In-Flight Emergencies

Welcome back to Behind the Knife. This is Jessica Millar, one of the Behind the Knife Surgery Education Fellows, and I'm here today with John McLennan and our special guest, Dr. Thomas Doyle. Dr. Doyle is a Clinical Associate Professor of Emergency Medicine at the University of Pittsburgh, but he's also the Medical Director of STAT MD, which specializes in providing care for in flight medical emergencies. Now, John, I don't know about you, but every time I get on a flight, I get so nervous that I'm going to hear that overhead ding and then someone asking, is there a doctor on board? Because I would just have absolutely no idea what to do. Thankfully, though, Dr. Doyle is here today to guide us through this anxiety producing scenario. So thank you so much for being here today, Dr. Doyle. Absolutely. My pleasure. Okay. So let's go ahead and get started. So you're an emergency medicine physician, so emergencies are your bread and butter. But in flight medical emergencies is kind of an interesting niche to find yourself in. So can you tell us a little bit about your background and how you found yourself in this field? Well, I did my residency in emergency medicine at this little place called Chapel Hill. Graduated in

2000. And I was very interested in EMS, critical care transports, like helicopter transports, and there were, there was a bunch of faculty, a lot of the attendings there had actually come from Pitt and so they were like, well, you should do a fellowship, if you're really interested in this, you should do a fellowship there. So I said, okay. So I looked into it. I applied and got in and did an EMS fellowship at Pitt which at the time was two years. So I got a, that's how I got my MPH. It kind of came along with it worked as an ED attending. I was also a flight physician. Because UPMC through the Center for Emergency Medicine has a very robust critical care transport program. They have what is it, 18 helicopter bases in five states with about 22 ish or 23, I can't remember the exact number rotary, rotary wing aircraft. And so, it was that that sort of got me to Pitt. And then, you know, once I got here I learned about the communication center. So UPMC has a communication center where we provide physician

consultation to ground EMS services to the critical care helicopter program. And then what I didn't know until I got there was, is that they also through the STATMD program, provide advice to airline and some other business clients. And so that's how I kind of, ended up doing this. So I started in 2000. fInished my fellowship in 2002, stayed on and then in 2013 I had the opportunity to become the medical director for the STATMD program as well as the communication center. I had been an associate medical director of the STATMEDEVAC, the helicopter program during that time, and so that's how I ended up where I am. Yeah, that's excellent. I mean, the background, I guess it sounds like you had an interest in this for quite a long time. And then eventually that just translated over to, you know, doing more of the in flight emergency kind of help. So I guess we hear about these type of in flight emergencies a lot on the news, like how often do they occur? I mean, how many calls do you get a year for with your group? Yeah.

We've actually published some research on this. If you look at the data, it's about one in every 600 or so flights. There's an in flight medical event and we tend to call them events because they're usually not emergencies. It might seem like an emergency to everybody else. But when you actually look at it, it's not necessarily emergency. So about, one in one in every 600 flights, which you're like, Oh, that doesn't sound like, but there's thousands of flights a day. So, it can get pretty busy. And I want to say we did somewhere around 17, 000 consults last year. There was an obvious dip during the COVID times. But last year air travel. Rebounded pretty robustly and things are just about back to pre pandemic levels. So, yeah, it can be quite busy. I was going to say, 17, 000 calls in a year sounds pretty busy. Now, of those calls that you receive, how often is there a medical provider on board, someone that can help? Like, what's the probability that I'm going to be the only

