If there’s a doctor on board, please ring your call button!

Well, it happened again. Recently, I was somewhere over Saskatchewan, returning from a lovely Mediterranean cruise, in that uncomfortable semi-conscious state that passes for sleep when you’re flying coach, when the airplane’s PA system rang out:

“If there’s a doctor on board, please ring your call button!”

If you’re old enough to remember the show “To Tell the Truth,” you know what happened next. In the show, four B-list celebrity judges guess which of three contestants holds a certain unusual job. Once the judges have made their guesses (guided by contestants’ answers to a series of questions), the real skunk breeder, or tea taster, or cemetery lot saleswoman is asked to stand. One contestant begins to rise, then checks herself and sits down. Then another. Finally the correct contestant stands. The audience lets out a collective “oooh.”

I’m guessing that the average packed Boeing 777 has at least a handful of doctor-passengers. When the call comes for a physician, I’m sure a few mutter, “no f-ing way” and go back to their Sudoku. But most, I think, respond like I do: we reach tentatively for our call button then, thinking better of it, stop, look around, start again, then finally push the damn thing. Even as we nobly hit the button, in our heart of hearts we hope that we’re number two – our guilt assuaged but our services unneeded.

And that’s what happened on Thursday. I waited a few seconds, heard another “Bing!,” breathed a sigh of relief, was elbowed in the ribs by my son Benjy, and then, shamed into it, hit the button. The flight attendant came over, thanked me, and told me that another doctor had already been selected. “I’m sorry,” I replied, which is weasel talk for “Whew!”

I settled back to “sleep,” but five minutes later she returned. “Perhaps you should come up.”

It is virtually always “come up,” since people with airplane medical illnesses seem to always be in business class. I don’t think business class actually causes folks to get sick on airplanes. Rather, as they taught us in Epi 101, this is an “association”: older wealthy people are both more likely to upgrade, and to get sick.

When I arrived, a very pleasant elderly American woman with asthma was panting like an overheated puppy, her concerned husband fretting next to her. The doctor already tending to her had not yet checked her vital signs, listened to her lungs, or administered a treatment other than oxygen. I wondered why, and then learned that the doctor was a radiologist (from Germany, as it happens). She seemed – what’s the word I’m looking for – yes, elated, to hand over the reins to me.

I opened the airplane’s medical kit, which used to contain virtually nothing but a stethoscope and a prayer, but is now stocked with a fairly complete array of medications (including epinephrine, Benadryl, atropine, Compazine, nitro, aspirin, and pain meds), as well as equipment for intubation and intravenous access. There’s also an automatic external defibrillator. Unfortunately for my colleague the radiologist, there’s no MRI or ultrasound.

This one was easy. I took a little history from the patient, listened to her lungs, and then recommended that she take a few extra puffs of her albuterol inhaler (she carried one but had been told to use it very infrequently, so she was waiting, patiently but mistakenly, until six hours were up to take another hit). Within 10 minutes, she was nearly back to normal. The flight attendants thanked me and I slouched back to my seat in coach.

I fly a lot (about 125,000 miles a year), and I’ve answered the “doctor on the plane” call about 15 times over the past two decades. (Once, I got called on both legs of an SFO-Philadelphia round trip!) Although the FAA estimates that there is one medical emergency for every thousand or so takeoffs, I must be getting on high risk flights or something, since I seem to average about one call a year, which would place the frequency at more like one in 50-100 flights.

In any case, this topic is one of the great sources of physician war stories (perhaps second only to municipal hospital ER horror stories during residency). So I’ll share a few of my experiences, in the hopes that some of you will share yours.

Standing in the cockpit soon after 9/11

I had to fly from SFO to Philly in late September 2001, just a few weeks after 9/11. I was scared to death. I noticed that no one dared fall asleep on the plane, and everybody had a look on his or her face that bespoke a fear of impending doom. The FAA had just announced its new restrictions on cockpit access and was in the process of hardening the doors; for now, someone approaching the cockpit too quickly would have been blocked by flight attendants and first-class passengers, and hit with weaponry consisting of serving carts and hot coffee.

