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Is There A Doctor Aboard? Medical Emergencies In The Clouds


Is there a doctor onboard? Dr. Celine Gounder has heard that page from a flight attendant five times, three of those cases turned out to be genuine emergencies - dangerously low blood pressure, dehydration, chest pains. In an article for The Atlantic, she describes attending patients whose medical histories are a mystery with problems completely outside her specialty, with limited resources, little or no backup and with a responsibility to decide whether to advise the crew to make an emergency landing. Dr. Celine Gounder joins us now from our bureau in New York. Good of you to be with us today.

DR. CELINE GOUNDER: Thank you, Neal.

CONAN: And tell us about what happened on your trip from Sao Paulo to Johannesburg back in 2009.

GOUNDER: Sure. I was flying to attend a conference in Rio de Janeiro. And on the flight from Jo-burg to Sao Paulo, two patients had low blood pressures. The first was a young woman who was dehydrated from having traveler's diarrhea and the second was more concerning. It was a middle-aged obese diabetic man. He was sweaty and dizzy. His blood sugar was normal - I did think I check that. But his blood pressure was really low. And my biggest concern was that he'd had a heart attack. I tried to put in an IV. One of the things you do when somebody has low blood pressure is you try to give them some fluids to support their blood pressure. And I just couldn't get the IV in. You know, this was a guy who's pretty obese; it was just hard to find a vein. And...

CONAN: You said what you needed was a nurse.

GOUNDER: Yeah. You know, any doctor will tell you that nurses are much better at putting an IV than a doctor just because they do it more often. They have more practice doing it. So I had him drink as much as I could so he could get fluids in that way. I put an oxygen mask on him. But I was still worried, I might have to perform CPR on him and, you know, it's hard to lay somebody out flat in the middle of the aisle to attend to them in the middle of a flight. I did ask the flight crew to have an ambulance waiting for him at the gate when we landed. You know, we were flying over the ocean so it couldn't really make an emergency landing. And I was pretty upset that they didn't really understand the severity of the situation. They took away his oxygen before we landed, and then at the gate there was no one there to meet him. He was literally the last person to get off the plane.

CONAN: His oxygen - this was a separate canister. They said it's too dangerous to have that rattling around the cabin.

GOUNDER: Exactly. Exactly. It was an oxygen tank and they were worried, you know, it might go flying, I guess, during landing.

CONAN: You said you checked his blood sugar. Was there, you know, equipment to do that in the - onboard, in the emergency kit?

GOUNDER: No. That was actually his own glucometer. There was not a glucometer, which is what you use to measure blood sugar, in the kit.

CONAN: So I'm - in other situations, you've come across, well, how much can they put in an emergency kit but on a plane, there's limited amount of room but, you know, maybe they could put a little more.

GOUNDER: Yeah. And I feel like, you know, some of the decisions about - or some of the things that are included in the kit you could actually do without. You know, if you break your arm falling in the middle of a flight, I suppose, you know, do you really need a splint emergently or could you wait until you land and not something bulky? Whereas having, you know, a glucometer to check somebody's blood sugar, to me that's something that would be useful to have.

CONAN: We're talking about what happens on aircraft and of course, the situation - you're at 35 - 40,000 feet. That alone creates some conditions.

GOUNDER: It does. So you do have a drop in your oxygen saturation. You have lower pressure of oxygen in the cabin. And for most people, you don't really notice the difference. You feel basically the same. Maybe a little more tired than you might usually. But for somebody who has heart or lung disease, that change in pressure can be significant. And one guideline, sort of, rule of thumb you can use if you're going to travel and you have a history of heart or lung disease, is can you climb a flight of stairs or walk 50 yards or so without getting short of breath? And if you can't, that lower level of oxygen on the plain is probably going to affect you.

CONAN: Five times that page has gone out. After those experiences, isn't there some way for the airlines to have resources of their own? They rely on volunteers?

GOUNDER: They do. They also rely - and this is something I learned just in reporting this story. I never was informed about this in any of the five incidents I attended to. Airlines have contracts with ground-based medical services. Med-Air is an example of one of these. It's based out in Arizona. And what you can do is if you're on the plane trying to respond, you can have the flight crew radio in to one of these ground-based medical services and you can explain, you know, this is the situation I'm dealing with.

And these are people who are expert in managing these situations, and they know exactly what resources you have on board. And I think we should do a better job - or the airlines should do a better job of getting them involved right upfront.

CONAN: Particularly if there's a situation where it's, you know, an oncologist or something, and somebody's having a heart attack.

Particularly if there's a situation where it's, you know, an oncologist or something, and somebody's having a heart attack.

GOUNDER: Exactly.

CONAN: Ingrid is on the line with us from Boston.

INGRID: Hi. Thanks so much for having me.

