You can’t always take your clinician cap off, even when you’re not at work. After all, you probably chose a career in healthcare because of your passion for helping people. Well, occasionally, that dedication might be put to the test in challenging settings, as one nurse and physician learned on an airplane two weeks ago.

The physician, Julia Loewenthal, a geriatric medicine fellow at Harvard University, discussed the experience in a series of tweets last week.

The story began with that fabled call from her flight’s attendants: “Is there a nurse or doctor on board?” Loewenthal quickly realized that she was the only physician present who’d treated adults but was thrilled to learn she was traveling with a cardiac nurse.

Loewenthal said the patient was “a middle-aged and experiencing crushing chest pain. We asked for the medical kit, took vital signs, and performed an exam. By the way, you cannot hear sh*t through a stethoscope in the air. I could hear bilateral breath sounds, but that’s about it.”

Luckily, her aircraft had more than the FAA-mandated contents of in-flight medical kits, but still, Loewenthal noticed several surprising oversights: “no pulse ox, no glucometer, few gloves, no Epi-pen, no Narcan. Some meds were in a different language without English translation,” she wrote.

“The FAA mandates the contents of medical kits for American Airlines. I flew on a European airline, but the kit had most items & more. Of note: no pulse ox, no glucometer, few gloves, no Epi-pen, no Narcan. Some meds were in a different language without English translation. 

Loewenthal and the nurse’s path forward was to administer 325 mg of aspirin and start the passenger on oxygen. You can deliver 2-4L oxygen by nasal cannula route. However, the tank will only last 1 hour or so,” she noted.

But then the duo began to worry their patient was having an MI. “The chest pain was ongoing, so we gave SL nitroglycerin, which significantly improved the chest pain and (fortunately) did not bottom out the blood pressure,” she explained.

After consulting with the pilot and the ground medical doctor, Loewenthal, and the nurse determined the best course of action was to divert the plane, which had departed from Boston. It was a complicated and expensive call, Loewenthal added, not to mention unusual. Aircraft need to be grounded in only 4.4% of in-flight emergencies.

Next, “During descent, I see that our passenger starts to slump forward in the seat. I get up, and they are pulseless,” Loewenthal recalled. “I remove the passenger from the seat, and the nurse promptly starts chest compressions. I ask for other passengers who are certified in CPR. I attached the AED pads to the chest and defibrillated ASAP. We give two more minutes of CPR and locate the Ambu bag and epinephrine.”

“But our passenger starts to move and talk!” Loewenthal continued. “They are hypotensive and tachycardic. The nurse starts an IV, and we start the 500cc bag of normal saline. We still have 20 minutes to go on the descent. Fortunately, the vitals stabilize, and there is not another arrest during landing.”

When the plane reached the ground, the paramedics took an EKG, which Loewenthal posted online. Thankfully, the passenger made it to the hospital.

Loewenthal went on to share the most challenging aspects of the experience. For starters, “Landing sitting on the ground with your post-cardiac arrest patient surrounded by medical equipment and an entire cabin of people staring at you” was nerve-wracking. She also felt slightly uncomfortable practicing medicine “in a resource-limited setting with unfamiliar people, unclear rules, and high levels of pressure.”

To conclude, Loewenthal revealed some things she wished she’d done differently. For example, “I wish we had established explicit team roles early,” she wrote. “I wish I wore a watch on a regular basis (the nurse had one)! I wish a third clinician had documented everything with explicit time stamps. I wish I could have had a full debrief with the flight crew and the nurse. I wish I could see the passenger and their family again.”

She also praised those who practice medicine exclusively in emergency settings, writing, “Can’t believe how many paramedics and EMTs do this every day with no follow-up and often in isolation.”‍

What Should You Do if You’re Asked To Help During an In-Flight Emergency?

First, only offer help if you’re not under the influence of drugs or alcohol. Then, according to a 2015 article in the New England Journal of Medicine, you should:

• Introduce yourself and state your medical qualifications.

• If possible, ask the passenger for permission to treat.

• Ask for the medical kit and the external defibrillator, if necessary.

• Ask for a language interpreter, if necessary, but always be aware of patient privacy.

• Take a patient history, perform a focused physical examination, and obtain vital signs.

• Administer treatment within the scope of your qualifications; keep the patient seated, if possible.

• If the patient’s condition is critical, recommend diversion of the flight.

• Communicate with ground-based medical resources.

• Continue to provide care until the emergency medical condition is stabilized or care is transferred to another qualified medical personnel.

• Document the patient encounter.

For emergencies that require some of the most intense interventions — such as trauma, allergic reactions, psychiatric emergencies, substance abuse and withdrawal, obstetric emergencies, and cardiac arrest — a JAMA review from December 2018 offers a high-level overview of how to approach each.‍

How Common Are In-Flight Emergencies?

Loewenthal’s experience was fairly unusual for several reasons. First, in-flight emergencies occur on only one in every 604 flights. Cardiac arrests account for only 0.2% of in-flight emergencies — but 86% end in death. According to the JAMA review, the most common in-flight medical emergencies involve syncope or near-syncope (32.7%) and gastrointestinal (14.8%), respiratory (10.1%), and cardiovascular (7.0%) symptoms.

If you’re worried about providing care on an airplane because of the potential for medical liability, know that you’re protected under the Good Samaritan law. Still, you have no legal obligation to intervene.