First Response: In-flight Medical Emergencies
TINO: You’re listening to Firsts, a podcast about first-time medical experiences. My name is Tino Delamerced, and I am a medical student.
(ambient airport sounds, and an announcement overhead: “Ladies and Gentlemen, in the interest of air safety…”)
TINO: I was sitting in the airport, reading about 2 med students who responded to a medical emergency on a plane. A passenger on their flight had fallen over, and the med students discovered that she had a low blood sugar. They gave her some juice and some food, and, well, she felt better.
(ambient airport sounds, and an announcement overhead: “Thank you, and have a nice day.”)
TINO: I was boarding this long flight from the east coast to the west. And I thought to myself, What if a medical emergency happened on my flight? Would I have answered the call? Would I be calm and collected? What would I have done?
(music)
TINO: Today, we’ll hear a story from a doctor…
LAURIE: My name is Dr. Laurie Garabedian.
TINO: …about an emergency on a plane.
Our flight’s destination is in a state that’s in the top 5 for having the oldest median age. This state spends the second most money on Medicare. And it’s home to several retirement communities. We’re taking a trip to Florida.
LAURIE: I was just in the terminal. I was traveling by myself. And I’m sitting down, and I’m sort of looking around.
You know, everyone else there was also just older, so much so that I had texted a friend of mine, (text sound) “Ha-ha, If there’s ever a time on an airplane where I needed to medically assist someone, today’s the day.”
TINO: If she sent me that text, I would’ve told her, “I’m not superstitious, but I think you just jinxed yourself.”
(music)
LAURIE: So we board the plane like normal, sit down, and just take off. Normal flight. Nothing exciting is going on. At some point I doze off. I have no idea when. I don’t know how long we’ve been in the air for. I wake up to that, (radio white noise) like, crackly sound of an intercom, and over the intercom, the flight attendant says, “If there are any doctors, nurses, EMTs, paramedics available onboard, hit your call light.”
(sound of a clock ticking, and tense music)
LAURIE: So I kind of take a second and wake myself up, [and] look around because I’m hoping someone else is going to hit their call light and that I’m not gonna be the only one on the plane, (sound of a clock ticking) but no one does. I’m sitting on the aisle seat, so I have my head down the aisle, looking up and down. Finally, I’m just like, “Well, I guess it’s me.” Take a deep breath and hit the call light.
(a breath in, the sound of a call light, and the abrupt stop of music)
LAURIE: The flight attendant starts walking back to come and see who hit the call light. And there was actually a guy like 3 or 4 seats behind me who was getting something out from the overhead bin. And she was like, “Oh, sir, are you the doctor?” And he was like, “N-No.”
I kind of raise my hand, and I tell her that it’s me, and like I understand the confusion. I had sweatpants on. I had my hair in a messy bun. And I actually did have the urge to tell her, “I’m a family medicine doctor, and I just finished my residency a couple of years ago, and I’ve worked in an ICU and an ER,” as if I’m trying to justify the fact I can take care of this person when literally no one else on the plane has medical training.
So she came back to meet me at my seat, and then at that point she brought me up to see the patient – the passenger. She, on her way up there, said, “We have an older lady who I think maybe has had a stroke.”
LAURIE: Okay.
(sound of a microphone being adjusted, and a cleared throat)
(music)
TINO: So you’re a fourth-year medical student. What do you do when you suspect that someone has had a stroke?
MEDICAL STUDENTS: I would get IV access, different types of imaging, CT, carotid ultrasound, CTA brain and neck, identify if the person is within the window for certain interventions like tPA, or you can do mechanical thrombolysis – I’m trying to think if there’s anything else – you can do bloodwork: an LDL, hemoglobin A1c, coagulation status, blood glucose – I don’t know what you else want me to –
TINO: Okay, so same situation, but there’s a small difference. What do you do when someone might be having a stroke on an airplane?
MEDICAL STUDENTS: Uh, [bleep]. Um… on an airplane? Honestly I have no idea.
TINO: So, faced with that very situation, Dr. Garabedian goes to meet the passenger.
LAURIE: I’m sort of kneeling in front of her, and I try to catch her attention, and I kind of yell her name out to her and see if she’ll respond to me, and she doesn’t. And her daughter is sitting next to her, and her daughter says to me, “She was talking to me…”
(fades in with previous)
DAUGHTER: She was talking to me. And then all of a sudden, she slumped over to her right.
LAURIE: And I was like, “Okay, how long ago was this?” And she was like, “I don’t know. Maybe a few seconds…”
(fades in with previous)
ANNA: Maybe a few seconds before they made an announcement?
