It’s mid-afternoon, July 13, 2005, and this reporter is catnapping 35,000 feet above Canada’s unforgiving Northwest Territories, en route from Atlanta to Tokyo Narita International.
Aboard Delta Air Lines Flight 55, a sleek 777-200ER, a quiet drama is about to play out, one that will intimately illuminate how airlines, crew members, ground-bound physicians and, yes, even some passengers can work in concert to pull people through a serious medical emergency.
A flight attendant has been hit in the head by a heavy serving tray in the rear galley. She’s showing signs of moderate concussion, a condition that demands close scrutiny.
The call goes out on the cabin public address system for a doctor. No one responds. Another summons, this time for a nurse. No one answers. Finally, the voice of the chief flight attendant pleads for anyone with medical experience to help. I pause, then push the flight attendant call button on my seat console. It’s been three decades since I was a U.S. Army combat medic. I just hope I remember enough to help
On board the Triple-Seven is a medical kit. I grab the blood pressure cuff and stethoscope and try to take a reading, the noise of the air rushing over the fuselage all but masking the telltale initial “tap-tap” systolic sound, as well as the fading “thump-thump” that signals the diastolic reading. It takes two tries to get a clear blood pressure, and it’s lower than it should be.
The chief flight attendant calls the captain, who initiates a call to the University of Pittsburgh Medical Center’s Stat-MD operation in the U.S. state of Pennsylvania, where emergency physicians are on call 24/7. He puts me on the line with a specially-trained doctor. I relay the vital signs, my overall impression of the patient’s condition.
It’s time to make a decision. If Flight 55 is going to divert, the nearest airport close to appropriate medical help is Anchorage. And if we’re going to make ANC we need to start descending shortly. The diversion will cost Delta upwards of $100,000. The captain, in whose hands the final decision lies, asks the doc what he thinks. The three of us – passenger, physician and pilot – converse one more time. The patient’s pupils are equal and responsive to pulses from my penlight. Her blood pressure is coming back up. There’s no blood in the ears. Best get her to the crew rest area in the upper “attic” of the Triple-Seven and have me monitor her for the rest of the flight.
No diversion, not this time. The rest of the flight is blessedly uneventful.
A Decidedly Delicate Balancing Act
According to the International Air Transport Association (IATA) airlines worldwide flew some 3.3-billion passengers in 2014, the last full year for which statistics are available. On the basis of data gathered between January 1, 2008 and October 31, 2010 authors of the May 2013 article Outcomes of Emergencies on Commercial Airline Flights in the prestigious publication The New England Journal of Medicine estimate “44,000 in-flight medical emergencies occur worldwide each year. Medical emergencies during commercial airline travel, although rare on a per-passenger basis, occur daily.”
Let’s sharpen that per passenger statistic a bit. U.S.-based MedAire’s air-to-ground MedLink service, based out of the Emergency Department of Banner Medical Center in Phoenix, Arizona in the US “receives an average of 37.5 calls for medical advice from aircraft in flight per 1 million passengers carried by the [airlines] that use our service,” says Dr. Paulo Alves, MedAire’s global medical director for Aviation Health. Some 70 airlines worldwide employ the MedLink.
“Taking care of passengers is something unique to the transportation industry and, in particular, to air transportation,” says Alves. In his paper The Challenges of Medical Events in Flight, he goes on to say, “Once a flight is airborne, there is no possible access to any established health care system.” That creates a dilemma, how to strike a good balance “between the immediate risk and cost of a diversion, vs. the implied risk – or even liability—when deciding to continue a flight with an ill or injured passenger.”
MedLink stats reflect one aircraft diversion per one million passengers flown. A diversion means a flight lands at an airport other than its intended destination.
Air-to-ground doctor-to-aircraft systems, endorsed by the International Civil Aviation Organization (ICAO), “can help in significantly reducing unnecessary diversions,” says Alves.
But what airlines want to prevent, at all costs, is an in-flight passenger death. While reported statistics are scarce, Dr. Alves says, “it’s estimated that one IFD (in-flight death) occurs for every 7.6 million passengers traveling. In addition to the human toll IFDs wreak, he says they can ignite “litigation and bad publicity for the airline.”
What Ails You
Most in-flight medical emergencies, or IFMEs, says The New England Journal of Medicine’s (NEJM) study, have to do with lightheadedness, fainting, respiratory symptoms or gastrointestinal symptoms. Just about 30 percent of those situations got better while the flight was still in the air, so much better that emergency medical personnel weren’t needed upon landing. When things did not get better, and the pilot asked for EMS help upon touchdown, just over 37 percent of those passengers were taken to a hospital emergency room.
“In addition to cardiac arrest,” says the NEJM report, “medical problems that were associated with the highest rates of hospital admission were stroke-like symptoms (23.5%), obstetrical or gynecologic symptoms (23.4%) and cardiac symptoms (21%).”
Drilling a bit deeper into data, the report found obstetrical symptoms rarely cause medical emergencies, “a finding that supports existing recommendations that air travel is safe up to the 36th week of gestation [pregnancy].” The majority of obstetrical or gynecologic symptoms—just under 61 percent of them—“occurred in pregnant women at less than 24 weeks.” As for the popular belief that pregnancy begets bunches of flight diversions, the study tallied just “three cases involving pregnant women in labor beyond 24 weeks which resulted in diversion.”
