The plane ride

Sometimes situations arise that put us, as physicians, in interesting and challenging circumstances. For example, take my flight to West Palm Beach, Fla. from Newark, N.J. about 20 years ago.

Arthur Topilow

I was taking the red-eye from Newark to West Palm to see my stepfather’s doctor. Mike, my stepfather, had suffered a myocardial infarction two days before and his doctor was going to meet with me early the next morning to go over Mike’s condition and plans. We were approximately one hour into the flight when I heard the announcement over the loudspeaker, “Is there a physician on the plane?” I knew I had to respond. I walked down the aisle toward three people who had gathered around a seated passenger. The man in the seat was not looking good — in fact, at first glance, he looked dead. He was alive, but was ashen, perspiring, unresponsive and had shallow respirations. He was obviously in trouble.

A tall man stood in front of me with a woman on his left and a flight attendant on his right. As I approached, the flight attendant said, “Who are you? You’d better have a seat. We have an emergency here.”

“I’m a hematologist. We should get this guy out of his seat and lie him down,” I replied. Most laypeople think that hematologists are strictly lab doctors.

“Who are you and what happened?” I asked the tall man in front of me while I tried to take the passenger’s pulse.

“I’m an emergency room doctor,” he replied, but otherwise mute. Apparently, there had been a lot of looking, but no talking or examining before I arrived.

“That’s very nice, but let’s get this guy out of his seat,” I replied.

The woman on my left said she was a nurse.

“Then let’s get this guy out of his seat,” I said to no one in particular.

The ED doctor remained silent. It was as if time was standing still for him.

The woman sitting next to the passenger, obviously the man’s wife, appeared frantic, and was not of much help. “He just came back from the bathroom,” she said.

“Let’s get him out of this seat,” I said exasperatedly for the third time.

A call to action

The ED doctor had disappeared. The nurse, flight attendant and I wrestled the man out of his seat and got him onto the floor of the cabin. The rear of the plane was empty of passengers, so we dragged him another 15 feet down the aisle toward the back of the plane. He remained unconscious and had a faint pulse.

He was not short of breath. The flight attendant brought oxygen from a small tank. We loosened his clothing. His pupils appeared normal. We elevated his legs on some pillows.

His wife finally gave me the story. “My husband was OK, but then he made several trips to the toilet,” she said. “He was having diarrhea.”

“Is he diabetic?” I asked.

“No, no history,” she said.

“Hypertensive? Cardiac problems?”

“No, nothing.”

“How old is he?”

“Fifty-three.”

I looked back at the passenger. He was now my patient. The nurse also had disappeared. I was able to rouse the man now. He was probably not hypoglycemic, but I asked for some tea with a lot of sugar to be brought anyway. He was awake enough to swallow it easily. I theorized that he probably had a syncopal attack caused by volume depletion with diarrhea. He also could have had a stroke or a myocardial infarction, but he denied any chest pain. There I was without a stethoscope, blood pressure cuff or intravenous set up. These were the days when planes carried neither a stethoscope nor a blood pressure cuff onboard — in fact, there was no medical kit at all on the plane. Fortunately, my patient was becoming more responsive.

I felt a tap on my shoulder. It was the flight attendant. “The captain would like to see you, sir.” It was time to report to the authorities. I walked down a long aisle to the cockpit. I felt 500 eyes on the back of my neck. The cockpit door opened and I was ushered into the inner sanctum. The door closed behind me.

Decision time

I was struck by the quiet in the cockpit. The engines were a whisper; the hiss of the air stream was just noticeable. I was in awe. The copilot was sitting on the right, with the captain on the left. His hands were off the steering wheel. The moonlight bounced off the clouds into the cockpit. The navigator got up, and I was asked to sit in his seat. I was speechless. It did not look like much was going on in the cockpit. “Can you tell me what’s up with our passenger?” the captain asked calmly and reassuringly. This was a man who was confident and in control.

“The passenger probably passed out from dehydration caused by diarrhea. He could have an electrolyte imbalance. We have him stretched out on the floor in the aisle, and we gave him oxygen and sugared tea. He has regained consciousness,” I said. “We did not have to give CPR.”

“Do you think we need to land the plane early?” the pilot responded. “We’re 20 minutes from the nearest airport and 45 minutes from West Palm.”

I remember this as a question on a test in medical school. I did not know the answer then, and I was not sure now. I am not sure my instructors knew the answer, either.

“Can we speed up a little and get clearance quickly into West Palm?” I said. “Can we have medics waiting for the plane, and get my patient off the plane first?” I asked.

“OK, will do. You know, a few months ago a pilot didn’t stop for a man with a heart attack, and the passenger died.” The captain was obviously more concerned than he let on. With a few clicks on his computer, he knocked off 20 minutes of flying time.