person on that plane that can help? It's actually pretty common. It seems like nurses or maybe it's because of the whole travel nurse thing, I don't know, but they're, they seem to be traveling a lot. So, there's a good chance that there's going to be somebody with medical background. It might not be a physician. But a lot of times there's a nurse or a paramedic or Like a nurse practitioner, a PA you know, that CRNA, you know, all that kind of stuff that are on there that, that are and they're very helpful as well. And sometimes in my opinion, they're actually more helpful. Yeah, I mean, I guess, yeah, I think it's, I feel like it's almost likely that you're going to have some sort of medical provider on that flight. You just don't know the level of training. I think that you guys provide a great backstop to kind of even out the ground now with your company. Do you advise airline companies on what equipment to keep on board? Or do you have a list of what equipment each airline carries on board for Yeah. So we actually we have a list of the kit contents from all of our client airlines, whenever possible, we actually try to get a physical kit

from them. So we can actually see it and see where everything's laid out, what things look like. Because when, you know, the issue is if there is a volunteer that's trying to. Help out and administer medication. They've never seen the kit before. You know, it's usually a stressful situation and so, you know, they open it up and there's like all this stuff, so, we can say oh Well, what you're looking for is in, you know The orange pouch and it's in silver coil packaging and kind of things like that or you know If we're going to give benadryl, it's a white and pink pill and some silver packaging things like that So we try to do that to be as specific as possible So what is actually in those kits? Cause I've heard various different things and like maybe some airlines carry some different things. So what can you expect to actually have on board? So in the U S there is a, there's a federal regulation. It's, and it's funny because it doesn't come through any medical entity. It comes through the FAA since they, you know, oversee aircraft. And so there is what basically what we call a basic kit that, Any

airline that has at least one flight attendant on board has to carry as well as they have to carry an AED, an automated external defibrillator. So, it's a basic kit, so they have to, and I can, if you want, I can read it to you, because I printed it out, because I knew you were going to ask this question. So, a blood pressure cuff, a stethoscope, some oral airways pediatric adult, large adult, a an ambu bag. A CPR mask with three sizes, an IV administration set with two Y connectors, alcohol sponges, some adhesive tape, scissors, a tourniquet more for starting the IV, not for like stopping massive bleeding. It's not a cat tourniquet. It's like one of those like rubbery IV tourniquets 500 CCs of saline solution, some gloves several sizes of needles. several sizes of syringes from like one cc to 10 ccs, what they call analgesic non narcotic tablets, 325 milligrams, which is usually Tylenol antihistamine tablets, 25

milligrams, which is usually Benadryl, and then injectable antihistamine, 50 milligrams in a single dose ampule. Atropine aspirin, a bronchodilator, usually albuterol, 50 percent dextrose solution epinephrine one to 1, 000 and epinephrine one to 10, 000, lidocaine nitroglycerin tablets. And so, so they have to carry that. So they can't subtract, they can't add. So, if an airline wants to add a medication or equipment they can do that. And what several of them have done is they've added an anti nausea medication, usually on Danzatron, sometimes Meclizine, or medications like that. Other ones have added things like A urinary catheter because there's people to get urinary retention. And so there's actually been diversions because of that. So some of the airlines have actually started carrying catheters in order to help out with that. If you operate in the U. S., you have to have that equipment in the

kit, but you are allowed to add. So a lot of the U. S. carriers will pretty much have this kit with maybe a couple extra medications, a couple extra pieces of equipment. Once you get out into the world, and you get some of the real super long haul airlines. Their kit can become much more comprehensive and they'll carry additional medications. Sometimes they'll also carry, you know, they'll carry like blood pressure control medication, steroids, they'll carry depending on where they are like benzodiazepines for seizures or agitation, things like that. In the U. S. pretty much, I would say, every. Domestic airline has gotten rid of their benzodiazepines because it's a controlled substance and it just becomes very difficult, because then now you're dealing with not only the FAA and the D. O. T. But the D. E. A. Who can send you to jail? And so if you can't account for all of your, Valium, that's going to be a problem for somebody. So, they have, yeah. Pretty much come to the conclusion, because you know, it's not like in a