Tool Kits to Combat What Ails You
AEDs, automatic external defibrillators, those wondrous machines that can shock a heart back to beating, are mandated for passenger aircraft by US Federal Aviation Administration regulations. So is a well, and specifically, stocked Emergency medical kit, or EMK. A number of other worldwide regulatory bodies recommend or require the same.
No mere first aid kit, EMKs are mini-pharmacies. They’re fitted with oral drugs such as Nitroglycerine tablets for heart pain. There’s injectable Epinephrine, to counter life-threatening anaphylactic shock, which can be triggered by severe allergies to things as simple (and potentially deadly) as peanuts.
How to Avoid an IMFE in the First Place
The best way to handle a medical emergency, in the air or the ground, is to avoid it altogether. Dr. T.J. Doyle is medical director of the University of Pittsburgh Medical Center’s Stat-MD program, which serves some 17 airlines throughout the globe. He says the most important role passengers can play in protecting their health aloft is to make sure they understand their own medical issues, particularly chronic conditions.
Included in the chronic category is COPD, chronic obstructive pulmonary disease, where supplemental oxygen may be necessary. “It’s important to remember that even if you don’t need oxygen on the ground, the cabin altitude is [usually] the equivalent of being on a six- to eight-thousand-foot mountain,” says Dr. Doyle. “So, even if you don’t need it at sea level there may be a possibility you may require oxygen at altitude.”
If you have a chronic pulmonary problem, Doyle suggests checking with your physician before flying, as well as the airline. That’s because “The solution now on the commercial airline side is portable oxygen concentrators.” Problem is “Most US commercial airlines either no longer provide, or give you the opportunity to purchase, on-board oxygen. Some of the Canadian airlines do.”
There are a number oxygen concentrators approved by various governmental regulatory agencies such as FAA and EASA, the European Aviation Safety Agency.
So, how about those cylindrical oxygen bottles with the masks attached that you may have seen stowed on board? Why not use those? “The onboard [portable] oxygen is technically not for passenger use,” says Stat-MD’s medical director. “It’s really for the flight attendants in the case of a decompression emergency so they can walk around the cabin…[Passengers] shouldn’t have an expectation it’s available for them.”
Another IFE-avoidance tip is a bit of a no brainier: “Make sure that if you take medications that you don’t put them in checked baggage,” says Dr. Doyle. “Have them with you in your carry-on.”
More than a few flyers forget. “We get calls from people on transoceanic flights,” he says. “A classic [example] is they have forgotten their Insulin is in their checked baggage and that their blood pressure is going to be out of control.”
Is There a Doctor On Board?
MedAire doesn’t track the percentage of time on-board professional medical help is at hand, but Dr. Alves estimates it ranges from 60 to 80 percent – physicians, nurses, emergency medical technicians and other first responders. As sort of a force-multiplier measure, MedAire runs training programs “designed to give cabin crew [flight attendants] the knowledge and skill to recognize and manage in-flight medical emergencies.”
Still, Alves says the fact remains “Many airlines rely on the kindness of stranger by paging for a medical volunteer.” Problem is, “A medical professional doesn’t board a flight expecting to go to work—he [or she] is a passenger first,” a passenger who “may not have the skills necessary” to handle the situation they face. AirlineRatings.com is aware of one doctor who has saved Qantas the Australian airliners three diversions to Hawaii over the Pacific.
Hovering over the situation, providing presumed cover for those strangers, is the Good Samaritan angel. In general, Good Samaritan laws offer legal protection to people who give reasonable assistance to those injured, ill, or in peril. But, as with everything involving the law, there are nooks and nuances you need to know about.
Alves says, “Good Samaritan regulations that may cover those assisting during a medical situation could be negated if any form of compensation is offered. Someone who is compensated is not generally regarded as a volunteer.”
Back to Delta Flight 55 for a second. After I tended to the flight attendant and got her settled in the crew rest area, the captain upgraded me to business class. I took him up on it, every few minutes checking on the condition of “my patient.” But—and here’s the irony of it—the moment I settled into that BusinessElite seat I may have stripped myself of legal cover, the Good Samaritan angel fluttering away outside the window.
Even if I had declined the upgrade, Good Samaritan might not have applied. That’s because a week after I returned home from Tokyo I found a delivery driver at the front door with a goody basket of crackers and confections and a thank you note from Delta.
Be compassionate, but play it safe. Assuming you’re qualified, volunteer to render aid. Remember, the physician, pilot, qualified passenger partnership really can save lives. But don’t expect anything aside from satisfaction in return. Decline anything that even hints of a gift.
The greatest gift in all is human life. Ground-bound physicians such as Paulo Alves and T.J. Doyle understand that. They also understand, says Doyle, while an in-flight medical emergency “may be a once-in-a-career [event] for the cabin crew, the pilot, and…the on-board volunteer,” it’s virtually a daily occurrence at companies such as MedAire and Stat-MD. That’s why having an experienced, aviation-savvy ground-bound ER doc at the crew’s beck and call can be critical, even when medically-trained personnel are on board.
“We do this all the time,” says Doyle. “We understand how [IFMEs] work…how they usually play out. It’s important that the flight crew trusts us.”
Whether to divert or not remains the captain’s call. Doyle says pilots sometimes disagree with the ground doctor’s recommendations.
But physicians thousands of miles away still have considerable sway as they help crew and on-board caregivers navigate the IFME storm, working to “take some of the fear and uncertainty out of the situation and, hopefully,” says Dr. Doyle, “help everyone onboard get through it.”