painful experience in-flight

[non-newtonian]

Thought you guys might be interested in this, from todays British Medical Journal.
Cannot understand why this guy thinks an aircraft
should be as well equipped as the local ER.



A painful experience

I was on an Airtours flight from Florida recently
when medical assistance was called for. The
patient had benign
prostatic hyperplasia and was in retention. Since we had another seven hours to fly,
holding on was not an
option. He needed a catheter, so I was reassured that the plane's
inventory of medical equipment included catheters and collecting bags.

But I then found
that there was no lignocaine gel, no lubricating jelly, and no gloves.

Performing a catheterisation without gloves or anaesthetic was not pleasant,
but the lack of lubricating jelly proved a bridge too far, so when the patient
started screaming I deputised
some antiseptic cream as an ersatz lubricant.

As the catheter was non-retaining, I advised the greatly relieved patient
not to drink any fluids for the rest of the flight and to attend accident and
emergency on his way home.
I then had to remain on alert for the next seven hours. Before disembarking I was asked to sign a form indemnifying
Airtours against any claim arising from the procedure and was
offered a bottle of wine as a gesture of appreciation.

I had expressed my concerns to the steward, but having heard nothing after a
few weeks I contacted Airtours. The company's flight officer explained that
Airtours
usually received inflight medical advice from an institute in the United States and the airline's medical officer assured me that
gloves had been
present in the equipment boxI just hadn't found them. He said that he had done hundreds of catheterisations and had never
used lignocaine gel. In a
subsequent letter, he insisted that the company's equipment was standard to all airlines, and that "the catheters are self lubricating, and being small and
atraumatic do not need lubrication or local anaesthetic." Really?

As a doctor, I had no choice but to respond to the patient's needs,
and without that choice I was forced to perform a difficult procedure with inadequate
equipment.
The poverty of the Airtours response was depressing, especially considering how much money I had saved the company;
if a doctor hadn't just
happened to be on board, the plane would have had to return to Florida.
Maybe in future Airtours should take one fewer passenger and a bit more
equipment, and maybe omit those magical self lubricating catheters.
I won't be travelling with Airtours againnot without taking my own lubricating jelly.


Liam Farrell, general practitioner.

Crossmaglen, County Armagh

[oncemorealoft]

"I won't be travelling with Airtours againnot without taking my own lubricating jelly."

Hmmm, shouldn't this be moved to Jet Blast!?


:eek:

[Unwell_Raptor]

I am typing this with my legs crossed.

If you are ill on a plane it's a bit of luck to have a doctor on board, but if he is going to poke things up the end of such a treasured and delicate item, I for one, would find some anaesthetic welcome!

[Brenoch]

No lubricating jelly on an Airtours flight from FLA, I just cant believe it...

:D

[timmcat]

Hmm.. perhaps someone slipped up then..

[Nopax,thanx]

Not only that, but this also raises the serious issue that, as a Doctor, you are morally obliged to assist a passenger in distress.

Although medicine is your chosen profession, you receive no payment for your professional act. You would never refuse treatment to someone just because you're not being paid for it...but suppose there's a complication a few days later? Are you liable?

There was an article in the papers about this a couple of years ago.......possibly James leFanu in the Telegraph, but don't quote me on that.

Whatever the outcome, you are to be praised for volunteering your services, and making the best of a poor situation.

It's a real conundrum, and I've no idea of a way round it.

[timmcat]

As the Doctor would be morally obliged to assist, surely any rational (!) court would take into account that the pax had a choice of no help at all, or assistance from the only qualified person on board. That moral dilemma should be taken into account if any litigation ensued from a Doctors well meaning actions. Also, the ramifications if a complaint was upheld ie. a sudden (apparant) drop in the number of Doctors travelling by air.

[Lawyerboy]

Nopax, thanx, I'm not sure that would ever really be an issue. In very simple terms, a doctor has a duty of care to anyone he or she treats, with the level of that obligation being determined by an assumption that they are as reasonably competent as a hypothetical professional that does what they do at the level of experience that they have.

