Dr. Todd Sontag, a family physician with Orlando Health Physician Associates in Orlando, Florida, was comfortably seated at the rear of the plane en route to Las Vegas for a vacation last summer when through his headphones, he thought he heard a member of the flight crew ask whether a doctor was on board. “So I take my headphones off and look around.” No one else around him had heard the announcement, so he stood up, and that’s when he saw a woman at the front of the plane commence doing chest compressions on a male passenger. Without a second thought, Sontag ran to the front of the plane to assist.
A retired firefighter also answered the call for help and he, Sontag and the woman commenced providing CPR for the man who was apparently having a massive coronary incident. “We did CPR on this guy for about half an hour,” which Sontag says was a little bit nerve-wracking given that the last time he performed emergency medicine was during his residency a decade earlier. “But it all came back. And the thing is, you lose total track of time. You’re focused on this, and you forget that there’s 150 people behind you watching everything you do,” Sontag says.
The plane had only been about 30 minutes out from landing in Vegas, so the trio worked on the man while flight attendants called to ground-based medical support and arranged for the flight to skip the landing queue and come in straight away. “As soon as we got down, the paramedics came on board and took him away in an instant,” Sontag says.
Despite the impromptu medical team’s valiant efforts, the patient passed away at the hospital. “It’s hard because it’s one of those things where you’re just trying to do everything you can. I kept looking back and asking, ‘is there anything more we could have done? Was there anything we missed?’ But we exhausted all the medical options and there really wasn’t anything more that could have been done at 30,000 feet in the air, half an hour away from the hospital. We gave that guy the best chance he could have had.” And the other passengers gave the team a standing ovation; several passengers approached Sontag in the terminal offering to buy him lunch or give him money for his services.
[See: 14 Things You Didn’t Know About Nurses.]
Although such dramatic in-flight emergency stories are relatively rare, it’s hard to say exactly how common in-flight emergencies are in the United States. According to a 2015 review article in the New England Journal of Medicine, “medical emergencies occur in 1 out of every 604 flights.” This may be an underestimate because not all emergencies are reported — incidents that result in a diversion are reported, but smaller problems are often resolved in-flight without further reporting, the study notes. In any event, the fact remains, “just because you’re on a plane doesn’t mean you’re not at risk. In fact, quite the opposite, you’re more likely to have a problem” at 30,000 feet than on the ground, says Dr. Elisabeth Poorman, a physician at Cambridge Health Alliance in Cambridge, Massachusetts, and clinical instructor at Harvard Medical School who has written about some of the concerns doctors face when called on to assist a passenger during a medical crisis. Although the cabins of commercial airplanes are pressurized, the atmosphere inside is equivalent to what you might find at an elevation of about 6,000 feet. This is high enough for some people, especially those with lung disease, to experience difficulty breathing. It can also cause drops in blood pressure, dehydration and other problems that can expose a previously undiagnosed medical condition or exacerbate symptoms of a known disease. Couple this with the stress of travel, which can include disrupted sleep and meal schedules or skipped or delayed medications, and the potential for medical problems increases.
When doctors travel, they know there’s the potential they could be called on in an emergency. Poorman says that looming possibility can be problematic for some doctors. “It’s the issue of always being on, and that’s the backdrop of everything” because you may be called on to assist during a medical emergency any time — at the grocery store, your kid’s soccer game or even while traveling for a much-deserved vacation. “On planes, there’s a limited number of people who have the skills to help, so there’s a little more pressure” to assist in an emergency. “Simultaneously, you’re probably going on vacation, and those two identities start butting up against each other,” she says.
But doctors aren’t required to help. “In the U.S., physicians and other health care providers are not mandated to render assistance in an in-flight medical emergency,” says Dr. Jose V. Nable, assistant professor of emergency medicine at MedStar Georgetown University Hospital in the District of Columbia and lead author on the NEJM study.
Even though it’s not a legal requirement here in the U.S., Nable says: “I think you could argue that there probably is an ethical obligation. As a physician, you’re a physician whether you’re in the clinic or you’re not. You have the training and expertise to assist others and render aid when others may not be able to do so, especially during times of crisis.”
