Medical Emergencies at 40,000 Feet

I have responded five times to "Is there a doctor on board the plane?" In three of the cases, it was a true emergency. Airline systems are woefully underprepared to deal with these situations. Here's what needs to change.
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I was asleep, the plane dark as we flew over the Atlantic on our way from Johannesburg to São Paulo, when a familiar page came over the intercom: "Ladies and gentlemen, sorry to wake you. If there is a doctor on board, please hit your call button."

This wasn't the only time my sleep had been disturbed for a sick passenger. The first time was on a flight from Chennai to Frankfurt. I was still a medical resident and, as I slid out of my seat to help, I realized that I had no idea what medications, equipment, or assistance, if any, I would find. While relieved that it was nothing serious -- just a passenger who didn't feel well after mixing sedatives and alcohol -- I couldn't believe that no one else volunteered to help.

At the hospital where I worked, I would have turned to a nurse for help -- but here I was alone.

This time I was escorted to see a middle-aged obese Brazilian man. He was sweaty and dizzy, his shirt unbuttoned, his hands trembling. Another passenger helped translate. She told me that he was diabetic and had taken his medications that day. I checked his blood sugar with his glucometer and saw that it was normal. Then I checked his blood pressure -- no small challenge to do over the hum of the engines -- and was alarmed to find it very low. I nervously rechecked it, but it was again low, perhaps due to heart failure in the setting of a heart attack, or maybe a severe infection, or possibly internal bleeding. I went through the medical kit that the flight attendant had brought, gave him an aspirin and pulled out the IV kit. He needed fluids to support his blood pressure until we could land. Repeatedly I tried to place an IV in each arm and hand, growing more and more frustrated, but I simply couldn't locate a vein. At the hospital where I worked, I would have turned to a nurse for help -- any doctor will tell you that nurses are better at placing IVs -- but here I was alone. A flight attendant brought me hot towels to wrap around his arms to bring out his veins, but to no avail.

I sat with him, the oxygen cylinder that the flight attendant had also brought him between my legs, for the next several hours -- so much for getting any sleep. I coaxed him to drink water since I couldn't give him fluids intravenously while checking his blood pressure repeatedly. It was still low but stable. I was afraid that I might have to perform CPR on him if his blood pressure dropped further. How would we get him out of his seat and flat on the floor if it came to that? I asked the flight crew to have an ambulance waiting for us at the gate. As we prepared for landing, a flight attendant took back the oxygen tank. I protested, but she told me that it would be unsafe to leave it with us during the landing. Once on the ground, the flight crew allowed the other passengers to deplane first, even after I reminded them that their passenger might have a life threatening illness. By the time I helped the man off the aircraft, there were still no medical personnel at the gate to receive us. I was appalled.

***

Over the past seven years, I have responded to five in-flight medical events, three of which were true emergencies. It's estimated that a medical event of some sort occurs once for every 10,000 to 40,000 passengers on intercontinental flights. Information about these incidents is limited by underreporting, variable data quality, and the inability to determine what happens to patient-passengers when they leave the plane. In the United States, an airline is only required to report an incident to the Federal Aviation Administration (FAA) when a passenger dies or if the plane is diverted due to a death or medical emergency.

What we do know is that more Americans are flying than ever before: U. S. airlines alone transported 732 million passengers last year and by 2024 that number is expected to increase to 1 billion. At the same time an aging population means many passengers are taking to the skies with more medical problems. The result is an increase in in-flight medical incidents -- an upward trend that raises new questions about what ought to happen when a passenger falls ill while in transit.

Flying is stressful on the body. We carry heavy luggage over long distances between terminals, rushing to make our flights. We cross time zones, which may complicate our medication schedules. Some of us are afraid of flying or just see it as an opportunity to tune out the world and relax, and so drink alcohol or take sedatives.

"I never take sedatives on flights because I feel like on almost every other international flight they ask if there's a doctor on board."

While most medical emergencies occur due to pre-existing medical conditions or an acute illness, the aircraft itself can contribute to health problems. The cabin environment, which is pressurized to the equivalent of 6,000 to 8,000 feet above sea level, causes a 10 percent drop in blood oxygen saturation in the average traveler. Doctors generally advise healthy patients who are traveling to high-altitude destinations to allow at least a day at 8,000 feet to acclimatize before ascending further. Unfortunately many physicians aren't fully aware of the risks of flying, especially for their patients with chronic diseases. (If you can walk fifty yards at a normal pace or climb one flight of stairs without chest pain or significant shortness of breath, you are probably okay to fly without supplemental oxygen.)

Common in-flight medical events include dizziness, fainting, diarrhea, nausea and vomiting, shortness of breath, chest pain, palpitations, and headaches. Of course sometimes things get more serious. Heart attacks, other cardiovascular problems, seizures, and strokes are the most frequent in-flight medical emergencies requiring diversion of an aircraft. I have attended to two passengers with low blood pressure, a passenger who didn't feel well after taking Valium and drinking alcohol, a passenger who lost consciousness, and a flight attendant with chest pain and shortness of breath. On one occasion, we had to divert the plane for an unscheduled landing. On another, I was asked to come into the cockpit to speak with the ground medical team.

The FAA requires flight crews be trained to coordinate the response to medical emergencies, to use first aid kits, to be familiar with the contents of the emergency medical kit, to use an automated external defibrillator, and to perform CPR. But flight crews also rely heavily on the assistance of health care providers aboard the aircraft. Studies by the airlines and ground-based medical support services have found that a health care provider is available and responds in upwards of 80 percent of in-flight medical events. The truth is, though, that many health care providers find themselves attending to issues they don't see in their medical practices, and most have no specialist knowledge about aviation medicine or the medical resources aboard the plane. If asked, many health care providers will volunteer to help, especially if no one else is available, and this can lead to problems.

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Celine Gounder

Celine Gounder, MD, ScM, is an infectious-disease and public-health specialist.

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