Cruising Altitude of Intuition Part 1

airline instinct intuition medicine pediatrician travel
A board certified pediatrician lends her skill to care and empathy in a challenging medical scenario for a pediatric patient aboard a flight from Dubai to Los Angeles.

Today, it's from the heart....

Oh, have I got a story for you!  

Once upon a polar route plane ride from Dubai to LAX, little did I know just how crucial my trust in my training and dedication to all of the long hours triaging patients would be....

30,000+ feet and Doctoring in a critical care scenario…. with no supplies or equipment.... you make the call.

In an instant—everything changed.

I was on a 16 hour flight from Dubai to LAX.  JD + I were coming back from a trip to Jordan we took during my second year of Residency.  As I squeezed my way back into our row after returning from the bathroom break to press play on probably my 3rd movie by that point, JD said they just asked for a Doctor overhead.

I began making my way about 30 rows forward on the plane (we were on an Airbus A380, the world's largest passenger aircraft with capacity of over 800, ours had maybe 300+ish passengers ballpark plus pilots and crew).  

When I arrived on the scene to answer the “Is there a Doctor on board the plane?" solicitation, I knew this was not going to be straightforward, and yet this was most definitely a scenario I could and was willing to care for this young passenger in any way that I could.

On first glance, it was obvious who needed assistance. She was huddled in the middle of the row laying on who I guessed was probably her Mother. She looked pale, weak, diaphoretic (sweaty- not letting you read through this post without throwing some medical vernacular your way- building up my Mamatricians!), and not super oriented. In the medical world we often sign our notes under the General section with our initial impressions of a patient AAO x3 (Awake, Alert and Oriented x3) which can be accomplished with observation and a few simple questions. So awake yeah, she was awake, alert (sure maybe with a little prodding), oriented- questionable.  

My patient was a small, frail, undernourished young girl maybe 6 years old.  She was clearly suffering from some type of viral gastroenteritis ("stomach flu") and was bordering on concerning dehydration.  I would come to find out within minutes that this case would be complicated by not being able to communicate well with her Mom and accompanying family, as they spoke what was felt to be a mountainous dialect of somewhere in the Middle East, perhaps Afghanistan or nearby nation.  The flight attendants on Emirates are very polished and typically cover a wide range of languages spoken by the passengers on the flight, this just wasn't one of them.  And I would need to make some critical decisions--- AND FAST.  

 I was initially relieved that 2 other Physicians had responded to the call- they quickly introduced themselves to me and identified themselves as Neurosurgeon Residents from Kuwait, and they were happy to defer this case to me since clearly it was outside of their normal scope of practice and was within mine.  They were willing to  collaborate as necessary.

Within just a few moments of arriving on the scene and beginning to assess my patient and let my clinical mind start cataloguing all of the information- presentation of the patient, trying to start eliciting a history from the family (which proved extremely difficult).... and actually I can confidently say that in the history of my career I have NEVER had to make such a critical decision triaging a patient with so little information about their present illness history, medical history, etc. as I did that day.  It was becoming apparent that any history and information would be very difficult to exchange between us due to language barriers, and I would need to go within, trust my instinct and training with the thousands of physical exams I'd performed to make clinical decisions regarding this young girl's care.  

I started making requests for equipment and medication, inquiring as to what was available.  Looking back, I went into total Doctor mode for this young girl and it was really a remarkable moment in my career.  I was ready for this, I had trained for this, just usually I could see these patients in fully stocked Emergency Departments and with tons of support staff and experienced Physicians around.  So yeah, this was wayyyyyy different.  And I had come to find out, not much was available.  They brought out some Tylenol that had an Arabic inscription on the front, and as I do not read Arabic (this made me want to learn this fascinating language though!), I wasn't sure the concentration, which in liquid form and for pediatrics we pay attention to mg/mL and then do some calculations based on the pediatric patient's weight in kg what an appropriate dosage is per 4-6 hours due to hepatic clearance (liver clearance) and the need to be aware of not causing toxicity with either too high a dose or too frequent of doses so as to overwhelm the body's capability to filter it out.  

About this time, the head flight attendant, called the Bursar (ding ding ding totes learned a new term that day in the flight attendant stratospheres), came to pull me aside and with a certain heaviness and urgency, she related that she had just come from speaking with the pilot.  

