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I just finished reading news that American Airlines is being sued by the family of a woman who died on board a flight from Hawaii. I won’t recount the all details here, but it seems she fell ill, a doctor on board recommended that the flight be diverted, he was overruled, the woman died, and the equipment on board was inadequate to revive her. Of course, that’s assuming she was revivable. The news account reported she died of a pulmonary embolism (PE), a blood clot traveling to the lungs. The death rate for a massive PE that requires CPR is about 75% in one study. But that is for the lawyers to debate. Reading the article prompted me to recall some of my experiences responding on airplanes as “the doctor on board.”

Flying several miles in the air with limited resources available makes responding to a medical emergency on a flight akin to practicing wilderness medicine. The airlines, I’m sure, want all of their passengers to arrive safely. The most prudent thing would be to divert every plane with a medical emergency to the nearest airport, but with roughly one in every six hundred flights having a medical emergency on board, roughly 80,000 flights a day in the United States, and an average cost per diversion of $100,000, it would cost $13,000,000 a day to divert them all. And that is discounting the cost of the inconvenience to the thousands of people who are also on those flights. So diversion is going to be a rare event. The FAA requires airlines flying in the US to have a basic medical kit that includes airway supplies, an inhaler plus seven other medications, and “basic instructions” for using the medications. Responders can advise the captain whether or not to divert, but ultimately it is the captain’s decision.

I’ve responded to three in-flight medical emergencies. The first time myself and a dermatologist rose when summoned. She quickly disappeared after acknowledging that an unconscious passenger isn’t really a skin issue. I found a somnolent older man with a distraught wife. I quickly discovered that he was diabetic and had, as prescribed, taken his insulin that morning. However, he had not, as one usually should, eaten breakfast. This combo left him with a low enough blood sugar to pass out. Of course, the basic medical kit does not contain a glucometer, to check sugar levels, or glucagon, a medication that can rapidly raise blood sugar. Fortunately, a nearby passenger who was diabetic and who had eaten breakfast volunteered his glucometer and helped me check the ailing passenger’s glucose level to confirm the diagnosis. After some sips of OJ with sugar added, courtesy of the flight attendant, the man was alert and feeling better.

My most recent experience was on a flight from LAX to MIA after my trip to Sichuan last summer. I walked back towards the back of the plane and said, “I’m a doctor, what’s going on?” The flight attendant responded by asking for my license. I laughed and told her that we don’t really carry those things around. I went back to my well-seasoned backpack (it’s been travelling with me since 1995) and brought her a business card. Credentialing complete, I turned my attention to my patient. She was an older woman who was quite heavy. She was hyperventilating and not looking well. I felt for her pulse, but her arms were so large I couldn’t feel anything. As if on cue, the flight attendant thrust a stethoscope into my hands and I listed for her heart tones and breaths. Being in the rear of an airplane in coach, I couldn’t hear a thing. Next step was to try the sphygmomanometer (that’s a blood pressure cuff and word that is much more fun to say than to spell). It was too small for the girth of her arm, but I went through the motions of putting it on and pumping it up. At this point I took score of the situation: no palpable pulse, not heart tones or breath sounds, and no measurable blood pressure. She met all the clinical signs of death! Of course, she was very much alive. One thing that is of abundance on airplanes is oxygen tanks. I had the flight attendant put an oxygen mask on her. At this point the woman next to her said, “she suffers from anxiety.” With the oxygen on, I asked the sick passenger how she felt. She smiled and said she was feeling much better. Fortunately, a little human contact and attention relieved her anxiety and I could confidently advise the captain that we could proceed to Miami.