How Doctors Think About In-Flight Medical Emergencies

I am not a nervous flier by nature, but on the first flight I took as a newly minted doctor, I sat at uneasy attention. I was trying to relax, but my professor’s words kept echoing in my head: “When you get on a flight, you are no longer just another passenger. You’re the doctor on board.”

I've not yet witnessed an in-flight emergency, but many of my colleagues already have, and I know that for me and many other new doctors just finishing medical school this month, flying will never be the same.

Dr. Judy Kwok, a doctor in my training program, has been involved in two medical emergencies in the air. The first was on a flight to Hong Kong. She remembers the overhead call for a doctor filled her with “complete dread,” she told me. She walked to the front of the plane to see a woman sitting up but initially unresponsive. The woman looked sick. “What happened?” Kwok asked, amidst the chaos. Many passengers were offering opinions — most unhelpful.

The sick woman began to speak, but not in English. A passenger quickly stepped up to translate. Finally, Kwok got the story: The woman had chest pain. A medical student had also responded and took vitals. The flight attendants — who are trained to respond to these emergencies — also arrived to help. They offered her an emergency medical kit, stocked with basic supplies and medications mandated by the Federal Aviation Association. Concerned the woman might be having a heart attack, Kwok gave her aspirin and continued to monitor her.

The flight attendants radioed an emergency call center. Kwok asked if they could divert the plane, but was told by the physicians who staff the center that their flight was over Mongolia.

The nearest airport was two hours away. They kept going. A short while later the woman looked better and was able to answer questions, and the flight continued to its final destination.

“I tried to be calm in the moment,” Kwok said. “But when I got back to my seat, I could see I was shaking.” Kwok was not told what happened to the patient after landing, as there is no systematic way for providers to follow up with patients they assist on planes. In most cases, we never know if we did the right thing.

In-flight emergencies occur about 44,000 times a year worldwide, according to a 2013 study in the New England Journal of Medicine.

Dr. Christian Martin-Gill, the study's lead author and assistant professor of emergency medicine at the University of Pittsburgh, said that health care providers could expect to be called on during an emergency on board a flight at some point during their career.

And in the majority of situations, they do, said Martin-Gill, who also staffs one of two call centers in the U.S. where doctors help direct care during flights. Physicians assisted in about half of in-flight emergencies, he says, and nurses or other providers in about a quarter.

Most of these emergencies were minor, with only one in 12 patients admitted to a hospital after landing. More than half of the emergencies were either fainting due to dehydration (37.4 percent), difficulty breathing (12.1 percent) or vomiting (9.5 percent). Only three in a thousand emergencies resulted in death.

(A side note: to avoid becoming an-flight emergency statistic, here's some simple advice from Martin-Gill: "Drink a giant bottle of water." By far the most common cause of medical emergencies is dehydration.  Also, if you have a chronic medical condition, carry a card in your wallet with your diagnoses and your list of medications, and consider alerting the flight attendants if you are concerned. )

While many providers are quick to jump in and help, others may hesitate because they are uneasy about working outside a medical environment without all the usual equipment and support, Martin-Gill said.

When I asked him if providers who do not manage emergencies on a regular basis, like a dermatologist, should assist in these situations, he stated, "Well, if someone had a rash, I could think of nothing better." Moreover, all providers "start with basic training" and can be very helpful in communicating the situation to emergency physicians who staff the call centers who can then direct providers on the plane on what to do next. The providers on board "are our eyes and ears," said Martin-Gill.

When responding to the call overhead, physicians are not alone.

Dr. Amit Chandra, an emergency medicine physician at INOVA Alexandria Hospital in Virginia, points out that flight attendants are also trained to use defibrillators and that all U.S. flights are stocked with basic equipment. In addition, all U.S.-based flights — and some international flights — have access to the kinds of call centers where Dr. Martin-Gill works. And if nurses or paramedics who are more qualified step up to help, physicians should defer to them, Chandra added.

Kwok agrees. Her second emergency happened a year later, on a flight to Los Angeles. She awoke to see a man having a seizure a few rows in front of her and jumped up to help before she could even be called. “I think a lot of physicians are nervous to answer these calls because they think they have to do what they do in the hospital,” she said. “But really, your job is to decide if they are sick or not sick." With one more year of residency under her belt, Kwok was able to direct those who offered assistance, including an army medic who had "really trained for this," she remembered. This time, the pilots were able to respond to her concern for the patient and divert the flight. She and the medic stayed with the man after landing, until an ambulance arrived.

I wondered, would she ever decline to help?

“If I didn’t think I was capable of helping, if I wasn’t in a state that I would go to work, then yes,” Kwok explained. Otherwise, “when we see someone in need, we will respond, right?”

The flip side, of course, is that doctors are still people, and always being "on" can be overwhelming. We may be on our way to work at our hospitals or clinic, and staying with the patient after landing could mean missing a flight out. Even if the trip is for pleasure, not having time to relax is one of the primary contributors to the physician burnout epidemic.

When teaching about in-flight emergencies at a conference of emergency physicians, Dr. Chandra noted that some physicians expressed resentment at always having to be available. He was "surprised," he said, and strongly disagreed. "This is why physicians have a special place in society. We are obligated to use our skills" when people are in need.

I agree. But is it OK for me to put my headphones on and have a drink?

Dr. Martin-Gill offered no hard-and-fast rules. "I don't provide any general recommendations." And flights are just one of the places where our professional obligations can bleed into our personal lives, from dinner parties to weddings, to shopping for groceries. Emergencies, Martin-Gill said, "can happen at any point in our lives as health care providers." That's the thing about in-flight emergencies: It's just another reminder that you're never not a doctor.

So if you see me on a plane, I might be watching the in-flight movie. But if you need me, sit back and relax: I'm here to help.

Correction: An earlier version of this post incorrectly identified the hospital Dr. Amit Chandra works at: it is INOVA Alexandria Hospital in Virginia, not New York Presbyterian. We regret the error.