Back to Table of Contents | June 2011

Cover Story

Is there a doctor on board?

Ten physicians share their stories about mid-air medical emergencies.

By Jeanne Mettner

For physicians heading off on a vacation or looking forward to getting home after a long conference, hearing the call for a doctor on an airplane can evoke a variety of responses. Those who spend their days and nights dealing with emergencies might be quick to stand up and confidently offer to help; others, concerned that they may not be able to handle a situation outside their specialty, may slump in their seats and secretly wish they had become anything but a physician.

Regardless, it’s not unlikely that physicians will one day hear those words and find themselves serving as first responders on an airplane. MedAire, a company that provides on-the-ground medical assistance for commercial airlines around the world, reports that more than 19,000 in-flight emergencies occurred among the airlines they served in 2010, of which about 470 required a premature landing. As only a third of commercial airliners in the world use MedAire, that number likely is a gross underestimate of all the in-flight emergencies that occurred. What’s more, airlines are not required to report emergencies unless they prompt the pilot to divert the flight. “There is no central data repository for the number of in-flight emergencies, and no one agency or organization has been put in charge of keeping track of those figures,” says Claude Thibeault, M.D., medical advisor to the International Air Transport Association, an international trade body for the airlines, and former chair of the Aerospace Medical Association’s Air Transport Medicine Committee. Although numbers are not firm, we know that in-flight emergencies happen often enough that a physician is likely to encounter one.

Minnesota Medicine recently asked readers to tell about situations they’ve confronted while flying, and to describe what they did and what they learned—about themselves and about what they would do the next time around.

“I had that rush of adrenaline, the butterflies, the whole thing.”

In 1996, David Bjork, M.D., and his wife were traveling to Disney World with two of their daughters and members of their high school choral group for a series of concerts and contests. Ninety minutes into the flight from Minneapolis to Orlando, the airline attendant called for a doctor. “I immediately got into this mode like I was going into a football game to take someone’s place,” recalls Bjork. “I had that rush of adrenaline, the butterflies, the whole thing.”

The patient turned out to be one of the students, who had type 1 diabetes and was in the midst of a hypoglycemia-induced seizure. The boy could not take in any food or drink to stabilize his blood sugar. However, Bjork found intravenous dextrose solution in the plane’s medical kit and administered it promptly. The boy recovered by the time the plane landed in Orlando and was able to participate in all of the choral festivities.

“For a moment, there was this question of whether to direct the pilot to land at the nearest airport or to stay on course,” Bjork says. “In the end, we continued the flight, but it was a tense few minutes. I felt like I had 300 eyes looking at me saying, ‘Don’t you dare divert this plane because we want to get where we are going.’”

Bjork has been called to assist in several other in-flight emergencies since then, although none have been as memorable as the first one. Now in his 29th year practicing medicine, when the call goes out he knows to ask for the plane’s emergency medical kit and do what he can. “Usually, when this kind of thing happens, my wife nudges me in the side and says, ‘Get going,’” he says. “You just have to do what you’re trained to do and let it unfold.”

“I couldn’t hear a thing.”

Two years ago, Charles Andres, M.D., was on his way from Paris to Mumbai with his wife when the French-speaking co-pilot experienced a sudden onset of lower, left-quadrant abdominal pain. Because Andres had lived in France for three years after college, he was able to communicate with the pilot. He discovered that she had never experienced this discomfort previously and that pregnancy was a possibility. “Once I showed my license, they opened up the medical pack, which pretty much provided all the equipment we needed for that particular case,” recalls Andres, a semi-retired emergency medicine physician at Cuyuna Regional Medical Center in Crosby. “I do remember that the stethoscope was just awful. It was like the kind you get your kids when they want to play doctor. I couldn’t hear a thing.”