hospital where you have like a pixies or a lockbox or whatever secure facility. I mean, they're locked on the aircraft, but if the aircraft sitting somewhere for a while, there's a whole bunch of people that potentially have access to it. So it's sort of from a, from a legal standpoint, it's kind of become more trouble than it's worth, which is a little bit unfortunate from the medical side. But I certainly understand it. Yeah, based off that list, you can kind of see the things that the airlines, you know, obviously see are most common for medical emergencies or events. Before we dive into that, I want to talk to you about kind of what every physician or nurse that gets on a plane has to think about, you know, what's the liability for a medical provider to take care of patients for in flight medical events. You know, I've heard mixed things. I actually don't even know the true answer. Can you help clarify that for us? Absolutely, that's a great question. So the Aviation Medical Assistance Act, I believe of 1998, actually specifically, which was federal legislation, specifically addresses that. And so it's a two part

law, for lack of a better term. So, the first part is that if you are a medical volunteer and you volunteer your services and, you know, an attempt to render assistance to another passenger, as long as you do not go completely outside, your scope of training and ability and things like that, like really, you know, off the rail somewhere. Then, per that law, you are not liable for an adverse outcome, for that passenger. And the second part is, as long as the airline in good faith believes that you are who you said you are then the airline is not liable, you know, for an adverse outcome. So, it's a pretty robust protection that's in place. Having said that could someone be sued for under assistance? Yes. That has happened. You know, the the good, it's sort of kind of quote, quote, unquote, good Samaritan protection. It is in place, it doesn't prevent the initiation of a suit, but all the suits that I'm aware of, and there's not a ton of them, have been they have not

proceeded with a judgment against the volunteer physician. And what has happened in those circumstances is that the airline basically brings the you know, kind of indemnifies the volunteer and provides the legal assistance to the volunteer at that point. But again, this is very rare, so I don't want to frighten everyone. If you were to offer assistance during an in flight medical emergency, is it okay to receive some type of compensation or to ask for some type of compensation? Not that I actually think anyone would be asking, but what are the rules around receiving compensation for your help? That is another good question. So that's an interesting question because it's airline dependent. And so one point I would like to make and there's no to the best of my knowledge, there's no case law around this or anything like that, but. The question becomes so if you let's say you provide medical assistance and the airline says, oh, thank you so much and gives you like a bunch of points or miles or something like that. And you

say, oh, that's so nice. That's one thing. If you turn around and say, Hey you know, I helped this person on this trip and now you owe me a business class ticket to Hawaii. You know, for my services. The airline might do that. They probably wouldn't, but they might, but now the question is, okay, well, now that you've requested compensation, are you still covered under the Good Samaritan regulations? You know, so once, once it becomes, okay, if you're being compensated for your services, do those protections still apply? So, that's just food for thought. For people, you know, my personal thought is that if if you do this out of the goodness of your heart and, and to channel the Hippocratic Oath and the airline wants to make some gesture to you, okay where I think it gets much more gray is if you start requesting compensation, because then I'm not sure what's going to happen and there's no, as far as I know, there's no precedent for that, but it's something to be aware of. Yeah, I mean, that is my, that's a good clarification because. You know, I've

been told or seen before that you're not allowed to accept anything from the airlines. And I really hope that people wouldn't ask for a situation like that either. But that does clarify a lot. Thank you. I think the other big question that we all have to when, especially the liability portion is that, you know, if you're in a hospital and you're on call, you obviously not going to be drinking or using any substances or anything like that. But if you were If you're on an airplane and you're just traveling and you might have had a few drinks before you got on the airplane, what kind of position does that put you in if you're going to provide medical care? Honestly, I wouldn't volunteer. If you're impaired, you know, and this is through no fault of your own, like you weren't planning on doing any, you know, doctoring, you're going somewhere, you're on a trip, you might be going on vacation, go to a conference, whatever, you're not on duty, you're not working for anyone, and, you know, you have every right if you want to have a beverage or a cocktail on the flight, that's fine. If you do that and, you know, they ask for assistance my advice would be you

