I just got back from a family vacation, which was perfectly lovely. What was not lovely, was the air travel involved. Is it just me, or has air travel become increasingly unpredictable in the last 5 years or so? I’ve been taking cross country and transatlantic flights since I was a babe in arms, and I never remember significant delays, missed connections, being rerouted. Whereas looking over the last few years, I can count on one hand the number of times I’ve made it to my destination on time.
Our outbound flight, for instance, was a transatlantic jet. We were delayed five hours due to “mechanical issues,” whatever that means. When we finally got airborne, they served “dinner” immediately (at like midnight) and then turned off the lights so everyone could get to sleep.
In the middle of the flight, somewhere over the Atlantic, I was jarred awake by a loud thump/shudder. What was that? In the aisle, a fellow passenger has collapsed. Like, totally out cold. Holy shit. I’m in the window seat, my mother’s by the aisle (also awake), I climb over her and kneel down next to the woman on the floor.
“Ma’am? Are you ok? I’m a doctor, can I help you?”
She groans and struggles to her knees. I give her my hand and try to help her stand, but she cannot bear her own weight. I ask her a few more questions, she grunts and can’t answer. There’s something dark on her lower face, but I can’t see properly because all the plane lights are off. Seems totally dazed, but tries to crawl to her seat, just a couple rows ahead. Because the flight is so empty, she has the entire row of 3 to herself, so I help her back into her seat and she tries to lie down to sleep… and promptly falls off the seats again.
At this point, I’m legit worried about her cognitive status and apparent aphasia. This is not just a simple mechanical stumble-and-fall. She seems concussed. Maybe hypoglycemic. Maybe post-ictal. Stroke unlikely, as she’s young, but we’ve all been sitting for a long time with lots of opportunity for venous thrombosis, and if she’d been walking back from the bathroom where she’d Valsalva’ed….
One of the other passengers has pressed the call bell for the flight attendant, and between the two of us, we are able to lift the ill passenger back into her seat. A couple other flight attendants hover nearby, nervously. One is holding the Green Sheet, the medical assessment summary, which I’ve filled out before on other passengers for much less. By this time she’s a little more alert, says she’s fine, says she’s sleepy. I want to take her back to the galley, where there is some light, and examine her properly. The flight attendant refuses, saying “She looks ok now. Maybe she just fell asleep.” I think of Natasha Richardson but bite my tongue.
“Ok,” I say. “I’m a doctor. I’m just a couple rows behind, in that seat right there.”
The flight attendant thanks me. The Green Sheet disappears. I climb back over my mother into my seat, my eye still on the ill passenger. She sits up a little while longer, talking to the person in front of her, then lies down again.
I check on her once more later in the flight, surreptitiously, when walking to the bathroom. She’s lying Roman-style across the seats, watching a movie. She looks alert. Later, as we’re waiting to deplane, I overhear her talking to some other passengers, explaining that she’s passed out before inexplicably, she must have been tired and/or dehydrated, she feels much better now. She says she has only a hazy recollection of what happened. There’s some dried blood along the vermilion of her lower lip; she must have split it on an armrest. But other than that, she looks quite normal.
Was I over-reacting, friends, to be thinking of life-threatening things like untreated (undiagnosed?) epilepsy or stroke or epidural hematoma? Maybe. I’m glad she did well, and that my original suspicion of concussion was likely correct. But I don’t think I was wrong to consider those more serious, if statistically less likely (but still biologically plausible) possibilities. This is how doctors generate a differential: what’s the most likely? what’s the most serious? As one of my attendings loved to say, don’t anchor on something (patient said she’s sleepy, therefore she must have fallen asleep… while walking after sitting in a relatively brightly-lit airplane bathroom) without considering evidence for and against all the other possibilities.
I’m still a little annoyed at myself that I didn’t insist on examining her properly though. I’m a neurologist. Of all the possible inflight medical emergencies, this is what I do. I’ve been consulted for far less by the ED back on terra firma. And to defer to a flight attendant, whose medical qualifications include … CPR? Why on earth did I do that, unless it was because he was in a uniform and I was in jeans?
If this ever happens again — and I hope it doesn’t, but I bet it will because I’ve been the “doctor on board” at least once a year since I was in medical school — I’m not going to back down. If someone ever had a bad outcome because I didn’t examine them properly, I really don’t know what I’d do with myself. To be honest, there’s not much I could have done, if I’d diagnosed stroke or epidural hematoma over the Atlantic. But to go against my own better medical judgment because of some perverse sense of not wanting to cause a scene…. ugh. I need to be better than that.