You're on your flight to vacation or for work. The seat belt sign goes off, and you're ready to catch up on the recent blockbusters you missed. Then you hear: "Is there a doctor on board?" What actually happens when someone gets sick on a plane? What do you do? What are the ethical implications? Rohin Francis, MBBS, has had this happen to him a few times and he gives us a blow-by-blow of one passed-out passenger he treated on a trip to India. Read the transcript below: Francis: What actually happens when someone has a proper medical emergency in a plane? This is a slightly new kind of video for the channel in that I'm going to tell you a personal experience, so let me know what you think, but I'm going to roll in some airborne biology, some of the legal implications of high-flying emergencies, so I'd like to take a minute, just sit right there, I'll tell you how I treated a woman with no pulse in midair. [MUSIC] Flight Steward:Could any medical professionals on board please make themselves known to the crew? Francis: Countless articles start by saying those words should strike fear into the hearts of every medical professional. Now maybe it's just because I've been around the block a few times and I seem to find myself in the wrong place at the right time or the right place at the wrong time and full disclosure, I don't really know how to use that phrase, but I don't think there needs to be any fear. While traveling, I have found myself immobilizing a C-spine on a high street, inserted a central line into a neck on the platform at Kings Cross Station. No, not that one. I have assessed an acute stroke up a ski slope, helped someone having a seizure on a train, reassured countless fainters, and I've provided medical assistance on no less than three flights, even though the one study that looked at this found that medical problems arise once every 604 flights. I guess the moral of the story is don't travel anywhere with me. Therefore, for any medics that are watching this, I hope by the end of this video you won't feel frightened if you are called upon in [the] future because isn't stuff like this the whole reason we went to medical or nursing school in the first place? Flight Steward: Is anyone a doctor? [MUSIC] Male: Yes. Francis: I was off on holiday some years ago. No, not that one. I was flying to India with some friends for a bit of a madcap cross-country race, and at that point, I'd been a doctor for a couple of years. In the U.K., that means we're still pluripotent stem cells. We haven't yet differentiated into our specialty cell lines, but I did know that I wanted to do cardiology. I was enjoying my second single malt whiskey and watching Up. Just when I was welling up at that montage, I heard the announcement go off. Initially, I didn't really pay it much attention. The stewardess sounded very relaxed. I felt very junior in my career, and I thought to myself, "Hey, I'm on a plane full of Indians. Surely about half of them are doctors," and I mentioned having a whiskey deliberately because it brings me to my first legal point. Do you actually have to help out? Strictly speaking, there is no legal obligation to help out, but I feel that there is a moral duty, and indeed, the General Medical Council here in the U.K., which writes a document called Duties of a Doctor, states that you must help if you are able. The exceptions are if you genuinely feel you're not competent, for example, you've been retired for many years or you feel you're incapacitated due to something like alcohol. Now I felt absolutely fine, but the one whiskey in my system did give me pause just hoping that somebody else would volunteer first. Soon afterwards, a much more panicked announcement came on and I figured I'd better make myself known. Now, when I was 26, I looked about 16, so I'm not sure I initially instilled much confidence, but hey, at least they believed I was a doctor. I was led to a lady slumped in her chair, unconscious. There was a man with her and she appeared to be covered in some kind of liquid. I asked the crew what was going on and they said they'd been trying to feed her orange juice based on the assumption that she was hypoglycemic, i.e., she had a low blood sugar. Now guessing a middle-aged Indian woman is diabetic is a good shout. After all, diabetes is very popular in India, but trying to force liquid down the throat of someone that's unconscious is what we refer to as a bad idea. They said she didn't wake up when they tried this. Now I'm significantly more concerned, so I talked to the man that's with her and he introduced himself as a GP or a family doctor. I could feel the relief practically wash over me. He was probably in his late 40s or 50, far more experienced than me, and so I asked him, "What's going on?" He said, "She's not really responsive, her pupils are equal. I can't feel her pulse. She doesn't appear to have had a seizure. It's too noisy to hear her breathing sounds," and I said, "Sorry, what was that middle one? You can't feel her pulse." Right. I immediately said, "We've got to get her out of here, somewhere flat so we can start CPR." The crew said that there were flat beds in business class, so they started trying to get that little aisle wheelchair thing, and I said, "No, we don't have time for that." So [the] three of us just yanked her up in the air and hauled her off to business class and put her on a flat bed. I was just about to start CPR when I thought, "I'll confirm cardiac arrest myself," had a