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Friday, July 27, 2018

Overachievers on a plane

"If there is a physician on the plane, please press your call light!"

The vast majority of doctors who have flown on airplanes have heard this, and most of us are willing, if not entirely eager, to respond. What follows is usually a far from ideal encounter with inadequate information, too much noise, a cramped space to work in and little knowledge of what is expected or even possible.

My experiences (I think there have been 3) were people who had become dizzy or had passed out. One of them was pretty frail, but none required that we land before our destination airport. What I learned was that:

1. More than one physician usually responds to these calls. As a general internist, I'm usually the most appropriate person to evaluate the patient (winning out over ophthalmologists, dermatologists and obstetricians.)

2. The flight attendants are very grateful, bring me an extra glass of juice and promise some kind of compensation from the airline which may or may not materialize.

3. It's really pretty challenging to do it right, and I end up spending weeks thinking about the ways I could have done it better.

Since the last experience, I have looked up what is in an airplane medical kit. There is a stethoscope, a blood pressure cuff, an IV and some fluid, some IV glucose for hypoglycemic patients, an asthma inhaler, some non-aspirin pain reliever and some actual aspirin for suspected heart attacks, some medication for severe allergic reactions and some stuff that might be useful in a cardiac arrest. All planes must carry an automatic external defibrillator, which is as it should be. There is nothing particularly useful for nausea, severe pain or anxiety.

There is no protocol that I was aware of regarding what needed to be done. There was no obvious way to communicate with the doctor who would take care of that patient after the event in the plane about what had actually happened. There was no way to find out whether the patient did OK after he or she got home that I could use to help guide my next experience.

I just recently had a discussion with a couple of other physician friends (overachievers I guess) about what we do and how to prepare for the inevitable "doctor on a plane" scenario. Despite not knowing whether we had made the right decisions (other than that our patients remained alive and presumably vertical at the end of the flight) we all wanted to do better. We had been good Samaritans, but we wanted to be very good Samaritans.

The first thing we discussed were our tools and tech. My kit includes a small ultrasound (if I'm going somewhere medical, which I usually am), a tiny two lead electrocardiogram which works with my iPhone and fits easily in my purse, my lightweight stethoscope (which actually works, unlike the ones on the plane) and a not-so-basic first aid kit with medication for various random diseases. My friend carries an oximeter (measures blood oxygen level) as well. I always have a downloaded copy of UpToDate, a constantly updated disease and treatment encyclopedia, on my phone.

I try to find out my patient's story, including medical history and what they think is going on. I provide as much compassion and reassurance as such a cramped space will allow. Still. I think I could do better.

The main problem is not that I didn't think to bring the oximeter, but the fact that the process is bad. Airlines know that medical emergencies happen when they are aloft. They should be less random about how they respond. According to Bloomberg, many airlines contract with MedAire, a remotely available medical service that serves aviation and yachts and other situations that require medical advice at unscheduled times. Apparently they must only use this service when they think they need it, because none of my events seemed to use any remote support. But it is available. Why, as the doctor responding to the emergency, did I not know that they were available?

A person who gets sick on a plane is in a bad situation. He or she is often old, sometimes alone and always vulnerable. It is frightening and embarrassing be sick on a plane. Airlines charge lots of money for their services and are at risk for expensive diversions and crushing damage to their reputation if these scenarios go poorly. They should try to get this right.

I would propose:

1. Ask people at the time they schedule a flight whether they are a physician and whether they would be interested in being called upon in an emergency.

2. If we say yes, get a copy of our medical license. If my relative got sick on a plane, it would be awfully nice to know that the physician who responded to the event was actually a physician or an otherwise qualified medical professional.

3. Give us a little information to read on the process, including what is expected of us, what kind of support exists, what is in the medical kit...

4. Have the flight attendants take some kind of medical history from the patient or relatives if possible and enter that data into a simple electronic form. Make it possible for the doctor to enter some information about what happened. Send that to the patient and or his or her primary care provider.

5. Compensate us in some (maybe small) way for volunteering, since it is not necessarily an easy thing to be on call on a plane. Compensate us more generously if we provide a service. Let us know what the compensation will be.

6. Tread gently around Good Samaritan laws so we won't be exposed to liability. From what I read, it looks like preparing for this kind of thing and even being compensated for it wouldn't create a problem.

This isn't just overachieving. Doctors actually want to do a good job whenever we take care of someone. When we respond to the inevitable "is there a doctor on the plane?" we are agreeing to participate in a system that makes it difficult to provide adequate care. That would be acceptable if we were in a refugee camp or disaster situation, but airlines could and should be held to a higher standard..

Dang. Just have to rant about some really expensive drugs: Lucemyra, Trelegy Ellipta and Andexxa.

The price of new drugs just seems to go up. I've stopped being excited about innovative pharmaceuticals that target various hard to treat diseases and conditions, simply because they cost so horribly much. Each of these new developments looks like a classic philosophical dilemma. Do I pull the lever that makes the trolley kill one person instead of 5 or do I save the one and allow the trolley to kill 5? Do I prescribe the new drug that potentially helps my patient but may destine a whole population to lousy health care by making the overall budget unsupportable?

