‘Is a medical professional on board?”
It was four hours into a flight to San Francisco. I was silently plotting how to extract my neighbor's elbow from my left ribs when I heard the call again.
”Attention, passengers. Is there a medical professional on board?”
Across the aisle, my boyfriend, Kevin, a second-year internal medicine resident like me, lurched eagerly toward the call button.
“What are you doing?” I hissed.
A flight attendant motioned for us to come forward, and as we walked toward the front of the plane, I felt the familiar apprehension that often accompanied facing an unknown. We were led to our patient—the very same flight attendant who had served our ginger ales on ice—lying across two first-class seats. She was young, a bit pale, and was clutching her chest and breathing rapidly. She smiled weakly: “You guys are the doctors? Oh, good.”
Her relief mirrored mine as I thought, “A young woman with chest pain? I've seen this before,” and my automatic differential diagnosis builder started to churn. A flimsy stethoscope was thrust into my hands, and a first aid kit appeared.
“What's your name?” I asked.
“Cheryl,”* she answered softly. Then, quickly: “I just want you to know I had a heart attack six months ago. I'm having bad chest pain again. I had three stents placed. Can those move?” Her voice rose an octave with the beginnings of panic.
My stomach dropped to the floor. This was real!
The flight attendant who led us to first class grabbed my elbow. “Should we land the plane, doctor?”
Chest Pain on a Plane
Before I could respond, Cheryl interrupted, “And I'm a diabetic.” She jabbed at a makeup bag, where I found her glucometer. I pricked her fingertip and stammered, “One-thirty-eight. Sugar's OK.” She smoothed a piece of monogrammed paper containing neatly written drug names: two for blood pressure, a blood thinner, some birth control pills, and aspirin.
She continued with her unprompted history as some color returned to her cheeks, “I've been exercising, like my cardiologist suggested. I went to kickboxing yesterday. What else can I tell you? I live in Ohio. I'm getting a divorce.”
She nervously rattled off facts about herself, and as they blossomed into a fuller picture, I brushed off the urge to feel like this was a board question, chock full of tricks that were placed in the case to make the differential diagnosis more confusing.
“This morning I had just terrible chest pain, but it went away with an extra aspirin. I was fine all day—really, I was! But now it's really hurting, and Shirley* said I should tell someone.”
She rolled her eyes at her colleague's back. Shirley was busy conferring with Kevin, both of them with elbows on the drink cart while riffling through the first aid kit.
Hearing her name, Shirley turned, her face a mix of exasperation and fear. “Well,” she scolded, “we still have two hours and 18 minutes until our destination.”
Cheryl bit her lip. “It also kind of hurts to breathe. I didn't have that with my heart attack before.”
She was irritated that Shirley had made her call for help but was worried this was serious.
Is It Up to Us?
I took stock of our casual appearance—dressed in jeans and sneakers, we were barely past intern year. I looked around to see if any latecomers had identified themselves as medical professionals. Without bloodwork, an ECG or x-ray, or a senior doctor, I knew we were limited. My already perspiring palms became increasingly moist.
I asked permission to do a physical exam and placed my back square with the aisle to create privacy from the other passengers. Obtaining a blood pressure was nearly impossible—all I could hear through the pretend stethoscope was the plane's engine roaring. I tried to detect the point where the dropping number bounced upward on the dial, but it was a best guess.
I wondered about the accuracy of the reading (165/70 mm Hg). Had I studied the effects of cabin pressure on human physiology in med school? I then strapped my own fitness tracker on her wrist for a makeshift heart rate monitor and counted her respirations while looking at the watch. I found no redness in her eyes or throat. I moved her starched collar to the side slightly to press on her sternum, and she winced in pain. I could not hear heart or lung sounds with all the ambient noise, but she was breathing more slowly now. I checked her legs for swelling and found none.
Shirley again: “Doctors, we can land in Denver now or the captain can go a bit faster all the way to San Francisco. We won't be there for at least an hour.”
Go faster? That's an option?!
Shirley pointed at several blank spaces on a clipboard: vital signs and clinical details. I scribbled down the blood pressure, pulse, and respiration rate. On the line marked for a “responding medical professional,” I wrote my name followed by “MD, PGY-2,” signifying my status as a doctor in just her second year of training.
“Let's try some nitro.” Kevin came over with the first aid kit. Cheryl accepted the small tablet, and we watched her silently for a beat, hoping that she might hop up and start dancing a jig.
She didn't, and my boyfriend piped up again: “We'll use the oxygen. And take these aspirins.” She chewed slowly. I fit the yellow mask over her face just as I'd seen countless times in flight-safety videos and noticed how something had shifted. It suddenly felt normal to be practicing medicine, just as I had been doing for 80-plus hours each week over the past 12 months of residency.
Kevin and I made eye contact, desperate for privacy. Despite the spaciousness of first class, this was no physician workroom and no place to talk in our own language. We bent our heads close and deliberated in low voices. “So we know she has coronary disease and diabetes, and she's on estrogen-containing birth control. This could be cardiac or even a pulmonary embolism, but with the history and exam, don't you think musculoskeletal chest pain from exercise is most likely?”
We went on like this. “Is it really up to us to decide whether to land?”
The Identity of a Doctor
Shirley squeezed between us. “Doctors, I've spoken to the on-the-ground crew and reported the vitals. Based on their recommendation, the captain has decided not to divert the plane. You're in charge to alert us if the situation changes.”
We asked if we could talk with that medical crew, and Shirley frowned. “I'm so sorry, but that's against protocol.”
I was frustrated. I hadn't realized that the improvised vitals would be relayed to a consultant on the ground. Nothing about the scenario fit a usual clinical situation, but it made me more uncertain that they were relying on data that I didn't fully trust.
We turned back toward Cheryl. “Any relief from the nitroglycerin?”
“Not really.” This actually made me feel better because it lowered my suspicion for a blockage of blood flow to her heart. “Would you sit with me?” she asked.
As we sped along to San Francisco, we filled the silence with soft small talk, our elbows not touching over the enormous armrest chasm. I learned about her ex-husband and her favorite restaurants across America. I was reassured that she was chatty, but still wondered if her heart muscle was actively dying while I listened to a story about her nephew's birthday party. I imagined the triaging physicians in San Francisco scoffing at the inexperienced doctors who did not land the plane for a young diabetic woman with coronary disease and severe chest pain.
We arrived, the paramedics efficiently boarded, and the captain and co-pilot came out immediately. A tall man with his belly over his belt, the captain took my right hand in his for a warm, grateful shake.
Some of my physician colleagues were shocked that we didn't land early, and others agreed with our management. Without typical tools, I cared for a patient in the best way I knew how, and of this, I felt proud.
We all have moments in which we realize the identity of a doctor is stuck on like glue; it isn't something that can be peeled off at the end of a shift or tossed aside like an identification badge. Of course, this identity transformation matured slowly, its tender green shoots sprouting at the beginning of intern year. Months later, it clung on like ivy, and at this moment, it was a beautifully developed cloak of moss. After this flight, I could no longer imagine not responding to such a scenario if it happened again.
This was tested just 10 days later. On a three-day public ferry journey from Alaska to Washington, we awoke in our tent on the ship's deck to an intercom announcement. A patient was in need, and health care professionals were being summoned. We slipped on our shoes in silence.
*Names in this story have been changed for privacy.
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Dr. Rosenblumis a fourth-year resident in combined internal medicine-pediatrics at Yale New Haven Hospital. She will serve as one of the chief residents in the primary care/internal medicine program at Yale after graduation.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.