When passengers fall ill at 30,000 feet: How medical emergencies are handled in the air

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'If there is a medical doctor on board, please identify yourself to a flight attendant."

Anyone who has heard that plea has probably wondered: How often does this happen?

Well, researchers have answers. There is an in-flight medical emergency once every 604 flights. Put another way, for every one million passengers, 16 will have a serious medical problem while on a plane. That's about 44,000 people a year globally. Air Canada flights alone deal with about 1,500 medical emergencies annually.

This, of course, is just the tip of the iceberg. The data, published in the New England Journal of Medicine by a group of emergency physicians from the University of Pittsburgh School of Medicine led by Dr. Christian Martin-Gill, include only cases in which formal medical advice is sought.

The good news – at least for passengers who fall ill – is that there is medical help on board surprisingly often. The research showed that when a passenger falls ill there is a doctor on the plane 48 per cent of the time, and a nurse on the flight 20 per cent of the time, and a paramedic or other health professional 8 per cent. One-third of the cases are handled by flight attendants alone. (Flight attendants receive first-aid training.)

Dr. David Henderson, a palliative-care specialist in Truro, N.S., was on a flight earlier this year when the call went up for medical help.

"You don't even think about it, you react," he said. "Then you realize, at 35,000 feet, there's not a whole lot you can do."

A passenger was having a seizure, and Henderson was able to stabilize him. Then came the $64,000 question from the pilot: Do we need to divert the plane to get emergency help?

In this case, the closest hospital was at the destination (Henderson asked that exact details be withheld to ensure patient confidentiality) so the flight continued and an ambulance was waiting to take the patient to hospital.

About 7 per cent of flights are diverted for medical emergencies. Airlines try to avoid this because it's costly, inconvenient for passengers and, most of all, because sick patients are often worse off in a strange city or country without family members or insurance. But the final decision rests with the pilot.

So what does the flight crew do if there is no doctor, nurse or paramedic on board or when they refuse to help? Medical professionals do not have a legal obligation to help, but many see it as a moral obligation. Sometimes health professionals don't feel qualified to help either: For example, a dermatologist may not have the skills to assist a passenger suffering a heart attack.

Some physicians have legal concerns but good-Samaritan laws generally protect them from any liability. Those laws also keep airlines from paying doctors, as doing so could invalidate legal protections. As a result, airlines usually send a thank-you letter and a gift of air miles.

"I got a very nice thank you from the pilot and I thought that was plenty," Henderson said.

There are well-stocked first-aid kits and defibrillators on all planes. All the major airlines have contracts with services that link them 24/7 to emergency-medicine specialists on the ground. There are several providers of this service, including STAT MedEvac, which operates a service called STAT-MD out of Pittsburgh; MedAire, located in Phoenix, operates a service called MedLink. A study published in the Journal of the American Medical Association noted, however, that there are few standard practices for responding to and tracking medical emergencies. This is a striking anomaly because the airline business is generally obsessed with standardization and monitoring.

The good news, at least according to the data that are available, is that the medical emergencies that occur in-flight can usually be handled by the flight crew, with the assistance of medical personnel on board or on the radio.

The most common problems are dizziness and fainting (37 per cent), trouble breathing (12 per cent) and severe nausea and vomiting (10 per cent). Pregnancy-related problems are uncommon: Women can fly safely up to 36 weeks of pregnancy, but the study found most problems occurred prior to 24 weeks. In the study of 12,000 medical emergencies, there were three births (all premature).

There are few cases of cardiac arrest (24 instances in the 12,000 cases in the study). But things don't always turn out well: 36 deaths were recorded in the study. A separate study of 19,000 in-flight emergencies recorded 94 deaths.

A death can be problematic, especially on a full flight.  In the book Airline Confidential, former pilot Richard Havers said that if a body cannot be isolated and covered with a blanket, the practice is to place it in a lavatory and hang the "out of order" sign. One carrier, Singapore Airlines, actually has a "corpse cupboard" for storing a body.

This may sound morbid but the reality is that, as air travel becomes more affordable and common, and flights longer-lasting, there have to be practical preparations in place to deal with illness and death. Considering that some airliners can now carry more than 800 passengers and can fly 12 hours or more non-stop, maybe there should be medical personnel on board as there are on cruise ships.

There are more than 2.75 billion passengers flying on commercial airlines annually; at any given time, there can be a half-million people in the air. In this perpetually floating city, medical care will be required with increasing frequency and we need to think of how that's best done. Is depending on the goodwill of doctors and nurses sufficient, or are more formal measures required?

Editor's note: In the original version of this article, comments from the book Airline Confidential, by Richard Havers, were wrongly attributed to Patrick Smith, author of Cockpit Confidential. This version has been corrected.