feel of her pulse, and I felt I could just detect a weak pulse. I measured her blood pressure and it barely registered. At this point, I decided to give her some fluid. Instead of the usual little plastic cannula that you put in a vein, all the airline had was a big metal needle, so I had to insert that into her vein and just tape that down, which is less than ideal and attach the fluid to the back of the needle. I listened to her heart for the second time with the kind of stethoscope that you get free with Lucky Charms, and it really is very noisy on a plane, so it was hard to tell if I was imagining this, but I thought I could hear a murmur and a murmur typically means that there's a problem with one of the valves in the heart. I was now in a bit of a quandary, as I didn't know that if she had a heart problem, giving her more fluid might actually make things worse. I checked her blood pressure again and I noticed that the gap between the systolic, the top number, and the diastolic, the bottom number, was very small and this can indicate a problem with the aortic valve. If the aortic valve, which is the main valve leaving the heart, gets stiffened and narrows, then this causes a narrow gap between the systolic and diastolic, but it also means that not enough blood is getting out of the heart and sometimes this means that not enough blood reaches the brain, and a person can pass out. Meanwhile, the crew had been trying to contact ground-based medical personnel. Nowadays, every airline has a company or in-house medical personnel that they can talk to on the ground to get advice in situations like this. Doctors often worry that they'll be asked if a plane should divert, but don't worry about that. It's the captain's decision whether to divert a plane. You can make a suggestion, but it's not your responsibility, and these days they will take guidance from the ground-based medical personnel. I borrowed a glucose meter from another passenger. I attached her to an AED, a defibrillator, and just continued to examine her and see if I could glean any further clues about what was going on. After what seemed like an age, she started to wake up. In truth, probably nothing I did actually made any difference aside from maybe the shock of being manhandled and transported to business class, maybe waking her up a little bit. She took a long time to come around, but eventually was able to tell me her medical history, and indeed, she had critical aortic stenosis, a very severely narrowed aortic valve, and really, she shouldn't have been flying at all. The crew offered me a seat in business class, and instead of it being an exciting first experience in business class, I was really there to keep an eye on her for the rest of the flight, which meant that I couldn't have any more whiskeys, but I did at least get to finish watching Up. It was at this point that the crew started behaving a little bit strangely. I had to fill in quite a bit of paperwork, and when I wrote that there was no cannula, they asked me to delete this and state that the kit was fully stocked. I won't mention the airline, but I do want to say it's none of the airlines featured in this video, all of whom were fantastic. There is no internationally agreed minimum medical kit, with different airlines doing their own thing, but most major ones will stock at least the following, a lot of which was missing from my flight. It's important to tell the crew, although I'm sure most of them would figure it out, that you want the emergency medical kit, not the first aid kit. They're two separate things. The first aid kit is full of bandages and whatnot. The emergency medical kit is the stuff you just saw on [the] screen. Ladies and gentlemen, please return to your seats and fasten your seat belts. We've encountered some unexpected trivia. Some people think that there is a link between medicine and flying because of the wings present on the medical symbol of the caduceus. Only the thing is, that's not a medical symbol at all. The Rod of Asclepius is associated with healing and has one snake. This is the caduceus, which is associated with Hermes or Mercury and it's often used in error as a symbol for medical organizations. It has nothing to do with medicine and this is snakes on a motherfucking plane. Apart from the usual medical problems that can occur anywhere, what are ones peculiar to being in flight? There are simple things like dehydration, but several center around the fact that airplanes are pressurized to the equivalent of about two and a half thousand meters altitude. This means that if you measured your oxygen levels in a plane, they're ever so slightly lower than at sea level. For viewers unaccustomed to using meters, that's 1.7x10-8 astronomical units. Healthy people barely notice this. However, if your oxygen levels are already low, going in a plane might be enough to push you over the edge. Another problem is that trapped gas expands. You've probably experienced this as your ears popping as the plane climbs or your crisp packet from the airport puffing up like a balloon because the air around it, the pressure has dropped relative to the air inside. This is why patients who've had surgery are likely to trap gas inside a body cavity, like brain surgery or chest surgery, are not allowed to fly for a period after their operation. This was dramatically demonstrated in 1995 when [a] professor of orthopedics, W. Angus Wallace, and junior doctor Tom Wang, both from the U.K., diagnosed