About an hour into this US Airways flight, I got the call: a woman in seat 22A was having chest pain. I tried to figure out her risk factors and the quality of the pain, but made little headway since she didn’t speak much English (I think her primary language was Polish or Czech). The flight attendants found another passenger who spoke the language, or something close, and she joined us to translate.

With chest pain, as with many in-flight emergencies, the real issue is whether the pilot needs to land the plane early – there’s only so much you can do on board, and administering TPA or performing an emergent cath are not among your options. I tried to sort out the character of the chest pain and the patient’s risk factors, but between the language barrier and the lack of an ECG, the nature of the problem was really anybody’s guess.

The pilot, communicating with his medical station on the ground (every major airline contracts with physicians who help them manage these situations), began sending messages back to me requesting details. The problem was that this quickly devolved into a bad game of “Telephone” – the ground doc posed a question to the pilot, who relayed it to the flight attendant, who ran it back to me, which sometimes prompted me to ask the patient through our passenger-translator. We weren’t making much progress, and in the post-9/11 environment, everybody was getting a bit twitchy.

Finally, I said to the flight attendant, “You know, this is silly. It really would be easier if I spoke to the doc on the ground myself.” “I’ll ask the pilot,” she said, and disappeared. “OK,” she said when she returned, “come up to talk to the doc and the pilot.”

Before I could fully process this, I soon found myself standing in the cockpit of an Airbus, right behind the pilot and co-pilot, about 3 weeks after 9/11. If I knew martial arts, I have no doubt that I could have taken the plane. And, it dawned on me that, if I were a terrorist, I could have staged the whole thing, with a partner playing the role of the “sick” passenger. The realization made the situation all the more surreal. I felt a bit ill myself.

Of course, nothing bad happened. We decided to treat the woman for indigestion (she had few cardiac risk factors), she improved, and we landed uneventfully a few hours later.

Peer pressure – from the pilot

Last year, I was flying back to San Francisco from Charlotte, and noticed an elderly woman and her middle-aged daughter across the aisle from my seat. The younger woman appeared to be blind and had the look of someone with a chronic illness. As the plane took off, she vomited. A flight attendant came over and asked, “Do you need to see a doctor, ma’am?” Please say no, I prayed to myself, but she said, “I think so.”

I had about 5 hours’ worth of work to do on this 5-hour flight, and I can’t say I relished the thought of spending the time rendering clinical care. But there I was. Despicably, I waited until they made the PA announcement before I leaned over to say, “I’m a doctor.”

I learned that the woman had hydrocephalus and a ventriculo-peritoneal shunt, and now suffered from nausea, a headache, and abdominal pain. This is a bad combination: it could mean that the shunt was malfunctioning or she had a serious infection. The idea of waiting nearly five hours for legitimate medical attention was troubling. I opened the airplane’s medical kit and began giving her anti-emetics and some pain meds. She improved for a short while, and then began to worsen. I told the flight attendant that we might need to divert the plane.

The pilot came out to speak to me – I was reassured that they were now enforcing the “no lay people in the cockpit” rule. “Doc,” he said, one pro to another, “I don’t want to tell you how to do your job, and you’re in charge here. If you say we need to land this bird, I’ll land it….”

I waited for the big “but.”

“But I need to let you know that when we took off, we had a full tank of gas, which will mostly burn off by the time we get to California. When you land a plane this heavy prematurely, you have to come in ‘hot.’” He explained that this meant landing at an unusually steep angle of descent while gunning the brakes to prevent the plane from overshooting the runway. “It’s not dangerous, really, but it’s a little scary, and we have to stay on the ground for a full inspection before we can take off again. It takes a few hours.”

“But really, doc, I don’t want to tell you how to do your business. It’s completely your call.”

