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What happens when you are the doctor on the airplane? (cockeyed.com)
363 points by JacobAldridge on Dec 27, 2012 | hide | past | web | favorite | 195 comments

I have had several medical emergencies onboard as a pilot. One thing I constantly say to physician friends (my wife is a doctor), is that we (the crew) expect from them to make as fast assessment of the situation as possible.

For example in my company we don´t have an online doctor to ask for help, so the volunteer has to take care of the situation. Recognizing the problem as soon as possible and prescribing the necessary action (Is not going to be easy with such limited capabilities, sometimes is just impossible, but is better an overreaction), is important because commercial planes fly at 8 NM/minute, and depending where are you flying ( flying over the ocean or africa) 10 minute delays could mean another 30 extra min to land or even several hours if you have passed a no return point in the middle of the ocean.

Don´t hesitate to take control of the situation regarding the patient, stewardesses and other passengers:

- Ask for the medikit (only physicians are allowed to use it). I have seen some chief stewardess resisting to bring it, just to avoid having to write the compulsory report. - If it is necessary to lay the passenger on the ground or other seats, bring him water or any other thing, just give the needed orders and ask for help. - Ask the stewardesses to keep other passengers away if they are interfering too much. - As soon as practicable give a report to the captain and if necessary ask him to land the plane. He will be waiting for it. - If possible never declare a decease onboard , first you could be wrong!, and it is a bureaucratic mess. Is better to keep trying CPR till the emergency team can take care of the patient. We apply this in Europe although it is not a written rule, I don´t know how it works in USA. -Remember when in doubt it is better to ask the captain to land. Everybody will lose an hour or two but a live will probably be saved.

I know I'm going to get down-voted for an information-free post, but I think it's awesome that you're a commercial pilot and participating in HN. It can sometimes get too insular with valley-type techies here. Thanks for participating.

Not for being "information-free" but for breaking the guidelines: "Please don't bait other users by inviting them to downmod you."

I don't think he was baiting users so much as apologizing in advance.

Well I am also founding my own startup..;) so maybe it doesn't count!

I wish there was a better way on HN to know someone's other disciplines. They're usually hidden out of context.

I like reddit's Askscience's method of having a short tag next to the username. This could be helpful.

It could be interesting. I wonder how it could influence bias on the reader though if it was that direct. I more would like to be able to explore a person deeper if they've said something interesting, etc..

"Ask for the medikit (only physicians are allowed to use it)"? Are you sure? As a paramedic, I know of several cases where it's been used by paramedics and even EMTs. In fact, realistically (though not for a moment to denigrate physician knowledge, and training, etc), arguably most of the equipment in a commercial airplane medikit is -more- familiar to a paramedic than a family practitioner or indeed any physician whose career isn't in the emergency center or operating theater.

Perhaps it was imprecise language, I would use 'physician' more broadly. I imagine he means "trained medical personel" e.g. and not the untrained flight staff.

My apologies I was writing on the move and I wasn´t too precise. In fact is anyone with medical training, paramedic, nurse, or physician.

(Always wanted to be a commercial pilot. My wife also is a physician).

Curious, what is type procedure to verify that someone really is a physician? The OP doesn't mention if a license was checked or otherwise. He relates having to speak to a someone on the ground before he could use the kit but doesn't indicate if any check of credentials was made.

A similar thing happened to my wife (an MD). She was asked by the crew if she had any sort of hospital ID. There turned out to be ~3 other doctors on board, so she wasn't needed, but they did ask for some kind of confirmation that she was indeed a doctor.

Yes you have to ask for professional ID.

Well is not so glamourous after all. A friend of mine is currently working in Oman, he has told me that there are tons of american pilots working there as the salaries can be double than in the states. For young pilots the salary can be as low as 1000$/month. So there is lot of emigration in this profession. If you really would like to enjoy flying, just try soaring!. Much more safe than paragliding (more expensive too and less convenient). Only the plane and your ability to extract energy from the atmosphere. Awesome!. Of course being in North America you must try a flight in a warbird!

Do you have access to an on-call physician? Would a provider at some level less then 'physician' (e.g. nurse practitioner or paramedic) be able to use the kit if they're in contact with a physician?

It would be extremely frustrating to watch someone die (or at least get sicker), knowing there was equipment on board that could help them...

Law and regulations vary, but essentially you can "practice" under the license of a physician (and in fact, throughout the US, that's how EMTs and Paramedics operate, through an agency or county Medical Protocol Director).

Everything in that bag is likely able to be used autonomously by a paramedic - it deals with acute care, not chronic, which unsurprisingly is what paramedics are used to dealing with:

* childbirth * airway management / ventilation, up to emergency cricothyroidotomy * ET / NG intubation, including RSI (rapid sequence induction, essentially sedation, anesthetization in preparation) * bleeding control / fluid resuscitation * pain management * seizure / neurological * cardiac events, drug administration, manual and automated defibrillation, pacing * diabetic * overdose / poisoning * less common on an aircraft, but trauma, including burns * medication administration via IV/IM/IO routes

Most paramedics work almost entirely autonomously via protocols and training, and do not require direct physician approval for drug administration (as opposed to nurses). This range of drugs is quite extensive (my county allows approximately 40, including adenosine, amiodarone, atropine, dopamine, etomidate, fentanyl, morphine, midazolam, lidocaine, furosemide, promethazine, succinylcholine, vasopressin).

Yeah, I was looking to clarify if there was some sort of medical control available.

I know for a fact that some airlines do have an on-call physician (the medical director for my paramedic program was one years ago, in addition to providing state-wide medical control for all flight based EMS services), I was just curious if the OP's airline did.

We have medical service, and they are called in an emergency if necessary(is not like they are in standby just for a plane to call them), but usually we first ask for a doctor onboard. It seems that AA first call their doctor as a procedure, it has surprised me, but it´s pretty logical if you ask me.

We don't have inmediate access to a physician via frequency(lime AA seems to have which is great), but surely the ground team would find the airport team if necessary. Mind you that even if you have access to the medical kit, you are not going to use it properly, I have some general knowledge but I can not distinguish an heart atack from a simple pass out. You could easily complicate a simple issue. I carry on my Iphone the special operations forces medical handbook. It has some gidelines on asisting a birth, and much more(from dressing a hunt piece to basic dentist instructions) but I don't think I Could dare to prescribe a drug based on things read on the fly.