know, if you think you're impaired, don't volunteer. Hopefully there's another person, but, that becomes then another gray area that you don't want to wade into. And in the U. S., you are not obligated to volunteer. Yeah, that's super helpful to know so I think probably the thing that John and I are most interested in is if We were asked to assist what types of events actually occur most often during flights And how should we or how should we begin to manage each of these? by far the most common event is syncope or people passing out or If you're from the south falling out, a lot of times what will happen is people, you know, are getting to the airport and the way the airport is now and security is now, maybe they haven't had anything to eat or drink, they get on the flight, they get up to altitude, maybe they have a glass of wine, they vasodilate a little bit, they get up to use the restroom and boom, down they go, you know, or something like that. Or, you're coming to or from Las Vegas and you've had A wonderful time, maybe too wonderful a time, and you know, you're all

dehydrated and you get up and you pass out, things like that. So, syncope is the most common followed by respiratory issues, followed by GI issues, nausea, vomiting, diarrhea, followed by cardiac issues. So, those are like the top three or four. Usually it's, you know, the events are the common events are pretty self limited and it's really just kind of basic care. So for, you know, a patient that's syncopized, lay them down, elevate their legs and most of the time they get better, you know, that kind of thing. Don't sit them right back up as soon as they feel better because then they pass out again, but give a little bit of time and they usually recover. You know, only about 2 percent of our consults end up on a diversion. So it's, it's most things usually with a little bit of time and a little bit of care, you know, sort themselves out. If I was a, if I was a provider on an aircraft and maybe I was, you know, a dermatologist and I'm like dealing with patient with like maybe is, having an acute MI or angina symptoms, like talk me through what you would tell me to do

in that situation. Sure. So, it most likely would be chest pain or shortness of breath or chest pain and shortness of breath. And so, we would try to gather the information and right now a lot of it comes through either a a radio patch or a sat phone patch. And so a lot of the airlines will have a form that they'll have either the flight attendant or if there is a volunteer, the flight attendants are more than happy to hand the form off to the volunteer to sort of fill out and gather some basic information. So, once that information is gathered. Or not gathered then we would be contacted. And so then if it came into me, I would ask questions, I probably would have some basic information like age, sex, the what the complaint is, possibly history, although that's variable. And, if there's been any interventions, prior to the contact. And so, you know, let's say it's a 60 year old guy who started complaining of chest pain. If I can try to get some further information on the chest pain, you know, is it, where is it located? What is the nature of it? And in

that case, you know, we can try. If they're not allergic to an aspirin, you can recommend giving an aspirin we could recommend potentially, you know, if we can get their blood pressure, which sometimes we can, sometimes we can't recommend giving some nitroglycerin, their shorter breath, you put them on the onboard oxygen, then basically see how they do. So if that seems to be working and the, you know, the chest pain gets better, their shortness of breath gets better, their vitals are good, they feel good, then it becomes, well, where are they, where are they trying to go? So, if. If there's an hour left and they feel better, okay. I think, my recommendation at that point would be if things seems to have stabilized, they feeling better, you know, I think we can make it that hour. I'd recommend continuing on and then we would have EMS meet the flight on arrival, you know, and see how they did. And then if their condition changed, you know, have them call us back and then we can revisit that. 1 thing to remember is that when you're cruising altitude, it is going to take. A half an

hour to get on the ground, even if they, you know, even if you say, oh, no, we got to land this plane right now. Like, the plan doesn't land right now. It's got to circle down. It's got to get to the airport. It's got to get up to the gate, so it's going to be at least 30 minutes from wherever you are to get that person on off the aircraft. So, if you're coming from Miami to JFK and something happens, there's really kind of no point in diverting into Philadelphia. Because you're not saving anything by continuing on in a JFK. I mean, if it's, you know, there's a baby coming out or arterial blood, you know, there's always exceptions to the general rule but that's usually the case. So, so in a case like that, it's, you know, do we have medications on board That can assist them. Do we have a volunteer on board that can is willing to assist them? You know does what we recommend is it helping and if it is okay, and if it isn't, you know Then we can consider diversion And the other important thing is that I can't tell anybody to do anything in these situations I can just recommend the only person that's going to divert the aircraft is the captain and the