If you’re a physician, remember that feeling you had during your residency, when you were admitting a patient to one of your pals, who was getting slammed upstairs? I don’t know the resident who didn’t factor the peer response into his or her decision-making. Most of us ultimately did the right thing, but it’s human nature to consider the “hurt” you’re causing to others even as you focus on your patient’s welfare.

Here, the “hurt” would be to about 300 people who would be delayed several hours – or perhaps even overnight – because of my decision. “Let’s give it another hour and see how she does,” I said.

If you’re not a physician, this might seem immoral, but I want to reassure you that I – and every physician I know – would find this to be an easy decision in a clear-cut emergency. But in cases like this, and what makes medicine so hard, is that we often don’t know what’s going on, and the chances are fairly good that waiting will be fine. In situations like this, it’s natural, and actually not inappropriate, to weigh all the consequences before rendering a judgment.

Luckily, this patient, like my 9/11 chest pain patient, did fine – or at least fine enough to make it until the paramedics could wheel her off the plane at the final destination.

Why certain kinds of humor aren’t appropriate at 35,000 feet

“Is there a doctor on the plane?” has been the source of Hollywood humor, as you might remember from this clip from the movie Airplane!, Here, Dr. Rumack, played memorably by Leslie Neilsen, answers the call, stethoscope helpfully already around his neck. But there is a time and place for humor and, well, this probably wasn’t it.

About 20 years ago, I was on a 747 flying to Chicago, as I recall. A flight attendant had passed out and was lying in plane’s rear galley.

By the time I arrived, she was already coming to. Her vital signs were OK (her heart rate was a bit slow, which is typical of this syndrome), and I was able to elicit the history of a tooth extraction the previous day and some lingering oral pain. So this was a clear case of vasovagal syncope; there was no need for worry.

Remember that this was a flight attendant on a jumbo jet, so I was surrounded by about 10 of her worried colleagues, as well as the co-pilot. “Do we have to land the plane, doc?” the chief purser asked. “No, I’m sure she’ll be fine,” I said. “She should rest, drink a little extra, and keep her legs elevated.”

Relieved, the group began to disperse to their stations. One of the other flight attendants walked up to me. “Thanks, doctor…. By the way, what kind of a doctor are you?”

“I have a PhD in English Literature,” I said, mischievously.

“Just kidding,” I quickly added, as I nearly scraped her off the ceiling.

I’ve now recognized that airplane emergencies are probably not the best time for jokes, though this seemed very funny at the time.

Why do this?

In 2000, an elderly woman, traveling with her husband, passed out on my flight – this time in the back of the coach section. I don’t remember doing that much – mostly getting her some fluids, elevating her legs, and handholding. She perked up. As we parted, she and her husband asked for my card.

A few weeks later, I received this note from their daughter; I still have it taped to the back of my office door. It said,

I understand from my father and brother that we almost lost my mother. As her only daughter, I am indebted to you for helping her live a longer life….

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 recently, and I’ll keep doing so in the future. I hope you will too.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • http://blog.themillionairenurse.com Dr Dean

    I have been called or “caught” a couple of times. The last one was a Delta flight from Costa Rica.

    A flight attendant had passed out. An ICU nurse and I checked blood sugar, monitored vital signs, and decided it was Vaso-vagal syncope triggered when she cut her finger on one of the carts…
    But a dramatic one!

    They took my personal info, and said Delta would be in touch. Never heard a word… At least the patient was grateful.

    You ever get a TY from the airlines?

  • rezmed09

    Wonderful stories and jobs well done. It is a great thing to be able to provide medical assistance and assessment for people in the unusual practice setting of 35,000 feet.

    Last time I did so, I read the statement on the outside of the medication box. It described the Good Samaritan Law, but had the disclaimer “except for gross negligence.” Isn’t that the description used in every malpractice suit?

    • SmartDoc

      Authentic iron clad Good Samaritan laws are needed.

      Otherwise it is just another liability profit orgy for the John Edwards Trial Lawyer Industry,

    • Matt

      ” Isn’t that the description used in every malpractice suit?”

      No. It’s not.

