Once a doctor, always a doctor

MEDICAL SCHOOL PERMANENTLY CHANGES YOU. It changes not only how you think, but also how you see people and, in turn, how they see and think about you. This has been most evident to me over the past several years, when after practicing full-time emergency and family medicine for more than two decades, I returned to working part-time in my former job of flying airplanes professionally. 

Fellow corporate jet pilot Doug and I leave the Regional Airport north of Seattle in the Lear jet just before dawn. It is a cold winter morning, and we have seven passengers on board the business jet with the plan to leave three in Ketchikan, two in Juneau and then take the remaining two to Valdez. We are to wait there for a couple of hours, then reverse the whole procedure, ideally getting everyone back to Seattle by dinner time. 

A small arc of the sun is visible on the eastern horizon as we start down out of 36,000 feet near Annette Island, about 70 nautical miles southeast of Ketchikan. The weather report says it is snowing in Ketchikan with visibility of one to two miles, scattered clouds at 2,000 feet, broken at 2,500 and overcast at 3,000. The wind is from the west gusting 12–20 knots. Anchorage Center clears us for the instrument approach to runway 29 and hands us off to the local frequency. Ketchikan Flight Service tells us there is snow on the runway, and braking action is unknown. We break out of the clouds at 2,500 feet about two miles from the runway to see that at 144 knots we are a bit high and fast, which is not where we want to be given the runway conditions. 

The power comes all the way back, full flaps go down and pretty soon we are nicely established on the glide path and doing the calculated correct speed of 132 knots. We make a smooth landing in blowing snow, the thrust reversers are deployed and I tentatively test the brakes – they seem okay, although hard to tell with all the deceleration generated by the jet engines. An Alaska Airlines 737 crew behind us on the same approach asks about braking. We are nearing the end of the runway and nail the brakes to see what happens. Good braking, we tell them. It is pretty clear their concern, like ours, was not the instrument approach as much as what was going to happen once the airplane was on the ground. 

When we exit the taxiway and enter Aero Service’s ramp, the Lear jet nearly comes to a crunching stop. No one has plowed the ramp, and the Lear’s high-pressure, small-diameter tires have trouble getting through six to eight inches of thick, wet snow. We power way up just to keep the airplane rolling and with some difficulty reach the lineman who is energetically waving us forward. 

Doug and I are working our way through the airplane’s 14-item shut-down checklist, when one of the passengers pokes his head in the cockpit and asks if he can open the door. With my headset still on, I nod “yes” and return to the checklist. Through the pilot’s window, however, I see that as the first man out the door reaches the ground at the bottom of the stairs, his feet slide forward and he loses his balance. He starts a slow-motion fall on what is a sheet of ice covered with snow. 

As his right arm moves backward to break his fall, my pilot brain goes quiet, and the doctor one kicks in with an unsolicited stream of diagnostic considerations.

I first think, “He must be right-handed”; I then see his right hand extend at the wrist, and I think,”Young guy – his protective reflexes are working pretty good.” But I also think, “Hmm…right hand extended at the wrist, probable Colles fracture or a fractured scaphoid (a small bone in the wrist) coming up here…or both…and on the dominant side…this guy does construction work… not good…I hope his arm takes the damage, not his head… what would we do about a subarachnoid hemorrhage here in Ketchikan anyway? That would be bad…a subdural hematoma would be better; we would have him back in Seattle by the time that showed up.” 

He catches the worst of the fall with his right arm, bends at the waist and as his gluteal muscles suffer a pretty good impact with the ground, I think, “I hope the snow gives enough cushion so he does not fracture his coccyx…those really hurt.” Now in full ER doctor mode, I am loosening my five-point pilot seat belt harness and heading for the airplane’s door. But before I can get there, he gets up, shakes his wrist a bit, rubs the snow off his pants and heads into the terminal. 

