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I am Dr. Adrian Silver, and I am Dr. Ko. Welcome to Life in Practice, where we explore the far edges of medicine and the depth of the human mind. One month we journey into the fascinating, the unexpected, and the sometimes unbelievable stories from our colleagues. The next, we focus on mental health and wellness, helping you care for yourself and those around you. Welcome to Life in Practice podcast. Since summer is prime travel season, we thought it'd be a good time to talk about a scenario many physicians have imagined. You finally settled into your seat, maybe halfway through a snack or movie, and then you hear the dreaded announcement: "Is there a doctor on board?" Today, I'm joined by four colleagues who have each had the unforgettable experience of being that doctor on board. They'll share what happened, how they responded, and what it's really like to care for a patient in the very unusual setting of an airplane cabin. Dr. Cower and I thought this would be a fun summer episode, but also a useful one because while we hope it never happens, it helps to be a little mentally prepared in case it does one day. And to round out the conversation, I'll close by sharing a few key pearls from a talk our colleague, Dr. Josh Weil, a former emergency department physician, gave on this topic several years ago, with his permission, of course. I'll also include his PowerPoint for those that want the deeper dive. Let's jump in first with Dr. Mark Williams Hi, Mark. Thanks for joining me today

Adrienne 1:42

So tell me, about your plane adventure. I've had two that I can recall. the first one was years ago, and it was, an older person that was short of breath. and that was a little scary. the oxygen, thank goodness, was working. but they weren't sure how much of a supply that they would end up having. Do they just use oxygen masks that drop down from the ceiling on a plane, or do have separate oxygen? They have... Yeah, they had a separate O2 tank. Oh, okay. in the end, what I ended up doing, and interesting, I thought, the cabins are pressurized at about 5,000 feet- which is fine if you're sitting on a park bench in Denver or Albuquerque. But for person-, struggling to breathe, asked the flight attendant if cabin... if the captain wouldn't mind depressurizing the cabin a little bit to something lower, maybe 2,000 feet. I didn't realize they can. can, and it helps buy time and saves O2, and that was just... And it was a longer flight, so it was actually kinda helpful. Yeah, that's smart. I had no idea they could do that. And, the second one, this is a little stranger, was flying back from and, we were minutes from landing, to the point where they had flipped on the lights overhead. and when they flipped on the lights, this woman a few rows behind me apparently had terrible sudden pain in her left eye or under her left face. Asked for any medical personnel, and, it was funny. good of people got out of which I thought was really nice. everybody was willing to help. Those conferences in Hawaii, right? yeah. Yeah. The funny thing, they all had different roles. one person, said something like, I'm an interventional radiologist," I thought, "Wait a second." but was a couple internists and, a couple of nurses. I, I just happened to be sitting a few rows in front of her. I went over there. I got up went down to her row, and I talked to her for a few minutes and just tried to assess where she was what was going on. And, the flight attendant told me, "Look, we're really close to so I know everybody's supposed to be buckled in, but we're gonna have to land plane with you sitting, kneeling in aisle right next to this woman." Oh, wow which was a little dicey. when the plane hit the ground, everything just kinda jostled around, me included. Everybody on board was kind enough to let me and the patient pass, and they'd already, radioed ground services. EMS was there, and I got to do a quick to the EMTs that I, met at the gate. you ever get any follow-up on what it was I didn't. I, I gave the paramedic person- personnel, just a differential, Could it have been like- spasm of iris, a sudden change, sinus pressure. did she have trigeminal neuralgia? I threw out a couple of thoughts- Yeah and, they took her off to the closest ER. Probably in Burlingame or Millbrae there's just not much you can do for of things Yeah. Tools. No, and I'm so used to having my tools and, in that- Yeah zone of, how I, how and where I operate. But no, this was totally different. So it was, good. I felt good about being helpful. I felt the vulnerability of not having, all the things that I'm used to, to practice with. So just, I know, it's just kinda left with, what can we do to sort this out, and is there anything I can do in the meantime to help mitigate the pain she was experiencing? Yeah, and you probably didn't even have time, to get pain meds to her? There were little. Yeah, there was really- Yeah there was little time. have you, had a chance to explore those kits that they have on most airplanes? I haven't, no. Remember talking about it in residency, but honestly, that was so long ago, on a, that's on a very dusty shelf. No, that's fine. I actually reached out to Josh Wile. He had done a talk on this- several years ago, and I found his talk. so I'll review that. I think he goes through, the kits. 'Cause I think it'd be for docs to know, like, when they're volunteering, like what they have access to I'm pretty sure there were aspirin, nitrates, and a few- Caffeine? Tylenol, caffeine, yep. That's, pretty limited toolbox. Yeah, and the AED kits, I'm sure. I didn't realize they have oxygen. that seems you don't think that's dangerous in a pressurized situation to have an oxygen tank? I guess must not be. Yeah, I guess not. Yeah, I Okay. I guess I'll take their word for it on that one. I'm glad both of them turned out okay. Did you get any nice perks for helping? You know what's funny? On the last one, on the way back from Hawaii, the attendant asked me for my name my seat said that she would, she said, we'll get you a voucher." I was that's nice. that's really nice of you. Thanks." And I told my wife about it, she was "Oh, cool." And then a couple weeks later, I got an email, and I told her about it, told my wife about it, and she was I said, I, I really didn't do much of anything. I just kinda knelt beside her in the aisle while the plane landed. I don't really feel what I did amounted to, some voucher." And she was "You fool, get the voucher. you helped out. It's okay. You know- Yeah don't worry about it." Yes. Free, yeah, take it. Those tickets are expensive, and they give them out, and you should take it for simply h- your presence being there was probably very comforting to that person, I bet.

