Flying Solo

by Danielle Ofri
AAMC News

The setting was an art museum, with light streaming in through panoramic windows, glinting off the ebony statues as well as the rows of chairs in front of me. It was quite an aesthetic step up from my usual setting for lectures — the standard grand-rounds lecture halls, with rows of residents furtively answering calls while I do my best to compete with overhead announcements paging Dr. Patel to trauma stat. In fact, there were no medical personnel at all in this audience. This was a gathering of medical administrators.

Like most doctors, I find it unnerving to be in a room full of suits. But I get that it’s important to hear other perspectives, not least because these are folks who have the power to make decisions affecting medical care. Plus, I appreciated that this institution chose to give its employees an evening at an art museum instead of a hospital conference room. The 30 rows of chairs were filled. A tasteful wine-and-cheese buffet lined the back wall. A photographer squatted in the corner, cameras and lenses dangling from his neck, taking the requisite corporate photos. Museum docents stood poised at the sides, ready to start the gallery tour as soon as I was done with my talk.

I was about midway through my presentation, just getting to the dramatic climax of a story that’s my reliable audience-grabber, when I heard a dull thud off to the side, like a sack of potatoes dumped on the floor. My first thought was that one of the museum’s statues had been knocked over by a waiter refilling the buffet. The clunk wasn’t quite loud enough to startle the audience, which was still looking straight at me, waiting for the punchline of the circuitous story I’d been forcing them to follow.

Out of the corner of my eye, I suddenly noticed the photographer slumped over on the floor, cameras askew around his body. Because he’d been squatting off to the side, he was out of eye-range for audience members, who hadn’t noticed a thing.

The novelty of being out of my element in a charming nonmedical setting abruptly splintered away. There were no medical comrades-in-arms to be had — no white-coated doctors or off-duty nurses in the audience. The gorgeous art museum suddenly felt like a liability — no overheard operator to page Dr. Patelstat, no crash cart parked in the hallway, no ED down the hall. Not even any medical students with laminated ACLS cards in their pockets. Just a room full of administrators in business casual, three bored waiters playing video games on their phones, and the two elderly museum docents clutching stacks of museum maps. I was truly on my own.

Medical instinct, though, is mercifully faster than calculated analysis. Before I’d even fully processed those thoughts, I’d already jumped off the dais and scrambled over to the photographer. The audience, which hadn’t seen what I’d witnessed, craned heads in confusion.

Luckily, the photographer rapidly regained consciousness. He’d started a new prescription for lisinopril a day earlier, plus hadn’t had time to drink much water during his busy day today. I made a reasonably confident diagnosis of a vasovagal episode in the setting of dehydration, mild hypotension, and ill-advised squatting in middle-aged years. (Followed by my perhaps immoderate exhale of relief — no v-tach, GI bleed, seizure, subarachnoid hemorrhage, AAA rupture. Whew!)

A few minutes supine followed by a tall glass of water brought the photographer back to his baseline. He was more sheepish than anything else. We agreed that he should hold off on the lisinopril and perhaps wrap up today’s session seated in a chair with the rest of the audience.

I made my way back up to the podium to complete my lecture, relieved for the photographer who was fine. (Okay, I’ll admit that I was also majorly relieved for myself that I hadn’t made a medical mess of everything in front of a hundred onlookers.) The riveting story that I’d been telling sort of lost its mojo, but, well, it was a small price to pay in the grand scheme of things.

Later that evening when I was reflecting on the day’s events, it dawned on me that during my entire medical career, I’d never actually had to give solo care like this. Any other time I’ve been party to a medical issue in the civilian world there were other medical folks around, either because we were at a medical-affiliated event, or because no matter how far afield I try to stretch my social ecology, it’s inevitably populated by a handful of creatures of the medical persuasion. This was the first time that I’d been completely on my own, with no backup at all. I realized how much I appreciate, and often take for granted, having medical colleagues in close vicinity for expertise, assistance, and — to be honest — moral support.

I reached two conclusions from this episode. One was that I’d probably better stick to giving standard grand-rounds lectures in drab hospital auditoriums. The second was that I would never want to be the lone country doctor. Too stressful! I started writing an article about the experience, but as with so many good intentions, it got buried in the general tumult of life and never got finished.