When I was in residency in the 1980's medication that cost a dollar a pill was crazy expensive. Inflation doubles that plus a little more, so think $2.25 and pill in 2018 money. But today's expensive medication costs 10-20 dollars a pill. Or $1000 a pill for the drug to cure hepatitis C. Or, in the case of a now pretty commonly used drug for advanced cancer, $150,000 a year. This is real money. On the lower end, it costs as much as all of one's food. At the higher end, it is enough to live like a rich person. If we insist that everyone have access to some of these new drugs we admit that we will never be able to offer universal health care. It would eat up all of the money we have.

Here are the new, latest and greatest drugs announced in The Medical Letter of Drugs and Therapeutics, a publication published by a non-profit not aligned with any pharmaceutical companies.

1. Lofexidine (Lucemyra) for opioid withdrawal: this is a central alpha receptor agonist, similar to the drug clonidine, which has been available and successfully used for the physical symptoms associated with ceasing to take opioid drugs when one is addicted. It reduces the anxiety, sweating, irritability and diarrhea that characterize withdrawal. It costs $1738.00 for a week supply. It is no more effective than clonidine which costs $1 for a week, though it does cause less reduction in blood pressure. The drug of choice for this situation is buprenorphine which costs $23 for a week.

2. Trelegy Ellipta: inhalers for asthma have been prohibitively expensive for years. People with airway obstruction, classic asthma with wheezing, shortness of breath and cough, usually require inhaled medication to open up the small airways in the lungs and to reduce mucus and inflammation. Originally the only drug for this was epinephrine which eased breathing when injected, taken orally or inhaled, but also sped up the heart and caused the shakiness associated with adrenaline release. Newer drugs worked on the inflammatory response, reduced the cardiac side effects and were longer acting. Inhalers cost less than $20 for a month supply when I graduated from medical school. Now some of the common brand name inhalers, combinations of long acting bronchodilator and a corticosteroid for inflammation, cost $300-$400. Now Trelegy Ellipta has been introduced which costs $530.00 for a month's supply. It includes 3 drugs rather than 2, and if one were to buy those three types of drugs as individual inhalers they would cost more than that. People mostly use a drug like this every day forever, at a cost of $6360 per year. Many of these drugs are not available as a generic, but even generics can be costly. Some of the generic combination inhalers cost less than $100 a month, but different patients respond differently and some have no luck at all with certain drugs or combinations and will end up on branded products.

3. Andexxa (andexanet alpha) will rapidly reverse certain anticoagulants ("blood thinners"). A few years ago the most commonly used anticoagulant, warfarin (coumadin), got some competition. A new drug was approved that reduced clotting by a slightly different mechanism and did not require regular blood tests to monitor it. Now there are at least 3 such drugs commonly used for patients who have a high risk of blood clots. They are considerably more expensive but also a bit safer and quite a bit more convenient. Unlike warfarin, however, which can be reversed by vitamin K or fresh frozen plasma, the new anticoagulants did not have an effective reversal agent. So if a patient on one of these new blood thinners came in having injured themselves, with uncontrolled bleeding, it was very difficult to stop the bleeding. We did discover that prothrombin complex (Kcentra is the brand name) worked pretty well. The hitch was that it cost about $5000 for the usual injection. We still used it, but it definitely put a dent in pharmacy budgets in hospitals. Andexxa was specifically developed to reverse two of these newer anticoagulants, apixaban and rivaroxaban. It can be dosed low or high, depending on the dose of the anticoagulant. One high dose treatment costs...wait for it...think high...YES. $49,500.

Costs of this magnitude are hard to put in context. I have read that there are about 750,000 people on the newer anticoagulants. If one in a hundred of them had a bleeding episode in a year which was treated with Andexxa, that would be nearly 400 million dollars. 400 million dollars is enough money to buy a year's supply of a nice cheap generic blood pressure pill for 10 million people to help prevent the atrial fibrillation which eventually leads to prescription of the anticoagulant. Or enough money to pay for a week's vacation to Hawaii for 10,000 people, which is mostly irrelevant.

What makes me sad here is that these new drugs are being pushed out of the pharmaceutical pipeline and, although they have the potential to reduce misery if used for the conditions they can treat, they will bankrupt either real people or health care budgets or both. The folks who could benefit from them will perhaps achieve better health only to be crushed by debt or unable to afford health insurance.

Something could be done to fix this.

Pharmaceutical companies are motivated to create drugs whose high prices and popularity will result in profits. We can, however, fund drug development in a different way. If academic labs developed drugs through grants from the National Institutes of Health or other government agencies, their costs would not need to be made up by sky high drug prices. In fact, since the government pays the vast majority of health care costs in one way or another, the payoff for these grants for drug development would be through lower pharmacy costs and also improved health and productivity. This kind of payment would favor affordability and efficacy, not just expensive drugs that add very little incremental benefit for patients.

For now, new drugs come from pharmaceutical companies and are priced beyond what a conscientious health care system can pay. Still, these drugs will be advertised and prescribed and health care costs will go up and medical debt will destroy lives. It's really hard to get excited about this most recent batch of wonder drugs.