6:47

Well, thanks for sharing your story, Mark. Boy, if as a pediatrician I was the only doc on board, I would be a little rusty running an adult code. So it's probably a good thing to hear all of your stories and just to know what's there for you and refresh your memory if you're traveling as a physician and willing to volunteer as a doc yeah, I'm looking forward to hearing the stories of others. In this next segment, we hear from Dr. Kristen Sterley. She is one of our pediatric hospitalists who was formerly in the Navy and has a few wild experiences to share tell me what happened. I'm dying to hear these stories. Okay, so my story begins with I,, was in the Navy for my internship in and with the Navy, many people do an internship and then they go off to what they call a general medical officer tour. So this is, you might go out on a ship, go out with the Marines. go do flight medicine or dive medicine, that kind of a thing. And so I had finished my internship, and this is relevant to the story. when you're in the military for residency in pediatrics, you actually have to do, a month of emergency room, adult emergency room. You actually have to do OBGYN, to do orthopedics for a month. And so the idea was that, as a medical officer in the military you needed to be able to go anywhere, any time, and, take care of adult patients, right? I did at least have that little bit of background training, but the rest of my training for internship had been in pediatrics. And I was on a flight from, California, so from s- LA to Japan, where I was going to be doing a year, as a general medical officer. So I actually served a year with the Marines over there in Okinawa, Japan. And so I'm on the flight with a bunch of my, other military people, but I wasn't with any of the other doctors, which is a relevant piece. So there was an overhead call, "Is there a doctor on the plane?" I have to admit, I sat there looking around thinking, "I hope else gets up," because, I've basically completed an internship and I technically have a medical license, but that's about it- and I'm a pediatrician. And so I looked around for a while, no one's getting up, so I finally just, pushed my, light for the stewardess and I go- I get up. They have me come over, and they bring me up to, It's an international flight, so there's the galley area, ob- there's space obviously over to the side, by the exit doors. And thank God, at that moment an EMT also showed up, so I was feeling much better about things. so the- flight attendant pulls out, it was unbelievable, this bag, for lack of a better term, almost a suitcase full, and it had so many drugs, and most of them were adult ACLS drugs, which technically I had ACLS and ATLS for as well as my, pediatric, basic life support, PALS, everything. But I didn't even recognize all of the medications. they had all of these different medications, as well as stuff to start an IV fluids. It was actually a pretty incredible kit of stuff that they had, as well as, I don't remember, it might have been a defibrillator at the time. Maybe they had AEDs at that point. Anyway, maybe it was an AED. Sorry to interrupt. Do you know if, was that so complete because it was an international flight, or do you know if all flights have that much equipment? I think this was probably true for all the flights- Okay 'cause it looked a pretty standard, I don't what airline I was on, but it looked a pretty standard, bag, backpack, suitcase type thing that they would have. Okay. and so fortunately the patient was breathing, which, and also had a pulse. But they looked they were starting to have a seizure, and I'm sitting there thinking, "Oh my God, I've gotta..." but I guess the EMT could have put the IV in. So anyway- But together between the EMT and I, we started asking some questions, and we were able to essentially piece together that the guy was super nervous about flying. So he'd taken a bunch of Benadryl Probably overdosed on it... And then decided to have a drink or two, I think he'd had two drinks, on this flight. We were maybe six, eight hours into the flight, so over the ocean nobody was gonna be helping us. Also, he had not been drinking any water. And so anyway, he just got super dehydrated. He'd passed out, and I think because of all the meds was just really twitchy. So we gave him some oxygen. eventually able to get him to do some deep breathing with an oxygen mask on, which seemed to help him calm down a little bit. And then we got him drinking some water. And so eventually they just let him lay there. They put a blanket over and let him lay out for a little while. But fortunately he was okay. So eventually I went back to my seat and the flight attendant comes over and she's "So I need to see your medical license to write it down for the information or whatever." And I'm thinking, they're thinking, "I there's a Good Samaritan law somewhere," but I of course had never, had not looked it up. And this was, I didn't have a cellphone yet either, right? This was, really pre, everything. So I, of course did not carry my medical license around with me. who knew? and so she's "Oh, that's okay," but she took my name and my phone number. So then the next thing you know, it's literally a half an hour later and they call for a doctor again. And someone else had apparently been trying to walk back to the bathroom and passed out because they too were not drinking enough