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.

While returning from an international malaria conference, Dr. Michelle Hsiang, a pediatric infectious diseases specialist at the University of California San Francisco, attended to an elderly man suffering from diarrhea and dehydration on a twelve-hour flight from Sri Lanka to London. She was uncomfortable caring for an adult patient with several long-standing medical problems. "I'm a pediatrician, so I'm not used to taking care of adults," she said. "I think it's funny that they call for any physician since many are not board-certified to provide the kind of care that is needed."

Health care providers may also not be prepared to respond to an emergency because they board the plane as passengers rather than doctors. Like others they may take sedatives to help them sleep or consume alcoholic beverages. Dr. Larry Chang, an infectious diseases specialist at Johns Hopkins University in Baltimore, explained how this has impacted him: "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."

***

Sometimes the inconvenience to the physician-traveler can be more onerous. Dr. Hsiang said, "Usually when I've been on other flights, they let the person who is ill off the plane first. But [on one occasion] they left me with [a patient] until the very end. It was an international flight, so it took an hour for people to get off the plane. I had to wait with him as if I was his nurse." When she and the sick passenger finally got off the plane in London, there was no one there to meet them (an experience not unlike my own). Dr. Hsiang waited with the passenger for another hour. When medical help failed to arrive, she finally advised him to continue drinking fluids until he no longer felt light-headed when walking.

When you're flying over an ocean and can't land for a few more hours, you want to get a better sense for the cause of a patient's symptoms.

Health care providers responding to in-flight medical events and emergencies are protected under the 1998 U. S. Aviation Medical Assistance Act, which states that persons providing assistance in the case of an in-flight medical emergency are not liable for their actions unless they are guilty of gross negligence or willful misconduct. But many health care providers worry about their responsibility, if not their liability, and some may be reticent to help in an unfamiliar environment, outside of their area of expertise. They are also subject to the same inconveniences as other passengers if the aircraft needs to be diverted.

Volunteer health care providers also report widely variable assistance from the flight crew when responding to in-flight medical events. Dr. Lisa Rosenbaum, a cardiologist at the University of Pennsylvania, was asked to help when a pregnant woman started having regular contractions on a flight from Boston to Portland, Oregon. She advised an emergency landing, but like many volunteer health care providers, she was frustrated later by not knowing if the woman had delivered safely. "The flight crew was awesome," and she told me, "I got a card a couple months later from one of the flight attendants saying that the passenger had delivered safely after they landed, and that she and the baby were doing okay. I had no way of following up. It was so lovely that she took the time to write me a card."

In addition, when more than one health care provider responds to an in-flight event, there may be disagreement over how best to manage it. Dr. Julien Pham, a nephrologist at Massachusetts General Hospital in Boston, once found himself at odds with another volunteer who told the flight crew that the passenger seemed fine based on a cursory assessment. Meanwhile Dr. Pham remained concerned after having interviewed and examined the passenger, and he continued to check in on him periodically throughout the flight.

The FAA, which stipulates the medical supplies that airliners must have on board, last updated its regulations in 2001 to mandate that the majority of U. S. registered commercial aircraft carry automated external defibrillators (AEDs), which may be used to shock the heart back into a normal rhythm, and that some additional medications and equipment be added to the medical kits. The required medications include: a non-narcotic pain killer; IV fluids for dehydration or low blood pressure; an antihistamine to treat allergic reactions; an inhaler for asthma; aspirin and nitroglycerin for a heart attack; IV dextrose for low blood sugar; epinephrine for allergic reactions or asthma; and epinephrine, atropine, and lidocaine as an adjunct to CPR. The kits must also contain a stethoscope and a manual blood pressure cuff as well as some other supplies.

