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. )