Is there a doctor on the plane

Started by lord_jeebus
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lord_jeebus

lord_jeebus

和魂洋才
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Further proof that people don't understand what we do...

Was on a flight last night when the announcement came requesting a "physician or medic." I volunteered. 60ish man with h/o CABG complaining of chest pain.

I introduce myself.

"What kind of doctor are you?" Legitimate question.

"I practice anesthesia..."

"S#!t...I need someone who knows something about hearts"

🙁
 
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lord_jeebus said:
Further proof that people don't understand what we do...

Was on a flight last night when the announcement came requesting a "physician or medic." I volunteered. 60ish man with h/o CABG complaining of chest pain.

I introduce myself.

"What kind of doctor are you?" Legitimate question.

"I practice anesthesia..."

"S#!t...I need someone who knows something about hearts"

🙁
Click to expand...

I get the feeling that dude would've said pretty much the same thing unless he heard "I'm a cardiologist" or "I'm a cardiac surgeon". No worries.
 
lord_jeebus said:
Further proof that people don't understand what we do...

Was on a flight last night when the announcement came requesting a "physician or medic." I volunteered. 60ish man with h/o CABG complaining of chest pain.

I introduce myself.

"What kind of doctor are you?" Legitimate question.

"I practice anesthesia..."

"S#!t...I need someone who knows something about hearts"

🙁
Click to expand...

say "Sir you've got two options...."

Option 1 - "Well I could lie and say I'm a cardiologist and ORDER "EKG, Trp I (and trend 'em out...), ASA 325, Nitro 0.4mg sublingual, Morphine PRN...."

Option 2 - "Truthfully I'm an Anesthesiologist so I'll start the IV, draw the blood, gave the ASA, Nitro, and Morphine myself, stick on the leads, do the EKG, interpret the EKG, and tell the interventionalist if this is a STEMI that needs cath lab pronto, an NSTEMI that needs a heparin drip and troponins trended out and possibly an intervention later, or if this is your GERD and you need to pop a Nexium. And maybe, just maybe, this is costochondritis and you need an Ibuprofen."

"Either way, best of luck with that chest pain. I'm here if you need me."
 
Southpaw said:
Option 2 - "Truthfully I'm an Anesthesiologist so I'll start the IV, draw the blood, gave the ASA, Nitro, and Morphine myself, stick on the leads, do the EKG, interpret the EKG, and tell the interventionalist if this is a STEMI that needs cath lab pronto, an NSTEMI that needs a heparin drip and troponins trended out and possibly an intervention later, or if this is your GERD and you need to pop a Nexium. And maybe, just maybe, this is costochondritis and you need an Ibuprofen."
Click to expand...


Could you actually do any of that stuff on a plane? What kind of medical supplies do they keep on board?
 
leaverus said:
Could you actually do any of that stuff on a plane? What kind of medical supplies do they keep on board?
Click to expand...

I'm sure you couldn't do any of it, but I'd still drive the point home. No idea what they keep on a plane. If they had a medical supplies kit, maybe you could check a manual BP, give some ASA and nitro sublingual. That's probably about it.

In the patient described, if I believed the situation to be serious after obtaining a thorough history, I'd suggest to the pilot that we get the plane on the ground and this guy to the hospital sooner rather than later. It's reassuring though that the guy has had a revascularization procedure, as opposed to someone who'd recently had stents and wasn't compliant with their plavix, leading me to believe that they'd thrombosed a recently placed stent. That situation was way too common during my time on cards consult.
 
lord_jeebus said:
Further proof that people don't understand what we do...

Was on a flight last night when the announcement came requesting a "physician or medic." I volunteered. 60ish man with h/o CABG complaining of chest pain.

I introduce myself.

"What kind of doctor are you?" Legitimate question.

"I practice anesthesia..."

"S#!t...I need someone who knows something about hearts"

🙁
Click to expand...

The guy seems legitimately concerned about himself. ANY physician should be able to obtain a thorough history in this patient, use what was available, and give the pilot some advice about how soon to get the plane on the ground.
 
