Is there a doctor on board?

I have been traveling a bit for residency interviews over the past few weeks, and given that planes, trains, and buses have become my new home, I have been thinking a lot about what I would do if a fellow passenger needed medical help. As we go into the holiday season, I imagine many people with medical training will be traveling, as well.

I was once called upon to assist a passenger in an in-flight medical emergency. It was when I was leaving for vacation after completing my third-year clerkships, and my relatively minimal hands-on experience put me as the highest-ranking medically trained person on the plane. I was thrust into a relatively unfamiliar situation and forced to apply my medical knowledge in the “low-resource” setting of the airplane.

Thankfully, the passenger was stable and didn’t require more than a history and basic physical, but the experience left me wondering how I would have responded if the situation had been more serious.

After the trip, I took it upon myself to learn as much as I could about airline medical emergencies, and what my role would be in one of those situations. I am writing this post to share what I learned. This will be especially helpful to any doctor, nurse, EMT, or other medically trained personnel who reads this and finds themself called upon to respond in the future (an in-flight medical emergency is estimated to occur about once in every 10,000-40,000 travelers).

If you are a medically trained person who has responded to a medical emergency on a plane, train, or in a restaurant, or if you are a person who has been helped by a medical person while traveling, please feel free to share your experience and insight in the comments.

The Call on the Loudspeaker
You just woke up from a nap. You don’t feel like working on your day off. You are unsure if you can help. You just enjoyed a glass of fine airplane wine with your shrink-wrapped meal. To top it off, you are a pediatrician/psychiatrist/pathologist/internist/obstetrician and you haven’t dealt with an adult/acute non-psychiatric issue/live person/child/man since medical school.

Here’s what I have to say: GO UP AND HELP. Medicine is a profession with an oath. Even if it isn’t your field or your specialty, you can always help. You have medical knowledge and know how to do a basic history and physical. You are not expected to act alone, and you know how to speak medical lingo with medical staff on the ground (more on that below). You know basic CPR, ACLS, etc. You know how to tell if someone is truly ill or requires hospital-level care.

If you recently had a glass of wine, do a self-assessment. Are you too incapacitated to offer help? Generally, there are no defined guidelines but rather rely on the provider to assess his or her “fitness for practice.”

Identifying Yourself
Go to the flight attendant and identify yourself by name and occupation. Tell them you are there to help. If the patient is conscious, identify yourself to the patient and ask permission to help. If this is not a patient population you are familiar with, be honest and say so. If you had a glass of wine, be upfront about it. Essentially, you are asking for informed consent. If the patient is unconscious or if it is a true emergency, then consent is implied.

Assessing the Patient

  1. Do a primary survey. Remember your ABCDEs. Airway. Breathing. Circulation. Disability. Environment. Start CPR as necessary.
  2. If you have not already done so and think you will need it, ask the flight attendant to bring you the in-flight medical emergency kit. This kit, which all large passenger planes are required to have, includes basic tools such as an automated external defibrillator (AED), an IV kit with connectors and IV normal saline, a bag-valve-mask and masks, a sphygmomanometer, and emergency drugs such as oral antihistamine, aspirine, atropine, bronchodilator, lidocaine, and non-narcotic analgesic. NB: Most airlines can also provide low-flow oxygen at 2-4 L/min.
  3. Take an AMPLE history from either the patient or their travel companion(s). This includes Allergies, Medications, Past Medical History, Last meal, and Events surrounding the incident. Most issues that arise are usually an exacerbation of a preexisting condition (65%; most commonly cardiac, pulmonary, or GI), and most new-onset issues are usually syncope (91%).The low-pressure environment of the cabin can create issues of poor oxygenation and expansion of gases in tight spaces. The cabin is pressurized to 5000-8000 feet, which means that one’s effective arterial oxygen pressure (PaO2) will be 65-75 mm Hg, which may be problematic for those with baseline oxygen delivery issues.

Making Management Decisions

  1. Every airline has on-the-ground medical support. You should request contact if you feel uncomfortable with the patient’s management. This service is especially useful if it is a patient population with which you are unfamiliar. They can help guide you through assessment and management, and because you are a medically trained person, you will be inherently more skilled in this than a layperson.
  2. Depending on your findings, address issues as needed. The following screenshots are from a travel-sized card that a colleague shared with me. Click to enlarge.
    Card1 Card2 Card3
  3. Speak with the captain. Your role is as a consultant. You are making medical assessments and recommendations, but the decision whether to land or divert the plane rests with the pilot alone. You will be an important piece in this decision, but the pilot has aircraft and logistical considerations to make and may overrule based on several factors. You should also take into account the medical facilities available at the potential site of diversion, considering their ability to handle the particular medical issue (or if it requires specialized care).
  4. Should you land the plane? Based on estimates, only 7-13% of in-flight medical emergencies result in a diversion, and this number has been further minimized thanks to airline medical pre-screening procedures, medical training for cabin crew, and online medical advice. In a retrospective review of cases where the plane was diverted, diversion was recommended when the issue was chest pain (acute coronary syndrome), exacerbation of asthma (not improving on available treatment), status epilepticus with reduced GCS, stroke with reduced GCS, and vaginal hemorrhage resulting in hypovolemia.