They were grateful for my assistance, and it was critical that I provide them a swift decision regarding what my medical opinion was regarding this patient.  You see, we were suspended over Northern Russia at the time, and the pilot was on the phone with a potential landing site.  We could land there so that the patient could be triaged for further and escalated level care if I deemed that appropriate.

BUT...... wait for it......

ALSO to keep in mind that if we landed, the entire plane WITH 300+ PEOPLE would be stranded in Northern Russia because the plane was too massive to take off again on the runway strip available.

Okay, so let that gravity sink in.  This is getting MAJOR here really quick.  

That's not all.

OH, and if I feel the patient is able to continue traveling, there will be a 10-hour period where we will be over the polar ice caps as we are on the polar route traveling from Dubai to Los Angeles, and once we pass this Northern Russia potential landing spot WE WILL NOT BE ABLE TO LAND FOR 10 HOURS.

So, I better be sure this patient can make it.  And I better have sound clinical reasoning if we land and strand the 300+ passengers.

WWWWWWHHHHHHHHHAAAAAAAATTTTTTTTT 

Can I please go back to scrolling through available movies, and planning my next meal?! My Mom actually said do you know how long the flight is when I told her about our travel plans, and I said something to the effect of, "If I get to sit for 10+ hours and watch movies and eat and have snacks and sleep and not get paged, that sounds like a vacation to me hahahaha") but no, this beautiful little girl was right in front of me, and I was in full Doctor mode wanting to help her feel better and call upon the resiliency of her little body.

I actually wrote in my entrance essay into medical school that I desired to become a Pediatrician because I was innately drawn to the care of children and the simultaneous vulnerability and yet extreme resiliency of their little bodies and the impact on their overall health.  I would witness their vulnerability and their resiliency time and again during my long years within the hospital halls.  And in this particular instance, within the metal walls of an A330 cruising at 35,000 feet.  

So this was my induction into the Mile High Club, Doctor's Edition.  Welcome to my world that day.  

Fresh off exploring the wonder of Petra (I teared up when I saw it), going back at night and sitting by candlelight listening to the gorgeous melody of the oud (a type of guitar) traveling up the sandy walls surrounding us, camel trekking in the Wadi Rum dessert, camping in the desert, swimming in the red sea, floating in a full body mud mask in the Dead Sea, and exploring Biblical sites thousands of years old such as where Jesus was baptized was still resonating in my soul.  It had been a whirlwind of a magic carpet ride trip, and true to our usual exploration, we were both exhausted.  I didn't have a long window (6 days) to be away from the hospital including the travel days, but I reasoned  I would get adequate rest on the flight..... hahahahahahah that backfired.

Okay, so back from that little reverie to the supplies they had on board. They brought me a rudimentary stethoscope so I could do my physical exam, a bottle of Tylenol (great for fever/inflammation), but not so much for AGE (viral gastroenteritis).  I inquired about Zofran which is an anti-nausea medication and if I had seen this patient in the ED, would have ordered this in order to stop her ongoing fluid losses through emesis (vomiting- there's your second fun medical word).  

I next asked (with much cringing) if they had IVF (IV fluids) and needles/supplies so we could potentially start replacing her losses.  A lot goes into choosing which solution based on fluid principles in the body (hypotonic/isotonic/hypertonic solutions), needle gauges appropriate to the size of the patient, rapid boluses to replete fluids quicker in a sick patient versus maintenance rate of IVF which is calculated based on the patient's weight so you don't cause fluid shifts or ion shifts in the body which could be detrimental.  And it's all part of an internal dialogue.  And typically, we have all of these options or can collaborate with pharmacy to order special IV bags.  These are the medical neurons doing a constant clinical dance during all of the decisions and ongoing care of the patient and monitoring how they respond.  Just typically, there are lab tests and vitals on machines available second to second and lots of feedback you can incorporate into your decision making and assessment of the patient.  In field medicine, wilderness medicine and here in aeronautical based medicine, you're the instrument and your patient is the teacher and you need to establish harmony in the most ideal way given the conditions. 

AND, we can collaborate with the needle ninjas. The nurses, the IV team even who are comprised at many pediatric hospital of the needle ninjas themselves who can find IV access in even the most difficult of patients. You see, when patients have fluid depletion, as in this patient, it is often very difficult to find IV access for them, and you can end up poking them repeatedly.  In young infants, sometimes we resort to IV's in the scalp, or in very young neonates, we can access them through their still fresh umbilical cord stump- fascinating huh?!  I have placed the umbilical cord lines in a neonate in the NICU and in the delivery room, and it humbled me each time.  