  • PAULMD

    I recently flew to Chicago with my wife for an overnight to celebrate our anniversary. She made the reservations and I saw on my boarding slip that she had me listed as “MD”. I was surprised because unless it is a formal introduction at some swanky event we never use credentials….not our style. We had a conversation about this and I asked her not to us the “MD” thing again on any reservations.

    There is no upside to it…only a potential downside. Because you are an MD you are an expert…..because you are an ophthalmologist at 35,000 feet and there is an evolving CVA….you also might be considered by some to be “Grossly Negligent”.

    If this is the world that people want, I will not jeopardize my or my families well being for fear of legal retribution, especially outside of my field.

  • ninguem

    Is there a Nurse Practitioner on the plane?

    • http://curbside.posterous.com Nuclear Fire

      LOL. Priceless.

  • http://www.aneurysmsupport.com/ Mike

    Great story that I very much enjoyed.

    I pray I never hear, “is there an engineer on board”. I’ll let you know right now, I will not climb out on the wing and take a look at that stalled engine.

    • Margie

      OK, that seriously had me laughing out loud! “Is there an engineer on board?”, indeed—nothing any of us probably want to hear.

      • http://www.aneurysmsupport.com/ Mike

        Thanks Margie, I’m happy it brought a laugh to your day. Actually, engineers do get the occasional request for services outside the office. Mine are usually along the lines of, “my car won’t start” or “my sewer won’t drain”, “can you help my son with his math homework”. While I’ll give them a jump or speculate on their sewer problems I usually tell them I’m not a mechanic or a plumber and, despite being an engineer, I didn’t like calculus any better than their kid.

        On a serious note, it is nice to know that now and then there are physicians like Doctor Wachter who will give of themselves and treat a patient in less than ideal or risky circumstances. I’m reminded of a physician back home. He was from Poland and had immigrated to the area in the 1950’s. This man had survived the war, including internment in a concentration camp. Around 1970 or 71 there was a major accident at a local mine. Hearing about it, this doctor left his office, went to the mine and volunteered to go down and treat the men still inside. He exemplified the best of his profession and, I suspect, there are a few more like him out there. Sadly, lawsuit, litigation, and regulation are trumping courage and compassion.

        • Margie

          Very inspiring story, and a reminder that there are good people around us. For me, it comes down to what I could live with if faced with such a choice. I would hope the Good Samaritan law would cover me, I would do my best, and be able to sleep at night. The oath I took wasn’t restricted to sea level crises!

          • http://www.aneurysmsupport.com/ Mike

            That’s nice to hear Margie, I knew there were others like him out there.

  • http://curbside.posterous.com Nuclear Fire

    Provide emergency medical care, in an unknown jurisdiction where I may not be licensed to practice, not covered by my malpractice insurance, outside of the scope of my practice in the litigious USA? No thank you. If I’m JAL or ANA, then fine; they’re not a sue happy culture.

  • http://drpullen.com Ed Pullen

    Once a few years ago I was asked to attend to two separate passengers on the same flight across the US. One old woman with COPD and an exacerbation, not too bad, and really just rested until we go there, and another with a panic attack. Two amazing things about this. First I asked the flight crew to have the COPD patient get helped off the plane first. They wanted to have paramedics come to her seat near the back of the plane and carry her out. I suggested we have her trade seats with someone at the front of coach during the flight so she could easily get off first. They had never thought of that or done it before. Second they offered to and actually did give me a free flight voucher.

  • Margie

    “Doctor on board” was my call to action a few years back on a flight from San Francisco to Maui. About halfway in, the call came. I had been upgraded so went “back” to coach to find an elderly woman who had passed out in the middle of a 5 seat block on a 777. With the help of the flight attendants and passengers, we rigged a blanket to drag/carry her to the galley so we could assess her/help her. I was told I had to show my medical license before I could help—I said “OK, but I’m checking for a pulse first.” Pulse intact, I dug out my license and we carried on.

