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March 28, 2014

You’re the Pilot: In Flight Medical Emergency

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Written by: Eric Auxier
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“Ladies and gentlemen, from the flight deck, this is your Captain speaking,” I begin, briefing the passengers over the ships’ PA during the final stages of boarding. “Welcome aboard Flight 92. We’ll be cruising at an initial altitude of 32,000’ . . .” I expect Flight 92 to be a routine flight. We’ve packed 184 passengers—3 shy of capacity—into our Airbus A321, and are about to ship off from Charlotte, NC (KCLT) to Phoenix, AZ (KPHX). The flight should be three hours and forty four minutes of smooth sailing.

A320 DashOn this leg, I act as both PIC (Pilot in Command—i.e., Captain) and PF (Pilot Flying). My FO (First Officer) is the PNF, or Pilot Not Flying. In other words, as PF my sole job is to fly the plane. As PNF, my FO manages the flight. That means he handles all of the radio calls and other communications, updates the weather, and generally deals with whatever comes up. Today, that task falls upon the broad and capable shoulders of First Officer “Big Yo”—costar of my recent Livin the Dream video, which chronicled our previous leg, just the day before. True to form, takeoff and climb out go without a hitch. But as I said in the video, “As an airline pilot, you gotta be ready for anything.” And today, that “anything”—as is often the case—begins with the ding! of the call button from the lead flight attendant.

“Domino’s Pizza,” Big Yo answers in typical, smart-aleck first officer fashion. “Uh, put the pizza order on hold, boss,” our First Flight Attendant Curtis says. “We’ve got a passenger back here that’s losing consciousness.” We perk up, and trade alarmed glances. “Who’s the patient?” Yo asks. “Elderly female. We’ve got her on oxygen and are asking for any medical personnel on board.” Yo looks to me. “MedLink?” I ask. “What about MedLink?” Yo relays, referring to our contract medical service. Nationwide, subscriber airlines have direct radio access to a medical doctor, who can assess the situation and help with both medical and diversion decisions. “We’re contacting them now,” Curtis answers. “You have the aircraft,” I say to Yo. “I have the aircraft,” he quickly replies, switching the autopilot to his side. From here on out, he’s the PF and I’m the PNF.

“Curtis,” I chime in, “this is Cap’n Eric. I want to emphasize that your primary duty is to keep us informed. You are our eyes and ears back there. Let the other three flight attendants handle the emergency while you communicate with us as necessary.” (see notes, below) “Aye aye, Cap’n,” Curtis says. We hang up.

MCDU contact Medical Emer crop“Whatcha wanna do, Boss?” Yo asks. “Steady as she goes,” I say. “Don’t declare a medical emergency just yet. But let ATC know what’s going on.” I don’t want to make any major decisions until our dispatcher, Barry, is in the loop, and we know more about the passenger’s condition and what the MedLink doctor says. To inform the company of our situation, I use the Multifunction Control Display Unit (MCDU, the computer onboard the Airbus). I type our situation into the ACARS (Aircraft Communications Addressing and Reporting System) and hit send.

A few minutes pass. During this time, Yo and I discuss our options. Memphis (KMEM) is dead ahead, but if we make a hard right turn St. Louis (KSTL) is not much further. Neither of us have been to KMEM before, however we’ve both been to KSTL plenty of times. Moreover, our airline has regular service there. We’re a little fuzzy on what KMEM has to offer us. Just in case, I pull up the weather for both stations. Good weather at both, thank goodness.

Curtis calls back. “We got a whole team of nurses on board,” he says. “Coming back from a convention. They’re checking her vitals.” “Great,” I say. “We caught a lucky break. Is she conscious?” “For now,” Curtis replies. “What does MedLink say?” I ask. “Still working on it,” comes the unfortunate reply. The MedLink system can be a little cumbersome at times, as the signal can be a bit sketchy. At least on this new A321, the FA’s can contact them directly. On our older models, the pilots have to do it, and then relay the info back and forth to the cabin. It places yet another burden on the pilots, as well as another barrier to precise and quick communication.

In the meantime, we are traveling westbound at Mach 0.8. At one mile every six seconds, the situation is always fluid; the decisions change with the scenery. KMEM is now a half hour in front of us. Beyond that, I note, is KLIT (Little Rock), and KMCI (Kansas City.) Our dispatcher Barry comes back via the ACARS. He informs us we have a good station at KMEM. There is no need to add extra time on the flight with a diversion to KSTL or one of the other options. After discussing it with Yo, we all agree on KMEM. But if we’re going to land, we need to start down soon. Very soon.