the dispatcher at the airline They're the ones that are they have operational control, they're responsible for the flight. So the volunteer can jump up and down and say, we need to divert, but you know, if the captain doesn't agree with that, then the flight's not going to divert. Kind of bouncing off John's question, like with some scenarios, you mentioned the most common events that can happen, which I think most of us would feel comfortable managing here at sea level, but how do these events change when you're at altitude? Like what kinds of changes in physiology are we just maybe not aware of that could change how these are managed? Yeah, it's mostly gas law changes and it's not necessarily a huge deal except for, a common event. Are, you know, the 2nd most common event or respiratory events. And so, an example of your question would be, you have someone that has a COPD history. Maybe they kind of get by on the ground, or maybe they take oxygen at night, or maybe they're on oxygen all the time. But, you know. They're going on their trip and they didn't think about it or they

try to bring their oxygen tank on board, which you cannot do. That's a DOT regulation. So you can't, you have to have a portable oxygen concentrator. You cannot bring an O2 tank on board. So, if so they may not have an oxygen requirement at sea level or maybe like 1000 feet, but when you get up to cabin altitude, so a flight flies around 35, 38, 000 feet. The cabin is pressurized between six and 8000 feet, you know, so it's like sitting on a little mountain. So, they're not pressurized down to sea level. So, it is not uncommon for someone that's sort of on the fence from an oxygenation standpoint on the ground to have difficulty once they get up to altitude. So, that's. That's a pretty common event is that, you know, and they might be okay if they're sitting, but then they get up to use the facilities, whatever. And they exert themselves a little bit and then they become short of breath. And so there is oxygen on board, but interestingly, at least to me, interestingly it is not really for the passengers, the oxygen on board. They call them walk around bottles. It's really for the flight attendants in the event of a cabin. Decompression.

It's so that the flight attendants could continue performing their safety duties. So they would basically, you know, have the bottle with them put the mask on and be able to walk around and make sure everything's secure. Well, hopefully the flight is descending to an altitude below, like, 15, 000 feet where everybody can breathe again, because the mass that drop out of the ceiling are different. Oxygen source. That's like a chemically generated oxygen source. And that only lasts for about 15 minutes whereas the walk around bottles are actually bottles and they can last Depending on the flow and the flow is actually quite low So their low flow is two liters a minute and their high flow is only four liters a minute So like in the hospital the ems world, it's like a homeopathic dose, but you know, they call it high flow, but usually that enough You know that 2 liters or 4 liters usually 4 liters of oxygen is enough to help those passengers out that are kind of on the fence. So that's 1 example of a flight physiology event. Other ones would be there's some thought that. You know, there's sort of a little bit of a vasodilatory effect once you get up to

altitude. There's also, you know, the cabin air is very dry, although the newer aircraft like the 787s and the A350s are better about this. And so people can get dehydrated pretty easily. Another thing that can happen, it's not as common, but you know, any gas bubbles are going to be affected by changes in altitude and so they're going to expand. So that's why they really don't want you flying with a pneumothorax until it's resolved. Another one that people don't think about is when people have retina repair surgery where they use the little gas bubbles to kind of push the retina back in place for a retinal detachment. That's a gas bubble. You go up to altitude, that expands and that is not good for the eyeball. Yeah, those are definitely good things that we'll think about too. And, you know, patients always come in and especially in my world where I'm, you know, a trauma surgeon. Or they're asking about flying with pneumothorax or post surgery things and you know, we have a pretty good standard protocol. We tell them wait till it's resolved, et cetera. I have, I kind of have a two part question. This is more just for my own curiosity, but