Given a recent event that happened to me, I may have said the same thing. Here is a brief description of what happened to me in a hospital setting after a recent case... We finished performing an ophthalmology case. In the recovery area the patient reported chest pain to nursing and the anesthesiologist. The staff anesthesiologist requested I call cardiology and then he left the hospital. Therefore, I ordered the troponin and EKG and waited with the patient for cardiology to arrive. The anesthesiologist didn't feel any responsibility even thought the patient first reported the complaint to him in recovery.

I previously thought anesthesiologists knew much more about hearts than ophthalmologists, but this anesthesiologist must have thought otherwise.

At first I did not feel this was a big deal. Then I realized the staff anesthesiologist was making 2x as much as my ophthalmology attending for every case done that day.
 
200UL said:
Given a recent event that happened to me, I may have said the same thing. Here is a brief description of what happened to me in a hospital setting after a recent case... We finished performing an ophthalmology case. In the recovery area the patient reported chest pain to nursing and the anesthesiologist. The staff anesthesiologist requested I call cardiology and then he left the hospital. Therefore, I ordered the troponin and EKG and waited with the patient for cardiology to arrive. The anesthesiologist didn't feel any responsibility even thought the patient first reported the complaint to him in recovery.

I previously thought anesthesiologists knew much more about hearts than ophthalmologists, but this anesthesiologist must have thought otherwise.

At first I did not feel this was a big deal. Then I realized the staff anesthesiologist was making 2x as much as my ophthalmology attending for every case done that day.
Click to expand...

Just a couple of comments and questions. First, the anesthesiologist was a lazy SOB who should've stayed. Where was the anesthesiology resident who either did the case or was covering the PACU? Give some more history on the patient.

Not that the anesthesiologist should be defended, but he was a consultant physician for your patient, just like the cardiologist you consulted. After the cardiologist drops by and gives recommendations, they'll peace out just like the anesthesiologist (unless he admits to cards). You did a medicine year or transitional year right? Are you that uncomfortable working up chest pain?

I'm intrigued by the economics in your scenario. I don't know much about medical billing as a resident, but you seem to, so please post the cases you were doing and the type of anesthesia provided (MAC vs general) and the reimbursement for each.
 
So I asked him when his chest pain started.

"The day before yesterday...when I fell and landed on it."

...

"It hurts right here" and points to the right.

"And it's been hurting since then?"

"Yes"

"Why did you think it was a problem now?"

"I think the ginger ale made it worse"

Took a full history, checked vitals, confirmed normal heart and lung sounds, confirmed that his chest pain was reproducible with palpation of one of his ribs. There was a neurologist who came back at this point -- didn't add anything medically, but I think the presence of an older physician calmed the guy down. Gave a synopsis of my findings to some physician on the ground who seems to be the one who decides in any situation what to tell the pilot to do regarding emergency landings and such (probably best to spare the volunteer that liability). Reassured the patient and went back to my seat. They offered me a first class meal but I had just eaten a burrito and wasn't hungry.

The emergency kit is fairly spartan but there was a defibrillator.
 
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lord_jeebus said:
Further proof that people don't understand what we do...

Was on a flight last night when the announcement came requesting a "physician or medic." I volunteered. 60ish man with h/o CABG complaining of chest pain.

I introduce myself.

"What kind of doctor are you?" Legitimate question.

"I practice anesthesia..."

"S#!t...I need someone who knows something about hearts"

🙁
Click to expand...

It's a US thing where anesthesiologists are not known, because lay-people are under the impression that all we do is put them to sleep and then the surgeon takes over. Apparently in other countries, like those in Europe where > 50% of the Intensivists are also anesthesiologists, we are better known. Last time I flew on Lufthansa, a German carrier, I found this on their website when I was searching for info on mileage: "Doctors on Board."

If you scroll down to their application form, you'll see the first specialty listed is "Anaesthetist." The only others are GP, GYN, Internist/Cardiologist, Neurologist/Psychiatrist. Then "Other." So, we need a better public image.
 
