By BOB WACHTER, MD

Well, it happened again. Last Thursday evening, I was somewhere over Saskatchewan, returning from a lovely Mediterranean cruise, in that uncomfortable semi-conscious state that passes for sleep when you’re flying coach, when the airplane’s PA system rang out:

“If there’s a doctor on board, please ring your call button!”

If you’re old enough to remember the show “To Tell the Truth,” you know what happened next. In the show, four B-list celebrity judges guess which of three contestants holds a certain unusual job. Once the judges have made their guesses (guided by contestants’ answers to a series of questions), the real skunk breeder, or tea taster, or cemetery lot saleswoman is asked to stand. One contestant begins to rise, then checks herself and sits down. Then another. Finally the correct contestant stands. The audience lets out a collective “oooh.”

I’m guessing that the average packed Boeing 777 has at least a handful of doctor-passengers. When the call comes for a physician, I’m sure a few mutter, “no f-ing way” and go back to their Sudoku. But most, I think, respond like I do: we reach tentatively for our call button then, thinking better of it, stop, look around, start again, then finally push the damn thing. Even as we nobly hit the button, in our heart of hearts we hope that we’re number two – our guilt assuaged but our services unneeded.

And that’s what happened on Thursday. I waited a few seconds, heard another “Bing!,” breathed a sigh of relief, was elbowed in the ribs by my son Benjy, and then, shamed into it, hit the button. The flight attendant came over, thanked me, and told me that another doctor had already been selected. “I’m sorry,” I replied, which is weasel talk for “Whew!”

I settled back to “sleep,” but five minutes later she returned. “Perhaps you should come up.”

It is virtually always “come up,” since people with airplane medical illnesses seem to always be in business class. I don’t think business class actually causes folks to get sick on airplanes. Rather, as they taught us in Epi 101, this is an “association”: older wealthy people are both more likely to upgrade, and to get sick.

When I arrived, a very pleasant elderly American woman with asthma was panting like an overheated puppy, her concerned husband fretting next to her. The doctor already tending to her had not yet checked her vital signs, listened to her lungs, or administered a treatment other than oxygen. I wondered why, and then learned that the doctor was a radiologist (from Germany, as it happens). She seemed – what’s the word I’m looking for – yes, elated, to hand over the reins to me.

I opened the airplane’s medical kit, which used to contain virtually nothing but a stethoscope and a prayer, but is now stocked with a fairly complete array of medications (including epinephrine, Benadryl, atropine, Compazine, nitro, aspirin, and pain meds), as well as equipment for intubation and intravenous access. There’s also an automatic external defibrillator. Unfortunately for my colleague the radiologist, there’s no MRI or ultrasound.

This one was easy. I took a little history from the patient, listened to her lungs, and then recommended that she take a few extra puffs of her albuterol inhaler (she carried one but had been told to use it very infrequently, so she was waiting, patiently but mistakenly, until six hours were up to take another hit). Within 10 minutes, she was nearly back to normal. The flight attendants thanked me and I slouched back to my seat in coach.

I fly a lot (about 125,000 miles a year), and I’ve answered the “doctor on the plane” call about 15 times over the past two decades. (Once, I got called on both legs of an SFO-Philadelphia round trip!) Although the FAA estimates that there is one medical emergency for every thousand or so takeoffs, I must be getting on high risk flights or something, since I seem to average about one call a year, which would place the frequency at more like one in 50-100 flights.

In any case, this topic is one of the great sources of physician war stories (perhaps second only to municipal hospital ER horror stories during residency). So I’ll share a few of my experiences, in the hopes that some of you will share yours.

Standing in the Cockpit Soon After 9/11

I had to fly from SFO to Philly in late September 2001, just a few weeks after 9/11. I was scared to death. I noticed that no one dared fall asleep on the plane, and everybody had a look on his or her face that bespoke a fear of impending doom. The FAA had just announced its new restrictions on cockpit access and was in the process of hardening the doors; for now, someone approaching the cockpit too quickly would have been blocked by flight attendants and first-class passengers, and hit with weaponry consisting of serving carts and hot coffee.

About an hour into this US Airways flight, I got the call: a woman in seat 22A was having chest pain. I tried to figure out her risk factors and the quality of the pain, but made little headway since she didn’t speak much English (I think her primary language was Polish or Czech). The flight attendants found another passenger who spoke the language, or something close, and she joined us to translate.

With chest pain, as with many in-flight emergencies, the real issue is whether the pilot needs to land the plane early – there’s only so much you can do on board, and administering TPA or performing an emergent cath are not among your options. I tried to sort out the character of the chest pain and the patient’s risk factors, but between the language barrier and the lack of an ECG, the nature of the problem was really anybody’s guess.

The pilot, communicating with his medical station on the ground (every major airline contracts with physicians who help them manage these situations), began sending messages back to me requesting details. The problem was that this quickly devolved into a bad game of “Telephone” – the ground doc posed a question to the pilot, who relayed it to the flight attendant, who ran it back to me, which sometimes prompted me to ask the patient through our passenger-translator. We weren’t making much progress, and in the post-9/11 environment, everybody was getting a bit twitchy.

Finally, I said to the flight attendant, “You know, this is silly. It really would be easier if I spoke to the doc on the ground myself.” “I’ll ask the pilot,” she said, and disappeared. “OK,” she said when she returned, “come up to talk to the doc and the pilot.”

Before I could fully process this, I soon found myself standing in the cockpit of an Airbus, right behind the pilot and co-pilot, about 3 weeks after 9/11. If I knew martial arts, I have no doubt that I could have taken the plane. And, it dawned on me that, if I were a terrorist, I could have staged the whole thing, with a partner playing the role of the “sick” passenger. The realization made the situation all the more surreal. I felt a bit ill myself.