I'm trained as a paramedic. I routinely make those sorts of assessments (much more frequently than most physicians, in fact). It's unlikely you carry anything in your medkit that I don't carry in my ambulance.

My question is mostly if the 'physcian' requirement could be circumvented if someone with medical training (other than a physician) were in contact with a physician on the ground. If, for example, I were to explain to a remote physician that there's someone on board who is experiencing A, B, and C, and I would like to do X, Y, and Z. If the doc concurs with the decision, would that be enough, or is there some set in stone policy that couldn't possibly be overridden?

Let me check the rules, but I certainly would give you access to the emergency kit, and control over the issue. Your experence and formation is much more related to an onboard sudden problem, than for example a dentist or any other physician who has forgoten basic ER knowledge.

I just checked and you are completely right, is any one with a medical training and a professional ID as an accreditation. It is just we call for a doctor as a generalization, but is wrong and we should be more precise.

> never declare a decease onboard

I had a friend on a transatlantic flight that got stuck in Iceland (they tried to get the person on the ground and to a hospital but there wasn't really anything that could be done) for... a long time... because of this. And IIRC, letting them off the plane was not really an option either, so it ended up being not only depressing, but pretty miserable in other ways as well.

As a physician, thank you for this. Is there a standard medkit load out?

There is an ICAO recomended kit list, but usually is more extensive than that, I have our company list (I'll search it and post it later) but trying to find if there is a more general one. Now a days there are also automatic defribilators (spelling?) in transoceanic planes. There should be some kind of general briefing for physicians, from airlines and medical asociations.

I believe this document has the current ICAO med kit. Interestingly, I work with the guys who draw up these supply lists for naval ships, and we're chopping one now. Will definitely include this in the discussion. I really hope you can send me your company list.


I found something better than my company list, this is IATA medical manual. It is much more extensive, and it covers almost everything related with health and flight. But you can find the recommended kit in the SECTION 6 passenger care, APPENDIX B. I suppose it will be of more interest for you.

I must also say that when there is a person onboard with high fiver or symptoms of a contagious disease, in the USA you have to notify to the authorities (the Federal and State Quarantine and Isolation Authority I think) immediately. I didn´t know it before I read the manual as I am not currently doing intercontinental flights.


Interesting - this is essentially an ALS (Advanced Life Support / Paramedic) bag.

Minus a laryngoscope and other vital airway kit items. Although I couldn't imagine trying to use one on the aisle of an aircraft, I'm sure there are many paramedics, anesthesiologists, and ER nurses and physicians who wouldn't hesitate if one were needed. All there appears to be for airway support are oropharyngeal airways. That's surprising and in my opinion (as someone with long-expired EMT training), unfortunate. The same goes for AEDs. A $2000 kit that could save someone's live from being claimed from the most common group of disease in the Western world (cardiovascular diseases) should be a no-brainer aboard a 200 million dollar aircraft. People are helpless at 30,000 feet and it's the airlines' responsibility to have the equipment available for qualified medical professionals who happen to be on board in the event of an emergency. AEDs could even be used by steward/esses who had undergone minimal training.

The aisle of an airplane would be an awesome place to intubate someone. One of my favorite intubation positions is having the patient lying supine, then lying prone 'above' them. This obviously only works of you have a fair amount of space in at least one direction (like an airplane aisle).

If you are interested in medical "hacks" on long-distance flights, the award has to go to two doctors who were on a 1995 British Airways flight from Hong Kong to London when a patient had trouble breathing. They determined that the patient suffered a collapsed lung, so they made an incision in her chest, and used a coat hanger, brandy, and a tube from a medical kit to drain the lung. As I recall the story, there was also a nurse who assisted but I can only find the AP story which references the two doctors.(1)

I also have a relative who is a doctor/med school professor who does a lot of traveling, and has had to assist the crew three times with in-flight emergencies. One was a heart attack, one was deteriorating condition of an unknown cause (the flight was diverted to evacuate this man) and the third was a guy who had intense bladder pains mid-flight which turned out to be the result of downing a huge quantity of beer before the flight and being unable to urinate.

1. http://news.google.com/newspapers?id=ZBxOAAAAIBAJ&sjid=p...

    intense bladder pains mid-flight which turned out to be
    the result of downing a huge quantity of beer before the 
    flight and being unable to urinate
was that due to the altitude or something else?

The stricken passenger had the option of using the restroom, but for unknown reasons could not urinate. They stretched him out on a row of seats which seemed to help the pain, but from what I recall was unable to go until they reached the destination airport. The total trip time was about three hours.

Beyond a certain capacity the bladder is no longer contractile and must be catheterized to urinate. Happens every day in the OR or PACU.

Really? What happened before modern medicine? I'm not being snarky: I believe you.. but a burst bladder would be lethal without access to modern medical knowledge. That seems like a epic fail by evolution.

Before modern life, we had plenty of opportunity to urinate well before it became a serious problem.

If we were intelligently designed, after all, I think God would call holding it for hours a "user error" and mark it "won't fix".

Now I have something to be paranoid about and will be going the bathroom as much as possible.

Alcohol is a double-whammy because it induces a degree of transient paresis, allowing the inebriated to hold it longer than they should. Just don't fight the urge and you'll be fine.

You should do that in any case. Putting it off is not good for your prostate.

You died. A burst bladder is quite fatal.

There are lots of epic fails by evolution, is more about quantity than quality so to speak.

An extreme outlier is hardly an 'epic fail'.

wow! I learned something today.

So just to confirm, you're saying that if (for example) I hold my pee for whatever reason, after a certain point, I might not be able to pee unless they catheterize my bladder?

"but for unknown reasons could not urinate"

Maybe that guy suffered from the Shy bladder syndrome [1].

[1] http://medical-dictionary.thefreedictionary.com/Shy+bladder+...

Huh. According to the article that you linked to about the coat hanger, brandy, and rubber tube: 'The aircraft's medical kit is "quite well-equipped for having babies and people who develop urinary blockages..."'. In fact, it sounds like the tube they used to drain the lung was a catheter intended for urinary blockage. I wonder why they couldn't use such a catheter for this guy; did that kit not have one?

If it progressed to the point of a true medical emergency, I suspect the kit at least had the equipment necessary for a 'quick and dirty' suprapubic aspiration of the bladder (stick a longish needle in from the front, and use a syringe to pull fluid out).