G-Man82 said:
If you scroll down to their application form, you'll see the first specialty listed is "Anaesthetist." The only others are GP, GYN, Internist/Cardiologist, Neurologist/Psychiatrist. Then "Other." So, we need a better public image.
Click to expand...
sounds to me like that's alphabetical order. you make it seem like they're listed in order of most desirable to least or something :laugh:.
 
leaverus said:
Could you actually do any of that stuff on a plane? What kind of medical supplies do they keep on board?
Click to expand...

I got a noontime conference on this very topic during internship.

The medical kit they have is limited in terms of quantities but really would get you through most jams. They have stuff for IV's, I think a 500ml of NS, a couple meds (diphenhydramine, epi, ASA, nitro, D50), a BP cuff, a stethoscope, gloves, gauze, tape, etc.

There are really only two outcomes if they call for a doctor overhead. Either
a) it's nonemergent, the flight continues as usual and an ambulance will be waiting on the tarmac at the destination, to get the pt to an ED ASAP, or
b) you+the airline's doc make the call to land the plane right now, which in any case takes 45 min to an hour to actually get to ground, and costs the airline a ridiculous amount of money
 
Southpaw said:
I'm intrigued by the economics in your scenario. I don't know much about medical billing as a resident, but you seem to, so please post the cases you were doing and the type of anesthesia provided (MAC vs general) and the reimbursement for each.
Click to expand...

It was the last case of the day - for some reason it was just the anesthesia attending - maybe the anesthesia resident had to leave for work hour rules or something.

I have no facts ($)to back it up - I am speaking from what the attendings are making. I am at a state institution - salaries are public knowledge. In general, the anesthesiologists make more than the ophthalmologists. I am not sure how many cases the anesthesia team is doing, but I do know most of the ophthalmology attendings are working 5 days per week (4 days of clinic with 30-40 patients per day - 1 day of surgery with 10-12 cases).

The starting ophthalmology salary in the city is 110-150. The starting ophthalmology salary for rural region is 150-200. In talking with my anesthesia resident friends, I know their future compensation is higher than this. I also know their possible vacation packages trump any other area of medicine.

Finally, many eye procedures have gone strickly to CRNA, nurses alone, or there is even a new article showing the safety of respiratory therapists managing eye cases. The decisions to do so are way beyond anything I will have an impact on, but in general, if anesthesiology does not have any responsibility in the situation I described above (chest pain immediately after MAC), I see no reason for their involvement in any of my cases unless it is general.
 
Medical supplies vary by carrier, but all of the major carriers have AEDs. If you assess the patient and feel that he/ she needs a particular med (NTG, EPI, etc) and they don't have it in their supply, I would ask the pilot to overhead for it. It is likely that someone on the plane has NTG pills epi pen etc.

- pod
 
200UL said:
Finally, many eye procedures have gone strickly to CRNA, nurses alone, or there is even a new article showing the safety of respiratory therapists managing eye cases. The decisions to do so are way beyond anything I will have an impact on, but in general, if anesthesiology does not have any responsibility in the situation I described above (chest pain immediately after MAC), I see no reason for their involvement in any of my cases unless it is general.
Click to expand...

Based on your numbers, your quoted salary is about 50% of what Merritt Hawkins quotes in their recent revenue survery. Sounds like you need to find a new locale.

http://www.merritthawkins.com/compensation-surveys.aspx

Again, while I personally would've stayed had I done the case, I don't see why you expect one consultant physician to stick around until another consultant physician shows up for the management of a very basic medical issue in YOUR patient.

And if you don't want an anesthesiologist involved, as based on your post it sounds like you don't, then simply don't request them. It's your choice. Within the OR, we're a consultant service. You don't want us? You don't have to have us. You want a nurse or an RT managing the patient during your case? Fine...hire your own and do it.

All of this being said, I would've stayed and I would've done my best to manage the patient and have you involved as much as you wanted to be.
 
200UL said:
I see no reason for their involvement in any of my cases unless it is general.
Click to expand...

