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During more than two decades of travelling, Alan Ezrin has seen and experienced more health crises in the air than most. He nearly died aboard a plane once, hemorrhaging internally throughout a Paris-to-Montreal flight from what was quickly diagnosed as colon cancer.

Years later, in a kind of karmic reversal, he helped a woman in her 80s survive a heart attack; he's a scientist and biotech chief executive officer, not a medical doctor, but he heeded the pilot's call for volunteers who could provide CPR. He had a heat-seeking device pointed at his forehead by airport health officials during the SARS epidemic - and passed the test. He once saw a fellow passenger on a transatlantic flight become hysterical when her baby's surgical stitches popped mid-flight.

And a year and a half ago, in Orlando for a surprise visit with his daughter, Ezrin nearly died again when a blood clot that had probably formed around an old surgery area was dislodged and caused a stroke; he believes the clot was the result of deep vein thrombosis, or "economy class syndrome," which research has linked to sitting in cramped seats for hours.

Yet nothing compares with the anxiety he felt when a coughing, Nyquil-swilling man slid into a nearby seat on a flight to Dublin eight years ago. Ezrin was undergoing chemotherapy; with his weakened immune system, a bad case of the flu could have killed him.

"I look back now and think, 'I probably should have thought twice about flying.' They were giving me enough chemo to drop an elephant. But it was a personal decision, made with my doctor, to keep going, keep on living a normal life," he says. "This guy, however, was sicker than a dog. How can you get on a plane knowing you're going to contaminate everyone? There's a lack of discretion or caring there."

To be sure, medical emergencies in the air and especially deaths - like that of a man last month on an Aeroflot flight from Moscow to Toronto - are exceedingly rare. Last year, British Airways - one of the few airlines that releases such data - carried more than 36 million passengers and reported just 375 life-threatening situations among a total of 31,200 "incidents," most of them minor events such as fainting spells.

But the number and severity of such incidents are increasing as aging populations, particularly affluent baby boomers, are taking to the skies in greater numbers than ever before. Britain's Civil Aviation Authority reported in March that domestic airlines were forced to make 58 diversions last year because of medical emergencies - a 26-per-cent increase over 2003. The majority of medical diversions, the authority says, are caused by passengers 51 and older.

And new aircraft such as Boeing's super-long-haul 787 Dreamliners, the first of which are due to come into service next year, probably won't help the situation. The planes can stay airborne for 15 to 16 hours without refuelling, and detractors warn they could increase the risk of blood clots like the one that almost killed Ezrin.

Spending even a few hours in the air, "your whole system is in a jumble," says Joan Sullivan Garrett, the founder and chairwoman of MedAire Inc., an Arizona-based company that provides ground-to-air telemedicine consulting for 70 airlines, including WestJet. "Especially when there's another underlying medical condition you may not be aware of, you can be completely out of kilter."

Few people realize that in the subtly oxygen-reduced and depressurized setting of a sealed metal tube at cruising altitude, it's as if you're seated atop an 8,000-foot mountain. Whereas a healthy person may simply feel tired or a little lightheaded after a long flight, someone with a serious heart or lung condition can struggle for air just getting to the washroom and back.

Alcohol makes things worse by interfering with cells' ability to use oxygen. The 41-year-old man who crumpled to the floor aboard the Aeroflot plane was drinking heavily throughout the flight, and it's believed that may have contributed to his death.

Meanwhile, the chili con carne you had before boarding may leave you inordinately bloated, as the distance between the gas molecules in your gut increases because of the reduced atmospheric pressure - a nifty altitude trick called Boyle's law. The same principle caused trapped air to burst the baby's sutured wound. It can also lead a closed head injury to swell to life-threatening proportions, or cause blebs - tiny blisters on extensively damaged lungs - to inflate and complicate breathing.

Then what? There's no quick exit off the highway in the sky.

The most your captain - whose primary responsibility is to safely ferry 300-odd passengers - can do is order first aid and divert the flight if needed.

If there's a doctor on board, she'll be asked to help the cabin crew, who aren't authorized to do more than their cursory medical training allows. With rare exceptions - France is one - physicians in most jurisdictions are not legally obligated to intervene; some may be reluctant, fearing a lawsuit should their efforts fail. In Canada, only Ontario, Alberta, British Columbia and Nova Scotia afford doctors protection from negligence proceedings through Good Samaritan laws. Of course, most doctors will do what they can, says Dr. Bonnie Cham, chair of the Canadian Medical Association's ethics committee.

But they will be armed with the sparest resources: an emergency medical kit whose contents are contentious and vary widely between airlines. In recent years, federal regulators have added heart drugs such as atropine, adrenalin and nitroglycerin, bronchodilator inhalers for asthma attacks and CPR masks to the kits' minimum requirements. Defibrillators are still not mandatory aboard Canadian planes, as they are in the U.S, although major carriers such as WestJet and Air Canada voluntarily carry them.

Nor has Canada adopted the recommendations of the Aerospace Medical Association, an international body, to stock umbilical cord clamps and drugs such as oxytocin for stemming postpartum bleeding. It "makes sense" to keep them aboard, confirms Dr. Gideon Koren, director of the Hospital for Sick Children's Motherisk program, an

advisory service for pregnant women.

