Thursday, June 28, 2007

Do we land this plane or not?

Went to a medical ethics conference today where the speaker asked us to comment on the following case (a true story from his own experience).

You're a doctor sitting in first class on a flight from Texas to Florida when an overhead announcement asks any physician on board to please press the call button. You do, and you're taken to one of the last rows where a woman has been having a tonic-clonic (grand mal) seizure. By the time you get there she's improved, but is still displaying strange behavior: opening and closing the shade, repeatedly flipping through a magazine, non-conversational. The crew wants to you examine her and determine if the plane needs to make an emergency medical landing. There is nothing in the on-board medical kit that would be useful for diagnosis or provisional treatment.

Although her condition seems to have improved, you don't know what caused the seizure and it is possible that she could have additional seizures or suffer a sustained seizure (status epilepticus, a life threatening condition). On the other hand, an emergency landing will cost tens of thousands of dollars and disrupt the travel plans of a full airplane (and don't doubt that the surrounding passengers are paying close attention to your every word and move).

An airport with a runway long enough to land the plane is nearby. The chief flight attendant is standing nearby, on the phone with the captain, and needs to know within 30 seconds: "Doctor, do we land this plane or not?"


At June 28, 2007 at 1:51 PM , Blogger Steve said...

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At June 28, 2007 at 1:54 PM , Blogger Steve said...

Is this the famed Kobiashi-Maru test? Can I reprogram the simulator just like Captain Kirk did?

On a more serious note: Does the doctor have anything to lose by telling the pilot to land the plane? Probably not. He will be incovenienced, as will the passengers. The airline will lose a little money. But doctors routinely side with patient health and safety over inconvenience and dollar cost. If medical ethics begins with "First, do no harm", then I think ya gotta land the plane.

At June 28, 2007 at 3:45 PM , Blogger Melinda June said...

Just land the damn plane already.

At June 28, 2007 at 5:41 PM , Blogger Tom said...

First of all, the patient reminds me of dozens I've sat next to... it's SO annoying when they do that to the window shade and let their copy of "Contrails" magazine hang over the armrest... oh right, they'd had a seizure, sorry. Doctor, you are cleared to land.

At June 28, 2007 at 5:41 PM , Blogger Tom said...

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At June 30, 2007 at 1:21 AM , Blogger Bethany said...

Well..if the doc was a specialist he would get a bit scared cuz he only knows about one thing and most certainly asks to land the plane; if the doc is a surgeon she'd want to cut the woman up and make a mess of the whole plane,and scare everybody-just cuz she can; but if you're a GP or ER nurse you would know the womans behavior was completely normal postictal behavior, pop some oxygen on her(all planes have it)get her some Ativan (or whatever the planes medical box or fellow passengers are carrying) and know that what she's going through looks much worse and emergent than it really is. And if she continues with status epilepticus than you can land the plane- you can always land the damn plane, especially between Texas and Florida. Her care would be no different on the ground than what you can provide in the air.

But of course they want you to land the plane, not for ethical reasons, but for liability reasons.

See, this is why ER nurses don't get asked these questions.

At June 30, 2007 at 9:09 AM , Blogger Megan J said...

And if a certain GI doc I know was on that plane, the patient would receive the most thorough rectal exam of her life. Apparently you can learn a lot about a patient’s condition from their rectal tone and anal wink response.

That said, I totally agree with Beth. Don’t land the plane, just watch and wait.

At July 1, 2007 at 11:23 AM , Blogger Melinda June said...

I want to know more about anal winking.

At July 25, 2007 at 8:49 AM , Anonymous Anonymous said...

Howdy: I am actually the doctor who had to make this decision. I was trying to emphasize the importance of ethics and the reasons that medical providers need to always consider the patient first, the rest of the stuff later. Although "any dude in health care would know this is a post-ictal state", I respectfully disagree. One specific case I recall is a gentleman who had a similar problem, no hx of seizures, and went into v-fib. Not a happy scenario. Land the plane, waste some money, the patient is first in line, and the potential for a medical disaster is apparent. I requested a landing as Atlanta was the only place available with the runway of the size we needed. Otherwise, we had two more hours in the air with no possibility for another airpport diversion. I did not treat the patient due to legal possibilites, but if she were to have a recurrence of seizures or some other unknown medical problem, I would believe her life could be in jeopardy. I don't know much about blogging...hope I get the message out, and I appreciate this way of communication. My best to all!


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