Learning on the Fly

By Paul Holzer ’18

This is how my summer ended:

“On behalf of Captain Jim Graham, Vice President – Flying Operations, [we] thank you for your caring and compassionate assistance to a passenger while you were traveling with us from Boston to Detroit, on August 2.

You really went out of your way… providing responsive assistance on such short notice… we’re grateful for your kindness. I hope we have the privilege of welcoming you on another, less “eventful,” flight soon.

Regards,

Customer Solutions Supervisor – Executive Correspondence
Corporate Customer Care / ATL
Delta Air Lines, Inc.

Paul Holzer '18

Paul Holzer ’18

After serving as a US Navy SEAL for 10 years and later as a civilian paramedic before attending Dartmouth’s Geisel School of Medicine, I am not completely unfamiliar with emergency situations. However, on a last minute business trip to Detroit this past summer, my skills and preparation were unexpectedly put to the test. A flight attendant asked several times for a medical professional to assist with an emergency situation, and when she received no response, my brother, realizing that there didn’t seem to be any “real” doctors or nurses on board, not-so-gently roused me from my blissful nap to “do something dude.”

After I freed myself from my spacious, economy window seat, the attendant told me a passenger had self-reported an onboard medical emergency. The passenger, a small-statured woman who appeared to be in her late forties and was visibly uncomfortable, had told the attendant she was experiencing “the most pain she has ever been in.” The pain had been getting worse as the flight went on. The feeling had been so undeniable and so persistent she had finally gotten scared and called an attendant for help.

I took a knee and started listening to her story. Prompted by just a few questions about onset, pain rating, and some personal medical history, she was very willing, and almost relieved, to have someone to talk to about her symptoms. She described feeling lightheaded, generally weak, and unable to “catch her breath.”  The unexpected, spontaneous pain in her chest was something she had never felt before—ever—and it had been getting worse since just after takeoff. She went on to describe a general feeling of discomfort with a notable tightness that extended to her back. (Yes, she actually said “tightness”.)

I was in disbelief. Was I unknowingly part of a CPR training video or episode of “What Would You Do?” The symptoms and overall scenario were so textbook this had to be staged. I literally looked around to see if someone was orchestrating a mid-flight training drill or playing a prank. Unfortunately, there was no proctor with a clipboard taking notes and no one was laughing.

Stunned and not quite sure what to do next, I held her hand. Sure enough, she was profusely sweating and genuinely panicked. I felt her pulse in her wrist—it was present and rapid, but certainly not the strong regular type one would expect, or hope, to find—it just didn’t feel right. When asked, she confessed without hesitation that she was a regular smoker and several members of her family had “heart issues” in the past.

In my head I knew there was a legitimate chance she was having a heart attack. The presentation was classic, but still part of me didn’t want to believe it or be the zealous medical student who overreacted and caused an unnecessary scene.

I suddenly realized that I had been interviewing my patient for the last few minutes from the lap of a very understanding and obviously patient man who had been seated next to her. I awkwardly apologized to him, stood up, and motioned to give the attendant the bad news, in private.

I told him that I was concerned that this woman may be having a heart attack—and then proceeded into an involuntary, thesis-defense of my medical student diagnosis. At this point, his eyes probably got as big as mine were already and I don’t think he was pondering the finer points of my differential. I continued to say that I feared if the passenger heard me say she was having a heart attack, her stress level might rise and exacerbate her already critical condition. I said that I thought we needed to land as soon as possible to get help without causing a panic, and asked if they had an AED available. I think he had stopped listening after “heart attack” and said he had to inform the Captain, immediately. He turned sharply, and left.

As he not so subtly made his way to the front of the plane, I realized there was a small, but legitimate possibility this passenger could die right here on the plane. I have to admit that it was one of the scariest moments of my life—the unlikely stakes were bad enough, but in past similar situations, I always had a teammate with me, often someone equally or better trained. Now it was just me, like it or not.

I had about a million, instantaneous thoughts. Don’t we still have about an hour to go? If she had an arrest, where would I take her? How would I even get her out of her seat? Where is the AED? Is there oxygen onboard? What if I’m wrong, and I cause her to panic and make whatever it really is even worse?

While we waited for what seemed like hours, I took a knee again and did the only thing I could do—talk to my patient. I will freely admit the patient interviewing classes at Geisel were not my favorite, but I have to give credit to Dartmouth’s On-Doctoring curriculum for preparing me for a moment like this where there was no intervention to perform, no consult or second opinion, lab that could be ordered, or form to complete. I’m not sure if she noticed my hand shaking, but she didn’t seem to mind either way. We chatted through a few more rote medical questions, but mostly about her family and her travel plans and how hot it had been this summer.

When the attendant came back, I was a bit more collected. I asked for the AED, for oxygen if they had it, and two baby-aspirin from the med kit. They brought out the medical bag, which turned out to be akin to an over-stuffed suitcase with all kinds of goodies, kept precariously closed by a plastic seal. Once removed, the contents exploded into the aisle like an overstuffed suitcase. After sifting through the remains, the attendant handed me a small packet of what he thought was aspirin.

That's definitely not aspirin.

That’s definitely not aspirin.

Perhaps it’s the level of detail and double-checking answers that ten years of standardized test and exam taking grinds into you, but I instinctively looked at the innocuous little paper square before handing the pills to the patient. The packet said “Non-Aspirin” in purple writing – turns out it was Tylenol, instead of the potentially life-saving aspirin I had requested. This small detail could have had serious consequences, and I was relieved that I had taken the few extra seconds to double check the contents before medicating the patient. We swapped out the meds, she chewed the aspirin with a grimace, and we went back to talking.

Overall, the crew did a phenomenal job of helping get the resources needed. That said I am most thankful for the expedited, emergency landing into Detroit. Airport medics met us at the gate, and they assumed care of my patient and proceeded to treat her for a potential heart attack. Looking back, I am proud that I could provide them with a detailed but succinct medical report, including the patient’s chief complaint, symptoms, past medical history, and medical interventions performed—another gift from Geisel’s training. With this information, the medics went to work immediately and the EKG leads were on in seconds.

As future doctors, we know that not all stories have happy endings like this one, and not all patient presentations are as clear-cut. However, I am thankful for the (previously) underappreciated parts of my Dartmouth education and training that helped me handle this specific situation successfully. This summer, somewhere between Boston and Detroit, I learned that sometimes the best clinical interventions can be as simple as just taking the initiative to get involved, paying attention to small details—and simply talking with your patient.

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