Articles and Case Studies

Is There a Doctor on Board This Flight? Inflight Member Experiences

04 Apr 2012

In our last issue, we discussed the common occurrance of Doctors being asked by cabin staff to volunteer their services to assist passengers who are unwell whilst flying
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Member: Dr Lau

We asked our Members to tell us their own experiences. Here are a few of the responses…

Case history

On a recent international flight, I provided emergency medical assistance to another passenger.  We were 2.5 hours’ flight from Perth, far from any airports where a commercial plane could land for emergency assistance.  The crew found a gentleman (Mr X) in obvious distress, and a nurse (Ms N) and I volunteered our assistance.

On initial examination, Mr X was approximately aged 60, unresponsive to any communication, sweaty and clammy, with eyes rolled back, making gurgling sounds, and having generalised tonic-clonic movements of all limbs.

Mr X was travelling alone, and seated by the window next to an empty seat.  His body was in full extension with his head wedged between the seat and the window, and his legs stuck under the seats in front.  He was a large man (>180cm), and it was difficult to reach him in the confines of economy class.  He was not wearing a Medic Alert bracelet, and the only information available from the crew was that he had eaten a regular meal, and had not been drinking excessively.  None of the surrounding passengers could provide any further information.  While we attempted to move Mr X, I asked the crew to search his bags for clues regarding medical history.

With much assistance, we moved Mr X across the aisle to a row of empty seats.  Mr X continued to have violent tonic-clonic movements of his limbs, was at risk of falling off the seats, and Ms N restrained him by sitting on him.

During these minutes of chaotic activity, differential diagnoses that crossed my mind included seizure secondary to syncope (perhaps due to dehydration or arrhythmia), a cerebrovascular event, excessive alcohol, or complications of diabetes.  With no history, clues, or diagnostic equipment, the question of “What do I do now?!” was quite daunting.  Furthermore, I was exhausted myself from 18 hours of travelling, and had been absent from clinical practice for about a year.

Fortunately, a crew member found a vial of Humalog insulin in Mr X’s bag, and I made a provisional diagnosis of severe hypoglycaemia based on the history of diabetes, the clinical state, and hypoglycaemia being the most common medical emergency in a diabetic, particularly during travel [4]. A glucometer was found in Mr X’s bag, but Ms N was unable to obtain a reading.

Crew members located the in-flight medical kit which contained 50% glucose but no glucagon. While being tightly held down by many people, a rubber tourniquet was applied to Mr X’s arm, and 5mls of 50% glucose was injected into his left cubital vein. Ideally, the glucose should have been diluted and given slowly, but this was impossible under the circumstances.

After 5 to 10 minutes, there was no significant improvement in Mr X’s condition, and another 5mls of glucose was given.  I attempted to do this through same vein, but failed, and the second injection had to be given in right cubital vein.

Mr X soon regained consciousness, and was reassured and informed that he was having a “hypo”.  A glucometer reading at this time showed a glucose level of 1.8mmol/L.  He continued to improve rapidly, and soon managed to drink cans of lemonade and eat a meal.

Mr X denied having other medical problems, or taking other medications. His only complaint was of pain in his elbows at the injection sites. Mr X was reluctant to speak to me, and considering that he had recovered sufficiently from his hypoglycaemia, there was no longer a medical emergency at hand, and we did not have a formal doctor-patient relationship, I respected his privacy.

Mr X checked his own blood sugar after his meal, and found it to be above 12mmol/L.  He complained to Ms N and me that his arms were painful, that we should have used smaller gauge needles, and that we had given him too much glucose.  We politely explained to him that he was severely unwell, his life was in danger, and it was difficult to work on a plane with limited space and resources.
Mr X’s ungrateful responses concerned me, and prompted me to report the incident to my MDO and seek reassurance that I was protected medico-legally in case of a complaint or claim.


Member: Dr Farquhar

Case history

I was sitting in an aisle seat and saw a man (Mr B) get up from his seat a few rows in front of me, walk towards the toilet area at the front, stagger slightly and collapse backwards, hitting his head on the corner of the wall barrier as he fell. I removed the things from my lap and went to help. I told the flight attendants that I am a doctor and they expressed relief to have me there.

Mr B had been unconscious for about 15 seconds, during which a non-medically-trained person had put him in a pseudo-recovery-position. I carefully returned him to the supine position to assess any response (which there was none at that point), breathing (he was breathing) and so I used a sternal rub to rouse him. After about 15 more seconds of verbal stimuli and sternal rub, he began to rouse and tried to sit up, but I told him to stay down on his back.

There was oxygen via non-rebreather mask available and we applied that. There was a first aid kit with a sphygmo, but it appeared to be broken as I could not get a reliable reading from it. After determining that he was orientated in time, person and place, I ascertained from Mr B his first name and his age – a 28 year old male. He had been feeling nauseated and had gone toward the toilet because he was feeling like he would vomit. He remembered getting up from his seat and feeling dizzy but did not remember collapsing. He reported no medical history, no allergies and no medications. At this point, I was able to briefly examine his head and noticed a laceration on the occiput in approximately the midline, which was bleeding.

Over the next 20 minutes, he was drowsy and complained of a sore posterior head. I gently palpated his spinous processes to determine whether he had any tenderness but he reported only tenderness around the lacerated area on his head. Regardless of this, I determined that as best we could, we would have to make all spinal protective precautions. We made a makeshift barrier system for either side of his head to keep it as still as possible. He did however sneeze several times and his neck did not remain still during these episodes.

