This article has little, yet everything to do with surgery. It is about decision-making under adverse circumstances. If you have not listened to the 43-minute YouTube video about King Air 559 Delta Whiskey, you should. It will inspire you. Then watch accident case study “Final Approach,” piloted by an orthopedic surgeon. These YouTube videos will force you to evaluate your decision-making under stress.
On Easter Sunday, 2009, Doug White took off from Marco Island, Florida, with his wife and two teenage daughters in a high-performance, twin-engine King Air 200. They were returning to Louisiana from Doug’s younger brother’s funeral. The weather was magnificent. The pilot was a graduate of the Air Force Academy who flew F-100s in the Korean War. Sitting in the co-pilot’s seat was Doug, who had flown smaller, less sophisticated aircraft but had not done so in years. He was totally unqualified to fly a complex aircraft. Several minutes after takeoff, the pilot slumped over and died after sustaining a fatal myocardial infarction. How Doug assumed the responsibility to fly the aircraft, as well as his interaction with air traffic control, is inspirational.
The severity of the crisis was made more intense because of the presence of his wife and daughters. But he never lost his cool. He picked up the radio and said: “This is Nancy 559 Delta Whiskey, and I am declaring an emergency.”
“What is your emergency?” came the response from Miami air traffic control (ATC).
“The pilot is unconscious, and I think he is dead. I need to talk to someone who is familiar with this aircraft and [can] help me land.”
“Do you have any flying experience?”
“Some, but in a much smaller airplane.”
“This is Miami, who is flying the airplane?”
“Me and the good Lord”
“What do you want?”
“I want the longest and widest runway you have in Florida!”
“Hold on 559 Delta Whiskey, we’re finding help.”
ATC found Lisa, a pilot who gently guided him through the initial stages of flying the aircraft. The interchange between Doug and Lisa is almost comical. Underlying the dialogue was her coolness and sense of reassurance. The listener can palpate the bond that was forming between them. She’s cool, calm and reassuring, while he remained controlled and firmly insistent on his and his family’s needs. The dire circumstance bound them together.
A decision was made to route Doug to Fort Myers. It is a large airport with less traffic. Other controllers were re-routing commercial aircraft to avoid collision since Miami was a far busier airport. Fort Myers was not as crowded and had a 12,000 ft. runway. It was an ideal choice.
The time came to “hand” Doug off from Miami to Fort Myers ATC. He was instructed to change frequencies to contact Fort Myers.
“I don’t want to leave Lisa.” Doug’s voice clearly anticipates his sense of loss.
Lisa gently reassures him to “tune in the Fort Myers frequency on the second radio. If you don’t find them, push the first button, and I will be right there.” Her tone is almost motherly. “If you wander too far away from the nest, I’ll find you and help you,” she seemed to be saying.
It worked. Doug changed frequencies and connected with a male ATC who proved to be equally calm, reassuring and supportive. By sheer coincidence, the Fort Myers controller had a friend in Danbury, Connecticut, who was a check pilot for the King Air. He knew every nuance of the airplane. They connected via his cell phone. Every question that Doug posed, including flap settings, landing speed and trim control, were relayed to the friend in Connecticut, who responded with detailed instruction. Each recommendation was clear and simple to follow. The controller never overwhelmed the neophyte pilot with information, prodding more of a “do what I tell you step-by-step and you will be fine” message. Confidence grew on both sides. The experience became just a normal Sunday afternoon pleasure flight.
With no wind and conditions perfect, Doug landed the plane like a butterfly nestling on a flower. Doug asked where to turn off the runway. Audibly exhaling or perhaps stifling his emotions, the controller’s response was “anywhere you want.”
Doug made the turn onto the taxiway. He knew how to retard the engines but not shut them off. As he approached the terminal, Doug remarked, “It would be a shame to come this far and then chop up people at the end of the runway!”
What we didn’t learn until the epilogue was that the Fort Myers controller’s cellphone connection with his friend in Danbury went dead, seconds after the plane touched down. As the saying goes, maybe there are no atheists in a fox hole. Or in airplanes or in an operating room.
The second emergency involves an orthopedic surgeon who took off from Sandersville, Georgia, on a beautiful Sunday afternoon in a single-engine Piper Arrow. He was returning to the Baltimore area with surgery scheduled for the next morning. He listed his primary destination as Dover, Delaware. Baltimore was his alternate. Weather conditions in the area were less than ideal but expected to improve. With an extra hour of fuel on board, there should have been no problem. The surgeon had all the “tickets,” meaning he had a decent amount of experience and was instrument rated—he should be able to land his aircraft in poor conditions.