After examining the woman in what Andres describes as “tight quarters,” he began to suspect that she had a kidney stone. The information about the medications in the medical kit was in French, and Andres was not confident about using them. So he used an application on his iPhone to identify the drugs and obtain proper dosage information. Andres administered an oral, dissolvable narcotic, along with an injectable nonsteroidal anti-inflammatory, then sat with the woman for a couple of hours before returning to his seat. “I checked in on her periodically; but when we landed, I ended up getting off the plane before she did,” he explains. “I never found out ultimately what happened; it would be nice to know how things turned out.”

Andres says that tending to a passenger or crew member in-flight can make you feel like you are flying by the seat of your pants. “It requires you to rely almost solely on your experience and impressions rather than on all the technology and testing that’s usually available in the clinic, and that can make you feel incredibly uncomfortable,” he says. “But we are obligated.” His advice to physicians who hear the question “Is there a doctor on board this aircraft?” “Go find out what you can do—now.”

“My first response was that I didn’t want to get involved.”

In 1982, Allan Solum, M.D., and his wife were traveling from Munich, Germany, to Minneapolis when he encountered his first-ever in-flight medical emergency. Less than an hour after takeoff, the announcement came that a doctor was needed. “To tell you the truth, my first response was that I didn’t want to get involved,” says Solum, a family physician at the Paynesville Area Health Care System. “I looked up and down the aisle several times, and when no one responded, I pressed the button.”

The ailing passenger was a college-aged male, who was lying on a collapsible bed near first class. He was pale and sweaty, and was massaging his abdomen and vomiting. “He admitted that he had been drinking too much and sleeping too little,” Solum recalls. “I examined him, poked and prodded him a bit, and looked for focal and rebound tenderness.” Solum concluded that the man had nothing more than a bad hangover.

The captain called Solum to the cockpit and asked if he should divert the flight to London or even go back to Munich. Solum said that after examining the patient, he didn’t think an emergency landing was necessary. “I was kind of surprised at the authority they gave my decision,” he recalls. “I think if I would have said, ‘Turn the plane around and go back,’ they would have done just that—at tremendous expense and inconvenience to the other passengers.”

Solum continued to check on his patient, and when they landed in Minneapolis 12 hours later, the two men walked off the plane together, shook hands, and parted. “In retrospect, I learned that a physician is always a physician, whether you are in the clinic or in the air,” he says. “We can’t hold back and hide just because we are on vacation; we have skills and expertise that can change the outcome of a medical situation—whatever that situation might be.”

“I ... have ... chest ... pain.”

On a flight from Minneapolis to Tokyo in 2005, Greg Plotnikoff, M.D., an internal medicine physician at Abbott Northwestern Hospital in Minneapolis, had just returned to his seat after tending to a passenger who was hit by an errant snack cart when he felt a soft tap on his shoulder. He turned around and found a Turkish man in his early 70s who was clearly distressed. “Are you a doctor?” he asked in strained English.

“Yes,” Plotnikoff responded.

“I … have … chest … pain.”

Plotnikoff’s mind raced. He reached over the seat and took the man’s pulse. It was fast and irregular. The plane was packed, and he worried about where he could further evaluate the passenger. Business class had one remaining open seat, so the flight attendants moved him there, and Plotnikoff opened the plane’s medical kit.

Getting the information about his history and medications was complicated, Plotnikoff says, “because the man’s English was not ideal.” He learned that the man, who was bound for Singapore, had no cardiovascular history. He was alone, hypotensive, and had irregular tachycardia. Plotnikoff gave the patient an aspirin, laid him flat in the seat, and did a one-lead electrocardiogram, which revealed atrial fibrillation with normal ST and T waves.

Plotnikoff’s assessment was that the man needed rate control with digoxin, fluids, and oxygen support. Before administering intravenous digoxin, however, he wanted confirmation of his differential diagnosis and treatment plan. But contacting a medical consultant on the ground meant he had to enter the cockpit. To do that, Plotnikoff needed to provide a copy of his passport and medical license and attest to the severity of the man’s illness and that he had no previous relationship with the patient. After confirming his treatment plan with a consultant from Mayo Clinic, Plotnikoff administered the digoxin, fastening the IV bag onto a hanger placed on the overhead bin. “At that point, the man went into normal sinus rhythm, his blood pressure came up, and his chest pain went away,” Plotnikoff says.

