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14 DILEMMA NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk Dilemma Dealing with an in-flight The last thing you want to hear when on board a long-haul flight: “Is there a doctor on board?” Dr Clement Lau shares his story I was travelling on a longhaul flight from Hong Kong to Finland with more than 200 people on board. Two hours into the ten-hour flight, I was suddenly woken up by a call for medical assistance. The first thought that sprung to my mind was “what should I do?” I had very limited clinical experience as an F1 doctor. I hesitated and thought about the consequences of providing help and what would happen if I didn’t know what to do. But what if I was the only doctor on the plane? The patient may be much worse off if he or she did not receive any medical attention. I conjured up confidence and stepped out to find out what was occurring. I approached the cabin crew who were stood surrounding the passenger. There was already another doctor there, a first year doctor from Finland. A ADVICE Officially, a good Samaritan act is where medical assistance is given, free of charge, in a bona fide medical emergency, upon which a doctor chances in a personal as opposed to a professional capacity. Waking up to the resounding call on a plane: “Is there a doctor on board?” you would immediately think: “Should I intervene?” The GMC would say yes – although you have no legal duty to do so (in UK law), you have an ethical and a professional duty to help. MPS advice is to do the best you can 42-year-old woman was experiencing sudden onset chest pain and breathlessness. She was overweight with hypertension, but had no significant past medical history. I explained my position to everyone present. At this point I was shown a piece of paper, which explained the good Samaritan law. It stated I would not be responsible for any medical assistance that I provided. I felt slightly relieved, but I wasn’t too sure whether this applied to me as a doctor practising in the UK. The patient did not speak English very well, but was able to speak Chinese. I took a history and translated this into English for the cabin crew and other doctor. We promptly gave oxygen, examined the patient and decided on a management plan. We moved the patient to a quieter area for observation. I also had to explain to the patient’s family about what was happening to keep them informed, and gave appropriate reassurance. We enquired about the emergency drugs box and also whether there was an ECG machine available. It was interesting that the crew never asked us at any point for any identification when we asked to access the medicines box, which contained drugs such as adrenaline and morphine. There was an automatic defibrillator that I used as a monitor. We gave the patient GTN spray to see if this would relieve the chest pain. After three or four puffs the chest pain improved. We therefore decided to give her 300mg of aspirin and continued to monitor her condition. We decided that we would each take it in turn to spend time beside her for a few hours in case any further in the circumstances with the resources available, working within the limits of your competence. By responding to the call you have taken on the role of a good Samaritan. MPS will assist you with any problems arising from a good Samaritan act anywhere in the world – whatever jurisdiction you’re flying in. Before proceeding: ■ ■ Consider whether any factors might be compromising your competence (alcohol, medication and tiredness) ■ ■ Understand that you will normally be treatment was required. Clearly our dilemma was whether this patient was having an acute coronary syndrome. The cabin crew told me they would contact medical ground staff, who would advise us on the best plan as to whether the plane required diverting or landing. After several attempts they told us they could not get any reception to contact the ground staff as we were flying over Siberia. The patient was still experiencing chest pain, but this was starting to improve. The cabin crew asked me repeatedly whether we should divert the plane or land it at the next city. This was a difficult decision to have to make and the situation I was dreading. My thoughts were on whether the patient could make it to the destination without requiring emergency medical assessment assisting experienced flight attendants – so don’t try to immediately take charge. During the emergency: ■ ■ Take a full history and carry out a full examination in order to make an informed assessment ■ ■ Suggest options for managing the situation (balance benefits and risks of treatment) ■ ■ Work within the confines of your expertise and training, except in a critical emergency ■ ■ Delegate and communicate appropriately. ROB BOUWMAN/SHUTTERSTOCK
