Off to a Bang in midair!

My three month adventure as a locum tenens doc in Bend, Oregon started off with a bang...before I even arrived.   Halfway between Chicago and Portland, the flight attendant asked, "Is there a doctor on the plane?"  I waved my hand, though not very vigorously.  She motioned me to come forward, and I had to turn my ear toward her to hear what it was about.  There was a woman 3 rows back who had terrible abdominal pain and was vomiting nonstop.  She asked me if I had a copy of my medical license with me, and when I assured her I did, we took the woman and her husband to the back of the plane.   I took a brief history...turns out she'd had bad pain when she boarded, but it had gotten worse, and now she couldn't stop vomiting.  She didn't have a fever, had no help from Pepcid, wasn't on any significant medication, bowels were working okay, and she had a previous appendectomy.   I tried to take her blood pressure and listen for bowel sounds, but couldn't hear a thing with my stethoscope due to the roar of the plane.  Finally I took her blood pressure by feeling her pulse begin as I deflated the cuff.  It was okay initially.  But the right side of her abdomen was quite tender.

So, they had me talk to the airline doctor on the ground by radio, and I said I thought she was safe to wait two hours until we landed in Portland.  But, the emergency medical supplies on the plane had nothing for pain beyond Tylenol, and nothing for nausea.   There weren't even any pillows or blankets on the plane!  There were supplies for an i.v., but I thought it would be impossible to start an i.v. with all the motion and vibration.   So I kept checking her blood pressure every 20 minutes or so.  And it started to go down, to the point her pulse was thready and she was feeling a little dizzy.   I insisted she lay down in the last row of seats and put her feet up.  Then I changed my mind...we really did need to divert the plane to land sooner.  I told the captain, who said he could have us on the ground in 30 minutes...in Billings, Montana!   It was pretty intense to make that decision which would make 200 people miss their connections.  The captain made it clear, it was my decision to make.

We landed in Billings, and there were no other planes in sight.  But there was an ambulance waiting.  They rolled a big ramp up to the back door of the plane, but we had to wait while the cabin depressurized before they could open the door.   I gave the first EMT a quick history, especially the concern about her falling blood pressure.   He came in and immediately started an i.v. while the woman was still lying on the back seats, while another EMT brought a collapsible stretcher aboard, after I stepped outside to clear other equipment from the ramp.  Soon they had her rolling out the door, while most of the passengers were standing up watching.  I slipped her husband a piece of paper with my cellphone number on it and asked him to let me know how it turned out.  The woman's father give me a big hug as he left...I smelled his aftershave the rest of the day.  After we landed in Portland, the flight attendant thanked me over the P.A. system, and I received a big round of applause from the passengers.

A couple days later, her husband called me from Billings...turns out she had a small bowel obstruction, probably due to scar tissue from the old appendectomy.  I had been thinking more about her gallbladder, but without an xray couldn't say for sure.  She'd been on a morphine drip for the first 2 days, then the pain relapsed when it was stopped.  They were worried she would need surgery.  

I know the flight attendants and the woman's family were grateful for my help, though the woman herself was annoyed at my frequent blood pressure checks and insistence that she lie down when she didn't want to....she was also unhappy when I didn't divert the plane immediately.   I was a little relieved when her dropping blood pressure made the decision clear...we couldn't wait for Portland.    I know it was an expensive decision.  The plane had to refill and recheck everything before we could take off again at an airport they usually didn't fly to.  They've got my name and license number now if they want to send me a flight voucher...I'd be happy with that, but I'm not holding my breath.   But, mostly I was happy to hear from the husband and know she was going to be all right eventually.