Not long ago I was on a flight back from Hawaii when I noticed a commotion near the lavatory, shortly followed by a call for a doctor. For a moment, I wondered if this was some fragment of a dream I was having, since I was on an overnight flight and had been intermittently dozing. After a moment I got out of my seat and introduced myself to the flight attendant. “Hi, I’m a doctor,” I said.
“Oh, thank you,” she replied. “Could you come with me? There’s been an accident.” I followed the flight attendant down the narrow aisle between the rows of seats and we stopped at the lavatory, where an elderly woman lay on the lavatory floor, her legs protruding out into the aisle. She was sweaty, complaining of chest and back pain, and could not put weight on her ankle, which had twisted when she passed out and hit the floor. The flight attendant looked at me expectantly as I elicited the history and assessed the situation.
“How far are we from land?” I asked.
“About two hours, plus or minus,” she said.
“Do we have a medical kit?”
“Oh, yes, we have two of them.”
Thus began my journey into the world of medical care on a commercial airline as well as renewed considerations about health care provider identity that had prompted the 2013 Question of the Year, “What is a doctor? What is a nurse?”1 With the help of a flight attendant, we proceeded to move the woman to the back of the plane where there was more room to examine her, check her vital signs, and open up the medical kit. In the kit, I was surprised to see a large array of medications—bags of intravenous fluid, splints and bandages, a stethoscope, blood pressure cuff—almost everything I might need to provide care to the woman. It was all set out in rows with an index that identified where I would find anything I might need. But I was not used to administering medications, setting up intravenous fluids, applying splints, or being the primary interface with the patient. These were tasks that we doctors usually assign to nurses or technicians. As I struggled to attach tubing and start an intravenous catheter, a Canadian paramedic appeared, and he promptly helped with the IV and fashioned a splint for the swollen ankle.
After speaking with the woman and examining her, I tried to reassure her and her family that we had the situation under control, though how much control does anyone have 30,000 feet in the air over open water? My differential diagnosis was a syncopal episode, perhaps due to an arrhythmia or dehydration, possibly a myocardial infarction, and a broken ankle from the fall. Of course, there were other possibilities: a dissection of the aorta, a ruptured aneurysm, a stroke, or an infection. Unfortunately, I could not test for any of the possibilities. Everything would be based on the history and physical exam, much as physicians had practiced them before most of the current imaging and laboratory tests had been developed. Since the woman was hypotensive, we gave her a liter of IV fluid and contacted the base physician in Houston, who agreed with our approach and said we could do whatever we felt was necessary. So there we were, 30,000 feet in the air, two hours from land. It was 2 AM and there was plenty of time for me to think. Here’s what went through my head:
I wondered whether anyone had studied emergencies that occur during commercial flights and what data there were that might have helped me manage the situation. As I later learned, an article by Peterson et al2 reviews in-flight emergencies that occurred between 2008 and 2010 on five domestic and international airlines. As was true for my patient, the most common presentation was syncope, reported in 37.4% of all cases. Physician passengers provided medical assistance in 48.1% of cases. The most commonly administered medications were oxygen, intravenous fluids, and aspirin, all of which I gave to this patient. That publication might be a nice one to add to the medical kit, as well as a useful article for all of us air travelers.
I also thought about what it meant to be a doctor on an airplane far from land, and how my identity had suddenly changed from passenger to flight physician. We all go through various identity shifts in our lives; we become parents, teachers, soldiers, nurses, doctors. The doctor identity can creep up on you during training, but once it takes hold, it is difficult to shake. We notice abnormalities in people around us: anemia, shortness of breath, diaphoresis. We may even consider the treatment possibilities and next steps, and what we would do in our clinic with our support staff of nurses, clerks, and social workers. On this flight I was both doctor and nurse, and that realization made me think about how those roles differ, as does the training that prepares individuals for those roles. Does our current educational system, division of roles, and scope of practice make sense, or are we following an outmoded vestige of a bygone era?
In this month’s issue there are several short essays3–11 that explore the questions “What is a doctor? What is a nurse?” The answers consider historical and evolving definitions and the various forces—economic, gender, tradition, education—that have created these professional identities. In a time of workforce shortages and financial limitations, there will be substantial pressures to reexamine the assumptions that have led to our current definitions and roles. In addition, Haddara and Lingard,10 in one of the RIME reports in last month’s issue, illuminate the long historical tension around interprofessional relationships and provide some context for our current questions. Such discussions can be healthy and lead to review of current training requirements and practice patterns. If a nurse practitioner can be trained in 6 or 7 years and provide an equivalent quality of primary care services to that of a family physician trained in 11 years, as suggested by one systematic review,11 what does that mean? And if the quality of care and scope of services provided by the nurse practitioner are only slightly lower than those given by a primary care physician, and the costs are half as much, then how should that affect our allocation of resources? The Question of the Year was meant to stimulate these and other questions, and our respondents have tried to provide answers.
Finally, I thought about how Hippocrates would react to my current predicament on the airplane. What would he say about my ethical duties, and what guidance would he have for me and all of the other doctors who end up providing medical care on commercial airlines? I suspect he would remind us that there was a reason why our education provided a general base of knowledge and experience and why we did not immediately begin our medical education with specific procedural training. He might also remind us of what a privilege it is to be able to serve those in their greatest time of need and how important the willingness to be present and provide reassurance can be for the patient and everyone else. As I changed from passenger to doctor, I found myself treating not only a patient but also providing reassurance to the pilot, flight attendants, and other passengers.
Some 400 years after Hippocrates, a Good Samaritan would come upon an injured stranger lying on a road and stop to provide care. That principle of caring for one’s neighbor would be adopted in medicine’s ethical principles and remains relevant today, guiding me and others in similar situations. For me, those two hours with my team of flight attendants and a paramedic watching over our patient until we got her safely to the ground are burned deeply into my memory. Sometimes I think back and chuckle at the absurdity of flying over the ocean and trying to listen for a heart murmur or rales in the lungs above the din of the engines, and I ponder all the things that could have gone wrong but didn’t. But at other times I remember this as a time when all of the noise of the engines seemed to disappear and the conflicting demands and roles in health care that seem so difficult and complicated at ground level could be distilled down to their essences. There would be no discussion about money, malpractice, licensure, scope of practice, or insurance. There would just be a health care provider—doctor or nurse—a patient, and a supportive team around them. This is what I hope I will remember when people ask me to think about the solution to the problem of providing health care in America “from the 30,000-foot level.”
David P. Sklar, MD