The pilot had asked if he should divert the plane. But Plotnikoff told him to stay the course. At that point, Tokyo was five hours away. For the remainder of the flight, Plotnikoff monitored the patient and wrote a detailed medical report on the English-only form that would be given to the medical team when they arrived in Japan.

About five hours later, the plane landed in Tokyo. Plotnikoff, who speaks medical Japanese, began explaining the situation to the medical crew. “It was the worst hand-off I could have imagined; there was no interest in the patient’s history, no interest in what happened on the plane, no interest in my report or my differential diagnosis and the next steps; the only interest was in getting [the patient] to the hospital,” Plotnikoff recalls. “Here’s an elderly Turkish gentleman who had no intention of going to Japan, who didn’t speak any Japanese, being handed over to people who didn’t speak English. It was horrifying.”

The next day, Plotnikoff called the hospital to check on the man. “They said they gave him another aspirin and sent him on to Singapore,” he says. “I was astonished.”

Plotnikoff advises fellow physicians to have a template for clinical decision-making in the event of an emergency that covers worst-case scenarios. He also says to not hesitate contacting medical support on the ground to review the assessment and treatment plan. “It took me a while to convince the pilots that I should be allowed to enter the cockpit, but the on-ground peer was worth it,” he says.

“She was all alone.”

Flying to New Orleans for a medical conference a decade ago, Laurie Drill-Mellum, M.D., was asked if she could assist a woman in her late 70s who was experiencing shortness of breath. The woman, who had congestive heart failure and was on her way to see her son in Louisiana, had just been released from a hospital in the Twin Cities. She was dependent on oxygen and was traveling without it.

Drill-Mellum, an emergency medicine physician with Ridgeview Medical Center in Waconia, examined the woman and told the flight attendant she needed oxygen. But the tanks on board were small. “We calculated that we’d only have enough oxygen for a two-hour flight,” she says. The duration of the flight was three hours. “The attendants asked me if this could become serious, and I said, ‘Yeah.’”

Once the attendants conveyed the gravity of the situation to the pilot, he diverted the plane and landed in Nashville. The decision upset the woman tremendously, which made Drill-Mellum feel both guilty and sad. Says Drill-Mellum: “In her hierarchy of needs, it didn’t matter to her whether something bad happened to her. She was very clear about that. She was all alone, wheeled on this plane without the oxygen she desperately needed. All she wanted to do was go home, and instead I was sending her to a strange hospital in a strange city. I had no choice. She wasn’t in extremis, but she could have been if we kept her up in the air.”

When Drill-Mellum said goodbye to the patient at the airport, she felt the woman would be fine as long as she received the oxygen she needed. She never heard from her again.

Although Drill-Mellum deals with emergencies all the time, she understands that other physicians might feel apprehensive when a call goes out for a doctor. She advises fellow physicians who find themselves in such a situation to take a moment to collect themselves before taking action: “When you are facing a difficult situation, take a deep breath and relax before standing up to do what you need to do.”

“What am I going to do if this guy crashes?”

Elizabeth Koffel, M.D., was in her last year of medical school at the University of Minnesota when she responded to her first in-flight emergency two years ago. Heading back to Minneapolis after doing a two-month elective in Puerto Rico, Koffel felt obligated to respond when the pilot’s repeated calls for a doctor went unanswered.

Warning the crew that she had not yet received her medical degree, Koffel was directed to a man in his early 50s. He was sweaty, his right arm was tingly, and he was drifting in and out of what seemed to be a sleepy state. Because she was not yet a doctor, Koffel could not gain access to the medical kit (she would have needed to give her medical license number to access it). All she could do was take the patient’s history, examine him, and dispense aspirin and oxygen.