and treatment, but also balancing the consequences for the other passengers if the plane had to be diverted. What would be the legal implications had I made a mistake with my judgment? I had to make a clinical decision about the diagnosis and decided against diverting the plane, at least until we had made contact with ground support. When Moscow was in proximity, the crew informed me that the pilot wanted to know again about whether the plane should be landed. At this point, the patient’s chest pain had eventually settled and I felt more confident about my decision not to land the plane. Shortly following this the cabin crew gained contact with ground staff who agreed with our management plan. We decided to document everything we had done in case there were any questions about our management plan. The last two to three hours of the journey seemed to last forever before we finally landed at our destination. Much to my relief, paramedics were waiting to take the patient to hospital. The cabin crew and patient were very grateful for my help and it turned out to be a great learning experience for me. Dr Lau is currently an F2 working at Stepping Hill Hospital in Stockport. Book review Doing Clinical Ethics: A Hands-on Guide for Clinicians and Others – by Daniel Sokol, barrister and senior lecturer in medical ethics at Imperial College London (Springer 2012) Reviewed by Dr June Tay, junior doctor in anaesthetics, London Doing Clinical Ethics is a concise and comprehensive book, which is easy to read. The author, Daniel Sokol, beautifully captures the theoretical essence of medical ethics and applies it to real life. He divides his book into five chapters, encompassing ethical theory and casebased discussions, teaching, writing papers and research in the ethical context. Chapter 1 provides a step-by-step guide to approaching a clinical scenario. Sokol summarises the sections into moral perception, moral reasoning and moral action. Within moral reasoning, he outlines the four principles: respect for autonomy, beneficence, non-maleficence and justice. He also introduces the “four quadrants approach”, which can be applied to every clinical case. These are medical indications, patient preferences, quality of life and contextual features. An example provided was the case of a 22-year-old woman, BMI 51, with a history of self harm, who set herself alight moments after discharge from the emergency department, and as a result had to be admitted to intensive care and a specialist burns unit. Tattooed on her chest was the following: DNAR (underlined) DO NOT RESUSCITATE. He clearly analyses the ethical issues employing the “four quadrants approach”, which makes for really interesting reading. What I gained the most from the book is encompassed in the next chapter, which covers writing and publishing a paper. Sokol draws most of the examples on writing an ethics paper; however, these are universally applicable to other topics and articles. The elements addressed and the examples given resonate well with the challenges faced by clinicians – authorship, rejections and abstract submissions. Most of this insightful advice is not obtainable from textbooks, but only discovered through an individual’s experiences and struggles. Nevertheless, these issues are applicable to a junior doctor’s clinical career. Not to be missed is the chapter on delivering teaching. Sokol elaborates on the various aspects of teaching junior doctors, medical students and other clinicians, with particular attention to teaching ethics. However, it is advice that one could employ to improve their teaching skills in general. Perhaps this chapter would benefit from further elaboration in a book on teaching skills. The final chapter consists of appendices using pertinent examples of ethical issues that clinicians may encounter. Sokol provides a few cases and discusses the ethical principles involved. Among the two that I found most pertinent to my role as a junior doctor are “The Slipperiness of Futility” and “The Dilemma of Authorship”. It is perhaps the most engaging chapter in the book as real-life examples are employed, which most clinicians can identify closely with. Overall, Doing Clinical Ethics is concise and uses simple language devoid of jargon. It particularly appeals to one who does not have the patience to dwell on lengthy prose. Perhaps some may feel that there is a lack of philosophical discussion of moral dilemmas, such as euthanasia and physician-assisted suicide. Others may feel that the aspects on teaching and writing ethics are too general and not particularly suited for a book entitled Doing Clinical Ethics. Nevertheless, it is a good read for anyone interested in medical ethics. If you would like to review a book, website, film or app email sara.williams@mps.org.uk 15 BOOK REVIEW NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
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Page 3 and 4: Inside this issue of New Doctor…
Page 5 and 6: Competency, in professional terms,
Page 7 and 8: LIFE IN VIEW/SCIENCE PHOTO LIBRARY
Page 9 and 10: A day in the life of… an F2 in pu
Page 11 and 12: I was not completely comfortable wi
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