Saturday, August 1, 2009

Budd's Excellent Adventure

So. a week ago my wife and I were about an hour and a half out of Honolulu coming back to Oakland on Hawaiian Air, and I had my earphones on. Ann nudged me and said, "They're looking for a doctor." Now, my Dad was a great and idealistic doctor, but he certainly had a jaundiced side. He taught me, when they come looking for a doctor, don't volunteer - you'll just get yourself in trouble! Knowing my Dad, this was the voice of experience, either personal or vicarious. But Ann doesn't come from a medical family, so she has always wondered about my attitude as a Samaritan. I take my father's advice seriously.

But on the other hand, I've always said, try this thought experiment. You are walking along and you see someone with an affliction by the roadside. The year is 1875 (the time of Dickens, say.) You can't do anything for the poor soul. Then, time travel forward to the present. You are a doctor, you have modern medicines, and you can go over and give him some medicine and cure him. What a mitzvah ("gift" - that's a Latin word.) Who wouldn't do it? Isn't it great to be a doctor!

So, you can understand how when she told me they were looking for a doctor, Ann looked at me with some expectation, but also with a question of what I would do. Since I hadn't personally heard the call or seen the flight attendants (where are those cute stewardesses of yesteryear??), I said, see if they call again, and back on went the headphones.

But the next thing I knew, I saw this young man I soon learned was 28 years old, a Pacific Islander of some sort, about 300 pounds as Pacific Islanders can be, lying supine at the bulkhead seat just in front of me and to the right, and an older lady (probably not as old as me, but time being what it is, still an "older lady") tentatively administering to him. So I went over and identified myself as a doctor.

"What are you?" she said.

"A pediatrician," I said. "What are you?"

"An internist," she said. "But I do hospice work for Kaiser, and I mainly tend to the website."

OK, it might have been her age group specialty, but I know acute medicine and I'm a guy, and as Ann says, there was no way I wasn't going to be in charge.

So the history was that Tony, the patient, thought he had an allergy to peanuts and had just eaten some cashews the plane had passed out. Guess it's not a peanut allergy (they don't cross react.) Way to go, Tony!

The internist had the airplane's blood pressure cuff and stethoscope, and she said his pulse was 160 and his blood pressure about 80/60. Classic anaphylactic shock, no doubt from the nuts.

It was a good thing the plane had an emergency tackle box that had epinephrine in it, because after all this is just the kind of emergency that happens, and can be treated readily and easily, a wonderful advance since 1875. Since the internist seemed a bit befuddled and hadn't even asked for the epi yet, I took the epi, tried to figure out how to use it - had to attach a needle, it looked like, but probably didn't have to, I just didn't know how to use it. The internist looked around for a nurse - doctors use nurses so much they don't know how to do so much any more - even the new pediatricians who come to our practice don't know how to give an immunization themselves, amazingly enough, let alone how to incise and drain a wound. Anyway, I gave the epi, then gave 50 mg. of Benedryl intramuscularly. All the while I was being a good doctor, reassuring Tony - who by this time was complaining it was hard to breathe, the cardinal sign of how these patients die, by airway obstruction. I hoped I didn't have to do anything heroic, like cutting into his trachea, lots of luck. Tony kept saying thank you, and breathed with some difficulty.

But his pulse came down and his BP went up in about 5 minutes and I thought he was turning around. Then a young, very young woman came up from the back and identified herself as a family doc from Maui. Where the hell had she been? This is really her specialty! She listened to him and thought he was wheezing. So did the internist. Well, he wasn't. He had upper airway sounds; I know wheezing when I hear it. He was so heavy and the plane was noisy so it was hard to hear anything, but they were worried about his wheezing. The FP wanted to give him something for wheezing so she shot in some terbutaline. Made him very tremulous. Then the fp went back to her seat, her magic done.

The internist said we should ask them to turn the plane around. I said I thought he was stabilizing and would be OK. I said if we turned around he would walk off the plane looking just fine and everyone would wonder what the fuss was about. He didn't complain about its being hard to breathe so much. I looked over at Ann and made a circular sign with my upraised finger and mouthed, "Turn around?" She shook her head decisively and mouthed back, "Unh-uh!" But she knew if we had to we would.

I talked to the captain on the phone and told him the difference of opinion, and I said I think he's stabilized so let's see. The captain talked to their contracted emergency service physicians on the radio and I guess they said stick with it because I didn't hear anything more. Tony's BP was up over 100 and his pulse down to 110. He was shivering a lot but that could be due to the terbutaline. I was on one knee beside him for about 45 minutes reassuring and monitoring. His BP came up to 120/80, then 140/100. Then his wife of one year, probably also about 225 pounds, asked if he could sit up. I said absolutely. He sat up, I took the oxygen away from him, and he slept sitting in a seat the rest of the way. Even with his weight, the Benedryl probably made him sleepy. We didn't turn around. There was an emergency crew waiting for him in Oakland and I quickly gave the history, and that's all she wrote.

So, I kept everyone cool and enjoyed being a real doctor, and Ann was very proud of me, and how I kep everyone calm.. I wondered what Hawaiian Air would do for me. It was interesting. When he went to the bathroom, the captain looked back and saw me and gave me a wink and a nod. The purser gave me a form to fill out and sign that I had attended to the patient. Aloha.

I suppose they figure, this is just what doctors do; there is a public trust. I didn't know whether to feel respected, or to feel like a sucker. Tony's wife did get my name - I gave her my card. She was very thankful and wanted to recognize me some way it seemed. Haven't heard from them.

I'm grateful that I didn't get into any trouble, that this particular good deed seems to have gone unpunished. O tempora, o mores.

Budd Shenkin

Ann and I were on the plane back home about 1.5 hours out from Honolulu when the attendants went looking for a doctor. Before I knew it a 300 lb. 28 yo Pacific Islander (I think) named Tony was lying on the floor of the plane in front of me with a pulse of 160, BP 80/60, complaining of difficulty breathing around the throat. Nuts had just been served. So there was this doc from Kaiser who did hospice work and drives their website, a very young FP who practices on Maui, a retired nurse, and me. So, we opened the crash box of the plane, I gave him epi and Benedryl, and the FP give terbuterol because she thought he had some wheezes. (I thought it was all upper airway - the guy was pretty heavy.) I talked to the captain, told him I thought Tony was stabilizing, we didn't turn the plane around, and the emergency crew waited for Tony at the Oakland airport, but he seemed pretty good by that time. You just never know what will happen.

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