    The bottom line is she was fine—dehydrated, hadn’t eaten or drunk during a long travel day. I checked vital signs, history, etc, and was very thankful for an ICU nurse who was there with me and who happened to have a second hand on her watch. I tried to look cool checking her pulse with my Swatch!

    A few distinct memories of this event: 1) the robustness of the medical kit these days (if you had a medical license!), 2)the heartfelt greatfulness of the flight attendants for the help, 3) the moment when I realized that we were over halfway to Maui–filling me with dread because there was no place to land early if we needed to but happiness because we were going to get to Maui!, 3) even at 35,000 there is all sorts of paperwork to complete, and 4) my fellow passengers giving me a pat on the back and a “Great job, doc” when I returned to my seat to enjoy the rest of the flight. All in all, a good day!

    • http://glasshospital.com GlassHospital

      You carry your medical license with you? In my state they’re inconvenient large sheets of paper we usually frame or tack up on the wall.

      Had they had impostors before? That would be troubling.

      Of course, if there were Wi-Fi, you could just log in and show your license online.

      Good for you for having it with you.

    • joe

      “The bottom line is she was fine—dehydrated, hadn’t eaten or drunk during a long travel day. I checked vital signs, history, etc”

      I wonder with the stinginess of airlines if this is something we are going to see more of with people who did not have the foresight of bring stuff on their own

  • http://www.pacificpsych.com/ pacificpsych

    Haha, great post. Love your description of the Psychology of the Called Doctor.

    If you, an internist, feel that way, imagine the sheer terror a psychiatrist experiences. I don’t think I’ve ever been called, I think I’ve just imagined the possibility of being called, but then, fear may have prevented the memories from being encoded…

  • paul

    just pound a few drinks at the start of your flight so it’s “not safe” for you to offer help. :D

    i read that on some blog once i swear it’s not my idea!

  • eddie

    As a mom of one of the docs replying above, let me tell you from my perspective, these called upon high flyers are the best of the best. Their oath to heal and care is never far from them , and an interrupted flight is nothing more than the continuation of sleepless nights and loss of private time first learned as an intern.
    Three cheers for the high flying docs!!!!!

    • Margie

      ah, thanks, mom! :)

  • PAULMD

    @ Mike

    Nice story about the Polish doctor. Truth was that he was practicing in an emergency situation on the ground and in his own state where I hope he was licensed to practice and had some knowledge of his state good sam laws. Not to detract from your story or his clear act of compassion, but it is somewhat different than being in the air @35,000 ft over ???. As an aside, with my luck, Matt would be on the same flight.

    Regarding the Hippocratic Oath…I never took it. I never swore to uphold whatever was in the mumbling rant conjured at my medical school graduation. From my perspective it is a nice historical bit of antiquated tradition. It has no legal bearing and is easily replaced by the medical secular oath that I took myself.

    I swore and affirmed that I would do the best that I could in helping my patients. That I would maintain and improve competency, knowledge and experience to the best of my ability and that I would be honest with them and treat them fairly within the bounds of the law and current moral and ethical guidelines.

    My personal belief is that if most people left their house for work each day with a similar personal contract with all they encounter that day, the world would be a better place.

    The dilemma for me is that a working creedo that I ascribe to is that you are dealt a hand in life and what matters is how you play that hand. Carload of children off a bridge into the icy river below, shirt off and I am in.

    By being on that plane and dealt a situation that I may be able to contribute positively to, I would be playing it WRONGLY if I hid my head in the sand. I know that I will continue to wrestle with that one as long as I practice medicine. The paralyzing fear of being asked to do the right thing can be just that.

  • eddie

    In response to Mike.

    Think you have rung a bell there, Mike!

    Perhaps we need a Personal Contract Day and give this old world a chance to recover and survive.
    Girls Scouts, Boys Scouts, Little League-” I promise to do my best… ” rolls out of the mouths of babes. What happens to the individual between scouts and Little League and adulthood? The mouth more active, the brain, hopefully, more developed, but the tire is missing air.

