Advertisement

The DO | Your Practice | Practice Wise

‘Is there a doctor on board?’ Advice and tales from 30,000 feet

Banner image

iStockphoto

William Bograkos, DO, was resting on a redeye flight from Los Angeles to Baltimore. Somewhere over Colorado, a call went out over the cabin speakers: “Is there a doctor on the plane?” Dr. Bograkos, a retired U.S. Army colonel, stood up and spoke to a flight attendant, who led him to the patient, a man with chest pains who was en route to a wedding. Dr. Bograkos gave him oxygen and had him take baby aspirin and nitroglycerin. Dr. Bograkos carries baby aspirin for emergencies when he travels; the nitroglycerin was the patient’s.

After the patient was stabilized, Dr. Bograkos coordinated with the flight staff and ground personnel to have emergency medical services waiting at the gate. Although he felt better after landing and wanted to head straight to the wedding, Dr. Bograkos insisted EMS take him to the emergency room to rule out any danger.

This story is an example of how physicians on flights can serve as good Samaritans and help flight staff care for sick passengers. It’s difficult to say how frequently physicians are called to volunteer on flights: U.S. airlines are not required to report in-flight medical events, and the Federal Aviation Administration doesn’t track them. Dr. Bograkos has answered the call on five flights. And MedAire, which provides medical assistance to crew members on about 60 airlines worldwide, assisted airline staff with 22,500 in-flight medical events in 2011. The company notes on its website that increasing air travel and life expectancy will likely mean even more incidents in the future. And recently, after hearing from DOs who volunteered, the AOA is taking steps to ensure flight staff recognize DO credentials.

What to know

What do physicians need to know to be ready to assist passengers in the air? And what level of care can be provided at 30,000 feet?

To start, identification is vital, says Dr. Bograkos.

“You need to have some ID in your wallet because it gives the patient confidence,” he says. “And it’s professional, and you’re showing respect that you understand the EMS system in the air.”

Dr. Bograkos recommends that DOs carry their state license card and, if they have them, their Advanced Trauma Life Support, Advanced Cardiac Life Support, Advanced Disaster Life Support and AOA cards.

In addition to these credentials, Dr. Bograkos says other DOs should carry baby aspirin like he does. It’s not necessary to carry any other medications, he says.

Almost all commercial flights will have a basic medical kit containing essential supplies such as oxygen masks and medical gloves, says Sanford Vieder, DO, the medical director of Botsford Hospital’s Emergency Trauma Center in Farmington Hills, Mich. And more and more flights now carry more extensive medical kits, which comprise IV bags containing a saline solution, catheters and other medications and can only be accessed by medical personnel.

Dr. Mitchell

“I try to become that calming force, to say, ‘Hey, everything’s going to be OK. I’ll sit right here beside you.’ ”
Dr. Mitchell

After presenting identification to the flight crew and receiving permission from them, the physician will examine and interview the passenger in distress. New DOs and those in fields that don’t require examination of patients, such as radiology and research, may wonder what they should do here, or if they should even step forward at all.

Stand up and respond anyway, says Mark A. Mitchell, DO, an emergency physician and the president-elect of the American College of Osteopathic Emergency Physicians.

“A lot of people would not feel comfortable responding,” he says. “But any medical assessment is better than none. Work within your scope, however, and realize that at 30,000 feet up, there’s nobody but you. Do the best you can.”

Hallie J. Robbins, DO, who has assisted patients on flights three times, offers an opposing perspective.

“Not every physician feels qualified or able to act in an emergency,” she says. “If you don’t feel like you’re the right person for the job, don’t volunteer, and don’t stand up.”

Some physicians have concerns about liability. Many physicians mistakenly believe good Samaritan laws don’t apply to them, Dr. Vieder says. But he notes that medical professionals acting in good faith in an emergency situation are protected by a provision in the federal Aviation Medical Assistance Act of 1998.

“You are protected against litigation if there’s a bad outcome so long as you don’t act outside the realm of your specialty or you don’t do anything that’s egregious,” he says. “So if I offer to assist on a plane and do what any other reasonable physician would do in a similar circumstance, I cannot be sued for taking care of that person.”

