The Patient Was…

The patient was a woman in her mid-thirties, who indicated to a flight attendant that she was suffering from severe abdominal pain. She did not speak English or another language recognized by the cabin crew, so she conveyed her distress by rubbing her mid-section, moaning, and grimacing dramatically.

When the senior flight attendant asked if there was a doctor on board, three of us responded. We were led to the back of the aircraft where the patient was sitting in the window seat of the last row. She moved easily to the space in front of the galley in the rear of the plane and lay on a blanket placed on the floor.

The three of us who responded to the call for assistance quickly introduced ourselves to one another. There was a young physician, still in his residency training in internal medicine. The second responder, an older man, was a surgeon from Egypt. I was the third.

The young resident physician excused himself and returned to his seat, indicating that since I was a more experienced physician and board-certified in internal medicine, he would defer to any judgement that I made. The surgeon and I shook hands, then knelt on opposite sides of the patient who lay quietly before us.

As I leaned forward to start to examine the woman, the surgeon said, “We have to operate.”

“What?” I said, sure that I had misheard him. The idea of operating upon someone on the floor of a commercial airliner in mid-flight was so absurd that I couldn’t really believe he had said it.

“We have to operate,” he repeated, emphatically. “Now!”

“What are you talking about?” I asked. “Look at the patient. She seems okay.”

Indeed, the woman was lying comfortably, neither moaning nor grimacing, and in no apparent distress. Ignoring the surgeon, who was glowering, I placed my hands on the patient’s abdomen. There was no indication of pain or discomfort; her abdomen was soft and nontender. I carefully palpated the four quadrants, right and left upper and lower, and she didn’t respond with any signs of distress. With the stethoscope contained in the airline’s rudimentary medical kit I listened to her abdomen and the sounds were normal.

I looked up at the surgeon who hadn’t moved from the woman’s side. He didn’t attempt to examine her, as I thought he would. He simply looked at me and said, again, “We have to operate.” Then he added, “It will be heroic.”

Suddenly, I got it. It was an “aha” moment for me.

I put my hands, as if protectively, over the patient’s abdomen, looked directly at the surgeon, and said firmly, “You will operate over my dead body.”

He rose to his feet, anger on his face, and retreated to his seat, to the visible relief of the flight attendants standing by. The crisis, this one involving patient and doctors, was over.

My epiphany, if it can be called that, was triggered by the surgeon’s use of the word “heroic.” Some weeks earlier, in a widely publicized event, a surgeon had performed an in-flight, life-saving maneuver on a passenger experiencing breathing difficulty from a collapsed lung. The doctor’s efforts were repeatedly described as “heroic” in world-wide news stories.

I’m convinced the Egyptian surgeon knew of this event and was consumed by the desire for similar recognition and acclaim when an opportunity seemed to present itself. Judgement and perspective were abandoned. The principle of “primum non nocere” or “First do no harm” was disregarded.

But even in the most charitable light, if one concedes that he really meant to help the patient, the surgeon illustrated the difference between what one intends to do and what one actually does. As the saying goes: The road to hell is paved with good intentions.