Generally speaking, this is done with an ultrasound, but in a pinch, you could likely just palpate the bladder.

This article has a bit more detail about the procedure itself; it mentions the flight attendants assisting, but no nurse:


This gives you a whole new perspective on techies who gripe about being roped into fixing the family computer over the holidays because they are "on vacation" and don't want to work!

I can't find it now, but my favourite 'doctor on a plane' story was from an anesthesiologist who struggles to sleep on a plane, so on a long haul flight took something to help him doze off. He woke up to the 'is there a doctor on the plane?' call, and called the flight attendant over. It turned out that he was the person that they wanted to attend to, they were concerned since he was passed out and drooling on the passenger next to him.

My dad, an electrical engineer, was once on his way back from a conference with a Concorde flight full of other EEs. In the air, the stewardess asked, "Is there an engineer on board?" Everyone responded enthusiastically. She was forced to clarify, "Is there an aeronautical engineer on board," to disappointment all around.

I must admit, some secret part of me always hopes I'll be in a situation on an airplane where they need an emergency perl script written . . .

I must admit, some secret part of me always hopes I'll be in a situation on an airplane where they need an emergency perl script written

On a flight from Sydney to Vancouver earlier this year, the in-flight entertainment system on my plane was broken. I spoke up: "Hi, I have a doctorate in computer science and I know a bit about these systems... want me to take a look?"

I was surprised when they agreed, brought me up to the front galley, and showed me their interface to the entertainment system (alas, the server itself was in the ceiling and not accessible). I ended up pulling out my laptop, borrowing a cat5 cable from one of the flight attendants (all of mine were in my checked suitcase) and running tcpdump on the plane's network. Alas, while that allowed me to diagnose the problem, I lacked the serial cable needed to connect to the server's console and wasn't able to fix it.

Don't leave us hanging :) What was the problem?

The AV server had been replaced after there were problems with it on the previous Vancouver-Sydney flight (the cabin crew told me this) but it looked like the DHCP server had not been updated with the new MAC address (or the replacement server hadn't been programmed to use the same MAC address as the one it replaced).

I considered sending DHCP responses to the server myself, but decided that injecting traffic would be too risky during flight... especially since I was flying back from a conference where one of the speakers had been talking about inadequate firewalling between IFE systems and aeronautical control systems.

> inadequate firewalling between IFE systems and aeronautical control systems

How is this possible? Why do they even need to be on the same network?

I didn't work on that particular system, but I can say from experience that systems on an airplane are a lot more interconnected than you might expect, just from seeing them as a passenger. There probably is a sequence diagram somewhere that says, "Inform pilot of movie progress, reduce intercom volume, dim cabin lights, reset passenger overhead lights, consult schedule to determine selected movie, lower projector screen, play movie." And there are probably similar diagrams for landing, maintenance, encountering problems, and so forth.

Furthermore, the IFE might not need to talk to critical control systems, but they both might need to talk to some of the same other systems. Cabin lights seem like a likely candidate. Displays for the pilot, too. And maybe maintenance fault logs.

It can be a real hassle to have totally isolated systems on different networks. You can do it, but you need a Good Reason. The easy thing, from an engineering perspective, is to make it so everything can talk to everything.

"Is there an aeronautical engineer on board,"

One of the top 5 questions you don't want to hear over the loudspeaker while flying on a supersonic jet.

Now I am intrigued and want to hear the other four.

#1 would probably be asking for a pilot. There have been a number of tests on simulators, and pilots licensed for smaller aircraft have a surprisingly low chance of being able to land a commercial jet.

I have heard someone tell a story about that happening once. They said that the cabin crew announced that they would be playing a game; they would call out an item, and give a free drink to the first person who could find that in their carry on. The first couple of items were fairly standard things; "a fountain pen", "a camera", etc. Then they got to "a commercial pilots license". Someone actually did raise their hand, and the cabin crew escorted them up to the cockpit.

There was never any problem with the flight, and he never found out what happened. Probably something like the co-pilot had a problem that prevented them from continuing to act as the co-pilot, and they wanted to maintain sufficient redundancy just in case.

That's not even fair, because the commercial pilot wouldn't have been able to collect his free drink!

The flight time requirement for a commercial pilot is only 250 hours. All flight instructors are commercial pilots. They are more common than you think.

Also, isn't there a pretty big distinction (even just in terms of required flight hours) for Commercial versus Airline Transport (ATP)? ISTR that ATP required at least 1k hours.

True, but in an emergency, the FAA probably wouldn't make a fuss :)

That said, pilots -- or even non-pilots -- can actually do fairly well landing a large aircraft as long as they're being talked through the process by someone experienced.

See http://mythbustersresults.com/episode94

I really wouldn't consider MythBusters a good source. The test they came up with for the snow plow episode is so far from a proper model, it gave exactly the wrong results and basically told folks something wrong and dangerous. It is fun entertainment and they try hard within those bounds, but they get stuff totally wrong sometimes.

I had the chance to land an Airbus 320 (simulator) several years ago. Yes, with instruction, I found it easier to land the plane than in Microsoft's Flight Simulator (http://boston.conman.org/2007/12/28.2).

Sometimes their tests are terrible. This is not one of those times.

Unassisted, perhaps, but what about with radio instructions? Modern aircraft with autoland systems mean that if you can punch buttons you'd probably be okay, I'd think. It might not be 'by-the-book', but looking at a video of the process it doesn't seem too complex: http://www.youtube.com/watch?v=LIaMALJjOEc

What's the other four?

That story seems _really_ fishy to me...

Why would electrical engineers fly to a conference on a Concorde? What good would an aeronautical engineer be _in flight_?

(Disclaimer: I'm Dove's husband. The man in question is my father in law, and I've heard the story from him firsthand, apparently much more recently than my wife did.)

> "Why would electrical engineers fly to a conference on a Concorde?"

The airline was moving a Concorde to a different facility (ie, it wasn't part of regular scheduled service). They decided to "upgrade" a bunch of passengers who were scheduled to be on a different type of aircraft. They moved the whole group of engineers together.

The stewardess asked for a "Concorde engineer", who was needed for after landing. It had something to do with the way the Concorde hooks up to the loading bridge at the terminal (it may have something to do with the unusual height of Concorde?)

