Be sure to read Part 1 first.
Exhausted, and suffering severe heat stroke, I clambered on to the plane and after stuffing the three jumpers, two coats and majority of t-shirts into the overhead locker I collapsed into my seat, begging the hostess for water. As the plane took off, I rummaged through my bag for some sleeping tablets. Prior to leaving for the trip I had asked a doctor who was a friend of mine to prescribe me sleeping tablets for the plane trip: “Find out the dose that will kill me”, I asked him, “Then just back it off a trifle!” I was not one for sitting around for long periods.
Half an hour into the flight, as I was about to take my tablets and slip into a state of blissful sleep (induced of course and possibly verging on a coma), I noticed an airline hostess come and speak to one of the passengers sitting approximately ten rows in front of me. Initially, I though the passenger must have been vomiting, as I heard the hostess say: “It’s a long flight… you’ll have to be able to eat or drink something”. Fifteen minutes later, the hostess was still by the passenger’s side and was starting to look extremely concerned. Other hostesses had congregated around this passenger and there clearly something amiss. On a whim, I hopped out of my seat to see what was happening and walked down the aisle to one of the hostesses. “I don’t mean to intrude”, I stammered, “But if the lady is being sick, I could give her an injection to stop it” (as I knew they carried anti-nausea injections on board international plane flights).
The hostess replied with what is now a very clichéd line: “Thank God you’re here!” she cried. “The lady’s unconscious… we don’t know what to do!”
I looked over the hostess to see an elderly lady slumped, unconscious, in her seat. Sweating profusely, her face ashen and with saliva dripping from her mouth, I didn’t need to be an experienced medical practitioner to realise that she was critically unwell. Her family, hysterical with worry and largely in tears, were opening her mouth and pouring in lemonade as she lay there, yelling in a foreign language as they did so. In amongst the diatribe, I heard the word “diabetes” mentioned.
“The first thing we need to do”, I said to the hostess, “is stop the family from pouring that lemonade down her throat. There’s no way she could protect her airway in this state, and if she aspirates the lemonade and we lose her airway… this is all going to end in tears!”
I immediately asked the other people in the aisle to stand up, then raised the arm rests and lay the lady down in the coma position across the centre seats. Panicking slightly, I asked an airline hostess to fetch the aeroplane medical kit, and to ask passengers on board if anyone was carrying a glucometer that I could use to measure her blood sugar level. Hostesses went running in all directions, returning quickly with medical kits, canisters of Oxygen and a glucometer.
I felt the thready, weak pulse of the elderly lady and knew that something had to be done quickly. Placing the oxygen mask over her face, I pricked her finger and waited for the glucometer to calculate her blood sugar level. I still remember my heart rate rise and the involuntary noise I made as I saw the result… a blood sugar level of 0.4mmol/L – to this day the lowest blood sugar level I have ever seen. Normal in the human body is around 3.5-7mmol/L, and with a level of 0.4mmol/L, this passenger had literally minutes to live before her body finally ran out of fuel. I turned to the hostesses, who by this time were standing on either side of the aisle holding up blankets to make a mini-cubicle in the middle of the plane.
“She’s in a hypoglycaemic coma”, I stated, “Probably caused by an accidental overdose of insulin or a lack of food. We need to get glucose into her quickly or she’s going to die”.
I wish to reiterate that at this point in my life I was not a doctor… I was a medical student… a medical student who had never treated nor seen a case of hypoglycaemic coma before. But I had read about them, and I desperately tried to visualise the textbooks I had scoured through over the preceding five years and remember the management possibilities for a hypoglycaemic coma.
My initial plan was to insert a cannula and give the patient a bolus of intravenous dextrose to quickly raise her blood sugar levels; when I opened the medical kit however, I realised in dismay that there was no dextrose solution inside. I quickly searched through vials and vials of medications that I had never administered to a human being, until I finally found a small vial of Glucagon… the antidote to insulin.
“Worth a shot” I thought to myself, as I saw the lady’s breathing slowing before my eyes.
I drew the contents of the vial into a syringe and injected the contents into the lady’s buttock… the second time in my life I had administered an intramuscular injection, and praying that I missed the sciatic nerve that I knew ran through the region.
Around this time, the patient’s husband who had been lurking behind the scenes – always with at least one can of beer in his hand – went utterly berserk. In broken English, obviously inebriated and with slightly slurred speech and overwhelmingly grandiose hand gestures, he rudely told myself and the airhostesses that there was absolutely nothing wrong with his wife (currently still lying unconscious and barely breathing on the seats in front of him) and she wouldn’t be getting this sort of treatment at home. He went on to reiterate that we were all over-reacting idiots, we should sit her up immediately so he could sit down and could he please get another beer as soon as possible as this one was nearly empty. I don’t describe myself as a confrontational person, but on this occasion I surprised even myself. I stood toe-to-toe with this man, cringing only slightly from the waves of alcohol emanating from his breath, and stated firmly:
“Sir, in case you haven’t realised, we are not at your home. We are 10,000 metres about the land and your wife is extremely ill. I’m the person in charge of looking after her at this point, and she will stay lying there until I am good and ready to sit her up. Any questions?”