Physicians cannot accept payment for services rendered if they want to retain immunity from liability under good Samaritan laws, Dr. Vieder says. However, gestures of thanks from the airline, such as a voucher for a free flight, don’t count as payment.

What to do

It’s important for the physician to try to calm the patient down if possible and keep the situation under control, Dr. Mitchell says.

“People can get panicked, especially when they are 30,000 feet in the air,” he says. “And the fact that everyone’s focus is on you—on a plane—increases your anxiety as a patient. So as a physician, I try to become that calming force, to say, ‘Hey, everything’s going to be OK. I’ll sit right here beside you.’ ”

Dr. Bograkos

“You need to have some ID in your wallet because it gives the patient confidence.”
Dr. Bograkos

Physicians who don’t have the equipment they need or the experience necessary to provide care can also assist in this regard, Dr. Vieder says.

“As a physician, you have the ability to bring calm to what is potentially an otherwise anxiety-provoking circumstance, even if you’re not able to provide medical care,” he says. “Physicians are able to think things through logically. Any physician has the opportunity to offer something in a circumstance like that and he or she shouldn’t be afraid. Just understand what your limitations are, and don’t go beyond them.”

But when it comes to treating patients, physicians in the air are going to be operating without much, if any, medical equipment, Dr. Bograkos says, which will limit their options.

“You’re a physician,” he says. “But without equipment, without a hospital, you’re just a highly educated EMT.”

Dr. Bograkos suggests physicians do a basic ABC—airway, breathing and circulation—examination, collect an AMPLE history and document both efforts. AMPLE stands for allergies, medication, past medical history, previous surgery, last time you ate and events leading up to the incident.

The documented AMPLE history will be valuable information for the EMTs waiting for the patient at the gate, Dr. Bograkos says.

The physician should communicate with the flight attendant about the patient’s status, Dr. Bograkos says. The physician can also make the recommendation to divert the plane, if necessary. The flight attendant will share the physician’s updates and recommendations with the pilot and co-pilot, who can coordinate any necessary emergency medical assistance, such as paramedics.

Physicians should also be aware that every U.S. airline will have access to ground-based medical support, says Erin Mitchell of MedAire. The volunteering physician can be the in-air eyes and ears for the medical support staff on the ground.

Friendlier skies for DOs

Over the past several months, two DOs brought to the AOA’s attention aerial incidents in which they rose to the call for a physician, but encountered confusion when they presented their credentials.

Dr. Robbins responded to a call for a physician onboard a flight from New York to Minneapolis. A woman had passed out following complaints of abdominal distress. When she revived, Dr. Robbins performed a craniosacral technique. She then spoke to the flight crew to request a wheelchair during the layover and discuss the possible need for paramedics.

However, the flight crew leader wrongly told Dr. Robbins that only an MD can call for paramedics.

Dr. Robbins shared her story with the AOA, who had recently heard about a similar incident involving another member.

To verify that osteopathic physicians were recognized by airlines, AOA staff reached out to the ones in question as well as all other major U.S. airlines. Most air carrier handbooks recognize both DOs and MDs, the AOA found, though some do not specify designations and instead note that any licensed health care professional can assist. One airline, JetBlue Airways, listed only MDs in its handbook. After hearing from the AOA, JetBlue said it would revise its handbook to include DOs as physicians who can care for patients on flights.

In Dr. Robbins’ case, Delta Airlines apologized in a letter and said it would have a service trainer make sure that particular flight crew—and other Delta flight crews—would be educated more appropriately in the future. The airline also gave her a $100 gift certificate.

Dr. Robbins suggests other DOs be vigilant if they encounter doubt in the air.

“Make sure you stand your ground—the person who’s hurting is worth the effort,” she says. “Be strong if someone is telling you that you’re not qualified and you are. Then be clear and recognize that the emergency has to be handled and the patient needs your focus.”

rraymond@osteopathic.org

14 Responses

  1. Matthew Geromi, D.O. on Feb. 1, 2013, 1:56 p.m.

    Great article. I am a former flight attendant and now a physician. I’ve been on both sides – first as a crewmember for many years and now as a physician. As crew, we appreciated it so much when a physician stepped up to help. Last year, I assisted a crew with an onboard emergency and although it was not a life threatening situation, the crew was appreciative for my actions and assistance.

