A surgical challenge on the evacuation train

I was sleeping on a flight and I am woken by a flight attendant asking a man in the opposite row “are you sure you’re OK?”

He was hyperventilating and complaining of chest pain. When the flight attendants started to bring out medical equipment from a locker, a curiosity spark lit up. I never experienced a medical emergency on a flight since graduating. I assisted a passenger on a train before, but never in the air.

I introduced myself, informed them I was training to become a surgeon and tried to get a brief history. I had no idea where to start. I asked, with little confidence, if there was any emergency kit? The crew proceeded to show me vials of adrenaline, an airway kit, an oxygen cylinder and plasters. The patient had low sats, so I went through my A to E in my head – thinking of my recent CCrISP -, putting on oxygen as we moved onto C and D, asking the cabin crew to be my “scribe” for the findings. A whirl of surgical differentials started spinning in my head when examining the abdomen. Could this be a pneumothorax, would he need a chest drain? Is this a perforation needing urgent intervention. Is this an episode of pancreatitis triggered by one too many in the bar pre-flight?

We often hear "It’s the Journey That Matters," but this took on new meaning for me one evening on a train. I realised surgical problems begin long before the first incision—sometimes in the everyday moments, often unnoticed.

It had been a long day, my mind cluttered with unread emails as the train hummed on. Suddenly, a shopping bag slipped from an elderly woman’s hand, spilling groceries. She barely reacted, staring at her hand as her grandson scrambled to collect the items. “Nan, you dropped everything!” he laughed, but she didn’t respond. Her eyes met mine, blinking as if clearing a fog. Her voice, slow and slurred, murmured, “Sorry, I just feel a little off”. Something felt wrong. This wasn't mere clumsiness but a silent alarm bell, a surgical emergency unfolding amidst the mundane.

Introducing myself, I gently inquired about her symptoms. "Can you raise your arms?" I asked. Her left arm wavered; the right remained motionless. Her history, reluctantly revealed, included a recent ‘tumble’, a detail she'd dismissed as trivial. My mind raced—could this be a stroke? An intracranial haemorrhage? The "FAST" mnemonic, a staple of stroke diagnosis, flashed through my mind: Facial droop, Arm weakness, Speech difficulties, Time to call emergency services. Without scans or senior clinicians, what was once just a memory aid from a lecture now felt very real. If this was a neurosurgical emergency, ‘Time’ was critical.