It was a moment straight out of a movie. Cyrus Komer, MD, was flying on Delta Airlines from Boston to Vancouver, Canada, on a ski vacation, when a flight attendant asked a question over the PA system: “Is there a doctor onboard?” Komer, a physician specializing in internal medicine, who had never before been confronted with an in-flight medical situation, hesitated. “I had to think about it,” he says. “I worried about trying to help someone without any of the tools with me that I normally relied on.”
But when that no one else came forward, Komer stepped up, and was brought to a passenger in business class who was lying back in his fully reclined chair, alert, but clearly upset and struggling for breath. After learning the patient had a history of a slightly weak heart and had just eaten, Komer guessed at a snap diagnosis: A slight shortage of oxygen brought on by a combination of the lower oxygen levels in planes at altitude, the high salt levels of airline food, and lying flat in a way that along with his weak heart allowed fluid to accumulate in his lungs, all compounded by a panic attack. Komer sat the patient up and reassured him. “He calmed right down and started breathing more easily,” recalls Komer. The flight continued on, and the patient was met by a medical crew upon landing.
In many ways, that incident typifies what happens when a passenger becomes ill during a flight: Help is available, the condition doesn’t turn out to be critical, and the flight goes on to its destination. According to Medaire, a Phoenix-based company that assists airlines in dealing with various medical challenges, less than one out of 50 in-flight emergency medical events require a plane to make an unscheduled landing. Even frequent fliers aren’t likely to be on many flights where an emergency medical event occurs — about one out of 600 flights report one, according to a 2013 study from the University of Pittsburgh. (Less serious incidents like nausea or headaches are more common and usually go unreported.)
“If you’re healthy, a flight won’t make you sick. But if you do get sick, it’s not a good place to get better.”
But those averages are of little meaning when a medical emergency pops up — and, in fact, the problems, level of assistance, and outcomes can vary quite a bit. Actress Carrie Fisher suffered a heart attack toward the end of a flight from London to Los Angeles in 2016 which ultimately led to fatal cardiac arrest in the hospital. But only one out of 20 significant medical incidents on flights are heart-related, according to Medaire, which reports the most common condition requiring attention is some sort of gastrointestinal problem, accounting for nearly a third of all events. A quarter of the events are neurological issues, mostly involving fainting or seizures.
Other than motion sickness, flying itself usually doesn’t cause health problems while onboard. “If you’re healthy, a flight won’t make you sick,” says Paul Alves, MD, medical director of Medaire. “But if you do get sick, it’s not a good place to get better.”
The dry air, lower oxygen levels, junky food, tight space, and the general stress of commercial air travel — especially the inability to get to a doctor’s office or hospital — can all combine to make an airplane a challenging environment in which to deal with a medical problem.
Flight crews have several options for dealing with problems that come to their attention. For one thing, flight attendants all undergo training in CPR and other types of emergency aid, and all commercial planes carry a medical kit that contains potentially critically needed drugs such as Epinephrine for severe allergic reactions and Tegretol for seizures. Planes also have oxygen tanks and automated external defibrillators. “The kits are usually pretty basic, but they can include significantly helpful medications and equipment,” says Marcie Harrison, a registered nurse who serves as chief flight nurse for Lifesupport Air Medical Services, a Canadian company that provides medical professionals and equipment to patients who need special care when they fly.
If the flight crew deems a passenger’s problem to be potentially serious, they’ll usually try paging for a doctor. Is it likely a doctor will be onboard? Actually, yes — there’s about an 80% chance a doctor will hear that page, according to Medaire’s records. But whether that doctor will come forward is another question. As with Komer, the Boston doctor, physicians tend to worry about whether they can really be of help, and hope someone else will step forward. For that reason, as few as 20% of doctors will answer the first page.