  2. Stephen Blythe, D.O. on Feb. 1, 2013, 2:14 p.m.

    A few years ago while at 35,000 feet reading an article in USA Today about in-flight medical emergencies I looked up to see a child lying unconscious on the airplane cabin floor at the front of the plane. I got there as the father and flight attendant responded. They provided their medical kit. We got an IV started and administered fluids – the young man remained unresponsive. The bad news, I discovered, is that the noise and vibration of the plane make it virtually impossible to determine blood pressure and pulse using traditional equipment. Even a palpable pulse and BP was not possible because of the vibration. The good news was the response from the flight crew. After a few minutes of non-response from this kid I advised the flight crew that he needed to be in an emergency room. The captain came out and advised me that we had “just passed over Tulsa and we will be on the ground in 15 minutes”. And we were. He was coming around as the paramedics took him off the plane. A BIG problem discovered also is that the plane cannot take off until everything in the emergency box has been replaced – and they don’thave extra emergency boxes to simply swap out – it took them about an hour of running around in the terminal to find all the pieces to replace what I had used. The next day the head flight attendant called and the child’s father called to thank me. He had apparently had a seizure due to an impending fever due to strep throat. The passengers never complained about the delay of their trip. It was nice to be able to help.

  3. Dennis Dowling on Feb. 1, 2013, 3:26 p.m.

    I have been in this situation a few times. There has never been a situation where the flight crew failed to allow me to proceed. However, none of them requested identification or proof. I did have a problem on one flight when a fellow passenger collapsed and bumped me and then hit his head and face sharply against my arm rest. He was lying prone and was responsive within a minute of me checking on him. I called to another physician on the flight, Peter Adler-Michaelson, DO, and we were able to turn him over after checking all neurovascular concerns and securing stability in his neck. Shortly afterwards, another patient collapsed but he was caught by a flight attendant. I requested that the pilot and co-pilot go on oxygen until we could figure out if there was a problem taht had wider ramifications. Peter saw the other passenger who informed him that the blood from the first passenger’s laceration made him woozy. The pilots were able to discontinue the oxygen (The overhead oxygen wsa not deployed for the passengers since we only saw the tow collapsed passengers and everyone else, including Peter and I, were feeling fine). The real problem occurred when the ground physician who was called wanted me to put the first passenger back into his seat. He reasoned that, if the passenger did not have significant neck pain or consciousness issues, we were safe in re-seating him. Given the circumstances, I over-ruled him and kept our patient in the aisle with the jury-rigged pillows, tape and magazines securing his position. The pilot gave me a choice of re-routing to Cleveland and landing in 15 minutes or continuing to our destination, Philadelphia, and landing in thirty. With the patient stable, we went to Philly (that made everyone, including the patient, happy). The paramedics came on board almost immediately and the transfer was efficient and seamless. Despite needing to complete three pages of forms, which Peter had to complete as well, we never heard anything from the airline. Given the opportunity, I would always respond. If I felt it was beyond my experience, training, or ability, I would secure the passenger’s saftety and insist on a quick landing.

  4. Jen Muhlbaier on Feb. 1, 2013, 3:57 p.m.

    What about medical students? Because we are not yet physicians, should we act like any other non-physician passenger?

  5. Cynthia Manninen, D.O. on Feb. 1, 2013, 5:18 p.m.

    In 2007 while flying from Amsterdam to Detroit I heard the call, “Is there a doctor on board?” I was the first to arrive to an elderly man in the window seat who was unresponsive. No pulse, no respirations. The male steward and I moved him to the aisle (with difficulty) and I began CPR. I was quickly joined by a just retired ER physician, his wife who was an ER nurse, an oncologist and an EMT. We had the ER doc run the code and did CPR for ? 45 minutes until we were able to land at a military installation in Labrador. It was a full flight and those passengers had to witness not only the CPR but intubation, an IV, meds, etc. Doing CPR on the floor while a jet lands is quite an experience. The code was called by the ER doc and the patient was removed by a local ambulance crew through the rear of the airplane. We also were on the ground for quite some time and arrangements had to be made for an autopsy at the nearest city in Canada. Fortunately my daughter was seated in a forward section and did not have to witness the entire episode. The man had been attending his 60th high school reunion in Hungary and was on his way home. It may have been quite some time before his seatmate realized that he was unresponsive and asked for help.
    The flight attendants were very grateful for our help and we were moved to first class for the remainder of the trip, given a bottle of champagne and a monetary coupon.

