Goodbye, Mr Chips
The touch is unexpected and wakes Anna immediately. The last thing she remembers is the heat of summer and tufts of scorched grass. She must have nodded off while reading and her brain had run with images of the story. But a moment is all it takes to re-orientate herself. The cabin lighting is dim but sufficient to make out one of the cabin crew, leaning over her. It is the flight attendant who welcomed Anna onto the plane. As soon as she sees Anna’s eyes open, she murmurs, “Are you a medical doctor?”
After years of having to switch from deep sleep to fully functional in only a second, Anna sits up, immediately alert. She nods.
“Please, could you bring your credentials and come with me?” It is phrased as a question, but the tone is more an instruction. Anna recognises the demeanour of someone who is used to being obeyed. It reminds her of the ward sisters and senior nurses in the hospital.
She slides out of the bed but as her foot lands on the shoes she kicked off earlier, her ankle twists and she stumbles against the wall separating her from her neighbour’s cocoon. His eyes flick open and he catches Anna’s muttered apology, as well as the flight attendant’s words, “Please hurry.”
Anna scoops up her laptop bag, leaving behind the laptop, and follows as the attendant leads her forwards. She is desperately hoping nothing is wrong with their captain or co-pilot. Nothing like this has ever happened to her before, but she is aware of stories from colleagues and knows what to expect. Or perhaps she doesn’t. First, she has to penetrate a layer of women, robed in black and softly keening. Laid out on the floor of First Class, surrounded by medical debris, is a corpulent man in robes, who to Anna’s trained eye is decidedly dead. His clothing has been cut open and pads are stuck to his torso, one above his right breast, another to his left lower chest. She notes they’ve been correctly placed. A male flight attendant is on his knees, one hand on top of the other as he pushes down on the dead man’s chest.
Another attendant taps Anna’s shoulder and gives her a handset. “Medlink,” she says and steps back.
“Can I take your name, please?” the Medlink operator says.
Anna gives it. Quickly, they run through her qualifications, employer, and registration. Then they say, “We believe the patient is asystolic. Your plane is more than thirty minutes out from the closest medical facilities at Goose Bay. The plane should be carrying epinephrine. Can you treat?”
Anna understands immediately. “Yes,” she says, but she knows the chances of success are infinitesimally slender. It is sometimes hard to accept that not everyone can be saved. The scene in the emergency room where the patient is resuscitated by the handsome doctor striding into the resus bay is played out on millions of television screens across the world. The truth is, even in a hospital surrounded by every modern piece of equipment with a fully trained medical team, the chances of saving an asystolic patient are around one in ten. Nine out of those ten will stay dead.
Here, in a plane, a long way from help – with just her, the flight attendants, a basic medical kit, and a defibrillator – there is almost no chance. Defibrillators save lives if the heart rhythm is disturbed, but not if there is no rhythm at all. Every anaesthetist does training stints in the Emergency Department. Anna fully understands what is happening.
The traveller is obviously rich, probably powerful. The airline will want no comeback. But twenty minutes of resuscitation is normally the limit. He has already been dead for a few minutes. The further delay until the aircraft can land, the time to deplane the man, and transfer him to hospital make survival impossible. Continued resuscitation past that point would be futile, only serving to further distress the patient’s family and reduce the patient’s dignity in death. And no one wants to divert an entire plane-load of passengers when there is no possibility of saving a life.
But everybody deserves a chance. As the defibrillator chirps No shock advised once more, Anna turns to the flight attendant, noting her name badge. Susie.
“How long has he been this way?”
But it is male flight attendant, kneeling on the floor and bouncing on the patient’s chest, who answers: “About five minutes. I got to him almost right away.”
“Susie, can you set a timer and where is your medical kit?”
Susie thrusts a kit at Anna. She opens it, extracts the stethoscope, and kneels beside the man doing CPR. “What’s your name?” she asks.
“Toby,” he pants.
But when Anna places the stethoscope on the man’s chest, all she can hear is the roar of the aircraft engines transmitted through the floor. She pulls the stethoscope out of her ears and looks up at the surrounding women.
“Was he eating anything? Is he allergic?”
Most of them stare blankly back, but then one young voice from their midst says, “No. No food.”
Anna turns back to Toby. “Can you blow into his mouth?” She puts a mask in place and Toby reaches the end of a compression and blows into the patient’s mouth. Anna is watching carefully. She thinks she sees the chest move. It is a tiny movement, but it means the airway is probably clear.
As Toby goes back to his chest compressions, she turns back to the women. “Did he have any weakness, dizziness, or fatigue? Does he have kidney problems?”
The same small voice says, “No. It did not look so. No.”