Liability Questions
Opening oneself up to liability is a common concern of the potential medical responder. This needn’t be a deterrent. No person responding as a Good Samaritan has ever been successfully sued. Many airlines have policies to indemnify the medically trained responder, and the US Aviation Medical Assistance Act of 1998 legally protects airlines and medical responders in Good Samaritan situations. Airlines can provide written confirmation of indemnification to the provider, if requested.

The responder can also do two things to help further shield themself from liability. First, talk to the ground medical personnel; any advice they give you or any decisions you make together on management become joint decisions with the blessing of the pre-approved medical personnel that the airline already has an established relationship with. Second, know your limitations and adjudicate them wisely. This applies if you are inebriated or otherwise impaired, or if you are presented with a situation requiring you to do a procedure that you are not trained or skilled in. “Be reasonable in how you treat a patient, but do not be afraid to be creative. Use your training and experience.”

Caveat Benefactor/Doctor

  1. The provider should avoid requesting or accepting monetary rewards from the airline for assisting in an emergency (seat upgrades and travel vouchers do not count). This transaction means the provider is no longer acting as simply a Good Samaritan, a situation that can be problematic later on. In general, the Aviation Medical Assistance Act applies when the provider is qualified to perform the service, does so voluntarily, in good faith, does not engage in “gross negligence or willful misconduct,” and receives no monetary compensation.
  2. You must continue to attend to the patient until care can be transferred to on-the-ground crew or others more skilled in management of the issue. Once the patient is in your care, you cannot abandon them until appropriate hand-off is secured.

Follow-Up
Once the patient is on the ground safely and in the hands of local medical teams, you may never see or hear from that patient again. But rest assured, you used your hard-earned skills in the care of someone who needed you, and you made things better. There is a 79% correlation between in-flight diagnosis and the final diagnosis later, and 60% of cases are reported to have improved thanks to help from a medical provider.

In Summary

  1. Always go up to help, even if you don’t think you have anything to offer (because you do).
  2. Make decisions as a team: pilot, flight attendants, on-the-ground medical support. You are not expected to act alone.
  3. Respect your limitations.

I hope this has been helpful. Thanks for reading and safe travels!

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8 comments

  1. Thanks for an interesting write-up!

    I have two stories that occurred during my travels (around Asia).
    1. Travelling companion felt weak and nauseous – pulse was extremely weak, and HR was 180, but he was able to stand and another companion was vigorously rubbing his back. There was no medical kit on this flight, and all I could offer was reassurance. Fortunately, by the time we landed, he had gone back to sinus rhythm and elected to see his own doctor another day.
    2. Man in his forties throwing up and having cold sweats. History was insignificant and vital signs stable. Sounded like food poisoning or gastric flu. I prepared a dose of prochlorperazine in a syringe and gave it to a young doctor (so young I had to guide him all the way) to inject into the deltoid. Within 10 minutes, patient was much relieved. Later the stewardess came by to get my name and email, but I’ve not flown the Airline again as yet. This Airline had a superb medical kit with electronic BP monitor and whole range of drugs oral/ iv.

    These two cases were not handed to ground staff, but to their own relatives. Case no. 1 might have become an emergency, but didn’t. Case no. 2 was primary care. I hope never to have to do resuscitation on board, touch wood.

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  2. I’m a medical student. and I’m ethically obligated to help anyone who will need, but I think I would only freak out, cause of the lack of experience… sad thing! :p

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  3. I feel that that’s the strange thing about being a student (I’m a PA student). You know how to do a lot of things, but you’re very much aware of all the things you can’t do (or can’t do well) yet. But you’re right, a student’s help would still be much more valuable than the average passenger, so get up and help! Thanks for sharing. Safe travels.

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  4. Really helpful, Thankyou. I’ve always dreaded that “call” a colleague of mine was confronted with a child that had been bitten by a scorpion- just as you described, she was able to speak to a specialist on the ground and all ended well! 🙂

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