In other words, if the treatment that they give to a passenger is questioned at a later date, a court would look at how experienced the doctor was, what it is he or she had to do, what materials he or she had to work with, and any other circumstances particular to the case. The court would then attempt to compare what that doctor did, in that situation, with what a presumed hypothetical doctor with the same experience would have done in a similar situation.

I'm not sure there is an obligation (legal at least) on doctors to assist passengers in distress, but I imagine that the doctor's professional body might have something to say if they didn't, and personally I think that there should, of course, at least be a moral obligation to assist. For what it's worth there is absolutely no obligation on anyone to come to someone's aid - if you're walking past a river and see someone drowning, there is not obligation on you to dive in and rescue them, even if you are an olympic swimmer or if the water is only knee high. Beware, however, if you do. If you attempt to rescue someone but are so cack-handed at it that you in fact make things worse, there is every possibility of you being sued for negilgence...

Funny old world, eh?

[Nopax,thanx]

You're dead right there, Lawyerboy.

I believe that the obligation is only moral (as in the Hippocratic Oath) rather than legal. The story just struck a chord as I remember reading about it in the papers; as I said, I couldn't exactly remember when.

From your reply it looks as though Doctors would be safe from litigation as long as they had acted professionally - and no doctor would ever insist on payment before treating a patient, except perhaps Dr. Nick Riviera, eh??

[PAXboy]

There is no legal obligation on a doctor to assist on an aeroplane, anymore than their next door neighbour.

In the past I have discussed this with a doctor friend of mine. He said that he always does repond if such a call is made but he know of many doctors who do not.

Some, when travelling, ensure that 'Dr' is NOT on their tickets and will not 'make themselves know to the staff'.

That is their free choice. NOW should we move it to Jet Blast??

[CS-DNA]

As a passenger (and i am not a Doctor) what i find most disturbing is the fact that this
Doctor "was asked to sign a form indemnifying Airtours against any claim ....".

This guy was not on call, was not being paid, and true to his professional ethos came to
assist a human being in distress. It may even be that any insurance covering mal-practice
would be void in that situation, yet he came forward.
Not only that, he also solved an operational problem. Imagine, a passenger solving an
operational problem, saving the company quite some $/£/€ ....
Reward, a pat-in-the-back and basicaly being told "If there is any fallout, you are on your own..."

As for operational problems, what would you think of instructing the F/A to call for an
IT professional the next time some on-board computer acts-up ?
Ridiculos, right ?

Just my 3 cent (0.3 EURO)

[411A]

The patient was lucky indeed that he had the medical problem on a British registered aircraft (and a Doctor was on on board) because generally speaking, many non-US airlines carry a much better medical kit than US carriers.

[ETOPS]

As the airline I fly for carries in terms of 40 million pax a year, medical problems like this happen quite frequently.

The co-ordinated response from the various departments that has been put in place works well - I have had occasion to use it twice recently.

On board medical kit and defib machine are well up to spec and constantly reviewed with the medical profession. BA indemnifies those doctors who come forward and offers in flight support through " Medlink" an Aeromedicine organisation based in PHX. In fact I fly with their number predialled up in the cockpit Satphone.

If all that fails we have no problem diverting - we even have special procedures for unplanned arrivals at non-gateway US airfields.

I wouldn't be too harsh on Airtours, at least they had something for the Doc to work with.

[Brenoch]

Lucky you.. Satphone in the cockpit, by the time my outfit gets that you all will be in hypersonic spacevehicles.. :D

[Standard Noise]

Why not make every airline carry indemnity forms which a patient must sign before the doctor gives treatment. That way, the patient agrees not to sue at a later date, if he/she decides that they didn't like the service. After all, if there is no legal reason why a doctor has to treat someone, only a moral one, I wouldn't blame a doctor if they didn't identify themselves on the flight.
Personally, if I really needed a doctor, and one was found, I'd be so grateful I'd sign almost anything just to get treated.

