What would you do?

[E-Flyer]

I have a decision making scenario that I would like to get your evaluated answer to.

You're on a IFR Slot for a flight from EHAM (Amsterdam) to CYVR (Vancouver). The estimated flight time is 9 hours and 45 minutes, and you have a fully loaded MD11 or just for ACA's purpose, throw in a 767 or 777. After an hour worth of delay at Amsterdam, you finally get your push and start clearance for departure to Vancouver.

You come up to the runway, take off, no problem's or anything, until about 12000 feet where you hear the steward ask for a doctor onboard. I guess by this point the captain has been notified of the situation.

The captain continued climb to desired altitude while the sick passenger was not doing very well ( I am assuming the captain didn't know that ). There were 3 pilot's on board, so the captain came down and personally evaluated the situation right after level off.

They decided to continue given the passengers situation. 3 Hours later, they came above iceland, and the captain decided to divert to BIKF. He had to dump fuel, circle, and had to land in what looked like 2-3 SM Vis with clouds around 10 seconds away from touch down (obs this was forecasted to some extent in the ENROUTE TAF's)

My question is this, given the condition's of the passenger after level off, and knowing that she was a foreign passenger, would you still continue? or would you divert back to Amsterdam where the passenger definitley has Visa requirements and perhaps friends and family ? Because at the end, what happened was that the captain decided to divert to BIKF, where my guess is that the middle eastern looking passenger would definitley not have visa and insurance requirements.

Or maybe the captain's mentality was that we can continue tagging along and at least make progress in our flight with the fuel remaining and deal with the situation later. But in that case, how about if the situation became life threatening right over green land? not much u can do there except for wair for another 200-300 nm right?


If I could have your decision's on this I'd be very thankful as I would find it a valuable decision making scenario to know about.


Cheers

[tonysoprano]

E-flyer.
At our company we have Medlink which would assist us in making such a decision. They and any medical staff on board, if available, would help us decide wether to continue or land. Having said that, the captain would probably have made a decision prior to entering Oceanic airspace. If he was comfortable with the patient's condition at that time, he would continue. If not, he would have many options for a landing in the UK or returning to AMS. The passenger's country of origin would not be a factor in this situation. By continuing over the Atlantic, the Capt was either unaware of the pax's condition or was confortable with a successful crossing. Many European companies do not have the services of Medlink available so the captain is on his own without a doctor on board.

[Rockie]

As with any of these types of post-mortem scenarios, we weren't there so our opinion is basically worthless to the situation. Having said that any decision regarding the progress of the flight is made by the Captain using the best information he has available. I will give him/her the benefit of the doubt and presume there was nothing in the passengers condition to warrant diverting until he did. People get sick all the time on aircraft for all sorts of reasons and usually all it takes is a little oxygen and TLC to bring them back around. Beyond that I couldn't say. Even some of the crewmembers aren't aware of all the information in a situation like that so the passengers certainly wouldn't be, and we can't second guess his decision.

[E-Flyer]

There was a doctor onboard

Cheers for the response !

[RB-211]

Tony gives a good explanation but as said in Top Gun ‘The data on the MIG is inaccurate’.

Medlink is available to any airline worldwide that has the cash to pay for it and the ability to communicate with it. I have used it worldwide on HF/Satcom and ACARS. It is a company based in the US that basically takes the guess works out of these situations. In doing so it takes full responsibility of the situation and absolves the Capt and the crew of any liability. This includes any doctors onboard. In other words it is their call........

If Medlink advises a landing at the nearest suitable airport (they chose according to the patient’s condition), the crew then do their job and decide if they can get in safely. If not they carry on and deal with it later.

P.S. Tony, sorry about Rome. I am sure the extra FRA will cause quite a stir!!!!

[tonysoprano]

Well gee, thanks for the briefing RB. You sure are a wealth of information. What ever it takes to feel good. Although I would be a little skeptical on the ACARS use for Medlink. Voice comm on HF or Flt Phones is the way we like to do it at Mapleflot. I'm sure it's the same at HRM's proud airline.

P.S. Tony, sorry about Rome. I am sure the extra FRA will cause quite a stir!!!!

It's only temporary bro - three month break. And hey, the beer in FRA is just as good. See ya there? Anymore news on your strike??? How's T5 these days?

[Jaques Strappe]

As Rockie said, the post mortem is with out basis really, due to lack of facts.

However, one thing about modern aviation and the Captains vocabulary is "Liability".

There have been several instances where a Captain has pressed on with either a sick passenger or crew member, thinking that the issue was a relatively minor one only to find himself in front of a judge being asked about his medical training background that assisted him in making such a call. This is where companies like Medlink are invaluable.

BA had an instance where the crew began to suffer from symptoms of food poisoning and eventually, the Captain was the only one left on the flight deck of a 747-200. He continued on to London ( rather than divert ) single pilot and was eventually charged and convicted under the criminal code for endagering the lives of his passengers. He sadly commited suicide before sentencing. Obviously, there are some more details to that story but it is a grave illustration of the consequences nonetheless.