New Dest MCDUJust like that, Curtis calls back. “She’s out again,” he informs us. “MedLink has advised us to divert.” “Roger that,” I respond, nodding to Yo. The trigger has just been pulled, and suddenly everyone is very busy. As Yo declares a medical emergency to ATC and requests vectors straight to Memphis, I brief Curtis. “OK, you’ve got twenty-five minutes before we’re on the ground,” I say as I type the new destination in the MCDU. “I’ll make a PA to the passengers letting them know what is going on as soon as I get the chance.”

As Yo turns direct for Memphis and begins his high dive, I type KMEM as the new destination into the MCDU, then update the weather. Good skies. No need for a time-consuming ILS approach. “Light winds, Yo,” I advise. “Which runway you want?” We both study our airport charts. “Since we’re approaching from the east,” he replies, “let’s do a straight-in to 27.” “Sounds good,” I say, typing it in. But that gives me a thought.

Loaded to the gills with fuel and passengers, we could be close to an overweight landing. I do a quick mental calc on the landing weight: approximately 178,000 pounds. Yep, we’re gonna be overweight. That gives us two options: Land overweight, or fly in circles to burn off fuel. I call the QRH Overwt Cropback. “Any updates, Curtis?” “That’s a negative, Cap. She’s still out, and we lost the MedLink connection again.” “Damn,” I mumble. I make an instant decision. “OK. Touchdown in 20 minutes.” With her medical condition unknown—and possibly dire—and with MedLink unable to advise, I decide the heavy landing is worth the risk.

I pull out the QRH (Quick Reference Handbook), and turn to the overweight landing checklist. With Yo still bombing into KMEM at 330-plus knots, I run the checklist solo, reviewing the procedures, considerations and calculations. One major issue that I must contend with: we may be too heavy for a go-around. I flip to the chart table and calculate. I breathe a sigh of relief: we’re heavy, but not too heavy for a go-around. Next, I flip to the landing tables and calculate. I make a quick call to the KMEM ground crew on the number two radio: they’re ready for us, and we’ll be using gate C-8. I eyeball the airport diagram again.

00253IL36L“Hey, Yo,” I say. “I’m gonna overrule you on Runway 27. Tell them we want 36 Center. It’s over 2,000 feet longer and is also closer to our gate.” “Roger that,” he replies, accepting my decision in an instant. He keys the mike. “Memphis approach, Flight 92. We’re gonna need 36 Center.” Since we are a Medical Emergency aircraft, ATC gives us priority, no questions asked. In short, we get what we want. “Flight 92, turn left heading 200°, vectors dogleg base for 36 Center.” Yo reads back the clearance and turns to 200° as I type the runway into the MCDU and set up the ILS. While the weather is severe clear, the ILS will help us stay on the proper track and glideslope. Especially with an unfamiliar airport.

As we bomb through 10,000 feet, Yo throws out full speed brakes to maintain 250 knots. As an emergency aircraft, we could wave that speed restriction, but that would mean we’d have a lot of splainin’ to do afterwards. Besides, a overly-heavy jet takes oodles of time to slow down. Oodles and oodles of time.

“Flaps one,” Yo commands. “Flaps one,” I reply, pulling the flap lever back to the first notch. The amber too slow bar, hovering near our speed, begins to recede. At this weight, we are between a rock and a hard place: barely three knots between max Flap speed and minimum flying speed. Moreover, the heavy, clean jet wants to go fast. Simply put, we can’t just “go down and slow down.”

Knot by precious knot, the airplane, ever so reluctantly, slows. “Hey, Yo,” I say. “I know you’re busy, but I need your attention for the last part of the Overweight Landing checklist.” Yo takes a deep breath. “Go ahead, Boss.” I read the final notes to him. “‘At touchdown, land as smoothly as possible.’—Duh!” I add. We chuckle, the humor helping to break at the tension. “I’ll record the VSI. ’On touchdown, use max reverse thrust and apply brakes as necessary—'” “Flaps two,” Yo interrupts. “Flaps two,” I reply. As PF, Yo gets to interrupt me at any time to fly the plane. Again, as always, priority one is to FLY THE PLANE. I continue. “‘Make an overweight landing entry in the logbook. A maintenance inspection is required before next flight.’ Overweight Landing Checklist—Complete.” “Roger that.”

