‘Is there a doctor on board?’ Advice and tales from 30,000 feet
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.
“I try to become that calming force, to say, ‘Hey, everything’s going to be OK. I’ll sit right here beside you.’ ”
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.’ ”
“You need to have some ID in your wallet because it gives the patient confidence.”
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.”