Anyway, the needle they brought out for an option was WAY TOO BIG for this small little girl.  And I can't recall now which IVF bag was available, but I don't think it had a pump or a way to deliver it except wide open which would have been okay for a bolus, but it wasn't the IVF I would typically choose for a pediatric patient.

So, it wasn't looking promising for IVF administration for this patient.

And with limited history and the little girl being frightened with all the attention, I needed to make a decision, and fast.  After all, the pilot was on the phone with Northern Russia, this little girl needed my care, her life could very well depend on my decision, AND 300+ people on this luxury airplane would be impacted by what I decided next.

INSERT WIDE EYES AND RACING HEART AND ELEVATED BLOOD PRESSURE.  But also, keep calm and appear poised and help project a sense of peace upon this situation for this little girl, her family, and the flight crew.

I closed my eyes, took a deep breath, said a lot of prayers I'm sure, and went within.  I imagined myself seeing this little girl in my clinic and seeing the guidelines in my mind of how we as Pediatricians typically triage patients we suspect have dehydration due to a secondary source, in this case likely AGE (acute viral gastroenteritis) aka stomach bug/stomach flu, etc.  We first determine if they are hydrated by our physical exam which includes many parameters like do they have an elevated heart rate/tachycardia.  I listened and hers was mildly elevated.  How is their capillary refill- this can be ascertained by pressing down on a fingertip or toe tip and releasing seeing the white area and watching closely how long it takes for the blood to re-perfuse the area making it pink again.  In a hydrated child, this refill should be brisk and immediate, and a capillary refill of < 2 seconds is considered "not delayed". I did all of these things and examined her to the best of my ability after I had her moved to the floor in an exit aisle where I could move around a bit more and be more thorough.  

We always prefer to orally rehydrate patients if they are able to take liquids PO (per os the Latin term for by mouth).  So, after some gesturing and me going to the kitchen to make an oral rehydrating solution with salt and water (that I still to this day feel like was a combination of Divine Intervention and following my intuition/training/instinct/knowledge with prior clinical experience), made her a solution and got her to drink some.  Pedialyte and other things are typically available to us, but not 30,000+ up in the sky, at least on this particular day. She promptly had an episode of emesis (another vomiting sesh), but was more oriented than before and able to follow my commands/gestures.

It was time to make a decision.  This is taking a lot of lines to write and I'm painting as accurate a picture I can of that version of me in her black Lululemon leggings leaning over this precious little body pleading with her to be strong and resilient and willing us to be a team to get her to the medical care she needed.

Did we need to land in Northern Russia for her to be whisked off to some medical facility for IVF or could I stabilize her/keep her hydrated enough to travel the remaining 10ish hours to Los Angeles?!  (Insert emoji with big eyes, maybe like 50 of them, no let's do 300+ for each passenger on that plane).  I felt all eyes were on me, and maybe even the pilot with eyes in the back of his head, oh no, those were the ACTUAL eyes of the pilot who had come to talk to me personally where I was tending to the patient.  

Don't worry, there are multiple pilots on these long flights, so it was one of them, probably rotating shifts.  Which makes me wonder, if we don't want pilots flying over 10 hours, why are we okay with Doctors working 28 hour shifts again?!?  Can I get an Amen!  I have done spinal taps on teeny tiny babies on hour 20+ of my shifts. And did them amazingly well I might add, and many many colleagues the world over give impeccable care on little or no sleep. I gave every ounce of my concentration and love and focus on those shifts to those babies, children and their families, often to the detriment of myself - just ask JD about the things I would say or how weird I would be waking up from post call sleep naps.  And I'm not alone in this, there are thousands of doctors around the world right now providing their very best care, even though they are extremely fatigued.

Back to the DECISION.  In my mind, seeing this young girl in my clinic, I would have likely referred her to the Pediatric ED where we could do what I liked to call ZO/PO/GO which is Zofran for anti nausea, a PO trial which is drinking something by mouth to see how the patient does and if they can keep it down (which would make me more confident they could go home or be monitored by their parents for ongoing fluid replacement with appropriate instructions on when to return if needed), and then go home.  And it wouldn't hurt to get some bloodwork because getting a chemistry panel on these patients really helps us understand where their electrolytes are, and how dehydrated they are.  And some IVF are available if they cannot tolerate oral fluids.