Of course, nothing bad happened. We decided to treat the woman for indigestion (she had few cardiac risk factors), she improved, and we landed uneventfully a few hours later.

Peer Pressure – From the Pilot

Last year, I was flying back to San Francisco from Charlotte, and noticed an elderly woman and her middle-aged daughter across the aisle from my seat. The younger woman appeared to be blind and had the look of someone with a chronic illness. As the plane took off, she vomited. A flight attendant came over and asked, “Do you need to see a doctor, ma’am?” Please say no, I prayed to myself, but she said, “I think so.”

I had about 5 hours’ worth of work to do on this 5-hour flight, and I can’t say I relished the thought of spending the time rendering clinical care. But there I was. Despicably, I waited until they made the PA announcement before I leaned over to say, “I’m a doctor.”

I learned that the woman had hydrocephalus and a ventriculo-peritoneal shunt, and now suffered from nausea, a headache, and abdominal pain. This is a bad combination: it could mean that the shunt was malfunctioning or she had a serious infection. The idea of waiting nearly five hours for legitimate medical attention was troubling. I opened the airplane’s medical kit and began giving her anti-emetics and some pain meds. She improved for a short while, and then began to worsen. I told the flight attendant that we might need to divert the plane.

The pilot came out to speak to me – I was reassured that they were now enforcing the “no lay people in the cockpit” rule. “Doc,” he said, one pro to another, “I don’t want to tell you how to do your job, and you’re in charge here. If you say we need to land this bird, I’ll land it….”

I waited for the big “but.”

“But I need to let you know that when we took off, we had a full tank of gas, which will mostly burn off by the time we get to California. When you land a plane this heavy prematurely, you have to come in ‘hot.’” He explained that this meant landing at an unusually steep angle of descent while gunning the brakes to prevent the plane from overshooting the runway. “It’s not dangerous, really, but it’s a little scary, and we have to stay on the ground for a full inspection before we can take off again. It takes a few hours.”

“But really, doc, I don’t want to tell you how to do your business. It’s completely your call.”

If you’re a physician, remember that feeling you had during your residency, when you were admitting a patient to one of your pals, who was getting slammed upstairs? I don’t know the resident who didn’t factor the peer response into his or her decision-making. Most of us ultimately did the right thing, but it’s human nature to consider the “hurt” you’re causing to others even as you focus on your patient’s welfare.

Here, the “hurt” would be to about 300 people who would be delayed several hours – or perhaps even overnight – because of my decision. “Let’s give it another hour and see how she does,” I said.

If you’re not a physician, this might seem immoral, but I want to reassure you that I – and every physician I know – would find this to be an easy decision in a clear-cut emergency. But in cases like this, and what makes medicine so hard, is that we often don’t know what’s going on, and the chances are fairly good that waiting will be fine. In situations like this, it’s natural, and actually not inappropriate, to weigh all the consequences before rendering a judgment.

Luckily, this patient, like my 9/11 chest pain patient, did fine – or at least fine enough to make it until the paramedics could wheel her off the plane at the final destination.

Why Certain Kinds of Humor Aren’t Appropriate at 35,000 Feet

“Is there a doctor on the plane?” has been the source of Hollywood humor, as you might remember from this clip from the movie Airplane!, Here, Dr. Rumack, played memorably by Leslie Neilsen, answers the call, stethoscope helpfully already around his neck. But there is a time and place for humor and, well, this probably wasn’t it.

About 20 years ago, I was on a 747 flying to Chicago, as I recall. A flight attendant had passed out and was lying in plane’s rear galley.

By the time I arrived, she was already coming to. Her vital signs were OK (her heart rate was a bit slow, which is typical of this syndrome), and I was able to elicit the history of a tooth extraction the previous day and some lingering oral pain. So this was a clear case of vasovagal syncope; there was no need for worry.

Remember that this was a flight attendant on a jumbo jet, so I was surrounded by about 10 of her worried colleagues, as well as the co-pilot. “Do we have to land the plane, doc?” the chief purser asked. “No, I’m sure she’ll be fine,” I said. “She should rest, drink a little extra, and keep her legs elevated.”

Relieved, the group began to disperse to their stations. One of the other flight attendants walked up to me. “Thanks, doctor…. By the way, what kind of a doctor are you?”

“I have a PhD in English Literature,” I said, mischievously.

“Just kidding,” I quickly added, as I nearly scraped her off the ceiling.

I’ve now recognized that airplane emergencies are probably not the best time for jokes, though this seemed very funny at the time.

Why Do This?

In 2000, an elderly woman, traveling with her husband, passed out on my flight – this time in the back of the coach section. I don’t remember doing that much – mostly getting her some fluids, elevating her legs, and hand-holding. She perked up. As we parted, she and her husband asked for my card.

A few weeks later, I received this note from their daughter; I still have it taped to the back of my office door. It said,

I understand from my father and brother that we almost lost my mother. As her only daughter, I am indebted to you for helping her live a longer life….

Answering the “is there a doc on the plane?” call is one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship. We worry a bit about liability (though the protections under Good Samaritan laws are fairly robust). No money changes hands (the airlines sometimes credit you with a few thousand frequent flyer miles or give you a free drink), and there are no CT scanners or fancy consultants. It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.

That’s why, despite the angst and the time (all told, I’d estimate that I’ve spent more than 20 hours providing clinical care on airplanes), I answered that call on Thursday, and I’ll keep doing so in the future. I hope you will too.

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I’d love to hear any stories you have about medical emergencies on airplanes – whether your role was as doctor, nurse, or patient.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.“