  6. Clarence Nicodemus, DO, PhD on Feb. 1, 2013, 5:45 p.m.

    I had a similar experience while I was a resident in 2007. The individual was unresponsive when I first saw him seated with an oxygen mask on in the rear of the plane where the crew had placed him after complaints of difficulty breathing. My residency was in Neuromusculoskeletal Medicine, but many of my rotations were in other specialty areas, so I felt fairly comfortable in responding. I was not asked for any credential, just my assurance that I was a doctor and that I could help. In attempting to examine the man, I also found that the noises and vibration within the plane made it impossible to listen to his heart sounds and to effectively evaluate his pulse. A crew member was on headphones in touch with the airline company emergency center talking him through things to check and do. He was also able to verify that I was doing the correct things. We came to the conclusion that he was pulseless and broke out the defib and emergency medical pack (EMP). I wanted to start an IV, according to protocol, but that required the use of a needle and needles on board the aircraft were scarce or disguised. In the EMP, there was a needle and an IV bag, however the needle was cased in a plastic “safety” device that rendered it impossible to use unless one knew how it was triggered or opened. Needless to say it was delaying matters. I had another crew member start CPR as she was trained, I tore apart the safety needle and attempted to establish a line and failed because there was no pressure. By that time, the defib paddles were unwrapped and available but shocking him did not good. Soon thereafter, the plane landed with a priority docking assignment, an EMT team boarded and took over. They debriefed me briefly and let me go without any further ID. I was the last to leave the aircraft. My wife was waiting for me with another lady who was also waiting for her husband. She was going to be disappointed when she found out about her husband. Overall, I think the crew were well trained and did a good job. The fact that they could get an “expert” on line to help is also good. The down side is the materials in the Medical Bag. They must be reviewed for appropriateness and ease of use to the first time user, such as I was. I did not need to be fumbling around with the needle and losing time.

  7. Thomas Horowitz on Feb. 2, 2013, 3:37 p.m.

    I have been drafted on several flights. I do carry a few items, as the flight medical kits are limited. ASA, NTG and Ondansetron have all proven useful. I also carry a small otoscope and a glucose meter. DO be conservative with the airplane kit, as there is no restock supply. When you find an item you would like is not available, DO NOT make a big deal about it. That only will increase the anziety of the patient and their family. Most important follow the lead of the cabin crew, they may not know medicine but they are experts on group dynamics in situations like these. I do agree we all need familiarization with the kits on board. Maybe we should have examples and flight medicine classes at AOA Meetings!

  8. Rose Raymond on Feb. 5, 2013, 1:57 p.m.

    Hi Jen, your question about medical students aboard planes is a great one. I asked Dr. Bograkos your question via email. He suggests that medical students identify themselves as such and behave like good Samaritans.

  9. Michael Band DO on Feb. 6, 2013, 8:42 a.m.

    I have volunteered a few times. Reoccurring themes are popping up and this is a great topic.

    Due to noise and vibration, the stethoscope is useless. I did not tell anyone (remain looking confident), but then checked pulse to at least verify heart beat.

    In the middle of my emergency help, I was asked to prove I was a doctor. I probably had some AOA card in my wallet, but no burgeoning proof.

    One of my emergencies the patient passed out from abdominal pain. Obvious treatment was keeping the patient supine with legs elevated. The flight attendants stated it was against policy to block the aisle and patient had to go back to her seat. I overrided her and it was not a pleasant scene. After what seemed eternity, the patient was able to get back to her seat safely.

    I really feel the airlines should provide us with more perks, as there is a doctor on most flights. I think they rely on us. They require us to fill out and sign forms after these events. There should be something in return, like first class upgrades for all doctors is available or a few free flights.

