The Pay Off At 38,000 Feet

Two hours out of Boston the man in the middle seat, across the aisle from me slumped forward in his seat, pallid, sweaty, unconscious.  
The man in the aisle seat jumped up and went for the flight attendant. 
I climbed over my wife in the middle seat and the woman in the aisle seat to get to him. 
He was awake, but not alert when I got to him.
The flight attendants arrived and did the is there a doctor on the plane announcement. 
As far as I could tell, I was the only one to respond. Flight from Boston to a very big doctors' convention and I'm the only doctor.
The patient, a 48 year old cabinet maker from Attleboro denied chest pain, abdominal pain, headache back pain. He denied smoking and any recent alcohol. He had eaten a hamburger in the airport before departure and had not been up late the night before, although he had to fight through a monumental traffic jam to make the flight, which was taking him to a mega bowling tournament in Reno, Nevada by way of San Francisco.  He gave all this history soaked in sweat and pale as a seagull's white head.  His father, a smoker, had died at 68 of an MI, but his brothers and uncles had no known heart history. The patient himself had no heart history, but had no health insurance and had not been seen by a doctor in years. He had been a fitness instructor in the Army, and his plastic goody bag was full of granola bars and he said he never ate fatty foods--the hamburger had been his first in months.

 His pulse was, best as I could tell, about 40 something when I first reached him, but regular, and it seemed to be getting faster as I held his wrist and talked to him. I could not hear his BP with the background engine noise, but it palpated at a systolic of 90.

The first decision was whether or not to move him.
He said he thought he might feel better if he lay down. 
I asked him if he wanted to pee or go to the bathroom and he answer was the first major punch to my solar plexus: He said he might be able to have a bowel movement. Didn't have to have a bowel movement but might be able to.

Forty years ago, a nurse at New York Hospital had called me to the bedside of a man just back from the cardiac care unit who was sweating and nauseated and complaining of chest pain and when he said he needed a bed pan the nurse ran for the crash cart and called the Cardiac Team. He arrested right in front of me before she could return. I asked her how she knew and she said, "When they're having chest pain and ask for a bed pain to poop, they are about to arrest." Everyone else from professor to nursing student nodded in assent.

Now my patient was talking about the same vagal nerve discharge sign.

I walked my patient down the aisle with my arms under his arms. He was 6'2"  215 pounds and outweighed me and I just hoped he would not collapse in the aisle but we got him the 13 rows to a row of seats the flight attendants had cleared off and he was able to lie down.

The flight attendants arrived with a pack which can be used  to defibrillate a patient. I had seen this pack at work but had never used one. They didn't have these things the last time I had to run a code in the hospital 30 years ago. I did know you could use them to get a rhythm strip EKG and to my great relief, he was in normal sinus rhythm at 60. No shock needed, which was a good thing because those airplane seats have metal feet and I wasn't sure about whether shocking him would shock me, the flight attendants or near by passengers. 

A woman who identified herself as an ER nurse arrived and asked if I wanted an IV. I did and she placed one in his right antecubital fossa and lo and behold the emergency kit even had normal saline to hang.  The flight attendants did this using a wooden hanger, hooking this to the overhead luggage rack. Apparently, they had done this before or were well trained or both. 

It bothered me the nurse had used the antecubital fossa, because in the old days, when I last did my IV's the metal butterfly would not last long when the patient bent his arm, but now the IV is a plastic, pliable angiocath and does not dislodge or cut the vein. We had angiocaths back when but removing the metal part was complicated and I preferred the old butterfly. They had prochlorazine in the kit and the nurse asked me i I wanted to give him some for his nausea.  When nurses ask questions like that under those circumstances, they are not really questions. That's what they did in her ER with this kind of patient, but I was reluctant because if he got less nauseated that would tell me he was actually getting better. Give him prochlorperazine and you lose that symptom to follow. On the other hand, if he was nauseated and started vomiting that would stimulate his vagal nerve and slow his heart rate, so I said yes.

The bottle had a rubber top and I put a 21 G needle on a syringe and pulled up 12.5 mg and handed it to the nurse to inject into the port on the IV line but she told me to take off the needle. "How're you going to inject it without a needle?" I asked. "These ports are needless now," she said, all but rolling her eyes. She knew she was dealing with an old gomer doc who hadn't run a code since needleless equipment came in. 

The flight attendant asked what I had given and I said, "Compazine" and the nurse said, no, it was Phenergan.  That's how old and useless I was: couldn't even remember the difference between those drugs, and just knew the brand names. 
(Actually, I looked online and Compazine is prochlorperazine and Phenergan is promethazine, so I was right.)