Ah. I guess it has been some years since I heard the story. Thanks for the correction. :)

If I'm on a flight and they're asking for aeronautical engineers, I'll be asking for their strongest and most expensive drinks.

Obligatory xkcd: http://xkcd.com/208/

The medical director of my paramedic program used to work for a hospital that provided medical control for a number of major airlines (generally speaking, even when they ask for a physician on a plane, they're also calling the airline's 'on call' doctor as well).

His scariest stories weren't due to the criticality of the patient, but rather the incompetence of the provider on board the plane (to the point that he, on several different occasions, had to instruct the flight crew to 'please keep him away from the patient for the rest of the flight'). Just because someone is a 'doctor' doesn't necessarily mean they're well equipped to handle a medical emergency (note: the physician interviewed here managed the patient perfectly appropriately).

It's possible he was just pandering to the room of soon-to-be paramedics at the time, but he said he generally instructed the flight crew to ask for a paramedic before a physician, simply because they're generally more comfortable working in the 'austere' medical setting found on a plane.

My wife told me about a famous dermatologist who flies in dread of getting that call and there being no other doctor available. When med school was 40 years ago, you're not necessarily going to be comfortable handling, say, a heart attack.

One of my paramedic instructors told me a pretty funny story.

Apparently they were on shift one Saturday afternoon, when a call came through for a Code 2 (Cardiac Arrest) at a local racecourse.

Anyway, it was about 15 minutes away so they took off in a hurry, all the while receiving notes on their terminal regarding the job. Apparently it went along the lines of this:

Initial: Unknown Age, Cardiac Arrest, Racecourse etc Update: CPR in Progress Update: Doctor has self accounced at scene. Update: Doctor has called patient as deceased. CPR ceased.

It took another 5 minutes for the paramedics to get to the racecourse, and they still unloaded their gear and made their way to the patient. When asking for the doctor, they found that it was actually the racecourse veterinarian who had made the call.

I'm assuming the patient wasn't a racehorse?

If I had a dollar for every time a dermatologist or podiatrist tried to be 'helpful' on an emergency scene... I could probably buy a coffee at Starbucks... The same goes for 'nurses.' If an ER nurse wants to help out, that's great. Invariably though, it's a nurse at a nursing home or dialysis center...

I don't mean to imply these folks aren't skilled professionals, but prehospital medical emergencies are generally well outside their experience, and the confusion that arises from that can be dangerous.

Unlike a podiatrist, a dermatologist went to medical school. If they're young, there's actually a good chance that they were among the very best medical students -- in the past few years, dermatology has become one of the more competitive fields in medicine because of the lifestyle (short predictable hours, high pay, minimal insurance hassles).

There are daft people in every field, but I would be delighted to have most of the derm residents and attendings I've met in an emergency (in fairness, I should note that this is a small sample, drawn from a couple top-tier hospitals, and biased towards people who do volunteer backcountry search and rescue).

Yeah, the podiatrist comment was a bit tongue-in-cheek.

Like I said, I'm not try to discredit these folks as skilled (and in many cases, extremely smart) individuals.

However, a couple weeks of a rotation through an ER during med school isn't really going to prepare you well for prehospital emergencies (SAR, on the other hand, can be great training for that). Making an assessment and clinical decisions based on fairly limited information isn't something I've found most physicians to be comfortable with, especially in an emergency setting.

My list of 'glad to see you' docs is pretty much: ER, OB, and Anesthesia.

I can't tell if you're joking or not, but a podiatrist does have to go to medical school.

On the other hand, it's good to have anyone step in to lend a hand, instead of standing back like sullen sheep.

That depends... If they start questioning my patient care decisions, I'm going to ask them to step away. Fortunately, we have preprinted cards explaining that if they want to take over patient care, they need to speak to my medical control physician (who will need to hear a _very_ compelling argument before they would be willing to hand a scene over to someone else)

In the UK vets are pretty highly qualified. And, unlike most humans, horses can't tell you where the pain is or what it's like.

I think I'd be happy for a vet to do some doctoring.

Are you implying that the emergency call was for a horse/dog in cardiac arrest, or just that the racecourse vet was the 'doctor' performing on the human?

Sorry, I should have clarified. It's late here, and I am tired.

The call was for a human, the 'doctor' who called it was a vet at the racecourse.

One of my EMS instructors: "On scene, any person claiming to be a physician should be assumed to be a dermatologist or proctologist until proven otherwise."

It could be worse--psychiatrists are also physicians.

My wife is a surgeon; while we were flying to Morocco last spring, a man on the plane accidentally put himself into a diabetic coma. A nurse was sitting next to him and thought that he was having a heart attack. The attendants called for a doctor; my wife recognized the actual issue, and revived him by rubbing honey on the inside of his mouth and gums (the onboard medical kit had nothing of use beyond rubber gloves).

The other passengers on the flight actually did applaud her, which was cute, but I think they mostly did it because it meant that the flight didn't need to be diverted to Heathrow.

Wow, shocking that the plane did not have glucose tablets. I carry the gel in my luggage just in case since it's particularly common and so simple. I guess sugar is sugar, but manipulating gooey honey sounds a lot harder that squirting gel pack.

(Don't want to rant too much, but it irks me that TSA has, once or twice, confronted me on the things.)

yes back when I helped organize a medium sized (1200-11300) camping event we always had plenty of sugar and mars bars to cater for diabetics that went out of balance this is in addition to what the on site St Johns team had.

Only had one close shave where some one diabetic had become and unconscious and thrown up in there sleeping bag - let me tell you seeing someone being carried towards you on a stretcher certainly gets rid of the hangover quick - this was pre mobile phones so i had to sprint to the public call box to call 999 (911)

Okay, I'll share random doctor flight story - last week some family friends were flying to Hawaii for vacation, and a man across the isle said he had been on vacation for several weeks and didn't bring enough heart medicine. He said he would just get some more when he got home, but halfway through the flight he slumped down in his chair, unresponsive. There was a doctor on the flight that used a stethoscope to find there was no heartbeat. (Not sure if the doctor had his own stethoscope or if it was in an on board kit.) The doctor just looked up at the flight attendant and shook his head. Luckily, this flight was not to Hawaii. It was just a layover from Houston to LAX, so they were able to land in Phoenix to have a medical response team take the passenger off. Apparently when they took him off, they didn't use a board or anything - one man grabbed his wrists, another his ankles, and they carried him off, but they couldn't completely lift him so his butt was dragging on the floor down the isle. I thought that was a little weird.