[Oblaaspop]

Just to put the record straight, I fly for Airtours, and whilst I can't comment on that particular flight/incident, I can say that whilst we don't carry KY jelly! (should have asked one of the stewards), we do carry over £3000 worth of other medical eqiupment/drugs in the doctors kit, in fact it is the same kit used by just about every other airline including BA. It has drips, hyperdermics, sedatives, adrenalin and god knows what else, plus there is a defib on board. So would the learned doctor please remember that they are not in a general hospital operating theatre, but 6 miles above the Atlantic.

Also the indemnity form that was signed, was to indemnify the doctor, not the company!!!!!!! Airtours also use Medilink in Arizona via a phone patch and having used it recently, I would say it is absolutly brilliant, they make the medical descisions whether or not a Doc is on board, and they provide the indemnity even if they talk a crew member through giving an injection!

A standard form is filled in with the doctors details etc so it can be varified if they are actually a medical professional or not.

I hope that clears up that one!

[CS-DNA]

Oblaaspop,

If, as you say, the Doctor is legally protected then i guess my earlier post is
absolute non-sense, and i stand corrected.

As for the lack of some items (the lubricant, the gloves and the other jelly),
the Doctor did make the best of what was available, and it is a matter of
logistics, easily solved if judged necessary.

You do have to agree that a catheterisation without lubricant sounds quite painfull.
I guess the exact condition of a "self-lubricating-catheter" is not one of the things
usually checked before each flight (it surelly would not cross my mind).

Thanks for settling the issue .

[Unwell_Raptor]

My legs remain tightly crossed.

I shall sleep in the foetal position tonight.

[NorthernSky]

ETOPS,

Satphone perhaps, but isn't your employer one of the ones to cease ACARS use as a cost-cutting measure after 110901? A great leap forwards.....

Returning to the main thrust of the argument, as the aircraft commander, I must say that in the majority of cases, the presence of a doctor on board who presumes to treat a sick passenger only increases the exposure to risk. Better, perhaps, to divert straight away that the cabin crew say the passenger needs serious attention, rather than involving individuals who may or may not be who and what they say they are and may or may not expose the commander, crew, and airline, to risk of claims.

The decision to divert in these circumstances is a very difficult one, not least on account of the paucity of accurate information available.

[Hand Solo]

Well if Airtours use the same medical kit as BA then the catheters are sealed, self-lubricating types and if they don't work as advertised then take it up with the manufacturer! I only remember this because of the initial safety training (courtesy of the cabin services dept.) where they asked 'Why are the male catheters longer than the female catheters?'.'Because they deserve it!'.:eek:

[gas_man]

this thread has really opened my eyes.
i am a doctor and am shocked that the Doctor "was asked to sign a form indemnifying Airtours against any claim ....".
what kind of deal is that.
as an anesthetist , used to caring people with life threatening problems , my actions would be judged quite severely by the courts. also, most patients are grateful for the care they receive ...but once they are well and talk to their friends etc ...the idea of profit creeps in and they then could decide to sue. even if i do my job well ...i still have to pay my lawyers to prove that i did my job well ..and that cost much more than a bottle of champagne.
i think this issue is an very important one that needs to be addressed by the medical community and the aviation professionals.

if things are not solved ...doctors might try to hide their identity or might just give non commital or legal responses. just imagine if a doctor on board tells the captain to land asap for an condition that is clearly not life threatening .... this then places the captain in a very difficult situation. a medically qualified person is saying to land ..but it is obvious that the condition is not too bad ..say indigestion. the captain would rather land ...since he /she would not want the weight of liability.
this is legal medicine ..... as is seen often in the united states ...where the law is treated better than the pateint.

airlines get free medical cover by the doctor, but the least a doctor would like is for their legal fees to be covered.
when i was in med school ....i saw this training video on resuscitation and it started by telling me that it was legal to drive on ignoring the road traffic accident .what a way to start training!

in the above case, what if the patient sued for mental trauma due to the pain?
the airline will turn around and say the captain is not a medic ....if he was told , he would have landed asap. now the doctor is on his own feet.
even if medical advise is sought over the radio , who is responsible?

i think doctors should be given a clear statement from the airlines . please help and you will be fully legally covered. otherwise , it should be sop to land asap for anything , even if the doc is working on the case. otherwise the doctor is the one who helps and also the one to get caught in any cross fire.
recently ,a friend of mine had to help out and he was apalled at the quality of medical kit. ... so not all airlines are equal.

