You’re the Captain: Medical Emergency!
Published in April 2015 issue
The following chronicles a recent event I had as captain, on a flight involving a passenger medical emergency.
By Eric Auxier
In an airbus A321 airliner traveling at Mach 0.8, events come at you at ten miles a minute. As Captain, you must make sound decisions, making use of imperfect information and limited time. Few decisions are black and white, but each is critical, and has consequences.
Now, you are the Captain. You get to call the shots, feel the urgency, the burden of command. And you must make the right decisions that result in a safe, successful outcome.
“Ladies and gentlemen, this is your Captain speaking,” you begin, briefing the passengers over the ship’s PA during the final stages of boarding. “Welcome aboard Flight 312. We’ll be cruising at an initial altitude of 32,000 feet…”
You expect Flight 312 to be routine; pack 184 passengers—3 shy of capacity—into your Airbus A321, and ship off from KCLT (Charlotte, NC) to KPHX (Phoenix, AZ). Three hours and forty-four minutes of smooth sailing. On this leg, you act as both PIC (Pilot in Command— i.e., Captain) and PF (Pilot Flying); your FO (First Officer) is PNF, or Pilot Not Flying. In other words, as PF, your sole job is to fly the plane. As PNF, your FO manages the flight— that is, handles all radio calls and communication, updates the weather, and generally deals with whatever comes up.
Today, that task falls upon the broad and capable shoulders of First Officer Mark. True to form, takeoff and climb out go without a hitch. But, as an airline pilot, you’ve got to be ready for anything. And today, that “anything”—as is often the case—begins with the “Ding!” of the call button being pressed by the lead flight attendant.
“Dominos Pizza,” Mark answers in typical, smart-aleck FO-ese. “Uh, put the pizza order on hold, boss,” First FA Curtis says. “We’ve got a passenger back here that’s losing consciousness.” You perk up, and trade alarmed glances. “Who’s the patient?” Mark asks. “Elderly female. We’ve got her on oxygen and are asking for any medical personnel on board.” Mark looks to you.
“MedLink?” you ask. “What about MedLink?” Mark relays, referring to the company’s 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,” you say to Mark. “I have the aircraft,” he quickly replies, switching the autopilot to his side. Now he’s PF and you’re PNF. Moreover, since this is an abnormal situation, Mark will also handle the radios while you manage the crisis.
“Curtis,” you chime in, “this is the Captain. 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.”
“Aye aye, Cap’n,” Curtis says. You hang up. “Whatcha wanna do, boss?” Mark asks. “Steady as she goes,” you say. “Don’t declare a medical emergency just yet. But let ATC know what’s going on.” No major decisions until your Dispatcher Barry is in the loop, and you know more about the passenger’s condition. And, more importantly, what the MedLink doctor says.
To inform the company, you use the MCDU (Multifunction Control Display Unit—the Airbus’s computer) to type your situation into the ACARS (Aircraft Communications Addressing and Reporting System—lots of acronyms in the aviation biz, and especially the Airbus.)
You hit Send. A few minutes pass. During this time, you and Mark discuss options. Memphis is dead ahead. But not much farther, if you make a hard right turn, is St. Louis. Neither of you have been to KMEM; to KSTL, you’ve been plenty of times. Moreover, your airline has regular service there. You’re a little fuzzy on what KMEM has to offer.
On the ACARS, you pull up the weather for both stations; Clear skies at both, thank goodness. Curtis calls back. “We got a couple of nurses on board,” he says. “They’re checking her vitals.” “Great,” you say. “We caught a lucky break. Is she conscious?” “For now,” Curtis responds.
“What’s MedLink say?” you ask. Curtis replies, “Still working on it.” You frown. The MedLink system can be a little cumbersome at times, the signal a bit sketchy. At least, on your new A321, the FAs can contact the medics directly. On the older models, the pilots had to do it, and then relay the info back and forth to the cabin. This was yet another burden on the pilots, and another barrier to precise and quick communication.
In the meantime, you are traveling westbound at Mach 0.8.
At one mile every six seconds, the situation is always fluid; the decisions change with the scenery. Memphis is now a half hour in front of you. Beyond that, you note, are Little Rock, and Kansas City. Dispatcher Barry comes back via the ACARS. He informs you the company has a good station at KMEM; no need to add extra time on the flight with a diversion to STL. After discussing it with Mark, you all agree on KMEM. But, if you’re going to land, you need to start down soon. Very soon.
Curtis calls back. “She’s out again, MedLink advises us to divert,” he informs you. “Roger that.” You nod to Mark.
The trigger has just been pulled. Suddenly, everyone’s very busy. As Mark declares a medical emergency on ATC and requests vectors straight to Memphis, you brief Curtis. “OK, you’ve got twenty-five minutes before you’re on the ground,” you say, as you type the new destination in the MCDU. “I’ll make a PA to the passengers as soon as I get the chance.”
As Mark turns direct for Memphis and begins his high dive, you type KMEM as the new destination into the MCDU and update the weather. Good skies. No need for a timeconsuming ILS approach. “Light winds, Mark,” you advise. “Which runway you want?”
You study your airport charts. “Since we’re approaching from the east, let’s do a straight-in to 27,” he replies. “Sounds good,” you say, typing it in.
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Loaded to the gills with fuel and passengers, you could be close to an overweight landing. You do a quick mental calc on the landing weight: approximately 178,000 pounds. Yep, overweight.
That gives you two options: Land overweight, or spin circles to burn off fuel. Another fuzzy decision to make. Risk an overweight landing to help a possibly critical patient, or burn precious time and risk losing her?