As he was approaching, the conditions did not improve. The weather information he received from air traffic control was overly optimistic and his exchanges with the controllers were less than informative. The controllers made suggestions offering two other alternative airports but both were socked in. He tried three airports and made two approaches, but backed off prematurely before reaching minimum altitudes. He circled around for an hour like a bee searching for its hive, looking for one clear strip after another. Each airport had a low ceiling, and each approach was aborted.
While he was certified to make an instrument approach and could have done that, he never tried. We will never know why.
Unlike the controllers in the King Air emergency, the attitude of the air traffic controllers in this exchange was neither helpful nor reassuring. At one point, he asked about landing at a military field, Dover Air Force Base. The air traffic controller sternly told the surgeon that he could only land at a military base in an emergency. “Are you declaring an emergency?” she challenged. Possibly because of pride, over-confidence, failure to grasp the severity of his condition, or fatigue, he never used that option. Until the end.
He flew around for an hour searching for a safe landing spot, exhausting his fuel. With obvious pain in his voice, he announces: “I am almost empty.”
Finally, he says, “I am declaring an emergency,” and asked for vectors for Dover Air Force Base. The controller from Dover says encouragingly, “We are turning the runway lights on for you, sir.”
Finally, with a quivering voice, he says “I am out of gas, I’m not going to make it.”
The surgeon-pilot crashed and died 2 miles short of the runway.
The way these two emergencies were handled stand in stark contrast. Both the response of the pilots and ATC reaction to potential disaster are vastly different. Doug had some flying experience but realized immediately that he was in over his head. He had the deliberate attitude of a person in a jam, and was not afraid to demand that the full resources of the federal government be used to save him and his family. All this with a dead guy sitting next to him and his family in the back. His forceful personality effectively created a team. Each conversation deepened the ATC commitment to save him and his family. Everyone became an active participant in safely landing the airplane.
There is an epilogue to the King Air incident that deepens our faith in the brotherhood of mankind. All the air traffic controllers, the pilot from Danbury, Connecticut, and Doug received an Archie League Award for their efforts. But what really comes through is the lasting bonds that were formed between Doug and the controllers. Their action validated the best instincts of protecting human life.
The cockpit transmissions from the Piper disaster generate a sinister feeling of impending doom. The exchange is painful to listen to, but instructive. As surgeons, we can identify with the pilot’s thinking and sympathize with his mistakes. We have likewise experienced indifferent staff members who were supposed to assist us at critical moments but gave less than 100%. Any of us who pick up a scalpel have, at one time or another, been “up to our ass in alligators.” (Lord, get me out of this and I’ll never do it again.) All of us have seen operating room personnel looking at a cellphone, or entering billing data into a computer when the operation was at the verge of falling apart, and some piece of vital equipment was lacking or blood was not arriving emergently. We have all looked around the room to see who was there to help us and found no one. It is a lonely feeling, much like the pilot, flying around alone on a dark, stormy night, attempting to find sanctuary.
This was likely the thinking of the surgeon-pilot who was trained to deal with unfavorable situations and not ask for help. Modern hospitals are terribly punitive, with surgeons expected to deal with adversity while relying on their own ability. Making demands or inferring unsatisfactory performance from ancillaries is sternly frowned upon and designates the surgeon as disruptive, kind of like being called a leper in the Middle Ages. His undemanding attitude made the controllers indifferent to his worsening condition, and the stark demand—“Are you declaring an emergency?”—backed him into a corner, challenging his ability. Of course, he should have declared an emergency and forced their total commitment to his problem. If he had, he would still be alive.
So how many times have we surgeons faced an emergency where we toughed it out and placed the life of the patient in jeopardy? Usually, we are successful but occasionally we are not. There are other surgeons and assets in the hospital who would have happily come to our aid. Like the King Air guy Doug, call for help early, and make a team out of your assistants. Then everyone gets a trophy. I still wonder how the controllers involved in the Piper crash slept that night.
Arthur E. Palamara, MD, is a vascular surgeon in Hollywood, Florida, and is associated with Memorial Regional Hospital, part of Memorial Healthcare System in the same city.