I am sharing this account of a serious medical emergency on a transoceanic flight because I hope it helps other health care providers assist people in the future and learn from the difficulties I encountered.
About 8 1/2 hours into a 17 hour flight, a gentleman had a syncopal episode in the exit row I was sitting in. His face was bleeding and he was having issues controlling his bowels afterwards. His wife said he was diabetic and had been anemic from a bleeding ulcer. He had already had a large amount of bloody stool which was on the floor of our exit row in front of the lavatory. My significant other ran get assistance from the flight crew.
On arrival of the lead flight attendant, we had gotten the man to the lavatory and he was very pale, weak, thready pulses, and barely palpable BP. Myself and another physician (in ICU) asked for the emergency medical kit, but the attendant refused until someone showed a medical license. In the aftermath, I confirmed that this was not protocol, and should not be demanded if the person responding seems reasonably competent. Out of 4 physicians on board, I was the only one with a pocket license because I was on the way to a conference.
The flight attendant then told the ICU physician that she needed to return to her seat because she didn’t have her license with her, but I insisted she assist. Initial BP on evaluation was 70/palp, pulses difficult to appreciate, BS about 130. We were concerned the patient was having a myocardial infarction due to the gastrointestinal bleed and diabetes. We transferred the patient to the floor between the lavatory cross-bridge area of the plane. We met an alarming amount of resistance to moving the man because the flight attendant was afraid we would disturb other passengers (as if having an aisle full of feces was not enough). We asked for the overhead lights in that area to be turned on so we could get IV access and place the AED, and were once again told that we could not because it might disturb other persons on the flight. My boyfriend then held his cell phone light over the site while I placed an IV. Another physician, an ophthalmologist, held the IV fluids under pressure. The IV blew after a few hundred ccs of fluid and a different IV kit was used to gain access. The AED indicated a normal cardiac rhythm. As the remainder of the fluids infused, I checked the medical kit for additional contents. There were no aspirin, no nitroglycerin, no masks, no body fluid cleanup supplies, no airways. There was a vial of epinephrine and D50. All of these items are required by the FAA for flights >35 people.
The pilot then came back to inquire about diversion, and while I was speaking with him, the attendant took the emergency kit back to the back of the plane and we had to go retrieve it. She became angry with us for needing to have access to it in spite of our very clear explanation that we needed to have it available if any further deterioration happened. The patient’s blood pressure was slightly better at this point and his color was improving. He had no further active GI bleeding.. We discussed with ground control that if his BP continued to improved we could avoid diversion, however the medical kit needed to stay with us at all times in case of emergency.
I administered vitals every 20 minutes from that point on.
I have learned a few important lessons from this that I would like to share with the Delta risk management and their safety team.
- The majority of the flight attendants were equipped to deal with a major emergency on a long international flight. They assisted me when needed and also provided me with constant coffee so I could remain alert for the 17 hour flight. The one individual that decompensated and, quite frankly, endangered the life of this gentleman, was the attendant in charge. After the incident, I reviewed FAA guidelines and spoke with a Delta pilot and confirmed that she should not have had the kind of ultimate authority.
- As a medical professional, when in doubt, always ask to speak with the pilot if you encounter resistance of the flight crew to assist.
- The emergency kit for a 16+ hour flight was less than ½ stocked. I reviewed the FAA ACA documentation for emergency preparedness and it was clear that it had not been stocked prior to this long transoceanic flight. I received no response from Delta when I alerted them to the FAA violation and escalated it to the FAA hotline. Additionally, I bought a pulse ox and a small purse sized emergency kit that I will carry on all future flights as well as an LED flashlight.
- The only person who can determine if a plane is being diverted is the pilot, that is regulation. It was unclear who was calling the shots on this flight entirely.
- Don’t expect so much as a thank you from the airline. They have all but ignored my account of the situation and never said so much as thank you. It is a risk management issue at this point and they are doing what they can to cover their tracks in an alarming way.
(Editor’s Update: Delta has been responsive to this situation and have been speaking with Dr. Evans.  We hope this helps standardize communication between physicians and flight staff in the future.  We have also learned that in-flight emergency experiences are highly variable and physicians have had positive and negative experiences on nearly every airline. )
It’s amazing that the airlines just “expect” a physician to help them when in need – we may be on vacation too? I have had 3 major in flight emergencies with absolutely minimal help from staff and an inadequate medical kit —-and barely a thank you – one airline was Delta and the other Turkish airlines (where we kept a man tied up for 11 hours as he threatened to bring down the plane necessitating the FBI at JFK) – again not even a thank you except from many passengers who wee terrified The airlines should have medical personnel or… Read more »
This happens to other professions as well. I used to be an interpreter and was called upon to interpret on a flight once. I think on some level, as people, we should have the reasonable expectation that caring individuals will help when they are able whether they get paid or not.
I don’t know about the US but in Canada I’m pretty sure that if you’re a doctor and you refuse to help in a situation, and it becomes known that you were there, you can be held liable for whatever happens. It’s the same with Red Cross first responder training.
I’d love to know what emergency kit you purchased that fits in your purse!