I guess I just don't get your post. It's like your rubbing in our face the fact that one anesthesiology attending was lazy and didn't help when you wanted it. I'm sorry, there are a lot of lazy people in my profession. I'm reminded of this all too often. Based on your post, you made it sound like all the ophtho people around you work extremely hard all day every day, so I won't even ask if you have a similar problem in your profession.

Merritt Hawkins does seem to imply however, that your profession is pretty well compensated. You also have a lot more innate freedom in your profession than I have in mine. I envy that.

Everything being said, I'm sorry you don't want neither me nor my colleagues involved in your cases. I can assure you though, there are many residents/attendings on this board (myself included) who feel we work extremely hard and would do everything necessary to ensure high quality medical management of your patient before, during, and after the operative setting.
 
200UL said:
It was the last case of the day - for some reason it was just the anesthesia attending - maybe the anesthesia resident had to leave for work hour rules or something.

I have no facts ($)to back it up - I am speaking from what the attendings are making. I am at a state institution - salaries are public knowledge. In general, the anesthesiologists make more than the ophthalmologists. I am not sure how many cases the anesthesia team is doing, but I do know most of the ophthalmology attendings are working 5 days per week (4 days of clinic with 30-40 patients per day - 1 day of surgery with 10-12 cases).

The starting ophthalmology salary in the city is 110-150. The starting ophthalmology salary for rural region is 150-200. In talking with my anesthesia resident friends, I know their future compensation is higher than this. I also know their possible vacation packages trump any other area of medicine.

Finally, many eye procedures have gone strickly to CRNA, nurses alone, or there is even a new article showing the safety of respiratory therapists managing eye cases. The decisions to do so are way beyond anything I will have an impact on, but in general, if anesthesiology does not have any responsibility in the situation I described above (chest pain immediately after MAC), I see no reason for their involvement in any of my cases unless it is general.
Click to expand...

At every hospital where I have had the pleasure to have worked, an attending anesthesiologist can't just "peace out" until the last patient has left the pacu. He probably mentioned it to his partner that was on call covering the PACU. He may have also noted the CP in pre op questioning and was just covering his bases with a consult. Who knows? We don't really know enough to make an accurate assessment. Seems reasonable, pre op CP, no sx to cx case over, maybe worse post op but stable, whatever- cards consult to sort it out.
I am quite chummy with some optho folks at my current hospital, and while their "base" may be that low, they earn >3 times that. Their pay structure is actually unusual. Only one day in the OR is the problem. They are also partly eat what you kill, so more work is more money. That's probably why they're not taking 6 or 8 weeks of vacation. I'm salaried with a variable bonus. I take my max vacation every year. There's nothing to gain by working 2 or 3 more weeks. The surgeons on the other hand ARE given productivity bonuses. Big difference. Many of them only take a few weeks off each year.
BTW, if you think for a second that an RT can help you with an emergency, you're high, and haven't done enough cases. Maybe, just maybe, they can bag or intubate an easy airway. That's about it. CVA, ischemia, acute delirium, allergy, etc. they're useless. If you want to put your sick old dessicated eyeballs under "twilight" anesthesia with that as your safety net, good luck.
 
Last edited:
200UL said:
It was the last case of the day - for some reason it was just the anesthesia attending - maybe the anesthesia resident had to leave for work hour rules or something.

I have no facts ($)to back it up - I am speaking from what the attendings are making. I am at a state institution - salaries are public knowledge. In general, the anesthesiologists make more than the ophthalmologists. I am not sure how many cases the anesthesia team is doing, but I do know most of the ophthalmology attendings are working 5 days per week (4 days of clinic with 30-40 patients per day - 1 day of surgery with 10-12 cases).

The starting ophthalmology salary in the city is 110-150. The starting ophthalmology salary for rural region is 150-200. In talking with my anesthesia resident friends, I know their future compensation is higher than this. I also know their possible vacation packages trump any other area of medicine.

Finally, many eye procedures have gone strickly to CRNA, nurses alone, or there is even a new article showing the safety of respiratory therapists managing eye cases. The decisions to do so are way beyond anything I will have an impact on, but in general, if anesthesiology does not have any responsibility in the situation I described above (chest pain immediately after MAC), I see no reason for their involvement in any of my cases unless it is general.
Click to expand...

