You are enjoying a cocktail on the way to Hawaii on a well earned vacation when a voice comes aloud overhead, “Attention all passengers. If there is a doctor or health care provider present, we ask that you please come to the front of the plane immediately.” From your vantage point in the back of the plane, it becomes clear very quickly that no one is volunteering. You find yourself being stared at by a plane full of people as you make your way to the front, to find a morbidly obese Caucasian female with a flight attendant at her side. You start your encounter…

She is a 60 year old hypertensive, diabetic, smoker who is complaining of mild epigastric abdominal pain that she feels kind of like “my reflux” but it’s not getting better despite eating almost a bottle of Tums, which usually does the trick. You notice she feels clammy but is not frankly diaphoretic. You are able to take a respiratory rate which is 18, her pulse feels regular at 90, and you don’t have a thermometer, blood pressure cuff, or stethoscope.

You reassure the patient and then the flight attendant takes you by the hand and walks you to a corner by the lavatories: “What do you think, doc? If we emergently land now we can touch down on the mainland. If we don’t land now we’ll be over ocean and will have to turn around. If we can make it the next 90 minutes to Hawaii without doing either, you’ll be saving the airline about a half a million dollars, and we will find a way to make it worth your while…