If someone becomes sick enough on the flight to possibly need medical attention, without proper background knowledge, medical history and training, the Captain is not really qualified to make a diagnosis. If he cannot defer that to someone who can, his ass is out there should he decide to continue in my opinion.

[E-Flyer]

The thing was that the doctor was on board and I guess at the time it wasn't necessary for a return to amsterdam. But then again, would you rather press on and burn fuel then dump less and at least have made progress in your flight or do you dump all the fuel, circle out the coast of amsterdam and make no progress? Remember, this was a fully loaded MD11 in September where people are coming back from their vacations. The flight was fully loaded.

[groundtoflightdeck]

I think you are focusing on the wrong parts. Airlines burn hundreds of thousands of pounds of fuel per day so to dump a couple thousand pounds of fuel isn't really the end of the world... someone dying on board is a bigger deal. On the customer service side the passengers, for the most part, will say they got to destination; or, not to desination, part way doesn't cut it. So if you push on then divert to Keflivik and the crew is time-x'd after landing (don't think you'll be making a quick turn). The passengers won't care they made it 1/2 way- they'd rather be at the departure city.

As its been pointed out we can't be armchair quaterbacks for all these senarios because we don't have all the info the crew did. You do have to be careful about pressing on with someone who might die... and you have to watch your own ass. This, as most diversions are, is a descion between the crew, dispatch, SOC and their resources. There are many factors that each part of the team will consider; which, in turn, will lead to a decsion. I should say that I don't work for Air Canada so this doesn't take into account what their COM might say on this.

[Rockie]

Don't focus on the fuel dumping because they wouldn't have to dump unless it was required for landing distance purposes, and Amsterdam has very long runways. It is entirely acceptable to land over max landing weight for a circumstance such as this, in fact A330's don't even have a fuel dumping capability and can land at max takeoff weight if required. In a case like this I would continue until a medical authority (either on board or Medlink) told me the person needed medical attention, or if none was available it seemed the prudent thing to do given the routing. But again there is not enough information here for any of us to armchair quarterback.

[E-Flyer]

Oh ok thanks for the awesome feedback you guys

[liketofly]

Personally, I would divert as soon as it was made clear that advanced care, beyond what was being delivered on the aircraft, was required. It a tough balancing act, I'm sure.

It is entirely acceptable to land over max landing weight for a circumstance such as this, in fact A330's don't even have a fuel dumping capability and can land at max takeoff weight if required.

Rockie,
Fuel dump capability is actually an option on the 330. Landing up to MTOW is permitted, although I do believe there is a requirement for some gear inspections afterwards.

Obviously in the case of a medical diversion this is not really an important consideration.

[Rockie]

The ones I flew didn't have it. A gear inspection isn't even required either. The techies check the maintenance computer for vertical speed on landing and as long as it's below a certain threshold you're good to go. The checklist calls for under 360 fpm but I'm not sure if that is the dividing line between no action or further inspection. You could for instance divert to another airfield without maintenance and land over max landing weight, but be able to proceed without maintenance action if your vs on landing was below that value.

No one wants to dump fuel if they can avoid it both for cost and environmental reasons. It is a last resort to be used only if you absolutely have to for landing performance reasons.

[E-Flyer]

The ones I flew didn't have it. A gear inspection isn't even required either. The techies check the maintenance computer for vertical speed on landing and as long as it's below a certain threshold you're good to go. The checklist calls for under 360 fpm but I'm not sure if that is the dividing line between no action or further inspection. You could for instance divert to another airfield without maintenance and land over max landing weight, but be able to proceed without maintenance action if your vs on landing was below that value.

No one wants to dump fuel if they can avoid it both for cost and environmental reasons. It is a last resort to be used only if you absolutely have to for landing performance reasons.

Hehe i'd hope your touch down would be along 50 and not 300 hehe.

[WJ700]

We had a LOFT scenario in the sim that was apparently based on a real life situation: three Doctors on board leaving LAX assess a sick passenger who all tell the Captain to land and get the sick person medical help; while Medlink is on Sat Phone advising to continue and ignore the other Doctors.

I've had a fair number of Medlink dealings and they are great. I'd have a very hard time going against their decisions since they haven't been wrong yet.

[Rockie]

No brainer. 11 doctors say continue and 1 says land. We land.

Why take the chance?

[rightseatwonder]

At that point all you are really talking about then is money. the money spent on the return vs. the person's health. On scene advice seems to trump medlink wouldn't it?

[WJ700]

At that point all you are really talking about then is money. the money spent on the return vs. the person's health. On scene advice seems to trump medlink wouldn't it?