To encourage health care providers to assist during in-flight emergencies, in 1998, Congress passed the Aviation Medical Assistance Act. Prior to 1998, “a lot of health care providers were hesitant about providing aid because they weren’t sure what their legal liability was, and there wasn’t a standardized list of equipment that was aboard an aircraft,” Nable explains. The act mandated a standardized, minimum medical equipment list for all U.S.-based aircraft and provides physicians, nurses, EMTs, paramedics and any other health care providers “immunity from lawsuits as long as they’re rendering aid in good faith and without gross negligence. This means that they’re acting within the scope of their training,” Nable explains. It also means not rendering aid while intoxicated or otherwise impaired.
[See: HIPAA: Protecting Your Health Information.]
Still, the help a doctor can offer aboard a jumbo jet is limited by space, equipment and support personnel constraints. Despite the list of required equipment, Nable says planes “are not meant to be flying clinics” that can care for people long-term or handle every conceivable emergency. “For the most part it’s basic stuff to be able to provide immediate, potentially lifesaving care. It’s almost a form of austere or wilderness medicine,” and the idea is to keep people alive until the plane lands and more advanced care becomes available.
During an in-flight medical emergency, a discussion may arise about whether or not to divert the plane to a closer airport. This can be a fraught decision that a volunteer physician may recommend. “Ultimately, it’s not up to the health care provider whether a flight gets diverted. That’s up to the captain,” Nable says, and such decisions must take into account multiple factors. “It’s not very easy to divert an aircraft. It puts the equipment out of place and you have a whole bunch of passengers who’ll be missing their connections. It’s also very expensive, and the closest airport might not have appropriate health care facilities for the patient’s needs, so it’s a pretty complex decision making process. The volunteer health care provider role in these situations is to come up with an informed recommendation.”
The good news for flying physicians is that even though you might be the only doctor on board, you’re unlikely to be the only person caring for the ill passenger, Poorman says. “The flight attendants have quite a bit of training, and there’s also an in-flight emergency call center that you can call to request to speak with on-call emergency physicians for advice.” She says this may help doctors who don’t have an opportunity to practice emergency medicine on a regular basis feel more comfortable assisting in a crisis.
She also notes that sometimes another passenger will be better able to assist, even if he or she isn’t a doctor. “If there is a nurse, a paramedic or someone else who has more experience working in non-traditional clinical environments, they might actually be the best person to dictate what happens and the response to an emergency.” She recommends “being sensitive to that and being helpful to that person but not necessarily taking over if they’re actually more qualified to be doing that work.”
When a crisis arises in-flight, physicians should remember that they are volunteers. The protections afforded by the AMAA may be invalidated if a doctor accepts payment for assisting a passenger. Volunteer health care providers may also be asked to provide identification or proof that they are a doctor or nurse, as the airline has a good faith duty to ensure the volunteer’s qualifications.
If you’re called on to assist during an in-flight emergency, Nable recommends considering the patient’s privacy and, when possible, to ask first whether they want assistance. “Before just jumping in and asking probing questions that could compromise someone’s privacy or make them uncomfortable, it probably would be best to approach these situations by asking questions first, such as ‘do you want me to help?'”
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
And Poorman says it’s OK to feel overwhelmed by the responsibility associated with such efforts; in some cases, physicians may have to derail their own plans to ensure the patient gets appropriate care. “It may not be clear what your involvement is going to be,” and you do have the option to forgo volunteering. That said, Poorman says she’s volunteered before and found it rewarding. “The fact that you’re able to help people in a time of distress in your day-to-day life, it’s the super-power of being a doctor. I really enjoy being able to do that, and it’s something I’m happy to do.”
And even though his first experience with assisting during an in-flight emergency was dramatic and tragic, Sontag says he wouldn’t think twice about helping in the future. He urges other physicians to “not overthink it. As long as you’re doing things that you’re comfortable with, that’s what our job is. Our job is to keep people alive, and so I would just hope that any other doctor would step up and help your fellow man.”
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What Issues Do Doctors Face When Helping During In-flight Emergencies? originally appeared on usnews.com