Also, is it legal to just put a blanket on the guy, pretend he's sleeping, and then deal with it when you get to your destination? Our friends missed their connecting flight to Hawaii in LAX because of this ordeal.

He absolutely deserved to have an AED hooked up to him, and CPR in the time it took to hook up the AED. If he was pulseless because of, say, Vfib, the AED could very well have saved his life.

If he had pulseless electrical activity, then there is an algorithm for that, too. Some would say that you aren't dead with PEA until you've got a needle in the second intercostal spaces bilaterally and one penetrating the pericardium.

Do they have AEDs on planes?

According to the article and to other discussants, yes, AEDs are provided on planes. I haven't personally seen the medical loadout on a plane.

Every plane I've flown on has an AED symbol or mention of AED (as well as medical kit) marked in one of the reserved overhead bins near the front of the plane - I'm pretty sure they're standard issue on every commercial airliner.

It's a little surprising to me they didn't even attempt CPR.

Out of hospital CPR has very slim survival chances. Being on a plane will result in at least 30 minutes of CPR even before an ambulance can take over. Chances on surviving that are extremely low. Therefore I can see why the doctor on the plane decided not to perform CPR. I have a medical degree myself btw.

This +10. Out of the 11 out of hospital arrests that I went to as a Paramedic (in a 6 month period), only 1 of them survived.

Ironically, the one who survived was a prisoner who had cut his own throat. He had pretty much bled out by the time we got there, with a tiny little junctional on the monitor. Today he has 0 deficits, and it is like the event never occurred.

Maybe I'm missing something, but even if there's only a 10% chance of survival I'd still want somebody to give it a shot. What is the downside -- somebody has to do it for 30 minutes until the plane lands?

That's 10% for someone who had access to advanced care within a few minutes.

If CPR goes on for more than 10 minutes or so in a non-hypothermic patient (with no other interventions), your chances of survival are basically nil. This is is especially true if you have a limited number of people doing compressions. Effective compressions are extremely hard work, and rescuer fatigue is a huge issue with CPR (we switch every two minutes no matter how 'fine' the person doing compressions claims to be). I doubt you could maintain effective CPR on an aircraft for 30 minutes (I suppose you could get a couple dozen people involved, but that seems unlikely).

If I'm not back in 15 minutes, please stop... At that point enough damage has been done to my brain that I don't want to come back...

Is CPR done on people with wounds like that? I would think the chest compressions would mostly just be pushing blood out, but I guess doing that is better than doing nothing?

The new protocol (at least for military, or at least serious trauma) is to treat massive bleeding above airway/breathing/circulation. I guess what you'd do is have someone applying pressure (or strap an israeli bandage around the neck, but not tightly in a way which would cut off circulation?) while someone else does CPR and then AED. The goal is to never have more than a 10sec break in chest compressions.

Depends where you are - In the area around the Mayo Clinic in Minnesota, or in the Puget Sound, return of spontaneous circulation rates can approach 40+% for witnessed treatable arrythmias.

Likewise in Pittsburgh, where the paramedics have been given protocols for hypothermia, ROSC outcomes for arrests are much higher than the national average.

My dad had a massive heart attack December 2'nd. My mom and I were at the house when my dad had it.

Having no medical training, I know how to perform CPR and was able to resuscitate him to get to the local hospital and then to Methodist in Indy. Every doctor attributed to him living past 30 minutes to my efforts .

Outlook looked somewhat good for the short term, but the longer he was in ICU his chances worsened. Due to longer term massive organ failure, he passed on 12/12/12. My dad was Wilbur Harold Crawley III: automotive, electrical, and acoustic engineer.

Remember that CPR will not restart a stopped heart. CPR's only use is to maintain some blood/air flow until you can get to a defibrillator or life-support machinery, in hopes of preventing damage to the brain or other vital bits.

And unless it's started pretty much immediately, it won't even accomplish that, which makes it futile.

It won't, but there are several shockable rhythms that present as "pulseless" that can indeed be converted. AEDs will shock VF and VT, and manual defib can help with others.

This type of situation is exactly the reason AEDs are now found all over in public places. Sure, CPR for several hours does not yield positive outcomes. But if this guy is slumped because of a shockable rhythm, that AED in the field is not at all useless - it will likely save his life, and minimize the deficits he experiences afterward. Especially on a plane, where the person was likely noticed down minutes after his problem started.

Or hook up an AED.

> Also, is it legal to just put a blanket on the guy, pretend he's sleeping, and then deal with it when you get to your destination?

Not to sound insensitive, but I wonder what the alternative would be? Declare him deceased and then do what? See this comment elsewhere:

"If possible never declare a decease onboard , first you could be wrong!, and it is a bureaucratic mess. Is better to keep trying CPR till the emergency team can take care of the patient."


Well like my friends experienced, apparently they divert your flight to land and get the person to a hospital (to officially declare him I bet - or maybe just a mortuary?) as soon as possible.

My wife was on a flight from Taipei to LAX when they called for a doctor. She didn't see whether or not a doctor responded, but there were no further calls or announcements after that. Later when she went to the bathroom she saw a body bag on the floor near the bathrooms. When the flight arrived there were police waiting. Nobody could leave the plane until they were done with the body. No details were given to any of the passengers.

I'm curious if insulin is a standard part of the medkit. I was on a transatlantic crossing once with a coworker who went into diabetic shock (that's another long story).

A nurse was onboard the flight but no insulin. We had to divert and my coworker was laid up in a Newfoundland hospital for 3 days.

Insulin isn't something you need acutely. Insulin is used to treat _hyper_glycemia (blood sugar too high). This is a gradually developing condition, and someone couldn't go from 'normal' to 'critically ill' over the course of a flight. EDIT: reading your description below regarding the stolen meds, this seems reasonable. He likely _was_ experiencing some symptoms of hyperglycemia even as you were boarding.

The most common type of 'diabetic shock' is _hypo_glycemia (blood sugar too low). The treatment for this is simply sugar (if the patient is conscious, they can take it orally, if they're unconscious, then they need an IV with Dextrose).

I suspect most airline medkits carry dextrose (the one mentioned in the article did). I would imagine many of them carry glucagon as well (glucagon can be injected into the muscle, which is quicker and easier than establishing an IV, and it signals the liver to release its glycogen stores (by breaking it down into glucose (sugar))).