“I’ll go back to check on our man,” I said.

The passenger was now lying on his back across several seats. He was awake, and able to speak, but weak, recovering from his syncope. His pulse was regular and stronger. He was not cyanotic. He had fainted sitting up, with no place to fall.

I returned to the cockpit. Passengers asked a lot of questions on my second walk down the aisle. “How is he, doc? Will we get to West Palm tonight?” they asked.

“Our passenger seems to be recovering, so let’s keep going,” I told the captain. “Who’s flying this plane anyway?” I asked. I was mesmerized by the scene in the cockpit. “Oh,” he said, “We’re on autopilot. Watch.” The pilot pressed a button, took the wheel and made a gentle turn left and then right. Then he pressed another button and we were back on autopilot. The copilot gave me a printout of our course, speed and time until arrival. “Have a souvenir,” he said.

I returned to the passenger and his wife. The man was more alert. His pallor had disappeared. “How are you doing?” I asked.

“Better, thanks. I just hope we can get to West Palm. I only have a week of winter vacation.”

I told him I had asked the pilot to speed up and that we were cleared for direct arrival into West Palm. He thanked me.

A grateful patient

“Doctor, please give me your address. I want to send you something. What is your shirt size,” his wife asked.

I wrote the information down for her distractedly, still hoping that I had made the right decision not to suggest that the plane land earlier.

We landed uneventfully at West Palm. All the passengers got off, and then the medics came on the plane to get my patient, which really annoyed me, although I knew he was stable. I never saw the ED doctor or the nurse again. I never heard from the airline. I had stuck my neck out, and, for a short time, I was directly involved in the plane’s course, the passenger’s life, and, indirectly, the money it would have cost if the plane had to land prematurely — it is estimated a diversion can cost from $3,000 to $100,000. I was a little miffed, but quickly got over it, especially after the next morning when I received good news from Mike’s doctor, who kept my stepfather alive for several years thereafter.

Several weeks later, I received a package in the mail from the passenger: a beautiful shirt and a tie from Sulka, a very pricey men’s shop with stores in New York, Paris and London. I still have the shirt, although it fits a little tighter now.

Several months later, my wife and I had an early dinner reservation in Manhattan, right next door to Sulka. We stopped in. A man arranging the ties looked up, and, to my surprise, he recognized me immediately. “Dr. Topilow, how are you? I spent two days in the hospital with dehydration and electrolyte imbalance. My potassium was 2.9. That was not so good, was it?”

I replied that it was not. I thanked him in person for my gift, and told him how great he looked. I thoroughly enjoyed my dinner that evening.

At present, enhanced onboard medical kits are mandated by the Federal Aviation Administration for all commercial airplanes. The extent of supplies can be somewhat intimidating for a hematologist, but a ground-based doctor is always available for consultation. The assisting physician-passenger may render medical care similar to the care that others with similar training could provide under such circumstances as legislated by the Aviation Medical Assistance Act. A recommendation to divert the aircraft should be considered if a passenger has chest pain, shortness of breath, or severe abdominal pain that does not improve with use of the recommended initial interventions. A recommendation to divert also should be made if a passenger is persistently unresponsive, has a cardiac arrest, acute coronary syndrome, stroke, refractory seizure or severe agitation. An excellent review of this subject is available in an article by Gendreau and DeJohn.

There is a coda here. A month ago I was once again involved in a medical event on a flight from Europe. A woman had edema and a rash on both legs. We were over the Atlantic. She appeared to have some kind of allergic vasculitis. I reassured the flight attendants that the passenger did not have a deep vein thrombosis and suggested that she seek medical attention as soon as she arrived home. The airline was very pleased and put 25,000 miles into my frequent flier account. Sometimes, it seems like the patients you do the least for are the most appreciative and the ones you struggle over are not. Medicine is always a cross between an academic pursuit and an exercise in human psychosocial interactions.

Arthur Topilow, MD, is in private practice at Atlantic Hematology & Oncology in Manasquan, NJ.

Some years ago a nurse and I performed mouth-to-mouth CPR on an 80-year-old woman during a winter flight from Tucson to Minneapolis. After 15 minutes it was obvious that she was not going to respond, but with numerous other passengers peering at us working in the isle, we thought it best to keep trying (for the remaining 20 minutes of the flight). I had a sore mouth for a week and a coupon for two drinks from the airline but no Sulka shirt. No matter, I was proud to have responded, unlike other doctors presumably on our weekend flight from sunny Arizona.

– Harry S. Jacob, MD

HemOnc Today Chief Medical Editor

For more information:

• Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346:1067-1073.