Since we are unfamiliar with the airport, and Yo has his hands full flying and talking on the radio—not to mention slowing down the overweight juggernaut—I brief the approach for him. “I have Memphis page 11-7, ILS Runway 36 Center approach, dated 12 April 13.” Yo glances at his chart, “I agree, 11-7, dated 12 April 13.” “Highest MSA (Minimum Safe Altitude) is 2,500 to the east, off of MEM VOR. ILS frequency 110.5, ITSE, tuned and identified, inbound course 360 degrees…” “Flight 92, turn right heading 330,” ATC cuts in, “cleared ILS 36 Center, contact Memphis Tower on one one niner point seven.” Yo replies and contacts tower, who clears us to land. I finish the brief. One last thing for me to do. I pick up the PA.

Cockpit PA 2“Ladies and gentlemen,” I begin, “this is your Captain speaking. As you are probably aware, we have a medical issue on board and are diverting to land in Memphis. We will be touching down in five minutes. I will need everyone’s cooperation today by remaining in your seats when we arrive at the gate—“ “Gear down, Flaps 3, Landing Checklist.” “Gear down, Flaps 3,” I repeat, do so, then continue on the PA, “—to allow emergency medical personnel onboard. We are hoping to continue on our way to Phoenix within the hour. Thank you for your cooperation.”

I hang up and read the Landing Checklist. “Engine mode Norm, Landing gear, verify, Down, Three Green.” “Down three green,” Yo repeats, then adds, “Flaps Full.” “Flaps Full. Landing checklist complete. Cleared to land 36 Center,” I confirm. On short final, to break the tension one last time, I say the famous Leslie Nielsen line from the movie, “Airplane!” still quoted to this day in cockpits worldwide:

“I just want you to know—we’re all counting on you.”

The gambit works. Yo chuckles, then pulls off one of the smoothest greaser landings in the history of landings. I don’t know whether to be proud or jealous. Hell, I’m both. At the gate, I once again jump on the PA. “This is the Captain. Remain seated.” Paramedics board the plane and tend to the passenger. Now awake but still quite dazed, the medics half-carry her off. Her daughter, obviously, deplanes with her. I nod to Yo, who turns off the seatbelt sign. “Ladies and gentlemen, from the flight deck, I want to thank you for your cooperation. We will be refueling and departing as soon as possible to Phoenix. For now feel free to stretch your legs, but please remain on board to help expedite our departure. I’m hoping for a quick, 30-minute turnaround so as to minimize our arrival delay.”

Sure enough, KMEM is a crack station. Despite the baffling arrival of different metal (our A320 was the first they’d ever seen, as opposed to the E190’s they are used to servicing,) we are closed and on our way in record time. We arrive in PHX not 1 hour late, even if we are two passengers light. As Captain, I will have fill out the requisite ‘event report’ paperwork within 24 hours. Otherwise, for me, the case is closed. However, again as Captain, after such an event I always have a ‘post-flight debrief’ with the crew.

Elvis has left MCDU LoAs we gather round in First Class to discuss the event, I start by saying, “I just want to say I thought you all did an outstanding job in back today, and that will be reflected in my report. I especially want to commend you, Curtis, who kept your cool throughout and kept us well-informed.” They nod their gratitude. “Now, does anyone have any comments, criticisms or questions about what we did right, or what we could have done better?” The discussion continues for another 15 minutes, all of us learning a little more about CRM (Crew Resource Management), crew communications, and emergencies. While I am proud of our near-flawless execution, next time, each one of us will perform that much better.

While I never head back as to the condition of our passenger, I have a feeling she turned out fine…

If a little baffled as to why she awoke in Memphis and not Phoenix.

—————————–

 

NOTES

Parts of the story Id like to emphasize:

—In an airplane, nothing beats experience. That’s why it’s so critical for airline pilots to have thousands of hours in the cockpit. For me, I learned to make this exact brief with a flight attendant during any “non-normal” situation. Otherwise, “our eyes and ears in back” may go deaf and blind, which happened to me during another medical emergency.

Our lead flight attendant said to us, “She’s not going to make it,” and hung up. With visions of all flight attendants busy defibrillating a heart attack victim, we high dived into Kansas City. On the ground and in the gate, the flight attendant said, “Oh, I meant she was in the bathroom throwing up and didn’t want to continue.”

Again, communication—especially during an emergency—is critical.

This is a good lesson in CRM—Crew Resource Management. In the old days, the Captain was God, and everyone else obeyed his commands. He made all the decisions, and everyone blindly followed. In today’s enlightened environment, every crew member is valuable and respected. The Captain is still the decision maker, and has final authority. But s/he values and considers everyone’s input. Communication is key.