number one so do you, how do people like, Medical providers usually handle these situations on the aircraft, you know, maybe they're called in the back of the plane to help out with somebody. What is your experience? How do people handing them? And the 2nd question is like, what's the best way to handle him? Like, how? What do you expect from that provider on the plane? And you guys have seen success from your company. That's a great question. So, you know, The way I view it as, you know, the way the volunteer should look at it is you are not alone, but also you're not in charge. So, it and I get it because, you know, particularly for the physician volunteers, you're not planning on having whatever events that has happened happening. Like, that wasn't your plan today. So, you know, you're on the flight. You're doing whatever you're doing. And, they ask for a volunteer and you may feel, Oh, you know, I'm a physician, is there a doctor on board? Oh, I guess that's me. I'm going to volunteer. And so, you know, depending on your specialty and

expertise the passenger may. fit right into your category or the passenger might be 180 degrees from your category, which usually what happens, you know, if it's a, if it's an OBGYN issue, it's a cardiologist, if it's a chest pain issue, it's a dermatologist, you know, that kind of thing. So I think that the best thing to do is to just sort of kind of the way I look at it is if you think of yourself as a data gatherer, maybe a procedure doer, and You can contribute to the decision making, but don't feel like this is all on you and that you have, you know, the weight of the world on your shoulders because I think that's what happens with a lot of volunteers is they're like, they don't want to be there. They're not comfortable with the environment. It's an austere environment. And you know, the first thought is, well, how, how do I get out of this situation that I don't want to be in? And it's like, oh, I know we need to land the plane. And that's 1 of the reasons that that services like ours came about is because, you know, that would happen a lot. And anytime something happened, you know, they were diverting flights, you know, that did not need to be

diverted. And that has a whole other cascade of downstream issues because you have a whole now, a whole plane full of passengers and crew that are not where they were meant to be and where they're supposed to go. And so you're throwing a big monkey wrench in the whole process. Now, obviously, if the passenger condition merits a diversion. And. Nobody has an issue with that and they're going to divert, but it's, the diversions that don't need to occur that are problematic as well. So I think if you view it from that event and, in the U S I think pretty much every U S airline now has a ground based medical support service that they're going to use. And so, and that does this all the time, so this is a once in a lifetime event for you. This is the fourth one I've done this hour kind of thing. So. We're going to be probably more calm about it, you know, unless there's reason not to be calm about it. And then, you know, we have experience in that area. So I, I think that's the biggest thing. And that's why sometimes, you know, I'll say I'd rather have a nurse or a paramedic because they can do things, but they'll listen to me. Whereas sometimes the doctors argue with me, cause they want to land and I'm

like, they're getting better. We've got time, you know, particularly. And I'll do kind of a waypoint thing. Like, let's say you're going from Minneapolis to San Juan, Puerto Rico, and something happens over Nashville. All right, well, we got time, you know, we're over, we're over land. There's plenty of places to go. Let's try some things, see if we can get them better. If we can't, you know, we've got Tennessee, Georgia, and all Florida. to sort that out, and most of the time, they do improve and you can continue on. I think in the last couple of minutes that we have, something John and I were just kind of interested in were some of the more interesting calls you've gotten for in flight medical events. Yeah, you'll get, you know, probably the most You know, the saddest ones are the cardiac arrest or somebody has gone into cardiac arrest and unfortunately an aircraft at altitude is a horrible place to go into cardiac arrest. The crews do and the volunteers do a heroic effort and we have had saves, but if it's an asystolic arrest you know, a lot of times it's not going to be