The man didn’t have a personal history of cardiovascular disease. But Koffel, who kept monitoring his pulse during the flight, was concerned. “I kept thinking, ‘What am I going to do if this guy crashes?’ It was terrifying. I knew I could do CPR, but it was such a tiny space.” Because they were close to Minneapolis, the flight was not diverted and when they landed, paramedics whisked the patient off in a wheelchair.

Koffel is now a first-year resident in internal medicine at Abbott Northwestern Hospital. She says the experience has changed her approach to travel. “Whenever I’m going on a plane now, I bring my own stethoscope and a small first aid kit,” she says. “It’s always in the back of my mind when I’m in flight that this could happen again.”

“We had no way to intubate her.”

While on board a January 2011 flight from Minneapolis to Miami, the first leg of a trip to Peru for a medical mission, Melissa Clark, M.D., a pediatrician with Metropolitan Pediatric Specialists in Burnsville, noticed something was amiss. Three rows in front of her, people were gathered in the aisle, and a tall, burly man was bending down, tending to someone. The flight attendants looked worried. Clark didn’t think to immediately awaken her traveling companion, Lisa Callies, M.D., whom she had just met and who was accompanying her on the mission. Instead, she walked up the aisle and introduced herself to the person at the center of the attention—a woman in her 60s.

The woman had experienced a brief, unresponsive episode, during which she stopped talking, couldn’t focus her eyes, and didn’t respond to questions. She was traveling to Miami with her sister and two adult daughters. Clark learned that she had metastatic breast cancer and that the trip was her “last hurrah.”

When Callies, an internist with Abbott Northwestern Hospital in Minneapolis, joined them, she discovered the passenger also had a history of atrial fibrillation. Because the woman was still feeling lightheaded, Callies took her pulse and found it was irregular. Her blood pressure was low, too.

Callies cleared out a row to make room for the woman to lie down, then went to call the medical responders on the ground. Clark stayed with the woman and held her hand. “She was telling me, I’m so glad you’re here. I’m so glad you are going to help me,” Clark recalls.

Ten minutes later, the woman went into full cardiac arrest. Callies immediately rejoined Clark and with the help of a former EMT on board began resuscitation efforts. Then the frustration began. First, the plane’s automated external defibrillator, a piece of equipment required on all U.S. flights, couldn’t sense the woman’s heart rhythm, and Callies could not override it. Second, the emergency medical kit contained medications that would have been appropriate for restoring heart rhythm, but they could only be delivered intravenously, which was next to impossible since the woman had just undergone chemotherapy and had no central line access or adequate vein to cannulate. Third, the endotracheal tube and laryngoscope, which were listed in the contents of the unopened medical kit, were nowhere to be found. “The woman had been vomiting, so she had no clear airway, and now we had no way to intubate her,” recalls Callies. “I was totally at a loss.”

In a last attempt at resuscitation, Callies, Clark, and the former EMT performed CPR with chest compressions only. The plane was diverted to Orlando and landed almost immediately. “EMS stormed the plane as fast as the pilot could park it and within 10 seconds had scooped the woman off the plane,” Clark recalls. She was doubtful the passenger would survive.

Two months later, Clark was traveling to Mexico with her family when a call for a doctor came over the plane’s PA system. “My first reaction was ‘Come on!’ Then my heart began to race, I started breathing fast, I had this fight-or-flight response,” she recalls.

The call ended up being for a passenger with a migraine headache, and someone else volunteered to tend to the passenger before she could. “That reaction made me realize what I already knew: I will always be a little different because of what I experienced. But I’m glad I was there to help,” she says.

“I began to worry about … his heart going into electrical chaos.”

Stephen Hustead, D.O., had embarked on what he thought was a well-deserved vacation when he boarded a plane in Minneapolis that was bound for Orlando, Florida, several years ago. An hour into the flight, his wife (a pediatric neonatologist) elbowed him in the ribs, prompting him to take off his headphones. She had heard the announcement.

“They’re looking for a doc,” she said.