You call the back. “Any updates, Curtis?” “That’s a negative, Cap. She’s still out, and we lost the MedLink connection again,” Curtis says. “Damn,” you mumble. You take a deep breath. “Okay, Curtis. Touchdown in 20 minutes.”
With her medical condition unknown—and possibly dire—and with MedLink unable to advise, you decide the heavy landing is worth the risk. A quick call to KMEM station on the Number 2 radio. They’re ready for you, Gate C-8. You pull out the QRH (Quick Reference Handbook), and turn to the Overweight Landing Checklist. With Mark still bombing into KMEM at 330+ knots, you run the checklist solo, reviewing procedures, considerations and calculations.
One major issue: you may be too heavy for a go-around (aborted landing). You flip to the chart and calculate. You breathe a sigh of relief. Overweight, but still light enough for a go-around. Next, you flip to another set of tables and calculate landing distance. You eyeball the airport diagram again.
“Hey, Mark,” you say. “I’m gonna overrule you on Runway 27. Tell them we want 36 Center. It’s 2,000 feet longer and is also closer to our gate.” “Roger that,” he replies, accepting your decision in an instant. He keys the mike. “Memphis approach, Flight 312. We’re gonna need 36 Center.”
Since you are a Medical Emergency aircraft, ATC gives you priority, no questions asked. In short, you get what you want. “Flight 312, turn left heading 200 degrees, vectors dogleg base for 36 Center.”
Mark reads back the clearance and turns to 200 degrees, as you type the runway change into the MCDU and set up the ILS. While the weather is severe clear, the ILS will help Mark stay on the proper track and glideslope. Especially with an unfamiliar airport.
As you bomb through 10,000 feet, Mark throws out full speed brakes to maintain 250 knots, the speed limit below 10. As an emergency aircraft, you could wave that speed restriction, but you’d have a lot of ‘splainin to do afterwards. Besides, an overweight jet takes oodles of time to slow down. Oodles and oodles of time.
“Flaps One,” Mark commands. “Flaps One,” you reply, pulling the flap lever back to the first notch. The amber too slow bar, hovering near your speed, begins to recede. At this weight, you are between a rock and a hard place: barely five knots between max flap speed and minimum flying speed. Moreover, the heavy, clean jet wants to go fast. Simply put, you can’t just “go down and slow down.”
Knot by precious knot, the airplane, ever so reluctantly, slows. “Hey, Mark,” you say. “I know you’re busy, but I need your attention for the last part of the Overweight Landing Checklist.” Mark takes a deep breath. “Go ahead, boss.”
You read the final notes to him. “‘At touchdown, land as smoothly as possible’—Duh!” you add. You and Mark chuckle, the humor helping to break the tension. “I’ll record the VSI. ’On touchdown, use max reverse thrust and apply brakes as necessary.‘“
“Flaps Two,” Mark interrupts. “Flaps Two,” you reply. As PF, Mark gets to interrupt you at any time to fly the plane. Again, as always, Priority One is FLY THE PLANE. You continue, “Make an overweight landing entry in the logbook.” A maintenance inspection is required before next flight. Overweight Landing Checklist-Complete-Roger that.
Since you are unfamiliar with the airport, and Mark has his hands full flying and talking on the radio—not to mention slowing down the overweight juggernaut—you brief the approach for him. “I have Memphis page 11-7, ILS Runway 36 Center approach.” You read off the revision date.
Mark glances at his chart. “I agree. ILS 36 Center, 11-7. Same revision date. Highest MSA is 2,500 to the east, off of MEM VOR. ILS frequency 110.5, ITSE, tuned and identified, inbound course 360 degrees…”
“Flight 312, turn right heading 330,” ATC cuts in. “Cleared ILS 36 Center. Contact Memphis Tower on one one niner point seven,” Mark replies and contacts tower, who clears you to land. You finish the brief. One last thing for you to do. You pick up the PA.
“Ladies and gentlemen,” you 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. We will need everyone’s cooperation today by remaining in your seats when we arrive at the gate.”
“Gear down, Flaps Three, Landing Checklist.” “Gear down, Flaps Three,” you 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.”
You hang up and read the Landing Checklist. “Engine mode Norm, Landing gear, verify, Down, Three Green. “Down, Three Green,” Mark repeats, then adds, “Flaps Full.”
“Flaps Full. Landing Checklist complete. Cleared to land 36 Center.” On short final, to break the tension one last time, you say the famous Leslie Nielson 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. Mark chuckles, then pulls off one of the smoothest greaser landings in the history of landings. You don’t know whether to be proud or jealous. Hell, you’re both.
At the gate, you once again jump on the PA. “This is the Captain. Remain seated.” Paramedics board the plane and tend to the passenger. They half-carry her off, now awake but still quite dazed. Her daughter deplanes with her. You nod to Mark, who turns off the seatbelt sign.
“Ladies and gentlemen, this is your Captain speaking,” you announce. “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.”
Sure enough, KMEM is a crack station. Despite the baffling arrival of different metal (your A321 was the first they’d ever seen, as opposed to the E190s they are used to servicing), you are closed and on your way in record time. You arrive in KPHX not one hour late, if two passengers light.
As Captain, you will have to fill out the requisite paperwork within 48 hours. Otherwise, for you, the case is closed. But first, you want to conduct a post-flight debrief with the crew.
As you gather the crew in First Class to discuss the event, you start by saying, “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. You run them through a quick summary of the event, emphasizing several important points. You finish by asking:
“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 you learning a little more about CRM (Crew Resource Management), crew communications, and emergencies. While you are proud of the crew’s near-flawless execution, next time, each one of you will perform that much better. Congratulations, Captain, on a successful outcome!