem to be responding.
The patient looked bad, definitely failing the Eyeball Test.
Then I overheard a crew member say,
“We are moving him to the back, so we can do CPR there if necessary.”
I said a prayer for the gentleman.
10 minutes later, another announcement was made.
“Would ALL medical doctors or nurses please identify yourself to the cabin crew as soon as possible.”
This announcement was different. There was a heightened tone, a sense of panic, and clearly a call of distress.
With no hesitation this time, I walked briskly to the galley again. There, I met the two doctors who had been attending to the patient so far.
There, the patient lay on the floor with a pillow supporting his head. He looked Bad. The older doctor (whom I later got to know as Dr K) had been in charge of the medical decisions thus far, communicating with ground medical staff. The Asian doctor was still standing by the side, looking rather helpless.
“Are you a doctor? What is your background?” Asked the Asian doctor.
“Internal Medicine, Singapore.” I replied.
“Great! I'm an eye doctor. You're the right doctor to be here now!”
(That was the last I saw of him)
On hearing about my internist background, Dr K looked thoroughly relieved, although I repeated emphasized resident in training. He was a pediatrician by specialty training, but has been in public health research, with minimal clinical practice, for the past 25 years! It was then that I noticed that the stethoscope swung around his neck was a pediatric stethoscope :p
He gave me a brief description of the patient and all the information that he had gathered so far. He had been having ?chest pain for an indeterminate amount of time prior to calling for assistance. By now, the patient's femoral pulses were still present, but he was not responsive to calling, and his peripheral pulses were weak if not absent. He was cold and clammy. Dr K could not get a blood pressure reading. Shock. Could be MI, PE, sepsis?
Whatever it was, all I had was saline anyway and he had definitely come to a point where IV access was required. Dr K clearly was not confident in doing so. He was ready to handover leading the resuscitation to me.
“Uncle uncle! Can you hear me?!” E4V1M4. Rapid shallow breathing. Unresponsive to calling. JVP not elevated. Pupils reactive to light. Lungs clear. Heart sounds regular. Cold peripheries. Absent radial pulse. Femoral pulse strong. Cholecytostomy tube in situ, draining bilious fluid. Abdomen soft.
Time to get IV access.
Among the minimalist equipment that was available, we had
ONE precious green plug and 1 pediatric IV plug. It looked unfamiliar, but I calmed my nerves as I swabbed the left cubital fossa with one of two precious alcohol swabs. How different can an IV get? Dr K had primed the IV line. All I needed to do was to get the line in. I only had one plug.
Boom. There was some flashback, and I threaded the cannula in gingerly. Thank God. Taping it down with primitive micropore tape, we ran the fluids, fast. There were only 2 pints of normal saline on board, nothing more.
“Oxygen, can we get some oxygen please.” I asked.
There were about 6 cabin crew, 2 doctors and lots of confusion. Things were flying around. Some were fixated on the AED as it threatened to shock a patient with a pulse (Everyone please note that the AED will almost certainly read VF given the moving nature of the aircraft!!). Others helped to make sure IV access didn't fall out. Another promptly gave me what I had asked for (gloves, torch, sharps box, oxygen, stethoscope) while another recorded the vitals and events.
I took the blood pressure. 130/80. The pulse oximeter read SpO2 95% on 100% oxygen and HR 48. Dicey. Don't collapse on me, please...
Dr K conversed with ground medical support over the phone. He had requested for an emergency landing, and it was wise to have called for one early. Instead of Hong Kong, we were to land in Beijing in 15 minutes.
Slowly but surely, the patient seemed to improve. I felt his radial pulses return. He became deliriously agitated, struggling with our restraints. Groaning incomprehensible sounds. E3V2M5, needing three men to hold him down.
The captain of the flight came by, spoke with ground staff and briefed the crew. Only two doctors to stay with the patient during landing. All others to return to their seats and fasten their seat belts.
So there we were on a rapid descent, my ears popping like nobody's business, Dr K and myself, drip running with the man appearing to be awakening. We were told to keep low on landing to minimize the impact on hitting the ground. I sat on the floor in the galley curled up just holding his arm straight to make sure the IV didn’t kink. With nothing else left to do, we had a little chat. Turned out that Dr K is a renowned Public Health Professor at the London School of Tropical Medicine and Hygiene, and also holds a professorship with the Royal Children's Hospital in Melbourne. On discovering my interest in infectious diseases and Public Health, he offered assistance with any application to the London School.
The landing could not have been better, pilot did a great job. The second pint of NaCl 0.9% ran out as we taxied on the tarmac. In minutes, paramedics arrived. Then came the next challenge.
“Doctor, can you speak Chinese?”
“Errrrr, a little...” I rehearsed what I needed to say in my head over and over.
In my terribly broken Mandarin, I recounted the history and events on board. They certainly gave me some puzzled looks in between but the message eventually got across. We helped to change the IV drip and bundled the man up in a down blanket. Dr K helped with the transfer off the plane. This was followed by some paper work and the man was scooted off to the hospital.
It was snowing in Beijing.
All of the above sounds rather heroic indeed, but all I really did was to set an IV plug and ask for some oxygen. Dr K had made all the critical decisions to move the patient and to land emergently in Beijing. I was but a small fry in the grand scheme of things. Nonetheless, I'd admit that the feeling of having contributed a little is pretty satisfying.
Cathay staff were thoroughly grateful, almost to the extent of making me feel bad. They put us in first class for the next leg of the flight and gave us duty free vouchers to use. The flight manager and captain came personally to thank us for our help.
Both Dr K and I missed our connecting flights, so he invited me to join him in the business class lounge in HK for the time being (still in my terrible pyjamas btw). We chatted about his many previous in-flight emergency experiences and this being the sickest he’s ever had to deal with. We also discussed his work in pneumococcal disease and vaccines, and the many hats he wears as he works with WHO, UNICEF and the like. He left me his name card, and asked to keep in touch. I love Australians!
I’m not sure what happened to the patient in the end and I will probably never know. I hope he is doing well. To end off, I read this
interesting article by Bob Wachter on his multiple encounters of responding to “Is there a doctor on board?”. He ends off with this paragraph.
“Answering the “is there a doc on the plane?” call is one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship. We worry a bit about liability (though the protections under Good Samaritan laws are fairly robust). No money changes hands (the airlines sometimes credit you with a few thousand frequent flyer miles or give you a free drink), and there are no CT scanners or fancy consultants. It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.
That’s why, despite the angst and the time (all told, I’d estimate that I’ve spent more than 20 hours providing clinical care on airplanes), I answered that call on Thursday, and I’ll keep doing so in the future. I hope you will too.”