That's what makes the scenario interesting, on scene advice doesn't trump medlink (in our case). It could be a Vet, a Chiropractor, a Dentist, or a University professor giving the advice and saying they are a Doctor... if your not careful or the information is relayed poorly through the FA, you could be in trouble. The main concern to me is that Medlink only takes responsibility if you follow their strict advice. If it is in your manual as a set policy that you must follow Medlink... then you are going against the manual. Medlink also considers airport facilities with Dispatch, while also considering what kind of Hospital is available. So if you land in Ontario California, what is to say that you didn't cause more of a delay for medical help than landing at LAX or continuing to YYC with a back up plan of landing short in Denver? I've heard that the responses were all different in our pilot group and the medical was just thrown in as a distraction to the remainder of the LOFT. However, I'm sure it was something learned by the company to see what different people did and why.
Myself, I'd probably land if it was an active Cardiologist (with ID) telling me to return to LAX because someone was having a heart attack. Otherwise I think I'd let Medlink tell me what to do. Anyway, I didn't do that LOFT myself but I'd heard it was an interesting one.

[Rockie]

That's why you check credentials. If the person is an MD and they say to land, we land. Responsibility or liability has nothing to do with it at that point, it's the safest thing to do concerning the patients health. An MD on site is better than one hearing words over a radio thousands of miles away every time, but either one of them saying get the patient to a hospital wins. Period.

Once the decision is made Medlink can offer up choices from a medical care point of view and get the ball rolling on the ground, but it's up to you and dispatch to determine which is most suitable from an aircraft operational point of view.

[WJ700]

That's why you check credentials. If the person is an MD and they say to land, we land. Responsibility or liability has nothing to do with it at that point, it's the safest thing to do concerning the patients health. An MD on site is better than one hearing words over a radio thousands of miles away every time, but either one of them saying get the patient to a hospital wins. Period.

Once the decision is made Medlink can offer up choices from a medical care point of view and get the ball rolling on the ground, but it's up to you and dispatch to determine which is most suitable from an aircraft operational point of view.

Sorry. can't agree with you there.

[Rockie]

That's perfectly alright WJ700. I'm not in any way offended so no need to apologize. I trust you're not offended that I don't agree with you either.

[Ryan Coke2]

While I understand the thinking of 'if any doctor thinks we should divert, we should follow that', it doesn't necessarily work as well in real life. You are saying (to paraphrase) 'to hell with liability, the persons health should be #1' which I also agree with, but the problem is that often the Doc on board, in addition to a dubious expertise in the area, also tends to have the mindset of liability--if in doubt, get the airplane to land. Even if they believe it to be a minor illness, they may recommend a diversion 'just in case', and they don't want to take the responsibility and risk of continuing on.

Whereas Medlink accepts that responsibility, and doesn't suggest a diversion unless they truly believe it is medically required, not a 'just in case' type of decision. They are also more experienced in typical situations which arise in the airline/flying world, and in diagnosing medical conditions third party from a remote location.

Having said that, and with the utmost respect and trust in Medlink (in both my peers and my personal experience), I wouldn't rule out listening to a specific expert on board, who was adamant with the need for urgent medical care, and possibly going against Medlink. Never say never sort of thing, but I would hope it would never come to that.

[Rockie]

I see your point in what comes down to human nature in erring on the side of caution for the MD on board. But the cost of continuing and being wrong vs landing and being wrong, especially under the advice of a licenced MD who has actually examined the patient is simply not worth it. In fact I would think it's irresponsible. You would be risking a persons life for the sake of saving some money and inconvenience. I would not be able to continue because ultimately the decision is mine and I would err on the side of caution as well.

[WJ700]

That's perfectly alright WJ700. I'm not in any way offended so no need to apologize. I trust you're not offended that I don't agree with you either.

Not at all. I find the thread an interesting topic from some of the usual on Avcanada. It's one of those areas that we see on a fairly regular basis and I'm certainly interested in the other point of view. I think I've had about 12 medlinks in the past few years and I've had a similar case coming back from CUN where a Doc was saying to land and Medlink advised to continue with the person on O2 and monitor vitals. Medlink ended up being correct in the end, we contiued to destination, it was fatigue that can present like a heart attack (according to the paramedics). That's probably why in most cases I will lean a little more toward Medlink in making a decision and the operating policy that supports it.

[Rockie]

Then your opinion is based on a past experience. But what if it had gone the other way and Medlink was wrong? Would the fact that they assumed responsibility for the passenger dying make you feel obsolved of your decision to continue?

It's not at all the same thing but years ago I had a passenger, also coming from CUN in fact, that had been banned from the flight for infractions he committed on the way down the week before. He was very apologetic and had a lawyer friend who offered to be responsible for him if he acted up on the way home. I politely explained to him that the only person responsible for anybody on that flight regarding safety is me, and that I could not allow him on the flight. The same principal applies here for me whether Medlink assumes legal responsibility or not.