About a year later, I found myself navigating that special circle of airline hell in which a two-minute hailstorm in the Midwest instigates an inexorable sequence of delays, mechanical inspections, electrical inspections, the Virginia reel of off-the-plane-on-the-plane boarding and reboarding, more delays, the inevitable “timing out” of the crew, the cancellation of flight, the rebooking at 3 a.m. on a line with 700 extravagantly cranky passengers, and finally rerouting to Philadelphia via East Timor. To add insult to injury, the book I’d been reading disappeared in the maelstrom.

And so, on my final leg of this endless, miserable journey, I found myself with nothing to do. The sudoku puzzles in the seatback magazine had already been filled in — incorrectly, I might add — by a prior passenger, and there’s only so much literary heft one can glean from a laminated airplane safety card.  

So I rifled through my computer, thinking I might coax an article out of one of the assortment of essay starts gathering dust in an untouched folder. Maybe I’d get something — beyond sciatica that is — out of this 15-hour tour-de-airport-lounge extravaganza. I happened upon the essay I’d begun last year about the fainting photographer, and figured that now was as good a time as any to finish it. I was about 45 minutes into my battle with the prose when the announcement came through the cabin: “Are there any medical personnel on board who could assist with an ill passenger?”

I’m not, by nature, superstitious, but I couldn’t escape the thought that I might have somehow conjured up this new medical situation by resurrecting the article about the museum rapid-response scene. I mean, what were the odds? I pressed my overhead button, noticing — with maybe more dismay than is seemly for a board-certified physician — that it was the sole illuminated light in the entire airplane firmament. If life was going to imitate art, I thought, could it at least do so with a few other medical professionals on board?

I made my way back to an elderly woman crammed in a middle seat who was feeling lightheaded and clammy. The airplane, unlike the art museum, had a medical kit, though it wasn’t much to write home about. The stethoscope was practically of Fisher-Price quality, useless in the gale of jet engine noise. The wrist blood-pressure cuff was hardly better, yielding readings of dubious accuracy. There was no glucometer to assess for hypoglycemia. The pulse oximeter worked, though, and I could at least be reassured that the oxygen tank the flight attendants had brought forward was unnecessary.

The woman improved a bit after drinking juice, shedding layers of sweaters, and cranking up the overhead air jet. Nevertheless, I accepted the offer of having paramedics meet us at the gate. I was relieved when they climbed aboard upon our arrival, with their reassuring medical kits, EKG monitors, and legitimate blood pressure cuffs.

These two back-to-back episodes (well, back-to-back, in a Ouija-board sort of way) reminded me of how much medicine is a team sport. And how zealously grateful I am that it is. Even if the immediacy of my medical practice feels solo, alone with the patient in the exam room, the actual medical care of most patients is anything but. We primary care folks may style ourselves as the self-reliant jack-of-all-trades type of docs, but there’s no way I’d be able to adequately care for my patients with diabetes, for example, without the nutritionist, the nurse, the pharmacist, the nephrologist, and the ophthalmologist. (Well, okay, occasionally the endocrinologist, too.)

Whenever I pack my bags for a trip these days, I fantasize about packing up that whole team — maybe with an ICU nurse and ED doc for good measure. A tad inconvenient, perhaps, but Lord knows it sure would be helpful the next time someone keels over in an art museum and it’s something more than just a wayward dose of lisinopril.

Regretfully, we’re limited to one carry-on and one personal item. No matter how strenuously I might argue to the ticket agent that my entire interdisciplinary medical team would be a very valuable “personal item” to have on board, I will have to make do with my small suitcase and bookbag. Perhaps now I’ll be more likely to stuff that bookbag with the Annals and NEJM instead of my usual New Yorker (though honestly, will a multicenter, double-blind, placebo-controlled megatrial offer more help in the heat of a medical emergency than a trenchant New Yorker cartoon?)

The truth is, the meat of our interdisciplinary team is in our relationships. The more we connect with — and actually listen to — our colleagues from across the medical spectrum, the more breadth we’ll carry with us when we face a situation alone. This spectrum carries across time as well as space, as we recall the pearls from our teachers in the variety of settings where our training and careers have taken us.

When we’re called upon to give medical care on the fly, we should be comfortable stepping forward. Even if we are physically alone, we have a whole team behind us — collegially, historically, metaphorically, psychologically. We do our best with the circumstances that we have, and usually — hopefully — that will suffice.

If not, there’s always 911.

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