LAURIE: …which at that point I have no idea how much time has gone by. I’m guessing like a minute or two, but it feels like 6 hours. And so I ask her what her medical history is.
DAUGHTER: She takes medications for high blood pressure and high cholesterol. Otherwise she’s been okay.
(music)
TINO: Then, Dr. Garabedian examines the patient.
LAURIE: Her right arm was kind of draped over the armrest, and her right leg was kind of splayed out to the side, and she definitely had a facial droop on the right side, so I was like, “Okay… This is gonna be a problem.”
(music continues)
TINO: While Dr. Garabedian meets the passenger, in the background, a flight attendant retrieves the medical kit onboard. Then, that flight attendant uses the satellite phone on the plane to call a doctor on the ground who can assist with the emergency.
As this is all going on, Dr. Garabedian realizes how prepared the cabin crew is.
LAURIE: I am very curious how much like they are actually trained in in-flight emergencies as well, because I have a feeling that the flight attendant knew more than she let on that she knew maybe because she was kind of always one step ahead of me, which was interesting. And she was also cool as a cucumber. Like really calm.
(music)
TINO: I also was curious about their training, so I reached out to Joyce Labitan, a retired flight attendant formerly based in Hong Kong.
JOYCE: Yes, every 10 months, we go back to safety training school. They teach us a little bit about everything: emergency childbirth, how to do all the basic things of first aid like choking, heart attack, strokes, bleeding, wound dressing, all sorts of things.
TINO: Joyce told me that, in the event that there are no doctors or nurses or paramedics on the plane, she even has administered medication herself.
JOYCE: We were told to give morphine, so I did an intramuscular injection.
TINO: She told me of another emergency that happened seconds before a flight took off.
JOYCE: She was pale, and she had a cold and clammy perspiration.
TINO: A passenger suddenly had this pain in her belly, and the airplane was moving toward the runway. So, Joyce called the captain.
JOYCE: I'm afraid this is appendicitis. And if it's appendicitis, a lot of things could happen in the next 12 hours.
TINO: Instead of embarking on a long flight across oceans, she asked to stop the plane to have the passenger examined. So they stopped; paramedics boarded; and they actually took the patient to the hospital.
JOYCE: If I hesitated to make that decision to make the call, then we would have to take off, and then we would have to dump all the fuel in the Pacific Ocean…
TINO: …because all the unused fuel in the tank would’ve made the plane’s landing weight too heavy…
JOYCE: …and then fly back to Vancouver.
TINO: Experienced cabin crew can make timely and critical decisions the way Joyce did.
PAULO: They are safety agents in the aircraft, primarily.
TINO: I also spoke with Dr. Paulo Alves, the global medical director of MedAire, an international company that provides medical and safety services for airlines.
PAULO: So they are trained to deal with how to extinguish a fire on board, how to command an emergency evacuation, how to control an unruly disruptive passenger, sometimes an aggressive passenger, and medical events.
TINO: The company MedAire also organizes the on-the-ground doctors who assist with in-flight emergencies.
PAULO: The setup, in a nutshell, is that we actually outsource to practicing ER doctors that we added a layer of aviation medicine into their training.
TINO: In our story, that is the kind of doctor the flight attendant would’ve called up, using the satellite phone on the plane.
But of course, while the cabin crew in the air and a medical team on the ground can respond to in-flight emergencies…
PAULO: Having someone to help is always a big relief – a big relief. And, of course, having someone in person – it's apparently much better than having someone over the radio. And we are extremely grateful to whoever volunteers in flight.
(music)
TINO: As the plane continues its path to the South, a flight attendant hands Dr. Garabedian the medical kit.
LAURIE: The next most important thing to do is just to figure out what my tools were, like what did I even have available to me? So I start looking through the bag.
There was Tylenol and Ibuprofen, and…
TINO: …fluids like saline and dextrose, plus the tools to give those fluids…
LAURIE: …an inhaler…
TINO: …a defibrillator and tools for CPR, which the flight attendants are trained to use…
LAURIE: …Band-Aids...
TINO: …a blood pressure cuff…
LAURIE: and a stethoscope.
TINO: …and other medications like aspirin…
LAURIE: …atropine…
TINO: …nitroglycerine, and antihistamines. At least in the United States, the medical kit is regulated by the Federal Aviation Administration. So you can expect American flights to have at least those items. But, to be honest, it’s not a lot to work with.
PAULO: The best equipped aircraft is probably less equipped than a bad hospital.
TINO: Dr. Garabedian realizes she can use some of the tools in the med kit to take a blood pressure, but for this passenger, who might’ve had a stroke, there wasn’t much else she could do.