Note the following:

—At all times, one pilot was flying the plane, while the other was handling the emergency.

—The moment we heard there was a possible medical emergency, I gave Yo the PF duties. Moreover, in a “non-normal” situation such as this, whether a passenger issue or a mechanical one, the PF usually works the primary radio as well, talking with ATC, while the PNF handles all aspects of the emergency. At our airline, normally it’s the Captain who handles it. I agree with this philosophy. The FO’s are plenty experienced and trained to fly the plane themselves, while talking with ATC and also keeping the Captain in the loop as to what’s going on.

—At 6-10 miles a minute, with imperfect information and limited time, the Captain MUST make the right decision. And nearly every decision is not cut and dry. Each decision is critical, has consequences. The Captain must always weigh the risks and potential consequences with the possible outcome. Hence my decision to land overweight.

—As you can see from the narrative, in a “non-normal,” things are happening, and fast. Split-second decisions have to be made, all the while with ever-changing conditions, distractions and interruptions. For example, ATC can call at any time, even in the middle of a checklist.

—In this narrative, I’ve tried to convey the urgency of the situation. The PIC has to balance the severity of the emergency with the reality of flight conditions; i.e., what is safest? The entire flight must not be jeopardized for the sake of one passenger; even so, the passenger’s medical issue is paramount. Real decisions, in real time, traveling at 250 miles per hour, have to be made.

—Finally, while time is critical, the PIC must resist the temptation to create a self-induced time constraint. That is, increase pressure on the crew with an unrealistic desire to “get on the ground.” While the passenger’s needs are critical, the PIC must assess the safety of the entire flight. Short of an inflight fire, any “non-normal” can be met—properly, and in its time.

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Eric “Cap’n Aux” Auxier is an airline pilot by day, writer by night, and kid by choice. An A320 Captain for a major U.S. airline, he is also a freelance writer, novelist and blogger (capnaux.com). His second novel, The Last Bush Pilots, captured the coveted Amazon TOP 100 Breakthrough Novels in 2013. Mr. Auxier makes his home in Phoenix, Arizona.

 



About the Author

Eric Auxier





 
 

 

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  • sjwecks

    Fascinating.

    Since reading this through the first time, I’ve been wondering: during a typical, uneventful flight, what phases of the flight really get an airline pilot’s heart pumping? Are there any? Is the approach and landing into a familar airport during great weather at all stressful? How about an unfamilar city? Are there any cities that, regardless of your experience, move your needle every time? (e.g., the New York area fields, or down through downtown San Diego.)

    Thanks for the great service you provide to us in chairborne masses!

    • capnaux

      Good question, sjwecks!

      I think any pilot would be lying if they said they can do all the above without a single increase in heart rate. When you’re “kicked into high gear” as I was in the above story, you can bet the adrenaline was freely flowing. I imagine it’s the body’s natural “fight or flight” reaction.

      For me, the very situation that gets my heart pumping is often the same thing I enjoy most. Not talking “adrenaline junkie” here, what I mean is that, at the level of flying airliners, most things are quite…routine and boring. So, anything offering the slightest challenge becomes something to look forward to—an ILS to minimums, the DCA River Visual to 29 or JFK Canarsie into 11L (I believe it is) are some favorites, because you actually have to FOCUS and to rise to the challenge. In the end, a successful approach = job satisfaction.

      Thanks for the question and comment, sjwecks!

  • Laura Victoria Duque Arrubla

    Great story! and great how you tell it. Besides the medical emergency, this is a very good lesson in CRM, and how a routine flight can become a potentially overwhelming situation very far beyond the easy flight on autopilot most persons imagine modern aviation is. Quick under high-pressure thinking and
    decision-making, multitasking and high workload for both pilots, needing to
    communicate each other and the ATC and the cabin crew and the passengers
    meanwhile flying and landing an overweight plane with the better piloting
    technique… that’s what commercial and airline pilots are for.
    On the other hand, I love the way you highlight the importance of the Pilot Not Flying role and job. Congrtas!!!

    • Capnaux

      Thank you, Laura! I agree, lots of good CRM lessons in here. I really scratch my head when there’s talk about single pilot airline flights or even eventually going to automation. As you point out, that may work ok for the routine flight on autopilot, but what if something goes wrong?

      • Laura Victoria Duque Arrubla

        That’s right!!! Who is going to analyze, compare, deduct, discard, select and decide the better course of action, when things aren’t going as planned or designed? I shared this publication in my very humble Human Factor page in facebook https://www.facebook.com/livingsafelywithhumanerror?ref=hl