water and had taken some kind of drug to try to relax on the flight. And again, fortunately they had just passed out and were breathing and conscious, But it was very eye-opening as to what all of the stuff they had on the plane. and the s- the flight attendants really well-trained in they had set things up and The next thing you know they're passing out bottles of water to every single passenger- Oh, I get it on the flight, making an announcement that everyone must drink. and then as a bonus they did, a few, I don't know, 30 minutes later they came by and they gave me some warm nuts and some ice cream that, you get, if I would've been in first class I would've had free access to. That was my big reward for standing up on the flight. But, yeah, it was, I was... I'm surprised I didn't pass out. I was so nervous about whole thing- Totally get it Having been an intern. Now interestingly, fast forward a year, I'm still with the Marines over in Okinawa, and I ended up being the medical officer in charge of this deployment that we did. And so in Micronesia, which is, a bunch of the islands in the Pacific, I- and Palau. anyway, so actually have their own, little mini Olympics. And so I had gone on a flight all the way to Guam from Okinawa, which was eight hours, stopping along several islands along the way on this military plane. And I'd gone and done a pre-thing. I'd done all the planning, gotten all the supplies. so and I had learned to put together kits, that had epinephrine and Benadryl and steroids, together in case someone got stung by a bee, 'cause this was all outdoors. Yeah. and so sure enough, one of my corpsman actually used the kit 'cause someone in a wrestling match got stung and was allergic, and he actually used the kit and saved someone. And then we were on the beach, and there was a canoe racing thing. and so they're coming in, and the next thing you one of the canoes tips over, and there's someone in the water who's not getting out. So one of my corpsman, all his military gear, in, grabs him out, and I had to then put an- she was actually having a seizure. I had to put an IV in her on the beach with all people around. Oh my God. But thank God for pediatric training. I actually did it on the first try and gave her some, anti-seizure, whatever benzo we had on hand, and, she stopped seizing. it turned out that she actually was, had a seizure disorder because when she was 16, her parents forced her to marry, and her husband had beat her br- hit so badly in the head that she had a seizure disorder. but she was in a canoe race. All right, Kristin- Anyway remind me to never be on call with you. a black cloud it sounds like. normally I s- I have a white cloud,\, but, yeah. Anyway. that's awesome. No, those are great stories. and you're not alone. the couple other people that I've talked to have been like, "Nobody jumps up when I say let's do an emergency room doc." yeah, everyone's "Is somebody else gonna do this instead of me?" 'Cause yeah, most of us get trained, but then we don't ever use those skills. And, it's good to know that they're probably in there somewhere, Thank you so much, Kristen. Those were, those were pretty awesome stories. Our next guest is Dr. Josh Kucker, who's one of our emergency room docs. So tell me, have you ever been on a plane when somebody, when the call went out if there's a, a doctor on this plane? Yeah, I ha- I've two cases, that I can think of offhand. I was with my now wife, who was at the time my girlfriend. We were going to Hawaii for a conference, and, for her, and we were almost joking, "Okay, you know, hopefully this is a vacation and nobody bothers us," and we are on the plane. You jinxed yourself. We did. We totally jinxed ourselves, and we were on the plane, and the call went out, and I sat there, and she looked at me. She goes, "Don't, don't you need to go?" I was "No, no, I'm not gonna go." And she said, "Okay." And then we saw a couple people get up, and then- The call went out again, "Does anybody have an EpiPen or Benadryl?" And she looks at me and she goes, "What is that?" I said, "I, I gotta go. I gotta get up." Yeah. So, so we were- I can't ignore this anymore yeah, we, we were halfway in the back of the plane and, and so I walk up to first class where the patient was, there's a guy there, there's a woman sitting in a seat. She looked okay just at first glance, and I, I tapped the guy on the shoulder. I said, "Hey, I'm a doc. Are you guys okay? Do you need any help?" And his- he whips his head around and looks at me and goes, "What kind of doctor are you?" I went, "I'm an ER doc." And he goes, "Oh, thank God. I'm a dermatologist. I'm going back to my seat now." So he literally turns around and goes back to his seat. So I start chatting with the patient, and, and she had eaten something that she thought was giving her an, an allergic reaction. Apparently, the, the flight attendant said that if they crack open the medical kit, it, triggers this monster paperwork trail and- Ah everything, the air- the plane is out of service 'cause they gotta restock it, and where we were going, they don't have a new one, so they have to wait for the next flight to fly in, and it was this whole rigmarole. So they, they try and, at least this crew, they tried to use- Do everything they could right, they tried to use, the passengers' resources. So I end up evaluating the lady. She was barely having any reaction. It