The nurse said her work here was done and left. 

I asked the flight attendants if I was the only doctor on the plane, a plane from Boston, the medical Mecca. She said they were one or two others but they said I looked like I had the situation well in hand. I said I'd like to have them come forward so we could have a Grand Rounds to discuss what to do with the patient. None ever showed. 

He was looking better, less sweaty and more comfortable and I was able to prod his abdomen which was soft and non tender without rebound.

I kept the monitor on him and the IV running. His rhythm monitor beeped along happily in NSR at 70. He dozed off but was easily arrousable and no longer wanted to poop.

The flight attendant arrived with a serious look and said the captain wanted to know if I wanted to divert the plane for an emergency landing.  She reminded me ominously, we had 4 hours to San Francisco.  

I had been thinking about this:  Over the years I had had young men without cardiac risk factors lose consciousness when I drew their blood. One even became briefly asystolic and I had to revive him with a chest thump, but he recovered and left my office, apparently unharmed. Like these men, this patient had no cardiac risk factors and he appeared to be recovering and was currently stable.

On the other hand, had he known cardiac disease, a midsternal incision from a prior bypass procedure, I'd have landed that plane. 

But I had, over the years, seen patients who initially seemed to be recovering and doing well arrest suddenly and die.

The flight attendants had asked for my medical license number. Everyone was covering the company. I was acting as a Good Samaritan, but if I sat there for 4 hours my Good Samaritan status might just expire and I knew I was exposing myself and my family to a possible career ending lawsuit.

On the other hand, this man had no health insurance and a visit to the hospital could do him significant financial harm. And what hospital? We were approaching Utah, and there is one of the best hospitals in Salt Lake, the University of Utah.

On the other hand, he was looking better and better, just the way my other patients who had vaso vagal episodes had when they recovered. 

I told the flight attendant they should have the EMT's meet us in San Francisco but I thought I could monitor the patient for now. She looked at me hard. I said I knew there was a contradiction there. If I needed EMTs at the end of the flight why did I not need them now? But what I was saying is I didn't want him getting on a flight to Reno without more evaluation, but right now, he looked okay. I'd leave that IV in for safety. They had epineprhine, atropine, and Heaven Help us, intubation equipment in the airplane kit. 

My wife moved up because the 70 somethings in the seats on my side of the aisle asked if he could have anything infectious and they wanted out. My wife arrived and said brightly, "Wow, much more leg room in these forward seats. You upgraded us."

She's a former ICU nurse and I told her to watch the monitor while I went to the bathroom.  I needed it but I also wanted to scout out the bathroom because I figured he might need to use it to urinate after his next bag of saline.

When I said, "I can't believe I'm the only doctor on a flight from Boston. Next to Washington, DC, Boston has more doctors per square inch than anywhere."

"Can you imagine your young colleagues coming forward?" she asked.

It was true. My young colleagues did not want an EKG machine in our office because they did not want the responsibility to read them or to act on them. This means 70 year old diabetics can come and leave our office with atrial fibrillation without anyone knowing. I examine every heart every time. "But that's not what we are here for," they told me. "We biopsy thyroids, get blood sugars down. We are not internists. We are endocrinologists, specialists."

But these are people, patients.

The head flight attendant came by to tell me she was applying for a refund of my ticket price because I was doing a service for the airline.

That was my Hemingway moment.  Hemingway, in The Sun Also rises, talks about the difference between living in France and living in Spain. In France, you tip your waiter well and the next time he gets you a good table and may even smile at you. It's all based on money, cash exchange. In Spain, the hotel keeper will not even give you a room during the running of the bulls time unless he knows you love bullfighting, unless he knows you share the passion for the sport. It's all about honor and passion and stuff like that. Money just sullies the whole relationship.

So now, I know it came from a generous and grateful place, I was being told I had performed a service for the airline and I was being paid off, and I should be gracious and say thanks for the money.

But it sort of made me sad. The patient was not even out of danger and they were already talking about the fee for my service.

After his 2nd liter of normal saline, he sat up and said he felt much better and his color returned to the shade of the living and I sat next to him and kept refilling his water cup and we talked about bowling, his time in the Army, his business as a cabinet maker and restorer of old New England homes.

We both noted, after a liter of intravenous saline and a liter of bottled water, he still did not need to pee, so he must have been dehydrated.

I was very glad he did not suddenly keel over and die.

He was very well by the time we landed in San Francisco and the EMTs arrived and asked for the doctor and looking at him they gave me the fish eye for the false alarm.

My wife told me not to worry about it. After all, nobody else had thought it was worth the money.





 




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