“Well, you’re a doc,” he replied.

“I don’t think the emergency involves a neonatal infant,” she countered.

Hustead, an electrophysiologist with Mercy Metropolitan Cardiology Consultants in Coon Rapids, went to the front of the airplane and saw a 40-something man whom the airline attendant noticed in passing was “not looking so good.” The man admitted he was having chest pain. For Hustead, such patients were familiar territory.

With the help of a nurse who had also responded to the pilot’s announcement, he got to work. The plane had an extensive medical kit, which included heart monitoring equipment. He attached two leads to the man’s chest to assess his heart rate and rhythm. “Normally with an electrocardiogram in the clinical setting, you’d have 12 leads, but even with two, the monitoring set-up showed remarkable electrocardiographic changes that were consistent with this man having an acute heart attack,” recalls Hustead. “The biggest thing I began to worry about at that point was his heart going into electrical chaos—ventricular fibrillation. Many people die before they can reach the hospital.”

Hustead administered aspirin, intravenous beta blockers, and morphine for pain relief—all of which were in the medical kit. When asked if he wanted to reach Mayo Clinic’s on-ground medical consultants by satellite phone, he declined, thinking that he would be talking to a fellow or someone in training.

After learning that Hustead was a cardiologist, the pilot asked him if he wanted him to land at the nearest airport, which happened to be Atlanta. Hustead told him to land. “By all means, I thought this was the real deal,” he said of the patient’s suspected heart attack. The plane landed almost immediately.

But the patient wasn’t out of the woods. The Atlanta emergency medical response team took an agonizing 30 minutes to get the man off the plane. “I tried to explain to them that I was a Minneapolis cardiologist, that this man needed to get to a cardiac center for primary angioplasty; but I really felt they didn’t take me seriously,” Hustead recalls. “I was worried that this man was going to have to be resuscitated right there on the plane in front of his wife and kids.”

A month later, the wife of Hustead’s mid-air heart patient emailed him to tell him her husband was doing well and to thank him for his help.

When Hustead returned home, he spoke to his cardiology group and hospital staff about his experience. He emphasized the quality of the medical kit on the Northwest Airlines flight he was on. “I thought it was reassuring for physicians to know that they can have the medical equipment and resources to respond to these cases,” he says. “Hopefully, that will facilitate people stepping up in the future.”

“They seemed skeptical at first.”

Jacob Tjaden, D.O., a fellow in child and adolescent psychiatry at the University of Minnesota, encountered his first in-flight emergency last January. About halfway through the five-hour flight to Peru, he heard the call for a nurse or doctor. Tjaden had settled in for the flight, and had even had a beer at that point. After hearing the call a second time, he responded.

When he approached the front of the plane, Tjaden came upon a fit-looking but distraught 19-year-old woman from Argentina. She spoke only Spanish, and the flight attendants’ English skills were not adequate for translating during a medical emergency. Tjaden knew a little Spanish. “I had to go back and forth with the flight attendant to try to convey what I was asking and understand her answers,” he says.

Tjaden learned that the woman was experiencing numbness on the side of her face and body. He provided his medical license number, so they could open the medical kit, but he only used the blood pressure cuff and stethoscope, which he describes as “crappy.” Tjaden found the woman’s pulse to be regular but tachycardic and noticed that she had low blood pressure. He learned that she had no personal or family history of cardiovascular disease but that she did have a history of migraines.

He concluded that she was having a migraine and a panic attack. He told the woman to let him know if her condition worsened before they landed and advised her to follow up with her primary care physician or urgent care. The rest of the flight was uneventful. At the end, the attendant told him the passenger was feeling better but still had slight residual numbness. Months later, Tjaden can’t shake the feeling that the crew may have found him a bit suspect—being only 30 years old, and wearing sandals and exercise pants. “They seemed skeptical at first, but in the end, they did seem appreciative that I helped.” MM

Jeanne Mettner is a Minneapolis freelance writer.