was more psychosomatic than anything. I think she kind of scared herself and it was probably anxiety. But somebody had some Benadryl- Yeah so we, we gave her some Benadryl, and I came back and forth a couple of times and checked on her, and she was fine. And, That's good the flight attendants, yeah, a couple hours later, you know, come down the aisle. We were... This is from LAX to Hawaii, and, you know, said, "Thank you very much. Let me get your name," blah, blah, "We'll give you a couple of points." And, you know, next thing there's a few, a few bonus cocktails on our trays and, so we... That was, that was our gift. That and I think we got some snacks from first class, and so that was about the excitement. Yeah. The cocktails, they, I think they were probably hoping that there weren't any other emergencies that were gonna come up. Yeah, no doubt. It was, it was, it was a thank you and, and it was also, yeah, "Here, you're off duty now. Have a nice, have a nice rest of your trip." Yeah, so in your other situation, did to open the kit and use it? So yeah, the other situation we did. So my wife, and I, on our first long vacation... We've been together 10 years, we have four kids, now six, with some, nieces who moved in with us. So we don't get to get away very often, and this was a trip a couple of summers ago. We had worked on plan to- We were going to Italy, a couple of stops in Italy. Great place. for the longest we were ever gonna be away, it worked out with my ex and my sons, they were with their mom on a trip, the, my stepdaughters went with their dad on a trip. And so we actually had time. So we booked this trip, and we're on the flight San Francisco to, Paris, connecting in Paris to Italy, and we're about three hours into the flight and we're, we're- my wife, we were kinda sitting towards the back of the plane, and I'm about half asleep and then I hear this crash, thump, and a whole lot people yelling. And I kinda open my eyes and I look down, and literally there is this probably 6'3", 23-year-old laying on the floor in the aisle, essentially at my feet, and all these other people who saw him go down are yelling and screaming and hitting the flight attendant button. And I, my wife is mostly asleep. I elbow her, I said, "I gotta go to work." And she looks at me and she just starts chuckling. So I get down on the ground, and this 22, 23-year-old grad student who was with a bunch of other students, and he had had a couple of drinks before he got on the plane and then I think had a couple of more on the plane, and did the classic thing of forgetting to eat. Got to altitude, st- started to feel a little funny, so he was gonna say, "Oh, I'm gonna go to the bathroom." And then he stood up, took four steps towards the back of the plane. Vasovagaled. Vasovagaled straight out. But he went down really hard. I asked a person who saw him, who was a couple of rows in front, 'cause I didn't see it, said, "Yeah, he just went limp and then bounced off one of the armrests on the aisle and just crashed to the ground." Whoa. So when I got to him, he was sort of coming around, and we talked a little bit and I examined his neck, and his neck felt fine and he didn't have any pain. After a couple of minutes, I sat him up and he promptly passed out again. Oh, I'm sure had no water, no Gatorade, no, no, no quote, unquote pre-gaming, as the kids like to call it. And yeah, you know, 8,000 feet of cabin altitude and dehydrated and yeah, down he went did you need to start an IV? Well, so we talked about it, and at this flight, the crew did break out the medical bag, and I asked them to. I said, need to check his vital signs," and got a pulse ox on him and everything. I don't think they actually carried IV fluids I would think IV fluid would be fairly standard on those kits I, I thought so, but he was feeling okay and was able to start, I had him sip some water, and they did have Zofran in the medical kit, so we gave him some Zofran And he was, he was nauseated, but he was keeping fluids down, so we just sort of put him in the back of the big jumbo jet, in the big galley there where there was actually a lot of room. And a couple of his friends at this point came down, and they took turns just laying him down, lay- sitting there with him. He was laying down, had his legs up on some blankets. and just kept, you know, kept sipping fluids, eating some crackers, sipping fluids, eating some crackers. And I'd go back and check on him every 30 or so minutes, check his vital signs, and he was fine. and by a couple, three hours into the flight, we got him up very tenuously, and he didn't, he didn't feel orthostatic when he stood up, and felt better. Um, and yeah, went back to his seat. And on the way off the plane, his, the professor who was running the trip came up to me and really thanked me and gave me his card and, uh, that sort of thing. But yeah, it was, it w- not very dramatic, uh, other than the fact that it occurred directly at my feet, and I felt I, I literally looked, I said, "You know, is a, this is a monster airplane. He could've passed out anywhere else other than at my feet, and I never would've known about it." known. Sixth sense- Yeah of, you get help. Oh, for sure. Yep. Yeah. Hey, so question for you. I don't know if you know this- Yeah but, you know, ethically, um, or legally, like, my biggest fear ever is that as a pediatrician I'm gonna, you know, get