Twenty minutes later I have my “pilot” hat back on and am getting some coffee in the pilots’ lounge when one of our fall guy’s buddies, having heard somehow that their jet pilot is also a doctor, asks if I wouldn’t mind looking at his arm. With seven of his friends looking on, I have him take off his shirt and conduct an exam specific to the arm. I see his distal circulation is good, the radius and ulna are both anatomically aligned, there is no point tenderness over the anatomical snuff box or over the distal radius and ulna. But I also think, “Sometimes you can get an elbow injury or shoulder dislocation with that type of fall,” and so now in full-on doctor mode, I say “hmm” and, nodding my head slightly, extend my exam proximally all the way to his chest wall, much to the confusion of my seven-man audience. When finished I nod a bit more, then say, “His exam appears normal, but I would recommend a follow-up x-ray as, based upon exam alone, I cannot exclude a wrist fracture.” Yes, corporate jet pilot or not, it is unavoidable: I am indeed still a doctor, and apparently acting just like they expect one to. My passenger/patient says, “Thanks, Doc,” and the entourage files out of my examining room/pilots’ lounge, making respectful and grateful gestures. 

A couple months go by and in between a series of shifts at the urgent care center, I am on another trip, this time over the Eastern Atlantic between Iceland and the Outer Hebrides at 41,000 feet. I am working as the co-pilot on a flight that started in Vancouver the day before and will end in London in the evening. The airplane is an almost new Citation jet, and we have an hour or so to go at 400 knots before reaching landfall. 

Fred, the pilot in the left seat, and I are making small talk between position reports to the Oceanic controller back in Reykjavik, when one of the passengers comes forward and with slightly slurred speech says she is dizzy and doesn’t feel well. I check the cabin altitude gauge just above my right knee on the instrument panel. It says 8,000 feet, which is normal when the airplane is this high, and well tolerated by most healthy passengers. I tell her the cabin altitude is just fine, and Fred tells her to return to her seat. We both watch as she then gets about halfway back into the cabin, falls in the aisle and stops moving. 

Since, regardless of other qualifications, it is the custom for flight crews to have the pilot in the right seat take care of this type of problem, Fred asks that I get out the spare portable oxygen bottle and then put the mask on her. I release my seat belt and take off my headset to do this, but as I approach her on the floor with oxygen bottle in hand, the doctor part of my mind starts waking up and I get another stream of diagnostic observations and thoughts. I see a normal height and weight female in her 40s, who has an anxious and frightened facial appearance, pink fingernails and lips, and a respiratory rate I estimate to be about 20. As my right hand shakes her shoulder and I ask in a loud voice, “Are you OK?”, my left hand finds her wrist and a pulse of 90 or so and regular. She mumbles she cannot feel her fingers and her lips are tingling. I think, “Not hypoxia…more likely too much oxygen and not enough CO2, probably with some respiratory alkalosis thrown in…looks like hyperventilation syndrome to me…” and I wish for a pulse oximeter to confirm my working diagnosis. 

As the other passengers look on with worried expressions, with some difficulty I get my passenger (now patient) in a recovery position in the narrow space between seats, put aside the oxygen bottle and rattle through the galley looking for a paper bag. I finally find one containing candy bars. Dumping those out I return to my passenger (now patient) and in my best authoritative ER doctor’s voice say, “I want her to breathe into the bag for five minutes, at which time I am confident she will feel much better.” The time goes by, and then in a somewhat surprised voice she smiles a little and says her fingers and lips now feel okay. Ten minutes later I have her belted into her seat, and between tears she starts telling me how stressful the previous several days had been and how anxious she had been feeling. I leave her with a couple Kleenexes and return to my day job in the right front seat of the airplane. 

Shortly thereafter we cross over the Hebrides and are cleared directly to Manchester, England. A half hour later we descend out of the clouds on an instrument approach into London’s Stansted Airport and see beneath us the patchwork of green fields and stone fences so typical of England. We land without a problem and taxi to Harrod’s, the business aviation terminal. As the two jet engines spool down with their characteristic whine, I head back to open the door, and our lady passenger/patient gives me an appreciative look and silently mouths, “Thank you, Doc.” In contrast, Her Majesty’s customs agent standing on the ramp by the open door sees my uniform shirt with four stripes and says, “Welcome to England, Captain.” 

Fred and I are finishing our post-flight pilot duties when he suddenly stops and says, “You know, Kevin, once you are a doctor, you’re really always a doctor, aren’t you?” I reply, “I guess so, Fred…there are some experiences in life that permanently change how you think and who you are, and going to medical school is definitely one of them.” 

Once you are a doctor, you will always be a doctor. 

Kevin Ware, D.O.'73

After logging 25 years of full-time emergency room and office-based medical care, Kevin E. Ware, D.O.’73, ABFM, AAFP, continues to practice part-time while also working as a professional pilot. He resides in Mount Vernon, WA.

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