salvageable. So that's kind of sad, just as dramatic, but usually happier, when there's a baby born on the plane that gets exciting and then, you know, you have had ones where people, get agitated and, if you can calm them down, it's great. There's a usually. The flight attendants have gotten very good at managing this, but one thing that happens is people, you know, that have, that are anxious about flying is a lot of times, or they want to sleep on the plane, is they'll take Ambien, and then maybe have a couple glasses of wine with their Ambien, and then they get, and then that relaxes them, and they get relaxed, and then sometimes they get so relaxed, they think they're at home. And not, you know, on the aircraft. And so, you know, when they decide it's bedtime, you know, sometimes they like undress and start wandering down the aisles and things like that. And so, the flight attendants are very good at sort of redirecting them, putting them back in their seat, putting a blanket on them. And, you know, they kind of merrily go on their way. So, I've had other issues where, and this is a newer thing where I had 1 person where they were kind of unresponsive. And I was

like, well, why are, you know, do we know why they're unresponsive? And the story was, well, the person next to them offered them an edible. And so they ate the edible and now they're unresponsive. And I was like, so I was like, well, I'm not diverting for this. So we'll keep an eye on them. And then why don't we have EMS meet the guy that ate the edible? And then why don't we have the police meet the guy that gave the edible? Because I'm pretty sure that's still illegal, you know, on an aircraft. So things like that. Yeah, I mean, that's super interesting. It feels like you guys have to continue to evolve with like the new current trend to and then definitely the over the counter medications mixed with alcohol. I can definitely see a big problem too. So yeah, that that's a good boy too. And one of the, one of the medications that a lot of the airlines have started adding is Narcan, you know, kind of for that reason. I do caution them though, because in the EMS world, If you give someone a dose of Narcan because they've overdosed, it's very likely that one of two things are going to happen. They're either going to start vomiting everywhere, or they're going to start swinging at you, possibly both. So, you know, I, and

there was a big sort of public push to put Narcan on the aircraft, which I don't object to at all, but, you know, people need to understand that. You know, there's not this utopia where, you know, somebody overdoses, you give them some Narcan and they wake up and smile and thank you when the flight continues on the flight's probably going to divert anyway, because of whatever else they're doing. So, but yeah, we do need to evolve. And one of the things we're looking at as well as is technology. And we're actually partnering with a company called flight care global. That has this really amazing technology where they have an app where sort of the whole intake process can be started on the app and then it can be transmitted to us via a web based browser. And so we have all the information that we need and we can actually. Message the flight back and forth you know, and do it via messaging or via radio. That's a new exciting thing we're working on because one of the biggest issues is communication is, you know, gathering the information. And then cause a lot of times, you know, the radios are up on the cockpit, but the cockpit door is secure. And

so it becomes sort of a game of telephone because if we don't get all the information up front. And when you start asking questions and they have to go hang on and they have to talk to the flight attendant who then has to go back and then they come up and so that can drag everything out. So that's one of the things we're looking at as well as how to, you know, leverage technology to make that more efficient. I could probably sit here and pick your brain all day long, but in the interest of time, John, do you have any other questions? No, I think it's good. Super interesting stuff. And thanks for joining us today. I mean, this is something that is, you know, like I said, relatively new to me. I think a lot of people don't really know that this type of service exists unless you were put in that situation. And hopefully I'm just not the one on the other side of that line one day. Yeah, no, this is, and that's, I enjoy talking about this, but that's another thing too is like, you know, if there's a pool of potential volunteers, it'd be great if they kind of understood, like, how things work in their role and to not not feel like the, you know, the whole weight of the situation is on their shoulders. There, there is, there are experienced people dealing with this, you know, and there's a bunch of other

factors that are in play. So you part of the team, but you don't have to run the team, you know, and you really aren't going to be liable, you know, if you're really trying not to offer help. Yeah it definitely makes me feel a little bit more comfortable knowing that next time I get on a flight, there's a whole team, yourself included, just a phone call away in Pittsburgh in case I ever hear that dreaded overhead message asking for help. Well, thank you so much again for joining us today, Dr. Doyle. We really, really appreciate all of your expertise in this. And normally we tell our listeners to dominate the day, but I would say you are already doing that every single day. Okay. Thanks, Dr. Doyle. All right. Thank you.?