a, get a call on a plane and gonna be, an old person, and I'm gonna have no idea- Right what to do. Like, do you know ethically, legally, um, simply having an MD after your name means that you have to respond to these? I don't, I don't think so. I'm not 100% sure. I know that ACEP, which is the American College of Emergency Physicians, they have, they have, uh, position papers on this- Mm uh, specifically for ER docs. And I think it is something to the effect of if you feel if, it, that there is not, I don't believe there's an absolute legal obligation because, you know, particularly on an airplane, especially if you're on vacation, I think, you know, people have the tendency to, to have some celebratory cocktails before getting on the plane- Yep and that puts you in a, in a jeopardized position. Right. so I don't think that there's a hard and fast legal. I think if you identify yourself and say that, "I'm a physician," particularly an ER physician, then you are then obligated. Obligated. Yeah. Yeah but if, if you don't, if you don't volunteer, you don't raise your hand, then I think, there's no punitive. They, the family couldn't come back and say, "Oh, you were, we saw the manifest of the flight and you were an MD sitting in seat 10C. You know, why didn't you- Right get up and help my dad?" I don't think they'd come back and do that. And what if things incorrectly? uh, w- there is still the, the Good Samaritan law. Does that protect physicians as well as laymen? It definitely protects laymen. As far as physicians, I, I think you could make the argument, and again, I'm not positive, I think you can make the of, for you, for example, being a pediatrician, you know, I, my scope of care ends at 18, and I haven't run a code or seen a code on an old person since I was in medical school, so I know. Exactly. Yeah. I don't, I don't think there is... You will be held to the same standard of somebody me, for example. Um, so I, I don't know. I think the, I think the overall Good Samaritan, you do the best you can. And then I'm, I'm sure you know that there are, that via the cockpit, via the flight crew, there are, all the airlines have contracts with a base station medical, I think it's out of Baltimore and Johns Hopkins, uh, where they, they have ER docs 24/7, uh, who can f- provide in-flight consultation Cool to know. Um, and what, what are usually on those kits? I assume Epi, Benadryl, you said Zofran's on there. Mm. Blood pressure cuff. You said pulse ox. Yeah, it sounds I've only seen a couple of them. Uh, ACEP again talks about what they recommend, and I think the airlines have adhered to that. But it's, it's all the basic stuff. It's, I think they have oral airways, and, nasopharyngeal airways, blood pressure cuff. There's a defibrillator on the plane in a different area. Basic medicines. I think they all have IVs, medication, basic medicines, and I think they have, you said, EpiPen, but also think they also have some ACLS meds. I'd have to look for sure, but I'm pretty sure you, there are drugs in order to begin running a code. So then what happens? Like you're running, you're, you're dealing with the patient. Is the flight attendant then kind of running back and forth to talk to the, the ground crew? Do they put you on the phone? Is, how does that work?, When I was, for example, with the kid who passed out, the flight attendant did ask me, "Do we need to turn around? The kid was awake and alert, no signs of injury, and so I was comfortable with him just sort of recovering from his vasovagal syncope. And he didn't have any risk factors that made me worried he was gonna have any arrhythmia or anything like that. Uh, I think that how I understand it works the cabin crew will talk with the flight crew. The flight crew can get the, the referral center, the ground-based crew on the phone with the doc, and then, you know, have ultimately put me on the, on the headset to talk with them- Okay kind of doc to doc, uh, and make a decision. You know, do we need to land right now, especially if you're over the continental US. Yeah. You know, within 30 minutes you can be on the ground at, at a moderate to decent size airport with- Right uh, an ambulance there. Um, and I know that there are, and I've seen case reports, yeah, cross-country JFK to LAX, and they landed in, you know, Wichita, Kansas to offload- Yeah somebody having an acute whatever. Uh, so I know that that does happen. Yeah. So like common things that you might experience. Allergic reactions I imagine are high. The vasovagal syncope is probably high. What else do you think, people should be aware of, I know when you're like hiking at high altitude, that certainly puts stress on the cardiovascular system. Does that happen just simply being at, at that altitude if the plane., Is, pressurized, right, that's true. Most airplanes are pressurized to about- 8,000 feet. So- I think, hiking at altitude you're obviously exerting yourself. Okay. Walking down the aisle on an airplane probably not as much. Everything that I've, that I've seen and that I've read and I've heard other people talk about is, is all basically the same stuff you get anywhere. Chest pain- Right. Yeah shortness of breath, allergic reaction, not feeling well, weakness, I've, read a case report of somebody walking down the aisle and clipped somebody's foot or clipped something and spun the wrong way and ended up with a- Mm-hmm fracture