[gas_man]

i was relived to read the posting from oblaasop above which i had not seen .

according to him :
Also the indemnity form that was signed, was to indemnify the doctor, not the company!!!!!!! Airtours also use Medilink in Arizona via a phone patch and having used it recently, I would say it is absolutly brilliant, they make the medical descisions whether or not a Doc is on board, and they provide the indemnity even if they talk a crew member through giving an injection!

so next time there is a problem on board , i will be glad to help. i don't want a free bottle of champagne ...rather, i would prefer a small lights and switches talk in the flight deck.

prasanna

[M.Mouse]

Northern Sky

<<Satphone perhaps, but isn't your employer one of the ones to cease ACARS use as a cost-cutting measure after 110901? A great leap forwards..... >>

Just to clarify we did not stop using ACARS after September 11th. We were asked to think twice before using it i.e. get enroute met via volmet if practical etc. Funny enough it is left to our good judgement.


<<Returning to the main thrust of the argument, as the aircraft commander, I must say that in the majority of cases, the presence of a doctor on board who presumes to treat a sick passenger only increases the exposure to risk. Better, perhaps, to divert straight away that the cabin crew say the passenger needs serious attention, rather than involving individuals who may or may not be who and what they say they are and may or may not expose the commander, crew, and airline, to risk of claims.>>

It is just this sort of 'cover my back' thinking, driven by the opportunist greed of those that believe somebody should be to blame for every misfortune that occurs in life, that serves to make life more and more unpleasant for us all.

If I am taken ill on your aircraft I hope I do not die while you spend several hours diverting to some godforsaken hole in Siberia, or elsewhere, where I would probably die anyway, rather than allow me to be treated by somebody able to help.

I speak from experience. The most notable incident was when a senior registrar on board on the way to Malaysia avoided us diverting by making a difficult but accurate diagnosis of the REAL cause of a crewmembers pain and subsequent collapse. We were over Iran at the time. I also recall the BA HKG - LHR flight where a splendid doctor carried out a remarkable improvised procedure on a young lady with a punctured lung, unknowingly received in an accident on her way to the airport. The aircraft carried on to LHR and the lady survived with little further trauma.

Unfortunately I also have experience of doctors (usually American it must be said) point blank refusing to help.

Their prerogative of course but a sad sign of the times in which we live.

[Sick Squid]

To clarify... the BA indemnity provided, which is the model used by other airlines is in favour of the Doctor, not the company. This is specifically to encourage medical doctors to answer a plea from the Captain.

I've used both satphone and ACARS to help resolve medical problems when there was no-one coming forward, and they are both fast (ACARS much faster than I thought it would be), accurate, and give that extra piece of information you require when balancing up the go/no-go diversion scenario. We may not use ACARS to check the weather in De Gaulle on an average summers day any more, but no-one would hesitate for a second to use it under any other circumstances.

If Airtours indeed use the BA medical kit, then there was sufficient equipment on board, including a gel (possibly lignocaine-derived anaesthetic gel, but can't recall) to allow a successful cathetirisation; there is even a wide variety of catheter widths to choose from. It was in the B-side of the case, the contents of which are only intended to be used by registered practioners, not crew or First-aiders.

[Unwell_Raptor]

I heard of a Captain who called for an anaesthetist on the cabin address. No response was forthcoming, so he repeated the call.

A passenger in Club said to a steward :- " I am not an anaesthetist, just a GP, but I might be able to help"

"Sorry, no use" said the FA. "We've got a consultant in First Class and he wants his lamp adjusted"

[steamchicken]

Ryanair would have charged the doc for use of the catheter....

[NorthernSky]

M Mouse,

Your ACARS traffic is down substantially. Were you habitually using it to waste the company's money, or have you cut back intelligent use to save money? (I know what I've heard from your trainers).