I imagine insulin is very rare. It doesn't keep for terribly long, most types need to be refrigerated, and the most common use cases are for things that don't come on 'suddenly' (generally someone experiencing severe hyperglycemia has had symptoms for hours or even days).

Don't forget the two big hyperglycemic emergencies: diabetic ketoacidosis and hyperosmolar hyperglycemic state.

I'd still say that the most important thing there is to give fluids, not insulin. When you're seeing a new patient and don't have a medical history, it's impossible to know how sensitive they will be to insulin, and the last thing you want to do on a transatlantic flight is take them from hyperglycaemic to hypoglycaemic. Giving enough fluids will allow the kidneys to do most of the the critical fixing of blood chemistry.

(I am not a doctor, but I am a diabetic who has experienced DKA.)

Yes, I agree that one critical element of treatment is fluid resuscitation. I think that because the person who started this thread was talking about insulin, that has remained a subtext throughout the conversation. My goal in posting was to alert people to the fact that blood insulin/glucose emergencies include states on both extremes of the insulin/glucose spectrum. I didn't mean to imply anything about management.

Sure, but DKA and HHNK aren't generally sudden onset sorts of things. Usually there's been a few hours worth of symptoms leading up to them.

From joezydeco's follow-up comment from a few hours ago, it sounds like there was a window of concern for several hours before boarding the flight. At any rate, there was no mention of this being sudden onset. Just encouraging people on this site who don't have a medical background to understand that there are indeed emergencies due to hyperglycemia/hypoinsulinemia.

Why would a diabetic person not travel with insulin?

Pretty much a collision of unfortunate events. We were at a work function until 2am in London and returned to our room to find it had been robbed. The thieves took his bag which contained his insulin kit.

So now it's 3am GMT and he can't reach his doctor in the States. We're supposed to leave at 8am for the flight home. No pharmacy is open and even if they were, they wouldn't help him. Nurses at Heathrow couldn't help him either.

So he decided to risk it and see if he could make it all the way home without having any trouble. He went into shock 4 hours into the flight.

Actually, IIRC insulin is classified as a Pharmacy-Only medicine in the UK, rather than Prescription-Only, meaning that it can be sold by a pharmacist without requiring a prescription, to address exactly this sort of situation.

Even if they've reclassified it as a POM in the 25 years since I stopped doing that stuff for a living, if you could have found a pharmacy in the UK, then under the Emergency Sale and Supply regs the pharmacist could, on their own recognizance, dispense a sufficient supply of prescription-only meds to get the patient back home.

(Caveat: I am an ex-pharmacist. Any advice I could conceivably give you is over two decades past its sell-by date and needs checking.)

Edit Current emergency sale and supply regs are described here:


What is your favorite sci-fi story involving a pharmacist?

I don't think I've ever read one. And I'm not planning on writing one any time soon. (The professional life of a pharmacist is, ideally, extremely boring. If it isn't, someone's going to be very ill, if not dead.)


Were I ever to become diabetic (and manage to figure out my fear of needles), I'm pretty sure I'd carry around spare insulin, like an epi-pen.

(Is it something that can be carried around trivially? Or does it need to be refridgerated? You know what, maybe I'll just eat healthier.)

Insulin will last around 30 days unrefrigerated. Refrigerated, it lasts until the expiration date, which is years for the insulin I have.

That said, insulin is used to treat hyperglycemia, which is usually not an acute incident. "Diabetic shock" refers to hypoglycemia, in which the individual needs sugar to raise their blood sugar to normal levels.

> Were I ever to become diabetic (and manage to figure out my fear of needles)

You get over it pretty quick when it is literally life-or-death, trust me ;-)

FYI. There's a 24-hour pharmacy in Earl's Court in London (called Zaffash I think)

Stupid diabetics exist, just like in the rest of the population (though it sounds like the diabetic in this case was just unlucky, from the grandparent's followup).

Depending when the person was travelling: some nations banned bovine insulin originating from some other nations over fears of bovine spongiform encephalopathy.

See, for example, this 2001 Australian document:


Many diabetics don't KNOW that they are.

That's not at all true - at least, not for diabetics that will go into shock or experience acute symptoms.

Diabetics experience a "honeymoon" period where they will experience some symptoms - almost always enough to trigger a trip to their PCP, urgent care, ED, etc. where they will be diagnosed and put on a treatment plan.

At most they will experience one event of being "very sick" if they don't get checked out at all during the months-long honeymoon before its found.

If most diabetics didn't know they were diabetic, most diabetics would be dead.

This happened once to my father on a flight. He's an orthopedic surgeon (the woman in this story really hit the jackpot with an a anesthesiologist--the only thing better would be an ER doc, I think), and someone was having chest pains. He determined very quickly that it was not a heart attack or other critical condition, but through the whole ordeal, the passenger next to the patient (who did not know the patient and had no medical training) kept second guessing my dad's requests and diagnosis. The flight attendants ended up "asking" this other guy to move several rows back to an empty seat.

Everyone's a critic.

I'm a former ski patroller, which is a kind of outdoors EMT / paramedic. Once, on a flight from Seattle to Boston (for a YC interview!) I walked to the aft bathroom only to find a young woman who had collapsed there, still prone and lethargic, with a stewardess standing over her with a look of annoyed disgust. An evaluation indicated she was probably just dehydrated, so I had the still-annoyed stewardess bring her water, which revived her. (Of course I recommended that she see a doc when we landed just in case, but I doubt she did.) After an hour or so we were able to get her back to her seat. The rest of the flight was uneventful. The only thing that never added up was the bizzare attitude of the stewardess.

(edited: semi-conscious -> lethargic)

How did you get the water into someone who was semi-concious?

Semi-conscious, if I recall correctly, covers a wide range of responsiveness. She was unable to stand and slow to respond to questions but was well-oriented w.r.t. person, place and time. Drinking water wasn't a problem. The possible danger is that they'll vomit it up after passing out, or that they have some issue that requires emergency surgery. Now you've put something in their stomach that they might vomit during surgery, which is somewhat dangerous. But she had signs of dehydration so I did it.

In retrospect I should have given her honey or the like just in case she was having her first ever diabetic shock.