dislocation of the ankle, so they had to reduce it in the back of the plane and all that sort of stuff. Yikes. Ouch. You know, and they splinted it and landed wherever they were gonna land. Nice. Well- Yeah I, I know if there's crying children, I can probably be helpful. Yeah. Beyond that, maybe I need to review my, uh, my ACLS before I get on the next plane. I would recommend just, you know, probably not hear the announcement. I would have my noise-canceling-. Headphones on and yeah. Yeah, unless, uh, unless it's the crying baby for sure. Yeah. Then I'm, I'm probab- there's probably a few more skills that I could muster, but yeah. I don't know about running the- No, no, no. Totally the- I'm, I'm teasing. Yeah. the code on somebody having an MI. Even I I don't wanna do that at 35,000 feet. No. God, no. No. And such a small- Yeah like, you talked about these transcontinental planes. Yeah, they're huge, but like most planes, y- you've got such small amount of space to work in, too, right? There's not much room to lay somebody out and truly assess them well. Yeah. for a long time, I would fly to LA for EPRP. Uh, the call center was down there before everybody started working remotely, and I would often think, you know, on these, these little, 75-seaters out of Santa Rosa down to LA- Yeah okay, if I gotta do something, there's, there's two spots. There's, no. Neither of them are very advantageous. No. No. Yeah. Well, luckily, knock on wood, it doesn't happen very often. No doubt. Well, thank you so much, Josh, for your time. I appreciate it. You bet. Our final interview is with Dr. David Dolana, who's one of my colleagues in the family medicine residency, and it sounds like he's had quite an exciting situation on his last plane ride, which I think occurred about a week ago.

Adrienne 29:43

Thank you for doing this. Tell me what happened. Oh, so the most recent flight, Oh, there's more? There were- you're a black cloud, huh? I know. I always thought of myself as a white cloud, but on flights maybe I'm a black cloud. Oh, okay. Remind me not to fly with you. Yeah, tell me what happened on your adventures. This was our leg from San Diego back to Santa Rosa on Alaska. So that's a pretty short flight, maybe an hour and a half all told flight time. And I was, flying with my wife and daughter. We were sitting in a row together, and then there was an open fourth seat, and a woman came in and she occupied that fourth seat, and, was sitting next to my daughter of course, who as a teenager- Oh, boy. was completely frustrated that she had this stranger sitting next to her. Yeah. Could have been. Instead of a- Yeah nice open seat. Yes. Anyways, in the middle of the flight sh- this woman falls asleep. She's probably, 30-something. And, she starts to kinda fall asleep and lean onto my daughter's shoulder. Ooh. 'Cause she has the woman has the window seat. And, Yeah and, then I get a text from Nohea. Grr. Oh. Oh, man. Love when you get a text from your daughter, two seats away on the airline. Right. And then my wife- I'm not gonna react. My wife looks over and she just starts doubling over laughing. So my wife and I are chuckling, and then this woman, kinda like slumps over a little bit more onto my daughter's shoulder. And, So Nohea's a little bit more frustrated, and she starts to gently- Yeah nudge her over. "Hey," "wake up, move over." And then the woman is not responding to her, and after a couple minutes Nohea notices that like she's not really breathing Oh, shit. Oh, shit. and she can't rouse her at all. So then she, asks mom for help, and she says, "Hey, Mom, this woman, like she's on me and she won't get up." And Theresa calls the flight attendant who comes over, and he's so funny. The flight attendant l- literally takes his pointer finger and like nudges her shoulder twice, you know- two gentle taps. "Ma'am." could I really barely touch you? Barely touch. "Ma'am, ma'am." Yeah. And she is completely out. So then- Jesus Theresa takes matters into her own hands and she's "Okay, Nohea, just trade seats with me." And so she goes over to this woman and realizes that she's not really breathing well. Doing okay, yes. Yeah, like she's not doing okay. And I look over there at this point and I notice that she is turning blue. Like I can see her- is your wife a doctor in the medical field? My wife is a phlebotomist. Okay. So she's really good at waking people up. Yeah. At 4:00 in the morning. She's Theresa from the lab." Oh, that's funny. but that didn't work. That didn't work, and her hand was blue. Theresa goes over there and she's props her up. And then she looks over at me and she's "You gotta come over here." So I slump across the row and then press the flight attendant call button again. And then we reposition her airway, with a jaw thrust maneuver, like head back- yeah, yeah kind of thing. She is probably breathing like four times a minute at that point. And acrocyanotic, and definitely has lost her radial pulse. Oh, wow. still has a carotid pulse. I flip up her eyelids and her pupils are completely pinpoint. Oh, smart. Yeah. Yeah. Yeah. And then, the flight attendant comes by and I'm like, what do you got?" An epi pen please. And she's You're like, "Can you..." She's can I help?" And I was "I, I was like, "We got a situation here." I was like, "What do you got in the medical emergency kit?" And she's "Will oxygen be helpful?" And I was like, "Oxygen is always