“Ethically, they should step up, but they’re under no legal obligation to do so,” says William Brady, MD, who specializes in emergency medicine at the University of Virginia’s medical center, and who has researched in-flight medical events. “When they do it, they’re doing it out of the goodness of their hearts, and most will.” In a more serious situation, such as a potential heart attack, flight crews will usually keep paging — and that’s when the response rate climbs to 80%. (In theory, a doctor who helps out could be sued by the patient if things don’t turn out well, but in practice, doctors who act as Good Samaritans tend to be fairly well-protected by laws and by juries — as long as the doctor avoids gross errors that could be seen as obvious malpractice.)
In addition to lacking the high-tech tools and comfortable, private quarters they’re used to working with, doctors are often in a specialty such as podiatry or psychiatry that has left them somewhat out of touch with emergency medical care — though some of it can come back to them when they need it, notes Lifesupport’s Harrison. (Assuming it was there in the first place. Harrison recalls the time a man responded to a page for a doctor and identified his specialty as “history.”)
Whether or not a flight crew can summon up an onboard doctor or another medical professional, the crew has another option: Getting a consult over the radio with a doctor on the ground who’s specially trained to deal with in-flight medical events. Every major airline in the U.S. contracts with an organization that can provide that over-the-radio support — it’s the main line of business at Medaire, which contracts with 150 airlines worldwide, providing an average of 100 ground-to-air medical consults per day. Medaire’s doctors have access to a database of 430,000 in-flight cases, as well as information on what medical supplies are onboard the plane.
It’s on those relatively rare instances when a passenger seems ill enough to be in potentially dire need of advanced treatment — typically when a heart attack or a stroke is suspected — when that most urgent question comes up: Should the flight divert from its destination and make an unscheduled landing somewhere closer? Even in emergency medical situations, that can be a surprisingly complex question, says Brady. Among the considerations: Will landing somewhere closer actually get the plane down that much sooner than the scheduled landing? How accessible and comprehensive are the medical facilities at different airports? (It won’t do a patient much good to end up in an ambulance stuck in gridlocked traffic or 80 miles from a hospital.) Does landing at a different airport entail potential landing delays and risks from worse weather, busier traffic patterns, or having to land with fuller fuel tanks? Can you justify severely disrupting the schedules of a few hundred passengers to provide what may only be a slightly faster trip to the hospital for one patient who may or may not be in real medical trouble? “Sometimes 30 minutes can make a big difference to a patient, but sometimes it won’t,” says Brady. “That’s a difficult medical judgment.”
The decision whether or not to divert is usually made jointly by the doctor onboard, if there is one, the consulting doctor on the ground, the pilot (usually the captain), and the airline’s operations center. But in all cases, the law is clear on who gets the final say about whether or not to land early — it’s the pilot. “The pilot has to weigh all the risks for all the passengers,” says Brady.
If there’s one aspect of in-flight medical problems that virtually all aviation and medical experts agree on, it’s this: Passengers who feel sick or who know they may be at high risk of a problem because of a condition shouldn’t get on a flight without consulting with a doctor.
For starters, if any airline personnel on the ground notice that a boarding passenger seems unwell, or needs help walking, or is carrying oxygen or other medical equipment, and the airline hadn’t been notified of a medical situation or disability, there’s a good chance the passenger will be denied boarding.
Of course, that doesn’t mean people with medical conditions can’t fly. Notifying the airline ahead of time of what to expect, and carrying a letter from a doctor explaining the medical situation and stating the opinion that the passenger can safely fly, will usually get the passenger on the plane.
Once on the plane, notes Komer, most passengers who are at risk for a problem would do well to take pains to hydrate in the dry environment, and avoid airline food, which tends to be high in sugar and salt and can potentially exacerbate a variety of problems such as hypertension and diabetes. (Actually, not eating airline food is pretty good advice for anyone.)
Sometimes even extremely ill patients need to fly — for an important family event, for example, or to return home after an unplanned hospitalization on a trip, or to see a specialist at a distant hospital. In those cases, traveling with a physician or nurse — the service that Lifesupport, among other companies, provides — can make the voyage possible on any major airline in the U.S.
For most of us, airplanes are anything but flying clinics, and there shouldn’t be any expectation of good care if a problem arises. But there’s some comfort in knowing that in the great majority of cases, one way or another, there’s enough care available to avoid real medical disaster.