The optho docs I work with make bank. All of them... retina guys, plastics guys, and the phaco guys. Hard not to when your doing 20+ phaco/IOL's daily a few times a week.
 
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
 
sugaree said:
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
Click to expand...

:corny: Man, those doctors are terrible. I wish I had some yard wide nurse who's only recent education came from "In Touch" magazine. Failing that, I'd sure as heck want a cocky medic with a superficial understanding of the pathophysiology of a patient, but more than enough testosterone to make up for any intellectual short comings.
 
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sugaree said:
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
Click to expand...

brilliant plan for the guy in v-fib who is able to chew and control his own airway.
 
sugaree said:
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
Click to expand...

The Code Brown can wait.
 
geogil said:
:corny: Man, those doctors are terrible. I wish I had some yard wide nurse who's only recent education came from "In Touch" magazine. Failing that, I'd sure as heck want a cocky medic with a superficial understanding of the pathophysiology of a patient, but more than enough testosterone to make up for any intellectual short comings.
Click to expand...

Speaking of yards, they are good for one thing, tending to their Farmville.
 
sugaree said:
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
Click to expand...

I'm an EM doc and I think this sounds stupid. I fly ~100K miles/year, and I just had the first time I ever was asked to help on a plane - 8 y/o who was trying to equalize, and had sudden pain in the face. I believe it was barotrauma to the nasolacrimal duct, or at least transient insufflation.

There was a woman I flew out here to see me for a few days, and she is a paramedic. On her way back to the mainland, there was a guy who was having chest pain, and he went into cardiogenic shock. My friend tended to him, and, as the plane was going to set down in LA, and they were more than halfway there, there was nowhere else to go. She did a fine job.

On the other hand, I have a good friend that is a neuroradiologist. 3 times she's been on a plane where they've needed a doc. One time was a double-banger - chest pain, and the guy sitting next to him had a seizure.

She did fine - didn't have to reroute (which costs airlines thousands, but not millions), and they made it to destinations.

As Bertelman says, liability is not the big issue. Even if you get a gift basket afterwards, that was not solicited, so it would be difficult for a tort for a "good Samaritan" action.
 
Doctor4Life1769 said:
🙄
Sounds like a murse to me.
Click to expand...

Wow, some of you people are ridiculously defensive. Ask any MD, EMT or paramedic or Anesthesiologist (for example) who is best trained for field emergencies. Seriously folks, this isn't about who is smarter than who. And what the hell does this have to do with being a nurse or not? Someone with chest pain who can chew an aspirin? Wow what a terrible idea.

I was saying that ED docs, EMT's and medics are great, not that doctors are "not great." Don't jump to conclusions. And by the way, is calling someone a "murse" supposed to be an insult? (what the hell is that anyway?) Is that like calling someone a "woman"?
 
sugaree said:
Wow, some of you people are ridiculously defensive. Ask any MD, EMT or paramedic or Anesthesiologist (for example) who is best trained for field emergencies. Seriously folks, this isn't about who is smarter than who. And what the hell does this have to do with being a nurse or not? Someone with chest pain who can chew an aspirin? Wow what a terrible idea.

I was saying that ED docs, EMT's and medics are great, not that doctors are "not great." Don't jump to conclusions. And by the way, is calling someone a "murse" supposed to be an insult? (what the hell is that anyway?) Is that like calling someone a "woman"?
Click to expand...

I realize you're a pre-med, so good luck. Your post showed great naivety in that you're unaware of the skillset of an anesthesiologist. I was an EMT, so I've had tons of interaction with ED physicians. I'd take the skillset of an anesthesiologist over anyone you've listed. Here's why:

With the knowledge of a physician we also maintain a clinical skillset superior to anyone you've listed (really, we do procedures such as IVs, central lines, airway management, administration of rescue drugs, etc. all day everyday).

Who does the ED call with the failed airway? Us.
Who do the nurses call when they need access but have no success? Us.