LAURIE: It's also really hard to hear a blood pressure on an airplane because there's a lot of background noise, and they give you one of those like plastic stethoscopes.
(music)
TINO: Meanwhile, the flight attendant phones in the emergency doctor.
LAURIE: And he kind of asked me to sort of give him the history of what’s going on and a little bit about the patient.
TINO: He asks if the passenger was being given any oxygen…
LAURIE: …which I had not because I did not know I had access to an oxygen tank…
TINO: So a flight attendant grabs the tank and sets it up.
LAURIE: The next thing he says to me is,
ON-THE-GROUND DOCTOR: Okay, listen to me. Do you think we need to land the plane?
LAURIE: Yeah, I think so. I think she’s having a stroke, and she needs to be in an ER within an hour.
ON-THE-GROUND DOC: Okay, great. Just tell the pilot.
LAURIE: (under her breath) I have to tell the pilot. Okay.
(music continues)
TINO: During a medical emergency on a plane, here’s how they figure out whether they need to change the course of a flight, and land sooner. It’s also known as diverting the flight. First of all,
PAULO: If the situations are truly life threatening, or limb threatening, or organ threatening, this is, generically speaking, the indications for us to recommend a landing…
TINO: But a medical team or volunteer has probably zero idea when it’s okay to land. An emergency landing…
PAULO: …is always a safety concern as well, where the benefit of one is actually impacting the safety of probably 300 other people in that aircraft.
TINO: A medical team can recommend for the flight to land, but they don’t have any actual power in making that decision. So, if a doctor suggests to land as soon and safe as possible…
PAULO: We will engage also a vital element that is called ops control, or dispatchers.
TINO: They take care of the flight’s logistics, like what weather will they encounter; what are the conditions at their destination; how much fuel does the plane need? But generally speaking…
PAULO: The pilot has the final say, because he is the one really in charge of the whole thing.
TINO: So the pilot, the dispatchers, and the medical team all have a conference call to decide whether the flight needs to be diverted.
(music up, recedes)
LAURIE: I talk to the pilot, and I tell him what’s going on. I talk with the ground doc and that we are probably in agreement that we need to land the plane and get her to the ER.
TINO: And the pilot says,
JOSEPH: We’ll be on the ground in 20 minutes.
(music)
(sound of a call light, and the pilot’s radio turning on)
JOSEPH: This is your captain speaking. A passenger on our flight needs emergency medical attention, so we’re gonna be landing soon and then resuming our flight from there. Sorry for any delay or inconvenience this may cause.
LAURIE: I realized I had made this decision for everyone on the flight, and that people had connecting flights or whatever. I just screwed this up for all of them, so it’s a lot of pressure in that way.
Interestingly, as soon as they made the announcement, there was this roar of voices.
(crowd of whispering voices)
LAURICE: It was just very strange. It was a very surreal moment to be standing there and just listening to all of this.
TINO: As they prepare to land, the emergency physician tells Dr. Garabedian to take some of the patient’s vital signs, like her blood pressure, her breathing rate (breathing sounds), and her pulse (heartbeat), every 5 minutes. She finds that the passenger’s vital signs are okay, but…
LAURIE: She’s still not alert. Her arm and leg are still weak on the right side. So I’m like, Okay, we’re still having a stroke here.
(heartbeat)
TINO: As she measures the passenger’s pulse, she can feel her own getting faster.
(heartbeat quickens)
LAURIE: Is it more than one a second? Yeah, it is. I feel like mine was 120. And they gave me like coffee, which I did not need because adrenaline was super high.
TINO: And then, 10 minutes before landing, something completely unexpected happens.
(heartbeat echoes, and music stops)
LAURIE: At that point, I was actually sitting behind her – kneeling kind of behind her. And so what I saw from my vantage point was that her arms and legs just sort of flailed up into the air. And I got the sense that she – because her head went up too – that she kind of lifted from the seat a little bit.
I’ve never seen that before. And I honestly didn't really know what to expect when I sat back in front of her – if she was just going to be fine, or was she having a seizure, or did something more drastic occur? Yeah, I was pretty shocked. When she ended up talking to me and being able to move her arm, and her face was back to normal, I was very relieved. But had that not been the case, I don't honestly know what I would have done.
TINO: So the passenger’s sudden recovery actually has a name. When someone gets stroke-like symptoms for a short period of time, like less than 24 hours, it’s called a transient ischemic attack, or a TIA. Most TIAs, like the one that Dr. Garabedian saw, resolve in about 10 minutes. It’s still technically an emergency, though, because you want to make sure that the patient did not actually have a stroke.