In the early days of commercial air travel, when flying meant being bounced around at low cruising altitudes for hours, it made sense to use nurses as flight attendants. That depth of medical expertise is deemed unnecessary today, given that planes fly faster to their destinations and soar high above unpleasant weather. Today, crews are thoroughly versed in first aid, but they aren't paramedics. And both training and emergency procedures differ considerably among airlines.

WestJet, for example, provides its flight attendants with satellite phones so they can get life-saving instructions from the ground, whereas on some airlines that information must be awkwardly relayed via the cockpit radio, through what is supposed to remain a locked door. Internationally, Virgin Atlantic, the British low-cost carrier bmi and Emirates are among the airlines that have futuristic telemetry devices to instantly transmit vital statistics to awaiting ambulances or a hospital.

Still, the industry consensus is that first-aid kits and training for health emergencies should be kept thin.

"If you're unfit, you have no business being on a plane," says aviation consultant Rick Erickson of Calgary's RP Erickson & Associates. "When you go to Wal-Mart, you don't expect that they're going to have a brain surgeon on staff. It's absolutely unfair to expect that an airline is going to be equipped to deal with every medical emergency."

If your high blood pressure, asthma or epilepsy is under control it's unlikely you will need a doctor's note to fly; but if you're unsure about a condition, make the appointment. Airlines can arrange equipment such as oxygen canisters during the flight or a wheelchair to greet you upon arrival; some, like Air Canada, offer telephone consultations with medical experts as well. Many insurers won't provide coverage without proof that your health has been stable for several months.

If you're contagious, some airlines as a matter of policy will bump you to a future flight, usually without charge; others, like WestJet, rely on the best judgment of call-centre or airport staff to resolve individual situations.

The key, experts say, is to get airlines involved in such decisions at least 48 hours before departure. Diverting a plane incurs tens to hundreds of thousands of dollars in unanticipated terminal fees, replacement crews, hotels and meals for passengers, as well as additional fuel charges. Given airlines' current struggle to make money with $128-a-barrel oil, Erickson, a transport economist, says they may eventually consider recouping those costs from passengers who should have known they were too sick to fly.

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Tips for healthy travel

Before you leave

Get trip insurance - and read the fine print. Don't omit details about an illness on the insurer's medical questionnaire; some policies require that you prove - by submitting a doctor's note, for example - that your condition has been stable for 90 days.

Check the rules for medical oxygen. WestJet allows you to bring your own oxygen on domestic flights or a portable oxygen concentrator (POC) on all flights. U.S. airlines and Air Canada prohibit personal tanks, but allow POCs and will supply oxygen for a fee - $150 per leg for Air Canada.

Know your rights. If you're unwell, you have a right to the most accessible seat at no extra cost. If you're flying on a plane with at least 30 seats, you're entitled to a wheelchair during the flight. Flight attendants are not obligated to help you in and out of the bathroom, so if you need help getting around because of recent surgery or a disability, make sure you have a companion there to help. For a fee, airlines such as American will provide a registered nurse for the flight.

You also have the right to keep the specifics of your condition private without fear of discrimination, according to Transport Canada, though for your safety and that of your fellow passengers, it's wise to disclose serious or chronic health issues. Expect to be denied boarding if you're visibly ill or contagious, though.

Plan a stress-reduced trip. Non-stop, long-haul trips are for the physically fit, so consider breaking an overly lengthy flight into two legs with an overnight stay.

During the flight

Keep critical items handy. Medication and items such as catheters, blood-sugar meters and syringes should stay in carry-on luggage. Keep original prescriptions and doctor's notes in a separate purse or bag.

Get up and move around. A walk around the plane every hour guards against deep vein thrombosis. London's Heathrow Airport reports a death per month from the condition. Some doctors swear by gradient compression hosiery, which may prevent blood from pooling by shifting blood flow upward along the leg.

If you're unhealthy, don't drink and fly. Oxygen saturation slips to 90 per cent at cruising altitude; combined with alcohol, insufficient meals and a lack of exercise, the lower oxygen levels can easily lead to fainting.

If you have life-threatening allergies

Wear a MedicAlert bracelet, bring your own food and epinephrine, know where the nearest hospital is at your destination and wipe down all surfaces around your seat.

If you're pregnant

The second trimester is generally deemed the safest time to fly. Complicated or late-stage pregnancies, or a history of pre-term labour, bleeding, toxemia, high blood pressure or miscarriage are all reasons to seek medical clearance before flying, says Dr.

Gideon Koren, a flight surgeon, pediatrics professor and director of Motherisk, a program at the Hospital for Sick Children in

Toronto.

If you're travelling with small children

Wake little ones just before takeoff and landing, and give them a pacifier or bottle to mitigate pressurization changes. Children with ear infections should not fly, as fluid-filled ears are more prone to rupture. Don't fly with an ill child, as common diseases such as measles and chicken pox can seriously harm a pregnant fellow passenger's unborn child.

Online resources

Public Health Agency of Canada Keeps a list of travel clinics across the country. http://www.phac-aspc.gc.ca

Motherisk Offers telephone advice on drugs, radiation and infections during pregnancy. http://www.motherisk.org

Travel02 Supplies oxygen to international destinations. http://www.travelo2.com

Transport Canada Has tips for carrying oxygen. http://www.tc.gc.ca

Anaphylaxis Canada Offers advice on travelling with severe allergies. http://www.gosafe.ca