Too soon thereafter the announcement came along with a light tap on the shoulder, “Would a physician please identify himself or herself?” I jumped up and discovered to my disbelief that with roughly 300 passengers on this B-777, apparently I was the only physician. I was quickly ushered to the passenger, who was in the lavatory sitting on the toilet being held by her daughter. Much to my surprise, the patient happened not to be the transplant candidate, but the elderly woman who had looked like she harbored tuberculosis.

I squeezed onto the lavatory floor and obtained the history. She was 93, had a history of hypertension on metoprolol, and her daughter was taking her from her home in the Philippines to South Carolina as she could no longer care for herself. They had already just completed travel from the Philippines to NVP-BGJ398 Tokyo (several hours of ground travel followed by a 4-hour flight) and apparently her daughter thought her mother might feel better if she sat on the toilet and tried to relieve herself. I did not think this was going to be fruitful as the daughter also shared that her mother had not eaten much or drank since the onset of EPZ-6438 concentration the trip. Unfortunately, the passenger (now patient) seemed to know just a few words in English and her daughter said that her

mother did not communicate very much anyway; this was not mitigated any by the fact that the daughter could not speak Filipino. I did not pursue details about their lack of ability to communicate with one another. My initial impression was that the patient may not have been too eager to leave her homeland for distant shores at this time in her life, and a candid discussion about this issue probably never occurred between them. Regardless, the patient could tell me only that she hurt all over. The enhanced

medical kit on many overseas flights is excellent (www.IATA.org/medical-manual), but for ideal use requires a team of health care providers and a bit more space than the typically oversold cabin. I found the blood pressure cuff and stethoscope to be useful. The patient’s blood pressure was 120/80, her pulse was regular, and I could not detect anything unusual on a cursory exam, except that she appeared somewhat cachectic and dry. She was not Fossariinae febrile. I could almost circle the largest part of her arm with my thumb and forefinger and her skin tented easily. She winced when I pressed anywhere, whether on her abdomen, chest, or limbs. She had no evidence of calf swelling, and moved all extremities equally. However, it was the sadness in her eyes that stayed with me. To start an intravenous line just for hydration would be difficult; her arm veins were tiny and collapsed. She would have required a neck or subclavian line that I was unprepared to place both because of the surroundings, but primarily due to my lack of expertise after so many years. I also doubted that this would have been her or her daughter’s choice at the moment.