In the case of my Brazilian passenger, it would have been helpful to have a digital blood pressure cuff so that I wouldn't have had to struggle to listen for his blood pressure over the sound of the plane's engines. A digital blood pressure cuff would also allow a layperson to check blood pressure. Ideally, I would have had an oxygen saturation monitor when responding to the passengers with chest pain, low blood pressure or loss of consciousness; one might argue that you could give them supplemental oxygen, but when you're flying over an ocean and can't land for a few more hours, you want to get a better sense for the cause of a patient's symptoms. I have had to overhead page for a passenger willing to lend me their glucometer and test strips to check a patient's blood sugar, and I have found that the emergency medical kit may not include insulin. Passengers may become dehydrated from vomiting and diarrhea, but oral rehydration solutions, essentially highly concentrated versions of sports drinks, which are easier to administer in flight than intravenous fluids if the passenger can drink, are not usually available. Granted, space aboard aircrafts is at a premium, and it's unrealistic to expect that an aircraft be equipped like an emergency room. Based on my own experience, I'd drop the requirement for medications like lidocaine and atropine and items like arm and leg splints in favor of tools to obtain basic vital signs and to stabilize and treat common medical events.

While the FAA has no plans to review its requirements, a consortium of organizations including the International Civil Aviation Organization, the International Air Transport Association (IATA), and the Aerospace Medical Association are currently working with experts in emergency medicine to review their recommendations for what the kits contain. Regardless of whether changes are made to the kits, they will only be useful if the responding health care provider is made aware of their contents. In the case of my Brazilian passenger, I could have used an AED to monitor his heart rhythm, but I wasn't informed that there was an AED on board.

***

In addition to the goodwill of travelling physicians, all the major carriers in the U.S. have, for at least the past decade, also relied on ground-based physicians and nurses with experience in emergency care and additional training in aviation medicine. Based at centers including MedAire in Phoenix, the University of Pittsburgh Medical Center's STAT-MD program, the Mayo Clinic Aerospace Medicine program, and sometimes an airline's internal medical department, these experts work with the flight crew and volunteer health care providers on board over radio or satellite telephone to assess and stabilize sick passengers, to guide the decision whether to divert the airplane, and to organize the medical response on the ground. According to Dr. Paulo Alves, the vice president for aviation and maritime health at MedAire, these professional services are essential if we hope to provide passengers with a consistent level of care. "I don't think that it's professional to rely on health care providers to volunteer their assistance," he said. Handling a potential emergency, Alves says, takes more than just a physician's skills, it also requires "a good grasp of how to manage a medical situation in a resource-limited environment."

The trouble is, volunteer health care providers are often unaware they can turn to ground-based medical support services for help. I wasn't myself until recently. Having the support of ground-based medical services would have alleviated much of my anxiety about potentially having to "code" my Brazilian passenger in a difficult, unfamiliar environment, and they could also have helped coordinate a more appropriate response on the ground.

According to Dr. Claude Thibeault, medical advisor to the IATA, "If you are caught in a medical emergency on-board, the first thing you should do is to ask if the airline has access to ground medical support. If so, then ask the flight attendant to call them immediately." Unfortunately, studies have also shown that volunteer health care providers are much less likely to make use of these services than are the flight crew, and not necessarily for the better. I would suggest an even more proactive approach: the flight crew should call ground-based medical support services whenever they page for a health care provider on board the airplane. This would ensure that initial steps are taken to assess and stabilize the passenger in a more systematic way, that health care providers on board don't turn down the help for fear of appearing incompetent, and that accurate, detailed information on these events is collected consistently.

In addition, volunteer health care providers divert planes for medical events more frequently and unnecessarily (as measured by rates of hospitalization after landing) than other responders. Diversions are inconvenient for passengers, potentially dangerous depending on where the aircraft lands, and costly to airlines. An emergency landing of a domestic flight may cost an airline about $30,000, while that of an international flight, $70,000 to $230,000.

Only one of the medical events to which I have responded resulted in an unplanned landing. My husband and I were on a flight from Atlanta to Tucson over the holidays when a man sitting across the aisle from us slumped in his seat. The flight crew asked me whether we needed to land. I really didn't know how to respond and was more focused on trying to attend to the passenger. I was relieved that the crew went ahead and decided to land emergently in Houston.

Ultimately, how airlines respond to in-flight medical emergencies is an important measure of their customer service, and one of which we would do well to be aware.

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Celine Gounder

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

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