Friday, July 27, 2018
Overachievers on a plane
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..