CONAN: Sure. Go ahead, please.

INGRID: I had a similar story. I'm a physician at Brigham and Women's Hospital in Boston, and both my partner and I were residents at the time. We were flying from Boston to Geneva with a stop in Amsterdam, and it was a full flight. And somewhere over the Atlantic Ocean, we hear the page go off overhead that they need a physician onboard. Interestingly, we were the only two physicians to get up, and I think, largely because we were residents at the time, we're just trained to respond to emergencies.

And we jumped up and a nurse got up which, as you were saying, was very valuable because she started an IV for us. It was an elderly woman who - unfortunately her husband only spoke German. She was completely passed out. She didn't have a pulse at the time, but we were able to resuscitate her. And the captain asked us if we needed to land the plane, which we did suggest that he would do. And we landed, I think, somewhere in Ireland. And, you know, they were grateful. They brought her off the plane. She was responsive.

And then we were told to get back to our seats. And we missed our connecting flight on to Geneva. And I thought, you know, we really do this because we believe in good - providing good care for people and, you know, we want to help people. But you wouldn't - you shouldn't be doing it to expect something in return. And maybe that's why we were the only physicians who got up. I just thought that was interesting.

CONAN: It's interesting. Dr. Gounder, you say, yeah, you're a physician and you're trying to help. You're also a passenger, and you don't want to divert an aircraft, you know, you're going to miss your flight.

GOUNDER: Right. I mean, you know, and this particular instance where I was flying from Johannesburg to Sao Paulo, I had a connecting flight from Sao Paulo to Rio. I was supposed to give a talk at a conference the next day, you know, and so just like everyone else, you know, we're traveling for a certain reason, whether it's business or pleasure, and if you do divert a plane, it'll impact you too.

CONAN: Thanks very much for the call, Ingrid.

INGRID: Thank you.

CONAN: Let's see. We go next to - this is Jack. Jack with us from Franklin in Tennessee.

JACK: Hi, Neal.

CONAN: Hi. Go ahead, please.

JACK: Yes, sir. I'm actually an airline pilot for a major airline and had a medical situation onboard last Saturday over the middle of the Caribbean, and it was kind of unusual in that there weren't really a lot of suitable alternates. We were over an hour from either Miami or Fort Lauderdale, a little under an hour from Nassau.

But as your guest mentioned, our company does contract with a firm that provides (unintelligible) And in fact, we are required to contact them either by phone or VHF radio to get advice as to whether to divert or not. And it just so happens in this case the radio link was not working. It was a remote station off Grand Turk Island. And - so we weren't able to contact the company.

We were fortunate to have a husband and wife physicians on board that were able to stabilize the patients. And it's kind of funny. It seems like in a lot of instances, given a little bit of time, people seem to stabilize and things look different by the time and get better.

CONAN: Sometimes they do, and I think sometimes they don't, Dr. Gounder.

GOUNDER: Yeah, I would agree with that. I mean, a lot of times, it's something minor. They just, you know, are a little dehydrated because they, you know, are traveling not eating and drinking normally. They might have some diarrhea and, you know, just with a little time, a little rest, some water, orange juice, whatever it is, they feel better. But it's hard to know in the instant, without knowing the patient or really much of anything about them. It's not always easy to make that call.

CONAN: Jack, what would you have done had there been no doctors aboard?

JACK: Well, we would have relied on what information we were getting from our flight attendants. I suspect, most likely, we would have wound up diverting. There were some alternatives, you know, Santo Domingo, Punta Cana, places like that. I wouldn't necessarily want to go if I were having a heart attack, but if the situation dictated it, I'm sure that's what we would have done.

CONAN: All right. Jack, thanks very much, and glad it all worked out.

JACK: Yeah. Thanks, Neal.

CONAN: Here's an email. This is from Catherine Collins, M.D.: Sudden turbulence, middle of the night, flying to Australia, plane dropped several hundred feet in an instant. Everyone not belted in flew upward. Many passengers and flight attendants hit heads on overhead compartments. I'm an ER doc. Gladly attended to several injuries but thankfully mostly minor. One flight attendant needed stitches on arrival. Airline mailed me a bottle of wine in thanks afterwards with a note of thanks. So there is unusually some reward for services rendered.

And it's interesting, Dr. Gounder, there is a Good Samaritan Law, that if you respond in an emergency, unless you do something really, terribly, terribly wrong or willfully wrong, you're going to be OK, you can't be sued.

GOUNDER: That's right. You know, as long as you're not being financially compensated for your services and you're not willfully doing something wrong to hurt the patient, you know, and that might also include somebody who misrepresents themselves as being a physician and practicing outside their scope of knowledge.

But, you know, if you're a physician or other trained professional and health care, you know, you're not going to be held liable for just doing the best you can for a patient.