LAURIE: So when she first woke up, she was kind of like, “Who are you? Why are you kneeling in front of me? What's going on?” I had to like introduce myself to her and explain the whole thing and, and whatnot. Within seconds after that, the ground doc calls me back…
TINO: …and she tells him, “Hey, the passenger looks a lot better, maybe even close to normal…”
LAURIE: At which time he said to me, and I was not expecting this…
ON-THE-GROUND-DOC: Okay, great! Then you can continue on to Florida.
LAURIE: I’m sorry, what?
(music)
TINO: Dr. Garabedian disagrees with the other doctor’s recommendation. She wants the passenger to be properly evaluated in a hospital as soon as possible. So, they talk to the pilot, who casts the tiebreaking vote.
LAURIE: I got out-ruled or outvoted or whatever.
TINO: And he decides that they will keep going to Florida.
(music)
TINO (distant): Were you concerned at all about, Am I legally responsible for this person?
LAURIE: I wasn't worried necessarily about being legally responsible for her because, again, there was literally no one else in the plane who had any medical training.
PAULO: I'm not aware of any case that a doctor has lost, working as a volunteer.
TINO: The Aviation Medical Assistance Act of 1998 is basically a Good Samaritan Law. It protects medical providers like Dr. Garabedian if they volunteer to help during an emergency.
There is some controversy, though, over whether people should accept gifts for volunteering. But Dr. Alves told me you can accept a gift, like a bottle of champagne or a flight voucher, as long as you make it clear that…
PAULO: …your act is volunteer…
TINO: …and that the gift isn’t compensation for your services…
PAULO: …because this is what will afford you protection under the Samaritan law.
(music recedes)
TINO: Thankfully, under Dr. Garabedian’s watchful eye, the rest of the flight is uneventful.
LAURIE: The flight attendant – she was also cool as a cucumber. Like, really calm.
TINO (distant): What about you?
LAURIE: Internally, I was not calm. I think you learn as a physician to be calm on the outside and kind of, put out that like layer of confidence, like you do know what you're doing. I distinctly remember my hand shaking while I was trying to like open up that bag the first time, so I was not feeling super calm.
TINO: Eventually, (landing sound) safe and sound, they land in Florida.
(happy music)
LAURIE: The good news is when there's an emergency on your plane, you get to be the first one taxied right to the right to like the terminal. And so EMTs met us on the tarmac. So they came in, as soon as we landed.
TINO: The passenger was scooped up, placed on a stretcher, and escorted, with her family, off the plane and to the hospital.
LAURIE: And the family actually emailed the airline a couple of days later to get me an email just to say thank you and to let me know that she was fine. So, ultimate outcome also is that she went to the ER, and everything was checked out. And she did okay, there, too.
(applause)
LAURIE: Before we get off the plane, the flight attendant had asked for everyone to give me a round of applause.
(cheers)
LAURIE: They had me meet the pilot who just like thanked me for my service or whatever. And I was like, thank you for flying us safely and all that good stuff. I'm like, okay, I kind of feel like in the same way that that's his job is to take off and land and fly people on the plane, I don't necessarily expect people to thank me for doing my actual job. Although I guess I technically wasn't at work. Yeah, it was voluntary.
And someone actually offered to drive me from the airport to my hotel, which was, I guess, worth it.
TINO: If you remember from the beginning of the episode, Dr. Garabedian had texted a friend before the flight, “If there was any day that I would have to respond to an emergency, it would be today.”
LAURIE: I called him when I got off the plane. I was kind of like, “So remember that text I sent you? He said, “That was karma.” So, lesson learned.
(music)
TINO: So my flight’s getting ready to take off. But I wanna say this before I go: if you’re a healthcare worker on a plane, and a medical emergency arises, take a breath, and answer the call. You’ll be the much-needed eyes and ears of the medical team on the ground, and you’ll have a well-trained cabin crew to help you, too. Oh, and if you’re a med student, hit your call light – they just might need you, too.
(call light sound)
(music stops, and a new song starts)
TINO: That was First Response: In-flight Medical Emergencies. Thank you to Dr. Laurie Garabedian for sharing her story. Thank you as well to Dr. Paulo Alves and Joyce Labitan for their interviews. Thank you to Jose Perez, Eric Handy, Lindsey Pileika, Connie Ge, and Danielle Chauvet for helping me with this episode. Thanks as well to Jackson Cantrell and WBRU for letting me use their studio. Music is from Blue Dot Sessions. You heard the voices of a few people standing in as actors for this story. A lot of those voices have been in prior episodes. If you can name those voices, follow, and direct message our Instagram page @FirstsPod for a prize. And, check out a full list of resources and credits on our website at firsts.site. My name is Tino Delamerced. You’ve been listening to Firsts.