I'm not simply tooting my own horn, but a little knowledge will take you far. Good luck with the apps.
 
I never get tired of nurses and medics puffing out their chests speaking with absolute certainty. Classic syndrome of "you don't know what you don't know."
 
sugaree said:
I was saying that ED docs, EMT's and medics are great, not that doctors are "not great."
Click to expand...

That's actually exactly what you said...

sugaree said:
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
Click to expand...

Understand that you are visiting an ANESTHESIOLOGY forum. We're not big fans of writing orders for nurses to complete. We chose our field because we are in direct contact with the patient, and don't have to rely on others to accomplish things like line placement, drug administration, etc. We identify problems, diagnose the process, and treat it. Expect a little pushback walking into our lounge telling us someone with a 4-yr B.S. can treat ACS on a plane better than us.

I recall once seeing a gaggle of ED residents jizzing over an intubation opportunity on a pt. actively seizing. They were imagining how difficult the intubation was going to be with him shaking and such. Guess what. Gave succ, and that guy was just as immobilized as every other ED intubation. They still high-fived when it was done. Needless to say, I have found that the energy level of ED docs tends to eclipse their knowledge base in certain scenarios.
 
sugaree said:
Give me a medic, an EMT or a nurse anyday and keep the doctors away. (unless of course you are an ED doc in which case move the hell over!) Chew on an ASA and get the paddles ready... and those O2 masks come in real handy.
Click to expand...

Imagine that you are an anesthesiogist or a surgeon, and you are experiencing chest pain on a transcontinental flight. Who would you like to see at that moment to assess you? A nurse? a medic? an EMT? Or would you want to see a fellow anesthesiologist?

Your stupidity is astounding. Refrain from proving the point by posting on here.
 
200UL said:
It was the last case of the day - for some reason it was just the anesthesia attending - maybe the anesthesia resident had to leave for work hour rules or something.

I have no facts ($)to back it up - I am speaking from what the attendings are making. I am at a state institution - salaries are public knowledge. In general, the anesthesiologists make more than the ophthalmologists. I am not sure how many cases the anesthesia team is doing, but I do know most of the ophthalmology attendings are working 5 days per week (4 days of clinic with 30-40 patients per day - 1 day of surgery with 10-12 cases).

The starting ophthalmology salary in the city is 110-150. The starting ophthalmology salary for rural region is 150-200. In talking with my anesthesia resident friends, I know their future compensation is higher than this. I also know their possible vacation packages trump any other area of medicine.

Finally, many eye procedures have gone strickly to CRNA, nurses alone, or there is even a new article showing the safety of respiratory therapists managing eye cases. The decisions to do so are way beyond anything I will have an impact on, but in general, if anesthesiology does not have any responsibility in the situation I described above (chest pain immediately after MAC), I see no reason for their involvement in any of my cases unless it is general.
Click to expand...

I have to say that the attending anesthesiologist in your case is responsible and should remain present for that patient until he/she is discharged from the pacu. It is his responsibility to call the cardiologist and take care of that patient. Not yours. It is not like this in private practice.

That being said your numbers are dead wrong. You seem to be echoing your academic attendings opinion. This opinion is not based on real fact. As for salaries, I am not sure how it goes in academics but in the real world the optho's in my town make 1.5-2 times what I do. They work hard, do alot of cases, and deserve to make what they do. On a per case basis, there is no eye surgery where the surgeon is reimbursed less than the anesthesia provider by medicare.

As for anesthetic management of eye cases, I have had more unexpected issues (ie intraop asystole, MI's post op, arrythmia's...the list could go on) with my eye patients than with any other patient population that I work with. These people usually have multiple comorbid conditions making their management complicated at times. If you would like to take the responsibility of managing both the operation and these multiple issues in addition to their anesthetic, good luck. When you propose CRNA or respiratory therapists monitoring your patients while you operate you are essentially taking that responsibility. You will be the only physician on the chart.

You should also look hard at those articles you are citing. They are usually propaganda put out by whatever relevant association is trying to advance its agenda.
 
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