On the last leg of a return flight following a quick trip to the US, floating in the haze of an hour's sleep and far too much screen time, the staccato coughing caught my attention.  "That doesn't sound good." There were only 90 minutes left till Nairobi.  The teenage boy sitting two rows behind me had definitely not been hacking like this before. 

I peered back.  He had that look of someone struggling for his next breath.  The glassy eyes stared off into the far distance as the patient concentrated on the most basic of tasks needed to support life:  moving air in and out.

The flight attendant came.  The term "asthma" floated above the background hum of the plane.  The seatbelt sign was on--for real--since the turbulence had become a little rough.  Southern South Sudan can be that way.  This flight wasn't like my beautiful glide into the capital of Juba a few months ago.  Great dust clouds sometimes swirl up over the mountains.  Friends and family will understand I was gritting my teeth and saying a prayer, as even the slightest rumble doesn't agree with me.

I offered my services to the attendant.  Even here, the long arm of malpractice law extends.  She was clearly uncomfortable with having me involved and asked to see identification.  My credit card read "Jon Fielder MD."  They will let me know if I am needed, she responded curtly.  For the time being, his mother would give inhalers.

The plane was now rocking pretty good.  Standing up a few minutes later, I swayed unsteadily and looked back, trying to gauge his condition while at the same time suppressing my own irrational anxiety.  The inhaler technique was inadequate.  I hate being pushy, but now was not the time to hold back.  Steroids were needed.  He hadn't received any in 12 hours, and then only a small amount.  I urged the mother to administer a much larger dose, asked for a pulse oximeter (to check oxygen status) and a stethoscope, and advised the attendant not to turn up the oxygen flow too high.  A "spacer" from the plane's emergency kit allowed more reliable inhaler technique.

Finally equipped with a stethoscope, I could hear almost no breath sounds.  Certainly no wheezing.  Was this because the plane is just too loud?  Or was the absence of wheezing signifying something more ominous:  nearly complete lack of airflow?  Given that the boy couldn't count above "one" without stopping to rest, I guessed it was the latter.  The absence of wheezes in the middle of an attack is an ominous sign.

We moved him by wheelchair to the front of the plane in order to facilitate evacuation upon landing.  I also hoped his nebulizer (a machine which aerosolizes the asthma medicine for easier intake) would work in one of the first-class sockets.  (Why I thought first-class flyers received more power than the plebeians in the back of the bus, I don't know.)  It didn't work.  So we continued the inhalers while waiting for the steroids to kick in and reduce lung inflammation, something which can begin within 30 minutes.

Upon landing, the boy was clearly much better, able to speak clearly, coughing less, and in fact ready to walk off the plane.  I pulled the lead flight attendant aside, "Next time, please call for a doctor immediately when someone is having an asthma attack.  This patent was very ill."  

I didn't share my full opinion:  Had we not acted aggressively, he probably wouldn't have survived the 3-4 hours to a Kenyan hospital.  (Ninety minutes to land, an untold time to clear immigration since they were not a Kenyan family, and then a long ride through Nairobi's streets in something less than a fully-equipped ambulance, followed by an uncertain waiting time in the emergency room.)

If an app could tell a flight attendant how to manage asthma, it wouldn't have helped much.  Accessory muscle use (meaning recruitment of strength not normally required for breathing), assessment of vocalization, and "that look"--all told me even before listening to the lung that the situation was serious.  What is "that look"?  It means, "If you don't do something, my eyes are going to roll back soon"--in his case, because of carbon dioxide building up in the blood.  While supplemental oxygen has a role, it would not reverse the underlying problem:  air couldn't move out of the lung.

The advice from the airport medical team?  Give another inhaler treatment.  That's appropriate--even if already obvious to the asthmatic's mother--but he needed steroids.  Since in my experience patients in Kenya and Malawi with severe asthma do not get adequate steroids, or even get them at all, I wasn't surprised that this instruction was missing from the airport.

Whatever comes out of the meetings in the US, it appears the "quick trip" was worth it.