  10. Sarah on Feb. 16, 2013, 7:14 a.m.

    Great article. I am a medical student, & I travel a lot. I have always wondered as to what I should do if the need for a doctor is announced like Jen M’s question. I am glad to see the response to her question.

    But I guess my question is, should I still identify myself & offer my services if I feel nervous about being able to appropriately handle the case & there are no other doctors on board?

    Thank you.

  11. Christina E. Fitch, DO, MPH on Feb. 20, 2013, 12:06 p.m.

    I have responded to flight needs twice so far. The second time the gentleman was hung over and hyperventilating because he felt nauseated, but his symptoms included chest pain. The blood pressure cuff and stethescope were worse than Fisher-Price, so I travel with my stethescope in carry-on now. He vomited and then felt better, but I remained sitting with him for the rest of the flight. I was never asked for identification and never had to fill out a form. I gave a verbal signout to the EMTs and was the last off the plane, I was also asked to interpret the EKG that the EMTs did within minutes of landing. I called the patient´s wife, per his request, to let her know which hospital to meet him at. Never heard back from anyone. This would be a great session to have at an AOA meeting!

  12. Haley on Feb. 20, 2013, 1:55 p.m.

    Thank you for this article! I had never considered what I would do as a student if a doctor was called for and none stepped forward. I have to say I am surprised by the comment above wishing for perks, etc. It seems like a shameful, selfish thought. Do good for the sake of doing good, not because you expect something in return.

  13. Dennis Penzell,DO,MS, FACP on March 12, 2013, 5:57 p.m.

    I was the individual, mentioned above, who had credentials questioned on a flight last fall. Not only did I show them a copy of my license (we get a pocket copy in Florida), but they asked for my business card as well. They finally consented to bringing the plane down when I told them to radio the “person on the ground” that I would not take responsibility for their decision, especially since I was the one who was looking at the patient.
    I agree that you cannot hear a BP at 35,000 feet!

    I do have a question though. At what point does our “emergency service” become elevated to another level or standard of care if we bring various equipment on board? What about medications other than aspirin or nitro?

  14. Steve Radjenovich D.O. M.A. on March 13, 2013, 3:57 p.m.

    Several years ago my wife and I were on a non-stop charter flight from the Cayman Islands to Minneapolis.While waiting in the terminal to board I noticed a man who appeared acutely ill.(cyanotic, dyspneic,and diaphoretic).I commented to my wife he belonged at the hospital and not getting on an airplane. We boarded the plane and took off.Somewhere over Georgia there was a call for a Dr. I responded. The sick passenger was the man I had seen at the airport! He was unresponsive,blue-black in color and barely breathing. This was before medical kits so I administered oxygen and loosened his clothes. He was in his 60’s and had “heart trouble” according to his wife.I asked about meds she stated he took “heart pills”.I .asked to see them – they were in their suitcase in the cargo hold. I discussed the situation with the Captain and told him I didn’t think the passenger would make it to Minneapolis. He pointed out a city just ahead and said that was Atlanta.The crew was very efficient. He got permission from his company to land, declared an emergency, the copilot got out Atlanta’s approach plates and we were on the ground in 15 minutes.At about 5000 feet the pt became somewhat responsive.Because we were an international flight and this was an unscheduled stop we were not allowed access to a gate. We were parked on a taxiway. Stairs were brought and the paramedics boarded. They did a 90 second evaluation and wanted this man to walk off the airplane! I stopped them and ask if they had an ekg machine in the ambulance. They did ,but didn’t want to bring it up! After discussion they did and the passenger had a rate greater than 200.they then got the cart and took him off the plane.They wanted him to walk because of the difficulty of hauling the cart up and down the steep stairs. The crew was very professional in their response. I was not asked for any identification at any time.I’m sure because of the unscheduled landing the company lost money.I wrote a letter to the company commending the crew on their excellent response and the fact that they probably saved the man’s life by landing.In retrospect the pressurization of the plane for 8000 ft is probably what tip the passenger into a cardiac emergency.HIs wife called me a few days later and he was doing better.

Leave a reply




Advertisement
Advertisement
Advertisement