It was the voodoo tactical kit on Amazon. Nice and small. I will be adding some basic mess to it
How does that work easily though with the US mandating everywhere around the world that small liquid containers are WMDs?? Going to take longer to get through security now, so what’s the point…
(Of course I’ve exaggerated above, this is the problem with security theatre, stops sensible things from being practised because it becomes too hard…)
I have responded to 2 medical “emergencies”, both on Delta flights. I have found their staff incredibly supportive and helpful. And I was thoroughly thanked by the inflight staff, including complementary drinks and miles. Perhaps one of our experiences was more the exception rather than the rule?
I truly hope so. However, I’ve heard many accounts of negligence from many airlines.
As an aside, I’ve generally been happy with delta and I won’t stop flying with them. I just want to help fix this
I cannot believe what you had to endure just to be able to help this man!
On behalf of all travelers who can only hope to have someone as wonderful as you around during an emergency: THANK YOU!
Sorry about your experience Janelle, Eric and I have had several medical emergencies on planes and have had great support from the flight attendants (including them holding our infant daughter during landing so we could stay with the patient). We did feel on that flight the medical kit was improperly stocked (only 500cc of fluids and yet had amiodarone).
I find it quite incredible that someone who is bleeding profusely enough to be hypotensive and need IV boluses, how that person could ever be considered safe enough to remain in the air for another 8 hours instead of diverting. Particularly if they are being “monitored” with minimal available medical equipment. What was the thinking involved when deciding not to divert?
It was actually more of a vagal episode following the initial melena occurrence. Per routine trauma protocol while working up the patient, IVs were placed. We had no airways to secure one. I was clear in my description that there was no further bleeding and that his vitals recovered with bolus, increased venous return, and eventually, calories. Additionally, diversion in the middle of the Atlantic wasn’t an easy feat either…we were over 2 hours from the nearest airport at the time of the incident.
I’m guessing that this was the Johannesburg to Atlanta Flight (I’ve done that one a lot). Given where you were probably at I can see why you made the decision you did.
Yep. That’s the one!
If you look at a map, DL201 (that’s the JNB-ATL flight) has very limited options. Ascension Island is it…and has no medical facilities. (A Delta 777 on this same route had to divert at Ascension a few years ago after an engine failure. It took nearly a week to get everyone off the island). Arriving at Atlanta, an airport equipped to handle a 777 with a medical emergency, and more importantly, EXPECTING to receive an international 777 with a medical emergency, saved many more hours than it would have taken if this 777 diverted to, say, Sierra Leone and then… Read more »
I too was a physician on a plane once for a patient with a syncopal episode, but we were less than one hour away from landing and the patient immediately awoke and was cognizant, alert and oriented x3. But in the chaos, I had to lift her legs and drag her to a clear location, and luckily the inceased venous return was the mainstay treatment. The two flight attendants treated me differently–the man treated me with respect and told me I called the shots on whether to land the plane…whereas the Female flight attendant insisted I check the lady’s blood… Read more »
Thank you for being a wonderful human!
And to think that flight attendants started out having to be nurses in early commercial aviation…
As an ER doc the most interesting issue is the decision to continue on the 17 hour flight given the risk of the patient de-compensating again. A tough call!
While their kit should have been fully stocked, don’t hesitate to ask if passengers can be queried about things like nitro and aspirin–I routinely carry both as well as my blood pressure medicine on flights.
Not sure if I would trust meds from an “unknown” source, even if they were in the prescription bottle. If they were OTC and sealed, perhaps.
I would escalate the behavior of this flight attendant to FAA, and also send this story to the press.
That’s awful. Thanks for being there for someone in need. If someone else is ever in this situation and needs oxygen, the pilots have masks with a large supply of oxygen in the cockpit.
Sort of hard to haul someone up to the cockpit and sit them in one of the crew seats…
I have been involved in a mid-air emergency as well. A lady with diet controlled diabetes likely had hypoglycemic event in the isle near the bathroom, and was on the floor. The flight attendants, although tried their best, but seemed ill-equipped to handle the situation. When I got up to help, I was met by a rude, who turned out to be head flight attendant, who demanded I show my medical licence before I could help. I have a pocket size licence in my wallet and upon showing producing it to her, she allowed me to help, despite the glaring… Read more »
For the flashlight, consider a headlamp. It’s hands-free and the light source will remain close to your line of vision. As an example, below is one that takes a AA lithium (alkalines are unreliable long term, chemical and power leak), good color rendition (many LEDs project blue-white light), and compact.
http://www.zebralight.com/H502c-L2-High-CRI-Neutral-White-AA-Flood-Headlamp_p_143.html#
Doesn’t have to be this brand, Petzl, Black Diamond and others make decent lamps.
Well since Delta didn’t do it, everyone else should. THANK YOU and THANK YOU to all of the other physicians responding to this article who have also helped us regular folks on flights.
Delta did respond to Dr. Evans, now that they are aware of this.
Thanks for your service!