This patient was very much straddling the need for IVF and given the opportunity to give her some, I likely would have elected to do so.  But as I hopefully illustrated above, this was not a possibility with the equipment available.

I have seen patients die of dehydration, so I respect this very much.  We learn in medicine to define a patient with gut instincts as "sick" vs "not sick".  She wasn't quite so straightforward. I felt she was hovering in between.  Of course, this would be super complicated. But making a gut decision was now, and listening to my intuition and inducting myself in the Mile High Club- Doctor's Edition was now.

She miraculously drank a lot of the rehydration solution I had made her (exact volume don't recall now), but I was taking furious mental notes to later transcribe on my phone note app you guys for her transfer to the next Physician.  I was in full clinical mode.

I closed my eyes again, did some pleading prayers to the Ultimate Physician above that He would use me as a healing agent, give this little girl strength and continue to allow her to rehydrate herself on her own accord. 

I gulped. I breathed in and out.  I told the captain/pilot and Bursar we could continue on the planned route.  They were so relieved, and practically danced away.  And there I was with my brilliant little patient.  

We only had 10+ more hours to go, with no opportunity to land.  Please, oh please let this decision be the "right" one and this little girl continue to drink fluids, and not decline.

You've been there, Mama. Okay, maybe not on an Air Emirates flight with a critically ill patient, a Northern Russian landing strip and a command decision to land or continue flying, but big decisions have loomed- those where you wish some Divine Intervention or billboard or sign in the sky would point you DEFINITIVELY in the direction you should go, or toward the outcome you desire.  We like facts and we like to be sure.  We like to control and we like to know.  We're human.  And on top of that we're Mama humans.

But many, many times in life, in fact all through life, each day we make micro decisions that can strengthen our Intuition (Mamatuition!) and instinct muscles, so that when the big decisions loom, we can get quiet and still and look within and call upon that internal compass that is the most sacred space to make decisions.

In my clinical practice, a pivotal vital sign for me in addition to the normal ones we collect of Heart Rate, Breathing rate, Blood pressure, temperature, etc. was looking the Mom in the eye and asking, "What do you feel is going on with your child?" Or what did they google/diagnose at home haha.  

I will make all of you into the Mamatricians that you are, hang out with me long enough.  I know how powerful you Mamas are! That's why I'm compelled to build this space is that I've witnessed it over and over again.  When I combine my clinical skills and expertise with a Mama's Intuition and her knowledge and expertise of her own child, we do some magical things together as a team, make some crazy hard diagnoses and everyone felt more validated, healed and empowered along the way. This is what I desire for all of you, Mamas.

These and many other patient encounters with Mamas and their babies pointed me toward an ever growing desire that when I really turned inward to listen realized, it was a calling. An unshakable feeling down to the very last cell in my body that I had to share my passion for empowering Mamas with the world. I had no idea, in that moment on the plane over Northern Russia, that my life would change forever. Or how it would plant the seeds of the trajectory of what was to come… or even more shockingly, just how much it would change… to sitting here getting to compose weekly waves to all of your brilliant Mamas.

What happened to the little girl and how did it go on the remaining 10ish hours of our flight?!  Stay tuned for next week's follow up email/blog.  It was getting so long when I wrote it out, I decided to split it into 2 waves of landing in your inbox. 

Fly those friendly skies Mama, until next week I'll be soaring in the Mama stratospheres with you!

P.S. It's spring break toddler preschool style and I've been raging at the beach with allll the sand and snacks and sunscreen, soooo I've given myself grace to waft this email your way today.  

You can't sit with us, j/k you totally can there is endless room on our beach towels in Maui- just bring the mangoes or seaweed, rice crackers, and all the the snacks we've been loving at the beach, or as bait to get in and out of our carseats WHO ARE WE KIDDING these days.

 -Anik

Inviting you to share what you'd like to see here

Use the form below or email [email protected]

By visiting this site you agree to Mama Mindset™ Terms of Service and Privacy Policy.

Aloha, Mama! Nothing on this website is medical advice and no physician-patient relationship is formed by being on this site. This information is not intended to be and does not constitute medical advice. You should consult a physician in your area before acting or not acting as a result of information provided through our content.