a potentially lethal injury on a plane from Hong Kong to London. Paula Dixon was a 39-year-old woman, who, on the way to the airport, suffered a nasty fall off her motorbike and sustained a chest injury. She felt okay and boarded the plane, but as the plane ascended during the flight, she developed sudden onset breathlessness and chest pain. What had happened is fractured ribs had punctured her lung, allowing air to escape into her chest outside the lungs, causing a tension pneumothorax. This is when a one-way valve is formed by the damage caused to the lung by something like a sharp fractured rib. Over time, gas accumulates, gradually compressing her lung. That trapped air then began to expand dramatically as the plane ascended. In what can only be described as medical MacGyverism, not to mention total badassery, the two doctors fashioned a chest drain out of oxygen tubing, a urinary catheter, sticky tape, a coat hanger, and a bottle of Evian. By making two holes in the cap and half-filling the bottle with water, they had made a one-way underwater seal. Air can come out, but as long as the bottle is below the chest, none can go back in. Dr. W. Angus Wallace: We used brandy to sterilise the equipment. One of the stewards felt that if we were going to do it we should do it properly, so a 5-star Courvoisier was produced. Francis: They reported that five minutes later she was without symptoms and enjoying the inflight entertainment. Another point I want to address is fear of potential repercussions. Colleagues often say that they're worried about getting sued if they help out, particularly on an American airline, for example. Different countries have different versions of the Good Samaritan Law. Airplanes typically follow the laws of the country at where the craft was registered, and the Good Samaritan Law states that unless incompetence can be demonstrated, you're protected from any recrimination. Actually, in the case of American airlines, the 1998 Aviation Medical Assistance Act states that unless [there is] gross incompetence or willful misconduct, [or you] are you doing something really bad [that] can be demonstrated, you would not be subject to any litigation, so you're well protected on American airlines, actually. Indeed, my experience on an American airline was very positive. I treated a woman with an acutely swollen leg on a Delta flight, and the crew were unfailingly nice and I even got a gift from the airline later. Now I never redeemed the gift because I just didn't see the point, but when preparing for this video, I actually learned that if I had accepted the gift, that would have counted as accepting payment, and therefore you're no longer protected under the Good Samaritan Law. Looking back on my experience of the flight to India, I realized that I was very fortunate to get a critically unwell patient whose diagnosis was in my own wheelhouse. The lady who fell off her motorbike was also very fortunate to have a professor of trauma and orthopedics on her flight, but beware the Dunning-Kruger curve demonstrated quite beautifully in this blog post from a chiropractor. I recommend reading the whole thing because it's back-crackingly narcissistic, but here are some highlights. Male: A young lady, seven-and-a-half months pregnant, was complaining of severe headaches, nausea, and back pain. She might have been experiencing premature labor. I assisted the patient to a standing position, palpated the level of the hips, and found a PD right. I adjusted the standard Activator listings in the standing position. I also adjusted the sixth thoracic area for the nausea and found the spinous axis was projecting way out to the right. 15 minutes later, the adjustment was complete and she was sound asleep in her seat. A man in coach was apparently having a heart attack. I could see his disappointment in learning I was not a medical doctor, but I volunteered to take a look at the patient. He looked cyanotic and in severe distress. He was perspiring profusely. I felt his pulse and found it weak but rhythmical. I did the applied kinesiology, neurovascular, and neurolymphatic procedures for heart problems. I also held pressure against his axis vertebrae. I returned with my Activator. I palpated his cervical and upper thoracic region and adjusted the second thoracic and the axis with the Activator. I can recall how disappointed the head steward was when he discovered I was not a medical doctor. However, when one considers, scientifically, the capabilities of a chiropractor and medical doctor on an airplane, who has the advantage? Does the medical doctor carry a suitcase full of cardiac meds? I think not. A chiropractor does not need an MRI or a CAT scan, an x-ray, or an automatic processor, even in an emergency. Your hands, an Activator, a bed, a couch, a chair, or a portable table are all you need to render care to 98% of the populace. Francis: That last bit might well be true because 98% of the populace aren't unwell. In the event of chiropractic claptrap, adopt the brace position and the pilot will shout quack, quack, quack. I stayed with my patient until we landed and handed [her] over to the waiting medical team. As far as I know, she was okay. Rohin Francis, MBBS, is an interventional cardiologist, internal medicine doctor, and university researcher who makes science videos and bad jokes. Offbeat topics you won't find elsewhere, enriched with a government-mandated dose of humor. Trained in Cambridge; now PhD-ing in London. Source