I was an MICP for 10 years, but have been out of the line of fire for almost 15 now. Even with those “expired” credentials, I have been the only responder on probably 6-8 flights as many years. I don’t know if I am just unlucky (for other folks) to travel with, but in each of those cases, the flight crew were happy to have the response. I always introduce myself as “I *used* to be a paramedic and am no longer certified, but I can help”.
As someone who flies Delta, I’ll say thank you! If this had happened to me, I would want someone like you to help. Thank you again for caring about others! Around two years ago, I was on an international Delta that was diverted because of an emergency. The odd thing is, they never asked if there was a doctor on the flight once. In this case, the woman’s appendix had apparently burst so they would have needed to have landed very quickly anyway. But it bothered me that they didn’t even attempt to seek anyone to help her. I’d say… Read more »
I’m a pilot and this should not happen. You’re absolutely right about escalating to the Pilot In Command.
In terms of forwarding this to the FAA, I would also look at filing a NASA ASRS report ( http://asrs.arc.nasa.gov/ ). The Aviation Safety and Reporting System is a non-punitive reporting tool, generally for pilots, controllers, and other aviation professionals which allows for any safety issues to be reported without threat of retribution. NASA takes those reports very seriously and uses them, along with the FAA, to implement rule changes and safety guidelines.
Though not a medical professional I think you would be better off with an led headlamp (which you can get from REI or other outdoor stores) a opposed to a flashlight. You can still use them hand held if you want though obviously they are designed to be worn and illuminate whatever you are looking at.
It sounds like Delta could have used SafetyCulture iAuditor to conduct pre-inspections on their medical bags. As most of the major airlines have utilized this product to conduct all types of pre-flight and inflight inspections.
During my travels with Qantas, I’ve had to utilize my paramedic skills twice and their medical kits were stocked as good, if not better than our bags on an ambulance.
This article describes what is required for a US airline operating under 14 CFR 121 (the US rules governing scheduled passenger operations). There is no mention in NZ CARs or Australian CASRs as to what must be carried. As an aside, it is not uncommon for the Americans to either over-regulate or have none at all, a bit polar opposites sometimes! When I was at United Airlines in the late 00s we had an “emergency medical kit” (EMK) and an “enhanced emergency medical kit” (EEMK); the latter containing a selection of drugs, IV equipment, and I think (from memory) even… Read more »
Wow – disappointing! When I helped out as the Dr for an emergency on a long haul international flight (QANTAS) the crew were exceptionally helpful, and the full medical kit impressive. I guess it varies between airlines….. Also definitely did not feel like the crew ‘expected’ me to help, but were exceptionally grateful when I did – even though we had to divert to Hawaii!
This was a great talk from SMACC DUB
http://www.smacc.net.au/2016/03/is-there-a-doctor-on-the-plane-joe-lex/
Thank you. I totally forgot about this!!
I understand that for every flight on some airlines there is a Federal Marshal, there in case someone tries to harm the passengers or plane. I wonder what is the incidence of such cases compared to the incidence of medical emergencies during flight. Does data support having a dedicated medical professional on board?
Why would airlines pay for services they are getting “free” from physicians travelling on their planes !!!! Lucky for them that physicians in “holidays” accept to work for free in very difficult conditions
While I understand the Editor’s Update–I am willing to bet it is five to one for bad to very bad experiences by physicians and in particular women physicians when attempting to assist in an in flight emergency. One or two positive experiences out of 60 or 70 bad experiences does not make the result a “highly variable” one but rather a long series of bad experiences. Please do more research Editor before making such a wide generalization. That is the job of Editor I believe.
airRx is a non-profit app that is meant to assist physicians who volunteer during in flight medical emergencies. It contains information about about medical equipment, medicolegal issues, the roles of the cabin crew, the flight crew and ground medical support. It also contains algorithms of assessment and treatment of 23 events that may occur in flight accounting for the great majority of in flight medical emergencies. It can be downloaded for $4.99 on the Apple App Store or Google Play Store. Once downloaded, all information is available in airplane mode.
Wow…Not even a thank you? They would have rather the patient died in the plane? No doubt you and the other doctors present kept this passenger alive. I am an RN, and once while shopping, the person ringing up my purchase fainted. I assisted her to the floor, checked pulse, respiration, etc while store security brought a first aid kit and called 911. Luckily, the person regained consciousness quickly. I stayed with her till the EMTs arrived and took over. This was a fairly minor emergency compared to the one you dealt with. After all was said and done, the… Read more »
It might be a Delta issue. I just returned from holidays where I was woken halfway between Sydney and LA by a request for medical assistance. I identified myself as a GP, assessed and managed the patient (a 9 year old boy, thank God it wasn’t as nasty as the OP’s case) and overall spent about half an hour providing professional services for free in the middle of the night and in the middle of nowhere. I know it’s unusual for doctors who help out to receive any consideration from the airline, but I was surprised that the Delta cabin… Read more »
It’s awesome that the majority of the flight attendants are equipped to deal with major emergencies. I’m taking a flight next month and I tend to overthink things a lot. Knowing they’re trained to handle emergencies gives me one less thing to worry about.
Hi there just reading through your post post hope its okay to ask a question. Was curious what you bring in your emergency kit for flights?