As for the 'hero' of your piece, it's my belief that he was under the influence at the time he carried out his 'procedure'. My recollection of his own account of it is that he had had a substantial amount to drink, and I wouldn't want anyone who had been quaffing the freebies for hours on end trying to save my life.

I posted about 'exposure to risk', nothing more or less. If you die, my exposure to risk is nil. If you live and sue my airline for allowing a doctor to treat you erroneously, my exposure to risk could be substantial. I have to be responsible for my actions, and if we are all concerned about exposure to risk (and we should be), then it's the people who believe that 'no win, no fee' arrangements, and these pathetic 'claims' companies whose advertisements block up the television schedules, are right, who will ultimately be responsible for the shift in emphasis from doing what seem basically right to doing what seem basically to carry low or no risk.

The ball's in your court! :p

(I'd rather do what's right - but that's not what I'm paid for any more).

[somewhatconcerned]

Why should a doctor end up in court at all for trying to help a pax out!!! At best it is inconvenient to have to apprear in court in the first place and worse could be damaging to his proffesional standing, all when said doctor was off on his hols.:mad:
If you travel on an airline..Caveat Emptor

[martinidoc]

The easy answer for any doc asked to sign a form idemnifying the airline against any claim is:

P*** O**,

particularly when undertaking catheterisation

[GlueBall]

No Butter/Margarine available from catered meals?

[Roadtrip]

With the aging population, these incidents are likely to increase. Unfortunately, the attitude of many people is that the airlines owe them transportation regardless of their physical condition. Next it will become a "right" to airtravel and that airlines are responsible for your medical condition even if you don't tell them.

It's amazing that some idiots take all kinds of medications, yet slam down alcohol, then have a reaction.

My favorite is the son that put his elderly father on a flight unconcious (he was "sleeping"). Of course he was probably actually dead, but I suppose he though it was cheaper to put him in a seat than have him examined at departure station and take the chance on having to ship his remains.

[DX Wombat]

:mad: I spent ages composing a reply only to have it eaten by the computer! Second attempt:
As a nurse I was struck by the apparently immature attitude of the doctor and what appeared to be an unwillingness, or maybe even an inability, to think around the problem. Perhaps he was so newly qualified that he could only use equipment he had used during training, or so old that he wasn't too sure about newer forms of equipment. Whatever it was, there was apparently, a marked lack of forethought. We all know that catheterisation is an uncomfortable procedure at the best of times so a couple of minutes careful thought and preparation would have been time well spent. The report poses many questions: why did the Doctor apparently not check the availability of an alternative to lubricating gel before commencing the procedure? Cool, previously boiled water could have been used even if it is not quite as effective as gel. If the poor patient really was screaming in pain why was an oral or, if available, intramuscular analgesic not administered first? Why did he not do a simple suprapubic bladder aspiration with a syringe and needle - I know this is not often used with adults but we frequently use it on tiny babies and it would have reduced the risk of trauma to the urethra by continuing to pass a catheter and relieved some of the pressure so that an attempt at catheterisation would be more likely to succeed, etc, etc. Doctors and nurses need to remember that, with the possible exception of the RFDS, aircraft are not flying hospitals and it is necessary to be able to think on your feet and be prepared to adapt. Don't knock the available equipment, be glad there is some available, after all, you won't find most other forms of public transport nearly as well equipped as aircraft. Talk to the cabin crew, they are usually only too willing to help. We look to their expertise in an emergency and they will, in my experience, give all the help they can when we need it. Mind you, start acting like a prima donna and throwing your weight around and I, for one, wouldn't blame them for vanishing to attend to others needs and leaving you to manage on your own. This is one time when different professions can work together to make a real difference, they know their aircraft and its equipment and we, hopefully, have our our medical / nursing knowledge. I will always be willing to help as I hope others would be if I or my friends and family were in need. It does pose a problem however in that I wonder how far the airlines would be willing to cover us as nurses. Hopefully it would be the same as for doctors. Anyone able to enlighten me?