    Could this personal contract provide the air and drive for everyone to work for and with each other?

    I think so…

    Thanks for your thoughts. Eddie

  • Leah

    These are such inspiring stories of how all doctors should truly be! As a nurse I thank goodness for a doctor like this because if it weren’t for them the flight attendants would then be calling for me! It takes a special person to give care mid-flight and not worry about anyone but the patient. I am not a big flyer, but as an emergency room nurse I would be the first to stop at the scene of an accident and do the same as the doctors above. We all worry about liability just a bit but the Good Samaritan laws are there to keep us safe if we are trying to keep safe those we are treating. I commend all of the doctors who have stepped up to the plate to take care of a sick person on a plane and if I’m ever in need I hope you are there for me!

    • errol williamson

      what an interesting piece, On a flight to London the call came. I waited until someone else would have answered. No one answered, my wife said I should ” fess up” I did. The medical kit was brought to me beside the patient who did not look very ill, possible some GIT upset. However before the assistant could open the Kit she asked for my licence. Licence? We have a number which is instantly confirmed by anyone in the medical fraternity. I had no licence, so I was told to my relief that I could not open the KIT without a licence. Thank you very much and a bottle of wine at the end of the flight. I will answer calls very reluctantly in the future.

  • http://myheartsisters.org/2009/05/22/know-and-go-during-heart-attack/15/reporting-impaired-incompetent-doctors/ Carolyn Thomas

    Another perspective – this time from a patient who had a heart attack while on a cross-country flight from Ottawa to Vancouver two years ago. (And YES! – I was seated in Business Class, although I’m not in the least bit “older and wealthy”!)

    I knew something was terribly wrong with me during this flight, but at no point did I call over the flight attendants to ask if there were a doc on the plane. Days earlier, I’d been misdiagnosed with acid reflux and sent home from the E.R. despite presenting with crushing chest pain, nausea, sweating and pain radiating down my left arm (the same symptoms I was once again now experiencing at 35,000 feet).

    So when my increasingly debilitating symptoms continued – well, hey! at least I knew it wasn’t my heart. After all, a guy with the letters M.D. after his name had already told me very firmly in the E.R. that there was nothing wrong with me that taking a few Rolaids wouldn’t fix.

    So not wanting to be a “difficult” passenger, I white-knuckled the five-hour flight. I did not want to make a fuss over nothing. I certainly didn’t want to be one of those passengers they have to turn the plane around for. How embarrassing would THAT be – and all for a brutal case of indigestion?

    This time, when the plane finally landed after the world’s longest five-hour flight, I did end up back in the E.R. – this time to a revised diagnosis of “significant heart disease”. I was taken directly from the E.R. to the O.R. and survived to tell you this tale.

    My guess is that passengers like me are more common that you doctors would believe. We’re the grim-faced sweaty heaps slumped against the window praying like mad that we’ll be landing soon. We are mostly women. Oregon researchers even identified this “treatment-seeking delay” behavior of women heart attack survivors – who apparently would rather die than be embarrassed by make a fuss!

  • http://mdhealoneself@blogspot.com Dr A Duker

    Glad to hear these stories I just had my first Dr on board experience 2 months ago on an Air France flight to Paris and they called for help with a 10 mos old baby with a fever of 103! I always kinda dreaded hearing this call as I travel a lot! Before the stewardess sent me she asked to see my ID as the other docs have mentioned I was put off all I had was my card. But I was the first to arrive along with a medical student, then 2 older docs arrived. So I gave my recommendations on going ahead with next dose of Motrin, keeping the baby well hydrated, removing extra clothing etc and one of the older docs was old school and put a bag of ice on the baby’s head! The other doc had his stethoscope with him I was impressed! The flight attendants were really appreciative I had to sign this log book listing my phone #, practice address etc. A month later I got a letter from Air France’s head medical officer thanking me, I was expecting a pen, frequent flier miles or something LOL. Actually not certain that I’d respond to this Dr on board call again I would never want to be liable for my participation.