'Is There A Doctor On Board?': What Happens During A Mid-Air Medical Emergency

Dr Deepak Gupta helped out a patient who suffered from a seizure mid-air.

On a flight from Delhi to Munich, LH 763, on 1 June 2023, a 60 year-old gentleman from Amritsar suffered from a minute-long seizure two hours after the flight took off. As soon as his wife informed the crew, they asked,

“There is a medical emergency on the flight. Is there a doctor on the flight?”

I identified myself as a doctor registered with the Medical Council of India to the air crew and to the patient’s wife, noted the medical history of the patient, ruled out any cardiac event, tested blood sugar, blood pressure, and pulse rate.

The patient was conscious but dull and drowsy. He even vomited once. His sensorium had returned to normal. I gave him a tablet with a glass of juice. The patient remained well. There was no further seizure and no flight diversion was needed.  

Inflight medical incidents (IFMI) can result from the exacerbation of a pre-existing medical condition, or can be an acute event occurring in a previously fit individual.

What Are In-Flight Medical Emergencies?

An inflight medical emergency is defined as a medical occurrence requiring the assistance of the cabin crew. It may or may not involve the use of medical equipment, drugs, assistance from a medical professional travelling as a passenger on the flight.

It can be something as simple as a headache or a vasovagal episode, or something major such as a myocardial infarction or impending childbirth.

But serious IFMIs are rare, as are flight diversions caused due to them. 

Flight diversions, though extremely rare, are often due to cardiac, neurological, pregnancy, respiratory issues. Only 55 percent patients need admissions in such cases.

However, when these diversions do happen, they can cost anywhere between Rs 3 Lakh- Rs 7.38 crore or USD 3,000 – 9,00,000. The pilot is advised by the ground team and the doctors on board if a diversion is needed. 

Did You Know? 

Approximately 2.75-3 billion passengers worldwide fly each year. One IFMI takes place every 600 flights. One major international airline has reported 3022 incidents occurring in something over 34 million passengers in a year.

What Happens at 36,000 Feet Height?

The cabin air in flights is relatively dry which increases the risk of bronchial spasm.

Although the main problems relate to the physiological effects of hypoxia and expansion of trapped gases, it is important to remember that the complex airport environment can be stressful and challenging to the passenger.

Some common conditions seen during IFMIs are: 

• Loss of consciousness

• Diarrhoea and vomiting

• Bronchospasm

• Asthma exacerbations

• Tension pneumothorax

• Congestive heart failure/pulmonary edema

• Angina pectoris

• Cardiac arrest

• Seizures

• Strokes

• Hypoglycemia/Hyperglycemia

• Severe pain

• Emergency delivery

• Air sickness

• Anaphylaxis

• Sinus/ Middle ear disease

• Head injuries, burns and scalds

In case of a cardiac arrest, the protocol includes early transfer to an intensive care facility for continuing monitoring and treatment, which is not always possible in the flight environment.

Some types of AED have a cardiac monitoring facility, and this can be of benefit in reaching the decision on whether or not to divert. 

In case of prolonged immobilisation too, we see deep vein thrombosis, which can lead to economy class stroke syndrome, which is seen in some 20 percent cases of stroke on board.

Why All of These Problems Happen

When the flight is at a higher altitude, relative hypoxia and saturation normally drop by 10 percent.

While it is usually well tolerated in normal individuals, problems can arise in those with respiratory or cardiac impairment.

Pneumothorax or ENT problems can be faced if there is a ‘trapped gas’ in the cabin. 

Did You Know ?

After getting an elective percutaneous angioplasty, one can fly after two days. If there’s low risk after STEMI, the patient’s age is less than 60 years, there are no signs of heart failure, normal EF, no arrhythmias, then they can also fly after three days. 

What Passengers Can Do

• Avoid excess alcohol and caffeine containing drinks.

• Remain mobile and exercise your legs. 

• Postpone your air travels if you have had any recent illness. 

For Passengers Who Might Be Pregnant:

• Air travel before 36 weeks of pregnancy is safe only for people who are not dealing with any pregnancy problems.

• Keep your seat belt buckled up.

• Drink plenty of fluids.

• Avoid gassy food and drinks before you fly.

• Move your legs, walk up and down the aisle every hour.

What Physicians On Board Should Do

• Come forward to help.

• Stay calm.

• Seek help if needed via telemedicine.

• Treat the passenger while they are seated.

• Create space.

• Turn on cabin lights.

• Ask for additional help.

• Ask the cabin crew to contact ground based telemedicine early in case of emergency.

• Open a two-way communication with the pilot to make the safest decision. 

From my personal experience, I’ve seen most in flight emergencies happen in the first 2-4 hours. Avoid taking alcohol so that you may be in a better position to help in case there is a call from the cabin crew.

Problems Faced by Physicians

• Unfamiliar clinical scenario

• Foreign and limited environment

• No idea of available resources

• No assistance often

• Airline policies

• Legal/ethical issues

Did You Know?

Prof Angus Wallace treated a case of in-flight tension pneumothorax using a coat hanger (trocar), a urinary catheter (cannula), and a brandy bottle for under water seal in 1995.

But There Are Laws In Place...

Although the crew are trained to handle common medical emergencies, in serious cases they may request assistance from a medical professional travelling as a passenger. Such assisting professionals are referred to as Good Samaritans.

An aircraft in flight is subject to the laws of the state in which it is registered, although when not moving under its own power (ie stationary at the airport), it is subject to the local law.

Some countries (like the USA) have enacted a Good Samaritan law, whereby an assisting professional delivering emergency medical care within the bounds of his or her competence is not liable for prosecution for negligence.

In the UK, the major medical defence insurance companies provide indemnity for their members acting as Good Samaritans. Some airlines provide full indemnity for medical professionals assisting in response to a request from the crew.

(Dr Deepak Gupta is a Neurosurgery professor. He can be reached at [e-mail]. Or you can connect with him on Twitter @drdeepakguptans. This is an opinion piece, and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.)