With that he mumbled something incomprehensible and stormed to the toilets.
I checked the lady’s blood sugar level again, and breathed slightly easier when I saw the level had risen to 2.4mmol/L. She remained steadfastly unconscious. “That’s much better” I said to the hostesses, “but we’re not out of the woods yet”. I remember feeling sorry for the hostesses, who by this time were fending off abuse from several passengers, who despite seeing the events unfold, were vigorously complaining that their meals were late.
Ten minutes later I took the blood sugar level yet again, and this time it had risen to 5.5mmol/L. By this time, the lady was regaining consciousness, and was holding her arms up in a prayer position to say thank-you. Soon afterwards I sat the passenger up and took off the oxygen, as her condition stabilised. “I think she should be fine now”, I said to the hostesses, realising for the first time how much I was sweating. The cabin manager helped the passenger sit up, then walked over and shook my hand. “Thank you so much”, she said “We honestly thought she was going to die. I’ll see if I can get you upgraded to first class to show our appreciation”.
The hostess returned a few minutes later to report that unfortunately, all first class seats were taken, but if I needed anything during the flight I was to let her know. Feeling mildly cheated, I returned to my seat and again attempted to settle down for a sleep. Not two minutes later, in the distance I saw the cockpit door fly open and the pilot march down the aisle of the plane, eventually stopping at my seat. While every single passenger on the jumbo jet stared at me, the pilot introduced himself, shook my hand and then asked me a question I never expected to be asked in my entire life:
“Mr. Kirkland”, he said “Thanks for all your help back here. I need to know whether we should divert the plane to Moscow to off load this ill passenger. If we don’t divert to Moscow, the next place we can land is India in six-hours time… I think you should be the one to make the call”.
I translated that as essentially meaning: “If we don’t land in Moscow and something happens to this lady… it’s your fault!”
Sitting stunned, trying to digest the magnitude of what had just been asked of me, I vividly remember thinking to myself: “I should not be making this decision”. I was a medical student and I thought I had done extremely well treating the patient at all, but now… now…. I had to decide whether 400 people got diverted to Moscow.
I thought for a while, wrestling with an internal monologue, which ranged from:
- “Moscow might be positively delightful at this time of year and besides, I have always wanted to see Red Square”; to
- “If I divert this plane to Moscow and the lady is well enough to get back on board I am going to be lynched by 400 furious passengers”; to
- “Are medical students even allowed to divert planes? I’ll probably get struck off before I even begin practicing medicine!”
In the end, I said to the pilot:
“Sir, the passenger was in a hypoglycaemic coma, almost certainly caused by taking too much insulin. I’m not sure what type of insulin this passenger in on; often it is a mixture of short- and long-acting insulin, and if that is indeed the case, when the long-acting insulin kicks in in around an hour’s time, the lady’s blood sugar levels may drop again. If that happens, I have no more medication to raise them, as I used it all the first time.”
“However”, I went on to add, “Because the lady is now conscious, and is able to eat and drink safely, she should be able to consume enough to off-set the long-acting insulin. And if worst comes to worst, and she does lapse in to another coma, I’m sure I can put in a drip and we can make up some quasi-sugar solution with saline and sachets of sugar. So all-in-all, I think it’s safe to keep going”.
Basically… I was just too scared to divert a plane.
The pilot seemed satisfied by this response, thanked me again and began the long trek back to the cockpit.
Thankfully nothing else happened for the duration of the flight and eight-hours later I arrived, sleepless, at Hong Kong airport. I was thrilled and a little overwhelmed when all the passengers on the plane let me disembark first, and clapped loudly as I left the plane.
After a two-hour stopover in Hong Kong, I once again queued to re-board the plane for the 10-hour flight back to Melbourne. As I scanned my boarding pass, alarms sounded and red lights flashed yet again. Wondering what could possibly be wrong now, I was pleasantly surprised as an airline hostess handed me a boarding pass for first class and welcomed me on board with complimentary champagne. I spent the next 10 hours in unbridled luxury.
All-in-all… it was probably one of the best days of my life. It must be nearly every medical student’s dream to take charge of a very public medical crisis, have a good outcome and for that brief second be “the hero of the day”. Sometimes, I still struggle to believe that it happened to me.
It was also the first life I ever helped to save.