helpful." I was like- Yes. And, I'm like, "Do you have any Narcan?" And she's "I don't know. I'll go back and check." They didn't know? Oh, my. I know. So she comes back with the oxygen. She's "I don't think we have any Narcan." What? And the other flight attendant comes, and I was like, "You gotta ask somebody on board whether they have Narcan." Oh, yeah. And that's when I made a mental note. I was like, "Why don't they have Narcan on these planes?" And I'm like, "I probably should be traveling with Narcan at this, in the modern-day world, right?" With all the- opioid-related overdoses and the mystery, pills that contain fentanyl. Yeah. Anyways, so luckily once we put the oxygen on her, she ends up taking one deep, like type breath, and then, her color starts to gradually come back and I'm feeling like my heart rate goes down about 20 beats a minute, and I'm like, "Okay, I think she's gonna be okay." Assuming that wasn't an agonal breath, right? It could have gone one way or the other, right? That was either the last breath or- Oh, man that was the one that, turned her life. She's "Okay, I'm coming back to life." Now, she's 30-something, right? So she's young. Yeah. Looks pretty vibrant. I was like, "Oh, that's good news." But, We, yeah, we couldn't get any, we couldn't find any Narcan, so luckily the- That's a lesson. Wow. The ar- the oxygen and the, repositioning did the trick. Like she was only in respiratory arrest at that point- yeah and heavily overdosed on whatever combination of stuff she took. We actually went so far as to, look in her purse to see if- yeah she had Narcan, and she had Ativan in there. There was no Narcan, but yeah, I don't think she was- That'll relax you on a flight. Yep. So- Oh she- That is a really good lesson. I wonder if it was because it's, they're such short, flights- as opposed to the national ones. That is a really excellent point. I think I will go pick up some Narcan from the, pharmacy before I go on my next trip. Agreed. This woman woke up literally two minutes before landing. She like started coming to and kinda grabbed the oxygen mask on her face and like she just looked o- "What the hell happened?" Yeah looked over at me like a deer in their headlights and was like, "What happened?" I was like, "You got-" "Next time please don't take so much Ativan." Oh my goodness. "You got really lucky to- today, sweetheart." I was like- "You could've died on this flight," and she just looked at me and she goes, "I had a really weird dream." Oh, no. Oh, wow. Was that her, white light dream 'cause actually heading that way? Maybe it was. Oh, man. and it sounds like you have other stories you've had to put your skills to the test in other ways? the one other time was actually a long international, leg. We had just taken off from JFK heading to Oslo- and we heard the call of the flight attendants ask was, "Is there any doctor on board?" And, every good doctor waits there for a couple minutes. That seems to be- Any other doctors on board but luckily I was it again, and they came over to me, and a woman had passed out in the bathroom. So she, when we got there, she was slumped over, and they had brought her slightly upright. She was conscious again, and she, her husband and the flight attendant and me, we all got her back to an empty seat. Turns out she had diabetes. And they were- And hadn't eaten. Yeah. They were like ending their several week vacation in the States And so the husband had the glucometer, this is, years ago, before the days of continuous CGM monitoring, right? So it's the old finger prick glucometer, and so he took the, the measurement and he's "Oh, the, her glucose is, something nanomoles per milliliter." And I have no idea what that scale is, right? That's the European scale to measure- Oh, glucose. The metric scale. Metric scale, right? And then he luckily had the conversion chart, so he kinda showed to me where her blood sugar was, and her blood sugar was very fortunately, 253. Oh, okay. And I was like, "Oh, great." So she hadn't given her insulin. I was like, that's, high enough so that she's not hypoglycemic." Yeah. And I was like, "It's low enough that she's not diabetic ketoacidosis." So maybe she was low and actually ate something- and then was just rebounding, or she struck me as, not the healthiest- person, just overall. I don't know what else was going on with her health, but- it could've been some combination of factors. She could've just went on the toilet and Valsalved, and- passed out, and had nothing to do with the diabetes. but the flight attendant, w- we were at that point, I don't know, an hour out from JFK. And the flight attendant, her thing was like, "Are we... Do we need to turn back?". And I was like, "Nope." "Nope, we're good." "Off to Norway we go." Oh, yeah, please don't turn around. You'll have a very angry flight of people. yeah, the theme of this inter- these interviews so far has been drinking too much, that people- don't eat and then they drink a ton, and then they pass out from that. that seems to be, that seems to be a theme. But the, the story about Narcan is a really good one. and hopefully after people listen to this, everybody will take Narcan with them on their next trip. Yeah. 'Cause- I hope so, too. I certainly will start to carry it- Yeah for sure. Yeah. thanks, David. Thanks for taking the time. Okay. Thank you. this will be a f- fun one to listen to for everybody.