She keeps up a running commentary for the MedLink doctor as she works. Praying there is no sudden turbulence, she picks up the largest airway, ready to insert. She takes a deep breath, then tells Toby to stop chest compressions. One quick movement, a twist, and it is done. Toby restarts compressions while she attaches the ballon and the mask, placing them over the patient’s mouth. She can see how tired Toby is, so she calls to Susie, “Are you CPR trained?”
Susie nods.
“Then take over. Toby, you can squeeze this balloon. Like this.” She shows him how and follows through with further instructions.
Susie kneels beside Toby. As his hands come up, hers come down. Toby reels back. Sweat patches show through his uniform. But he crawls to the head and starts work.
“Has anyone given adrenaline or epinephrine?” she asks, covering both names for the drug.
Everyone shakes their head. Working quickly, Anna finds the medication in the medical kit. She checks the strength. Then she starts to prepare the patient for an intravenous injection. They are already past the time for optimum efficacy. She draws the drug into a syringe, steadies it above the vein she selected, and slides the needle in. Mercifully, the plane flies steadily throughout.
She breathes and watches, but there is no sign of a return of spontaneous circulation. The defibrillator is still giving its sad message and there is no discernible pulse. Another flight attendant – Vicky, according to her name badge – kneels beside Susie. As they swap over, Anna begins preparation for a second dose. Just as she is about to inject it, the plane jolts slightly. She holds still, in case there is another bump, but all is still. She goes for it, then rocks back on her heels to wait. Still no change. She watches the timer Susie set on a mobile phone. The seconds add to the minutes of the time the patient has been dead.
Anna hangs her head. This was an improbable save from the start, but hope is incredibly strong in humans. She speaks to the MedLink doctor. “No reversible cause,” she states. “Twenty minutes of CPR, two doses of epinephrine administered, and no sign of return to spontaneous circulation. Are you in agreement if I pronounce death?”
“Yes.”
Anna screens out the sobs and the muttering, and concentrates on running through the sequence. Respiration, verbal stimuli, pain stimuli. She uses her phone light to check the pupils, then palpates the carotid artery. When she has finished, she gives her time of death summary. She has no idea where they are or what the local time might be, but presumably the operator does.
Then she turns to the flight attendants. She leans across and stills Vicky’s arms. Toby is openly sobbing as his hands drop away from the AMBU bag. Susie looks like she may collapse. Anna takes one look at their distraught faces and realises they are now her patients.
“You all did magnificently. You were absolutely wonderful.” Where her hands are still on Vicky’s arm, she squeezes gently. “Even in a hospital, this would have been difficult. The odds were always against us.”
It is only as Anna looks up that she grasps how many people have been watching her. One of the pilots is standing behind her and she doesn’t realise until he speaks. “I’ll let the captain know. He started to divert as soon as notified, but we’ll probably correct for Los Angeles now.”
“Wait!” Anna calls. She stands, so she is closer to his height. “They need a break. They will be physically and emotionally exhausted. Make sure they get some tea and something sweet – cake or cookies.” She indicates Toby, Susie, and Vicky. She’d known from the start how low was the chance they could save the patient’s life, maybe one or two per cent. They hadn’t. She had known that no matter how hard you try, you cannot save everyone. They hadn’t.
He nods. “We’ll rotate some crew up from Economy.”
She leans closer still and lowers her voice further. “And the deceased?”
“The First Class suites are very private. I’ll get two of the strongest crew as soon as I’ve notified the captain. They’ll help me lift him back into his suite. We’ll cover him and keep him there until we land. There’s nothing else we can do. There’s no spare space on an aircraft.”
She lets him go. Then she returns to the dead. She removes the bag and airway, detaches the defibrillator, and tries to pull his clothing together. A nurse would normally do this, but here, she is the best person. An unrecognised flight attendant appears, and Anna indicates the syringe.
“That is clinical waste. It needs careful disposal,” she says.
“I’ll deal with it,” he says with a nod. “Thank you for your help. Is there anything you need? A brandy, perhaps?”
“No, thank you.” Anna gives a resigned half-smile. For someone who was a doctor through the last pandemic, if she’d had a drink every time she’d lost a patient, she’d be an alcoholic by now.
As Anna crosses the short corridor from First to Business Class, she feels as if she has stepped from one world to another. Here, people slumber on, or stare vacantly at screens, entirely unaware of the drama that has just played out. The drone of the engines dominates, a thick, monotonous blanket to other sounds. In that mind-numbing atmosphere so peculiar to long-distance flights, Anna heads to her seat. She is used to this, after all. Moving from drama to calm, death to life.