August 2018, Volume 68, Issue 8

Short Communication

When three emergency physicians flew together

Sana Shahbaz  ( Aman Foundation )
Asad Mian  ( Aga Khan University Hospital, Karachi )


I feel movies and television are over-romanticized versions of real life. Although, truth be told, I am awed by how characters in Grey\\\'s anatomy can work miracles while looking perfect with full heads of hair (a personal struggle), great social lives, as well as finding empty call rooms for quickies while on call in the hospital.
Emergency physicians are never short on two things; one is adrenaline and other are interesting stories. I am an emergency physician and I share below my first (likely, not last) experience of emergency medicine up in the air: that is, on a domestic flight I assumed would be as uneventful as my love life. My story involves a few emergency physician friends; an important thing to state here given the fact that the only people we can socialize with are other ER physicians, due to similar time constraints and socially awkward sense of humour.
Unlike what television series project, we do not make tons of money. Since it was meant to be a work-related trip we had bought the cheapest tickets possible, especially given the 24 hour notice while adjusting our ER shifts at the last minute. Dr Shah, one of my colleagues, had barely managed to board the flight as he had come right from the hospital after signing over his patients. Dr. Arif, my other colleague, and I already boarded the plane, as we caught sight of Shah sitting up ahead, towards the front.
The plane did not take off on time, which I found unusual, although it could have been a routine occurrence for domestic flights to be delayed; after all this was my first domestic flight in 7 years. My only thoughts were that we land safely and
prior to that we get proper food. Hence you can imagine my joy when food was actually served, so yes - the plane did take off after an hour\\\'s delay!

I was about to dig in, when one of the flight attendants paged:

"Hello! A passenger is facing a medical emergency. Is there a doctor on board?"

Arif and I, clearly more interested in the food at that point, looked around for someone else to raise their hand. No one did. So, we reluctantly put our hands up. The flight attendant asked us for verification. That was difficult given the dinner trays in front of us: you see, our doctor ID cards were in our hand luggage stashed away in the overhead bin. Luckily we remembered that Shah was sitting up ahead and likely carrying his ID card given he was still in his hospital scrubs, so we informed the flight attendant to contact him. We then happily resumed our meal.
Only a few minutes likely lapsed when the attendant rushed back to us and literally snatched our food away.
"Your doctor colleague is urgently requesting your assistance for the patient in
Arif and I rushed towards the front of the plane, ignoring the curious glances of our fellow passengers.
Shah was kneeling down next to the patient. Interestingly there was a fourth doctor at the site:
"I\\\'m Dr Omer and I\\\'m a family physician", he introduced himself.   
Doctor stood beside the patient; had a stethoscope strung around his neck, and he was trying to assemble the blood pressure apparatus from the plane\\\'s first aid kit.
The patient who appeared to be in his 50s, was severely short of breath, sweating profusely and about to collapse. Once Omer had managed to get the blood pressure reading it was alarmingly low. To add injury to insult, the patient as well as his companion did not speak Urdu or English. Luckily, there were some medical reports in a file that they were carrying. I quickly realized how sick he really was: he was suffering from malignancy. Although I had read several books and
experienced many patients with the same symptoms, the fact that this scenario was occurring in midair, and not in the all too familiar hospital setting, made it more nerve wracking. There were several passengers wanting to be part of the action; they threw several random suggestions at us with respect to managing the patient, but we already knew the essence of what was needed. 
Placing the patient on oxygen did wonders for his breathing.
Dr Omer, the family physician, was unable to find anything useful in the airplane medication / first-aid box. Even if he had, there were no intravenous cannulas or a drip administration set. Regardless, that didn\\\'t stop him from creating \\\'what if\\\':
"What if we had bromazepam? This patient\\\'s low blood pressure and breathing difficulty would benefit from that!"
I knew that bromazepam was a medication with a calming effect used in panic attacks and as such could take away respiratory drive too. So I was glad that Dr Omer did not have access to that medication.
"What if there was angiosid? That would have helped for sure" Dr. Omer went on.
Another good thing that angiosid also wasn\\\'t available. It can drastically lower blood pressure, especially in a patient with blood pressure already on the lower side.
After politely declining his suggestions and thanking him for his skills demonstrated thus far, I personally took charge of the medication box and was able to recover two intravenous cannulas.
Dr. Arif put the intravenous cannula into the patient and I then pushed in normal saline via a 50 cc syringe. Since we did not have access to a blood glucometer, we prophylactically gave dextrose; we essentially ruled out a pneumothorax by auscultation and hearing bilateral air entry; we gave him 2 puffs of salbutamol and IM hydrocortisone along with aspirin (orally).
The few interventions above made a marked difference in the patient\\\'s status. His blood pressure improved and his breathing became more comfortable.
Through the above the airplane staff remained really cooperative. One of the flight attendants kept track of the oxygen cylinder gauge so the tank could be replaced before it entirely ran out. Quite amazingly, the airplane staff continued the food and beverage service: there were food trays being passed over our heads!
The pilots managed to cut down on the flight time by 15 minutes on our request to take the shortest route possible. The civil aviation ambulance was on the ground waiting for the flight to land and then to safely transfer the patient to a nearby hospital. Although we asked if they wanted us to accompany the patient to the hospital, they graciously declined; they were immensely thankful for caring so well for the patient, while up in the air.
Several days after that episode I started thinking about that experience. It occurred to me that there was serious lack of thought given to \\\'life saving\\\' medications on board an airplane. I wondered why an expensive long haul flight not have an emergency physician on board for unforeseen emergencies. It also made me think about that patient; what a remarkable coincidence that three well trained emergency physicians took a domestic flight at the same time; especially in Pakistan where emergency medicine is very much in its infancy. I can literally count the number of trained emergency physicians on my fingertips. This episode also brought forth the importance of emergency medicine training and how that translates into any situation, whether on land or in the air. It got me to think about how far we doctors should go to manage patients on an inflight emergency; especially when we are unsure of the diagnosis. It is an exciting notion to put yourself forward in an emergency-like situation up in the air, but it can take a totally wrong turn if your management causes harm to the patient and in worst cases, death.
I recalled that the medication box had lacked some lifesaving medications, air way equipment, intravenous lines of different sizes and drip sets. The airline staff had asked us to make a list of medications and equipment that we thought was lacking.
Experiencing emergency medicine midair was not part of the trip but that\\\'s the reason why we do what we do. At the end of the day it\\\'s all about saving lives!! Every day or anywhere, be it land or air.

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