39:42

Thank you to everyone who has listened so far. I mentioned in the beginning of the interviews that Dr. Josh Weil, who is a retired ED physician, did a talk on this several years ago, which was outstanding, and I was able to get in touch with him and get his presentation, which will be included in the email that you all should receive. And I just wanna take a second to summarize some of his big points. I think the biggest one is that, um, as a physician on an airplane, you're not expected to turn the airplane into an ICU. Your job is to stay calm, assess the situation, use the crew and ground medical support, and help make the safest decision possible with limited tools. He also talked about just the anxiety of getting that overhead page of, "Is there a doctor on board?" And that most of us think about, am I obligated to respond? Am I protected legally? What if I make the wrong call? What equipment is even available? And do I decide whether the plane lands? So the good news is that under the Aviation Medical Assistance Act of 1998, physicians are generally protected when they provide emergency help in good faith, unless there is gross negligence or willful misconduct. Physicians are generally not obligated to assist, but if they do assist, they should stay within their ca-capabilities, document what they did, and avoid accepting compensation beyond perhaps a thank you gesture, because compensation may complicate Good Samaritan protection. It's also important to note that international flights are more complex because laws may vary depending on the aircraft, airline, departure country, destination, and location in flight. The good news in all of this is that medical in-flight emergencies are fairly rare. Older reviews suggest around one in six hundred and four flights had a medical event. More recent estimates are expressed as twenty-four to a hundred and thirty events per million passengers. Most cases, luckily also are not dramatic codes. Most in-flight cases are, syncope or near syncope, GI symptoms, respiratory symptoms. Cardiovascular events are only about seven percent. Cardiac arrest is only about point two percent, and other things are listed such as seizure, stroke, injury, pain, et cetera, with variable, um, frequency. About twenty-five percent require post-flight evaluation. Around four percent of flights are diverted, about six percent are hospitalized, and mortality is about point three percent. So the takeaway point of this is that needing to divert the flight is rare, but high stakes. It may cost twenty thousand to seven hundred and twenty-five thousand to divert a plane, but the physician's focus should remain on patient safety, not airline costs Another point that came up was that the airplane environment changes physiology, that commercial cabins are pressurized, but not to sea level. They are often equivalent to a high altitude environment with cabin pressures around eleven to twelve PSI compared with sea level around fourteen point seven PSI. The main consequences of this are that gas expands up to thirty percent, which can worsen sinus pain, ear pain, bowel discomfort, or pneumothorax risk. Even healthy people may have a mild oxygen saturation drop, for example, from around ninety-seven percent to ninety-three percent. And conditions that may become more concerning in the air, such as chest pain, shortness of breath, COPD or pulmonary disease, pneumothorax, severe anemia, recent surgery, pregnancy-related emergencies, seizures, stroke symptoms, or a syncope with persistent instability. In terms of which resources are actually on board, airplanes are required to carry emergency medical kits, though exact contents and availability may vary. Flight attendants generally have first aid training and likely AED training. AEDs are typically on board, and airlines often have access to ground control medical support. What's interesting is what's not on board, and apparently, most kits do not have a pulse ox, a glucometer, definitive airway, benzos, antibiotics, a scalp or cric kit, insulin, calcium, furosemide, delivery kit if you have to deliver a baby, EKG or steroids. And Dr. Weil had some helpful guides. There's an article from JAMA in December two thousand eighteen, which has, useful cut out cards for you to carry. And there is an app called AirRx, which is a free app that lists information about the kits. And that concludes this podcast. I hope this was interesting to everyone, and, uh, please let me know if you have any questions or any thoughts about future podcast idea. Thanks again for listening, everyone. This has been life in practice.