The ethics of being a doctor on board

It was Christmas Eve, and where most people are home with their families, residents are all too familiar with spending holidays inside the hospital. As such, I was traveling back to Austin for an early morning shift on hospital service, when I encountered an ethical dilemma that has stuck with me since.

A mere 20 minutes after the plane took off, I heard the dreaded words: “A passenger requires medical attention. If there is a physician or medical personnel on board, please identify yourself to a flight attendant.” I froze and sat silently but turned to see the commotion at hand. Again, they asked if there were any medical personnel on the plane for assistance. Thoughts raced through my mind; do I sit quietly, or do I get up and try to help? And try should be emphasized because I am not an experienced physician by any means; I am a family medicine intern who has had only basic training in emergency medicine.

On the other hand, I likely know an immense amount more about medicine than these bystanders. Or do I stay out of the happenings, avoid the potential of looking like a fool? Or worse, what if something tragic occurs to this passenger and I am intertwined with the outcome?

In the end, my instincts took over. I hurried back to a crowd of flight attendants surrounding a man. I introduced myself as a resident intern to the staff, and they had an immediate look of relief. I did a quick survey: middle-aged male, unresponsive to verbal cues and eye rolled back in his head. I climbed into the seat next to him to assess his airway, breathing, and circulation. Good, I thought, he’s got an open airway, breathing on his own, and equal and strong radial pulses.

So, what next?

Right then, he started to shake, his body slouched, and blood spewed from his mouth as he coughed for air. At this point, differentials are running through my mind, and I am wondering about his vitals, his heart sounds, and his pulmonary exam, but I don’t have any equipment! A flight attendant presented an oxygen tank with a mask and said that it was about all they had on board. I regrouped. This must be a seizure, I thought. Why he’s having a seizure, I have no idea, and I have no way of finding out. But without further ado, we lowered him to the ground and held his head to avoid potential trauma.

Over five minutes had gone by at this point without returning to consciousness when I got the next question, “should we turn the plane around for an emergency landing?” I recall my head nodded before my mouth opened. I usually have a senior or an attending at this time to look up to, but at this moment, I was all alone. And at this moment, my decision mattered.

It was several more minutes before the man started to improve consciousness. He was eventually able to follow commands. I asked him to stick out his tongue, revealing bloody bite marks on both sides of his tongue. With slow speech, he thanked everyone for their help.

Fortunately, this man was stable upon leaving the plane. But this incident got me thinking, is there an underlying responsibility that physicians have to help in any situation where medical attention is needed? Would I have been at fault if I had continued to sit quietly in my row without anyone knowing that I am a resident?

The Good Samaritan Law states anyone “who renders aid in an emergency to an injured person on a voluntary basis … is not obligated by law to do first aid in most states, not unless it’s part of a job description.” Don’t we swear in our Hippocratic Oath that we will act in goodwill to our fellow humans? Isn’t it, therefore, in our permanent job description to be willing to volunteer our services when needed?

According to several sources, there is no mandated reporting system in place for airlines to document in-flight medical emergencies so statics are limited; however, a 2015 New England Journal of Medicine article references a study that estimates that medical emergencies occur in 1 of every 604 flights. It further estimates that cardiac symptoms represent ~ 8% of medical emergencies on commercial airliners; syncope or presyncope (37%), respiratory symptoms (12%), cardiac arrest (0.3%); stroke (2%); and seizures and postictal state (5.8%).

“Although U.S. health care providers traveling on registered U.S. airlines have no legal obligation to assist in the event of a medical emergency… many other countries, such as Australia and many in Europe, do impose a legal obligation to assist (NEJM).”

However, if airlines do expect medical personnel to jump to the scene, perhaps airlines should hire an additional medical staff member to act as the inflight provider rather than expecting that medical personnel is present and willing to assist. Alternatively, airlines should at least have basic medical equipment readily available to be able to assess the patient in these situations. While the flight attendant offered oxygen and a first aid kit (and allegedly airlines do carry AEDs), there was no stethoscope, blood pressure cuff, or glucometer, which are basic instruments to properly assess critical values.

In this situation, my hesitation to help was secondary to fear, and it wouldn’t have been legally wrong to just sit there. I would argue that there was only one correct choice in this situation, and it is to offer what you know at the time.

In reality, I did very little in terms of medical service. But I was able to provide a sense of relief to fellow passengers and flight attendants, and most importantly, everyone was safe. We, as physicians, have the esteemed responsibility to offer our skills in whatever way we can, even if we are off duty on Christmas Eve.

Jocelyn Worley is a family medicine resident.

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