No, the possible danger is that they'll aspirate the water and you'll compromise their airway. Sounds like she wasn't semi-concious though, just tired, and maybe a little lethargic.

Of course, if they are that badly out of it - I decided she wasn't. It sounds like I used the wrong term, thanks. Fixed.

I have one question regarding the question: "Did you end up getting sued?"

Why would the doctor get sued? Why would that question even be asked? I didn't feel like any type of catastrophic event happened to merit a lawsuit.

You'd be surprised. A course was held recently on in air medicine here in NZ. The airline running the course said that they would foot any resulting legal bills that resulted, from anywhere on earth. However there was one condition - medical staff called when on a plane will give their time for free. The airline had received invoices for medical staff time in the recent past.

I just want to tell you both good luck. We're all counting on you.

An interesting interview. I wonder if he gets upset if people call him Shirley?

I was flying transatlantic with a friend who has a medical degree when they called for a doctor.

There was an older fellow who had a heart condition for which he was taking medication. His reasoning had gone something like "I need to take one of these pills four times a day, but I'll be traveling, so I'll just take all four of them right before checking in". Needless to say, this didn't work very well, and he was having sort of issue with his heart as a result. The poor guy was so scared he literally shit himself.

My friend actually had to make the call whether we needed to land on an airport in Greenland to get the guy to a hospital. He thought about it for a minute and decided that the guy was going to live, so we continued to Amsterdam, where an ambulance was waiting.

As a "thank you" from KLM, my friend was allowed in the cockpit during landing (this was before 9/11), and he got a bag full of little bottles of alchoholic beverages. Unfortunately, he's a teetotaller.

Everytime I have seen a doctor call on airplane it was either an allergic reaction to food, or some guy who opened his duty-free bottle on the plane and had a little too much fun.

Cool story.My girlfriend is a flight attendant. I hear a lot of stories from her and it is very common to ask if there are any doctors on the plane. What crazy is that people in-flight non stop (we just don't hear about it). Anything from heart attacks to other health problems, even just because they are old.

Sometimes they will put a blanket over the body, sometimes they will pretend that the person is sleeping. Depending on the situation.

I don't really get into the details but that's the scoop.


I used to work with a consultant paediatric neurologist who had the call go out on a trans-pacific flight for a heart problem. She was hesitating before responding because the last time she had anything to do with hearts or adults was in medical school 20 years earlier, and was frantically running through what she could remember of cardiac medicine. Just as she made up her mind to respond she was beaten to the response... by a cardiologist.

This was a very interesting article, given that I just experienced something similar.

Flight from SFO -> IAD last week. As soon as we took off, they asked for a doctor. He spent 2 hours treating the patient before they started drink service, and continued until we landed. We were all quite worried about the person, but found out at the end of the flight that they had overdosed on NyQuil. That made the whole ordeal fairly frustrating.

Overdosed on NyQuil? How much NyQuil did he take?

I have no idea how big a typical bottle of NyQuil is, but assuming it's somewhere in the ballpark of 10oz (we'll call it 300ml to make the math easy). NyQuil has 325mg/15ml, so our hypothetical 10oz bottle has ~6,500mg in it. That's certainly a respectable dose of Tylenol, but it's not likely to be fatal in a couple hours for an average sized adult...

I'd guess that the problem was excessive sedation due to the antihistamine, rather than acute liver injury from acetaminophen toxicity.

"The medikit was actually really comprehensive ... that contained ... even morphine."

I am surprised that it contained morphine. Pain killers would not help much in resolving whatever medical issue is occurring.

Besides, is it not dangerous to report the fact that morphine is available on a flight? Some medkits are easily accessible and can be taken when the flight attendants are not looking.

When you have a myocardial infarction or acute pulmonary edema inflight, you'll be glad there's morphine available.

It is amazing how well morphine can work, and how utterly useless it can be at other times. I found it to be incredibly helpful during the AMI cases, especially for putting the patient as ease, especially when they understand the gravity of the STEMI that they are currently experiencing.

We went to a fractured tib/fib (Football injury) and we loaded him up with the maximum dose over the course of treatment (50 minutes or so) and it didn't even touch the sides.

Looking back we probably should have called for the IC guys and done some ketamine + realignment.

If major turbulence occurs -- enough that passengers are thrown around -- I can see all kinds of uses for morphine.

As an opioid in rapid sequence induction, potentially used for tracheal intubation.

Opioids are rarely in RSI.

RSI uses a sedative and a paralytic. The sedative is almost always a benzodiazapine, and occasionally a dissociative or hypnotic sedative like ketamine or etomidate.

Morphine would be a _very_ poor choice for a sedative in an RSI protocol.

Actually, no idea why I grabbed onto morphine in that discussion.

Our protocols call for vecuronium, atropine, etomidate, succinylcholine. However, we do also use fentanyl if indicated to deal with tachycardia and ICP.

One other thing I noted in the original article was bemoaning the lack of pulse oximetry, "to assess if patient was exchanging oxygen". Treat the patient, not the number. If your patient is in respiratory distress but has 100% SpO2, treat the distress. If your patient appears /comfortable/ and /normal/ at 90%, go with what seems appropriate to their case.

(In fact, our MPD excludes Pulse Oximetry and Blood Glucose from BLS protocols on the grounds of 'treat the patient' - though my opinion tends to differ on the latter).

PulseOx is great for trending treatments. If the pt starts out at 90%, and after your treatment is sat'ing in the mid-90's, that's a very useful datapoint.

There are a few extremely important caveats with pulse oximetry. PulseOx is useless if your patient isn't perfusing their periphery well (either due to hypothermia, or shock). You also need to consider that it only measures the percentage of hemoglobin that is bound to _something_, that something could just as easily be carbon monoxide. The other commonly overlooked issue is that certain types of lights (fluorescent lights are the worst offender) play havoc with pulseox meters. Your average fluorescent light will happily sat in the mid-80's. Be sure to cover the finger (or toe) that the sensor is on with something opaque.

If I was the patient I would love to hear that my oxygen levels were normal and that I am not at any risk of dying any time soon. I would say treating the patient should include first measuring how urgent it is.

Additionally if you panic you can easily imagine having trouble breathing, or that your trouble breathing is worse than it actually is. I have experienced this first hand when just relaxing removed most of my problems.