CONAN: We're talking with Dr. Celine Gounder, an infectious disease and public health specialist about the article she wrote for The Atlantic about emergencies at 40,000 feet, on aircraft. You're listening to TALK OF THE NATION from NPR News.

And if you'd like to read the article, there's a link to it at our website. Go to npr.org, and click on TALK OF THE NATION. And this is Mobean(ph). Mobean with us from Jacksonville.

MOBEAN: Hi, Neal. I'm actually a pediatrician. I'm (unintelligible) specialist. And when I were - I went five occasions when (unintelligible). What I want to say is when their call is if there's a physician on the aircraft, I wish and pray that there is an internist on the plane, because it's usually not a child, but I have had raised my hand sheepishly a few times.

I think that's really scary, but I think that does make a difference because at least, you know, one of - I heard your caller was saying that a German - speaking out of that situation when I was a resident and looked like patient (unintelligible) we've asked (unintelligible) bunch of thumbs, and, well, take this. It helps but I think it's really scary that, you know, when they say, is there a physician, I think they should say that the physician, there is not a pediatrician on the plane.

CONAN: A physician that - well, Dr. Gounder, I wonder - and thank you very much for the call, Mobean. Do you wonder - I did not see this in your article - that some physicians went traveling and that call goes out, some doctors don't respond.

GOUNDER: Certainly some doctors don't respond because they don't feel comfortable practicing outside of their scope of knowledge or in an unfamiliar environment. One thing I would say is, you know, with the exception of maybe a radiologist or a pathologist who's far out of med school and training, doctors can generally perform a basic physical exam and obtain vital signs. And that in conjunction with ground-based medical services really does put you in a position where you can manage things.

Now, one of the doctors I interviewed for my piece, Dr. Michelle Hsiang, she is also a pediatric infectious disease specialist, and similarly found herself in uncomfortable situations where she was being asked to help with older people with complicated medical issues that she hadn't really ran into since medical school.

But had she'd been offered the support of ground-based medical services, I think she would have been in a much more comfortable situation because she knows how to take a blood pressure, she knows how to check vital signs and perform and exam.

CONAN: Let's go to Greg. And Greg is on the line with us from Birmingham.

GREG: Yes, Neal. Thank you. I appreciate very much what the doctor shared. I've been in a similar situation about 15 years ago on a flight from Seoul to Seattle-Tacoma, Sea-Tac, and they made a call about an hour from Seattle. The flight crew made a call out in the cabin for any medical professionals. And I responded - I'm a paramedic - along with a retired veterinarian. And our patient was a young military man who was unconscious. And we had to determine what caused him to be unconscious and do a little Sherlock Holmes work.

The flight crew was helpful in letting us know how much - roughly how much alcohol he had consumed, which probably added to the situation. He also had a little Dopp kit with him that contained numerous prescription medications. And we noticed that he's - we took his vital signs. This was 15 years ago, but they did have a blood pressure cup and a stethoscope on board, so we were able to monitor his vital sign, keep his airway open and provide him supplemental oxygen. He was breathing on his own but we've supplemented that with a little bit of the bag and oxygen.

And they gave us a direct flight or direct path right into the Seattle-Tacoma. We didn't have to wait for any other flight. That was helpful. And the ambulance actually met us on the tarmac before the plan even got to the jet way.

CONAN: And did you ever find out what happened to your patient?

GREG: I never did. I did receive a letter from the airline about a month later thanking me for assisting in that situation but never did find out what happened. Because his pupils were sluggish the way they were, I have a suspicion that he probably accidentally overdosed. A lot of people take sleeping medications on long flights like that, and when you combined those with alcohol, it can have a disastrous effect.

CONAN: I wonder, Dr. Gounder, as a passenger, do you ever any more order a glass of wine or a cocktail or take a sleeping pill?

GOUNDER: I used to take Ambien on flights. I used to do a lot of traveling, long traveling to sub-Saharan Africa. And that's part of the reason that you could say I'm at risk for running into these in-flight medical emergencies. Long flights are more likely to run into these things.

But I stopped taking Ambien because I was just too worried I was going to run into the situation where I've gone asleep at taking a sedative and wouldn't be able to respond. I'm not completely a teetotaler. I do have the glass of wine or two with dinner on the plane but that's about it.

CONAN: Well, Greg, thanks very much for the call. I'm glad it worked out.

GREG: Thank you. Bye-bye.

CONAN: And, Dr. Gounder, thanks for sharing your story.

GOUNDER: You're welcome.

CONAN: Dr. Celine Gounder, infectious disease and public health specialist. She joined us from NPR's bureau in New York. We put up a link to her article on The Atlantic on our website. I'm Neal Conan, NPR News in Washington. Transcript provided by NPR, Copyright NPR.

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