The flight attendants informed me that we could not have him remain on the floor for landing and that we would have to move him to a row of seats. I did communicate the importance of keeping his neck still and straight, however it was the policy of the airline that he had to be in a seat and with a seatbelt on.

Compromising, we were able to move Mr B towards a seat by allowing him to pull himself along the aisle on a blanket with the aid of flight attendants, with myself remaining at his head to stabilise it and minimise any movement as much as possible. For landing, he was positioned across three seats with blankets positioned to stabilise his head, and myself in the seat in front, where I was able to turn back and use my hands to help maintain minimal neck movement. Due to the weather, the landing was quite bumpy and Mr B moved a fair bit on touchdown.

All this time I continually asked Mr B questions to try and detect any changes in conscious state, and to ascertain whether he had any new pain besides that of his occiput. He did not report any new pain, and there was no acute neurological change in my presence.

During the flight, the flight attendants arranged for an extraction team and paramedics to be present on landing in order to remove Mr B from the plane with safe spinal precautions. Once this team arrived, I reported the details as best I could to a safety officer and then again to a paramedic. Once I confirmed with the paramedic that he was happy to take over care, I filled out some paperwork requested by the airline staff member, and I exited the plane.
I had read that in an incident like this that it would be important to let my MDO know as soon as possible so I rang MDA National’s Medico-legal  Advisory Service immediately following the flight. Upon determining that I did not need any urgent advice at that time, I was happy to follow up over the next few days instead.


Member: Dr Hare

I have 2 in-flight or holiday medical emergency experiences:

Case history

The first was on a flight over the Bay of Bengal. There was an announcement over the public address asking if there was a doctor on the flight. The previous year I had been an anaesthetic & intensive care registrar so I offered my services. Also on the flight was a female paediatric resident.

I was immediately taken up to first class where there was a gentleman (Mr G) lying in the passageway unconscious and blue! I felt we needed more room and I asked the cabin stewards to carry him up the circular staircase to the first class lounge which we cleared all of the other passengers. As I commenced resuscitation I got a limited history that he was a Dutchman and was asthmatic.

The captain opened the door to the cockpit which opens off the upstairs lounge and kept the door open at all times so that we were in full communication. That couldn’t happen now since the heightened security after 9/11. He immediately increased the cabin oxygen concentration from that of the normal equivalent of 10,000 feet to 2,000 feet and I’m sure that helped the man’s condition.

The emergency oxygen masks do not operate unless there is a depressurisation but the airline had a small oxygen cylinder and masks which I immediately employed. The staff also produced their then standard medical kit which included IV access and ampoules of adrenaline and aminophylline. I immediately gave Mr G IV aminophylline slowly and his status asthmaticus improved, his colour improved and he regained consciousness.

The captain said he would do whatever I told him and that the choices were a) return to Kuala Lumpur (2 hours), b) put down at Bombay (Mumbay) (1 hour), or c) continue on as planned to Bahrain (5 hours). As his condition was stable and I still had more IV drugs and oxygen, I allowed the Jumbo 747 and its 500 passengers to continue on to Bahrain.

The plan was to put Mr G off the plane at Bahrain. He now felt OK and pleaded with me to be allowed to continue to Amsterdam, the next stop and his destination. I said I would only agree with this if doctors in Bahrain could supply me with further supplies of IV bronchodilators and oxygen. Of course they couldn’t, so I handed him over to Bahrain medical staff.

My wife and I were then upgraded from row 500Z in economy to the first class lounge and given lobster and champagne. When we eventually arrived back in Australia, the airline sent me a letter of thanks and requested a medical report which I completed.

Case history

My second experience was on the overnight car ferry from “greasy” Brindisi in Italy to Igoumenitsa in Greece (via Corfu).

We could only afford “deck” class which was just that – an open deck to lie on, not even a seat. About 2 hours out from Brindisi in the middle of the Adriatic in pitch darkness we heard a commotion at the rail of the deck. Apparently someone had fallen overboard. The ferry began circling with spot lights shining on the water trying to find the man.

I had been working in anaesthetics and intensive care in England and was aware of the difficulties of resuscitating salt water near drowning so I thought I had better offer my services. The crew took me up to the bridge and the captain instructed the crew to take me down to the sick bay where I presumed I would get things ready in case we found the man overboard. Of course the Captain and crew including the sick bay nurse were Italian and had no English and I had no Italian.

When I got to the sick bay I was surprised to find a young white American male (Mr T), drunk, semiconscious, white as a sheet, with blood and vomit all over him. He had stab wounds to his abdomen, chest and forearm. It was only then that I was told the story. Apparently drunk Mr T had been baiting another American (Mr E). Mr E stabbed Mr T and then jumped overboard. We never found him and presumable he drowned in the middle of the Adriatic.

Anyway I set out to help Mr T. He had obviously lost blood, so I managed to indicate that I wanted an IV infusion which they had, but they had no IV cannulas only a metal needle which I had to hold in his vein while I gave him a rapid litre of Hartman’s.

Then on examination I was able to determine despite three stab wounds he had not damaged any viscera in his abdomen or chest nor structures in his forearm. I then proceeded to sew up his wounds without local anaesthesia (there was none), but found his blood alcohol level sufficient anaesthesia. I then returned to my wife on the deck, slept the night, and had no further communication from anyone.

In neither situation did I even think about medical negligence or medical indemnity.


The case histories are based on actual medico-legal Member experiences; however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved.

 
Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Practice Manager Or Owner, Psychiatry, Radiology, Sports Medicine, Surgery
 

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