There's a very interesting book I read called "The Worst Is Over", which discusses this very thing, and talk in detail about how to talk calmly, soothingly and reassuringly to your patient, and the benefits thereof, from the more obvious (anxiety) to the less (pain relief and the perception thereof).

Reading between the lines just a little bit, I got the feeling based on the doc's description of his patient's behavior earlier in the flight that he suspected she was just being a drama queen and that this was more of a "psychiatric issue." Perhaps he wanted to test that hypothesis?

Fentanyl is reasonably commonly used.

Oh stewardess, I speak jive.

Here's the google cache version (site is under heavy load) ... http://webcache.googleusercontent.com/search?q=cache:www.coc...

An uncle of mine was in a situation like this once. He was sitting in first class and had to tend to someone in economy class. He decided that it would be best that he stayed by the man he was tending to so my uncle swapped seats with the man's wife. They gave him a bottle of wine for his help but I would have expected something more.

What airline was that? They should have at least given him a round-trip ticket since he missed a part of flight he paid for.

I was half-dozing on a Southwestern flight when a stewardess came on the PA system calling for any physician to identify themselves.

I spoke up, and the crew directed me toward the back. They already had this incredible medical kit opened in the aisle. I mean they had everything....ACLS drugs, defibrillator, suction, a complete mini-pharmacy, and what looked like a few plastic-7 wound and/or trauma kits at the least. I mean, I was practically drooling over this high-tech kit.

Of course, it was also at that moment that I started frantically running through cardiac code algorithms in my head, and pondering exactly how long it had been since I'd actually dealt with a code in a hospital, with plenty of trained staff, lab support, etc.

Of course, it wasn't any kind of life-and-death situation at all - a young person very stressed and anxious about relocating and the actual conditions of the flight, who'd been hyperventilating, hadn't eaten or had anything to drink for many hours, near-syncopal, etc etc.

I tried my hardest, but couldn't think of a single thing to use out of the medi-kit. I wanted to use it.

I just sat down next to her and listened, which is 90% of medicine anyway.

Southwest was great - gave me two round-trip tickets to anywhere for taking a few minutes to talk.

A colleague at University of Hawaii wrote a paper about dealing with psychiatric emergencies in the air. One thing that stuck out in the paper was the interesting phenomenon of what he called "honeymoon psychosis", with one of a young newly married couple away from home for the first time, possibly on their first flight, all leading to some interesting disturbances on those long pan-Pacific flights.

My father is a doctor who travels a lot and he loved it when the call went out for a doctor. Most of the time it was stress-related, and he'd tell the stewardess that the patient needed a calmer environment, so was there a spare seat in first class? Then, of course, he would accompany them to keep an eye out for anything really wrong.

He'd been an army doc and was flying around as a volunteer physician, so he was qualified if anything bad did happen, but most of the time it just involved sitting in first class and talking with the patient. There are worse ways to spend a flight.

> they had everything....ACLS drugs, defibrillator, suction, a complete mini-pharmacy, and what looked like a few plastic-7 wound and/or trauma kits at the least.

That's very reassuring. Any intubation equipment (or at least airway adjuncts (LMA, King, etc))? BVM?

Would not they check the passenger list for Dr's first? I remember being told that this was an occupational hazard for Phd's that you might be assumed to be a MD Dr.

As a physician and government traveler, the online booking service never asks for my title, and even if it did, I'd have to choose: Dr/MD? LCDR/USN/MC? Most identities online don't require a title and I don't offer. It only induces spam.

Just as an entertaining aside - the British Airways registration page currently includes Viscountess amongst other titles. Even so it's relatively limited - in its early days it contained a bizarre list of titles including the, um, uniquely prestigious "pope". Presumably the result of over-enthusiastic data population of the DB from some authoritative resource.

Just taking a random guess, but it could be that it's easier to use the intercom and ask everyone instead of digging out the passenger list and scanning to find someone whose prefix was 'Dr' (if such info is even included on a passenger list). This is just speculation, though.

I think that's the reason why. Also if there's no physician on board but there's an EMT/nurse, you wouldn't know that from the passenger list. Plus it's entirely possible that even if there's a doctor, she isn't listed as one.

ObTrivia: In the UK it is convention that surgeons drop the Dr title and revert to Mr/Mrs/Miss/Ms.

(History: http://www.newmediamedicine.com/forum/modernising-medical-ca... )

I'm confused. Why is this on HN?

To paraphrase the rules, if you see a submission that doesn't belong, just flag it and move on. If enough people agree, it'll go away.

Because hackers use their wits and experience to deal with strange circumstances under less than ideal conditions. As do docs on planes.

It's a first-rate submission.

I for one find glimpses into other fields fascinating.

You and I both, brother.

Unreadable on mobile (pre text or something preventing reflow). And no byline or date, so completely useless. Fuck off basically.

Fuck off? There's no need to be so rude.

In the future, use ihackernews.com. It provides a mobile friendly link to stories using viewtext.org. The viewtext.org link for this story (http://viewtext.org/article?url=http://www.cockeyed.com/pers...) works perfectly on my phone.

Outside of the parent's bad attitude, he does have a good point. No timestamp on the article makes it hard for me to place the story in context.

It is one of my pet peeves when I come across some morsel of information online but I can't evaluate if it is still applicable because there is no timestamp anywhere.

That's a pet peeve of mine, also. There's usually a date, but often not near the top and/or not in a standard format. Then there are these sites that use relative times, e.g., 0 minutes ago, or 865 days ago ...

In the current case, there is a timestamp of sorts at the bottom of the page: "Updated December 27, 2012 Copyright 2012 Cockeyed.com".

Here is blog owner's About page, last updated January 27, 2012: http://www.cockeyed.com/personal/about.html.

Is there some form of timestamp which is better than the full date at the bottom of the page?

Personally I find it useful when it says it was an hour ago, or a day ago, or 3 days ago etc up to a week. Then the date is what I want.

Yes. And it also helps if it's near the top of the post, as opposed to being buried in a signature or something.

Bottom of the page would be OK, too, if people always put it there. But they don't.

Consistent date placement promotes efficient search engine result scanning (Google's date constraints are highly imperfect).

I upvoted the article just because of your ignorant comment.

iPhone? Hit the 'Reader' button in the URL bar. Anything else? Get the Readability or 'Instapaper Text' bookmarklet installed.

Then quit posting your personal problems here.

Article looks just fine on iOS, no Reader necessary.

Readability is your friend.

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