As soon as this question comes up over a plane’s PA system, passengers begin to curiously look up and down the aisle for signs of a medical emergency in progress. Of course, as only could be asked of human nature, the immediate reaction is motivated by both voyeuristic curiosity and genuine concern. Physicians and other health care providers share this response but also have another question come to mind: Could I really be the most qualified person on this plane?
The more time you spend flying, the more likely you are to become party to an in-flight medical emergency. Our friends who lead the George Clooney “Up in the Air” lifestyle probably have a number of stories up their sleeves when cocktail party conversation moves in this direction. Some may have even been inconvenienced by having a flight diverted for an emergency landing. How big a problem are in-flight emergencies? It has been difficult for curious physician-epidemiologists to get a handle on this due to the airline’s industry’s poor data collection and/or unwillingness to share data.
One of the most informative attempts was made by Michael Sand, a German surgeon, and colleagues who asked 32 European airlines to share data. In a 2009 paper in the journal Critical Care, the authors describe that only four carriers kept track of the necessary data. Of these, just two were willing to make the data available. Between 2002 and 2007, the two airlines recorded 10,189 in-flight medical emergencies. The denominator, needed to figure out just how many this was given the amount of passengers per flight per unit time, was 613 billion revenue passenger kilometers (rpk). That unit is not at all intuitive to me, but more than 2,000 events per year for just two airlines seems like quite a bit. How did those emergencies play out? As you probably guessed, syncope (fancy doctor talk for “passing out”) was the number one type of emergency and accounted for 53%. “Gastrointestinal disorders” (9%) and “cardiac conditions” (5%) came second and third – these descriptors are so vague, the complaints could have ranged from belly pain to a heart attack. “Fear of flying” was not far behind at 4%. The flight was diverted to expedite emergency care in 279 cases – not insignificant. Remarkably, there were 52 deaths during the five years examined, again just for two European carriers. Two babies were delivered. Perhaps most interesting, in 86% of the in-flight emergencies, a health professional came forward and was willing to provide assistance. In a nice piece in the May 23rd Times, Katie Hafner relates a number of physicians’ personal in-flight experiences. She also talks with Dr. Paulo Alves from a company called MedAire that provides emergency medical advice by phone for more than 60 airlines. In 2010 alone, they handled 19,000 calls resulting in 442 diversions and 94 deaths. In a recent JAMA commentary, Melissa Mattison and Mark Zeidel, both internists at the BI in Boston (on Longwood Ave.), make a reasonable argument for more standardization and mandatory data collection to improve air flight medical outcomes.
Although a rigorous calculation would have to compare the likelihood of a population having a medical emergency on the ground compared to up in the air, the statistics do make it seem that people are more likely to request emergency assistance when flying. If that is the case, one could reasonably hypothesize that flying itself is dangerous. On the other hand, most of the people who receive medical attention on flights have an episode of vasovagal syncope (again, passing out) or experience vague complaints – all problems that can be produced entirely by anxiety. All one has to do to be reminded that air travel is a remarkably anxiety-producing experience for many is to check out the bar crowds when strolling through a terminal. In addition to alcohol, self-medication of other sorts is very common. Many prefer valium to a pre-flight cocktail.
Stress and anxiety can produce emergency symptoms in the absence of an actual medical condition. Importantly, anxiety can also exacerbate a pre-existing medical condition (for example, a person with coronary artery disease has a heart attack on a plane). There are also conditions that seem to be precipitated by factors unique to flying, such as changes in atmospheric pressure and physical inactivity in a seated position on long-distance flights. The later can cause deep vein thrombosis, a blood clot in the large veins of the lower legs that can break up and lodge in the lungs causing a serious condition called pulmonary embolism. The former can cause collapsed lungs in people with risk factors. The craziest first-hand in-flight emergency story that I’ve heard comes from Toshi, a Japanese post-doc that I worked with years ago as an undergraduate in Marc Montminy’s lab. He placed a chest-tube on an international flight in order to decompress a tension pneumothorax using the goodies in an in-flight emergency kit, a classic life-saving procedure.
I answered the call about two years ago on a flight home to Boston. When the announcement came, my nose was buried deeply in a novel, possibly Roberto Bolano’s, “The Savage Detectives”. I quickly scanned the aisle and saw a flight attendant standing next to a tan and fit-appearing middle aged couple. She was a well-preserved brunette in a state of near-panic as she repeatedly asked her companion if he was alright. He had the look of a former high-school athlete, still in reasonable condition. He was pale, sweating profusely, and breathing deeply as they worked to loosen his button-down shirt and recline his seat. I noticed the couple earlier in the flight when they ordered cocktails. They had the look of a newly in love couple of above-median means. Perhaps this was a second marriage and they were returning from a romantic weekend outing?
Initially, I did what I usually do when there is a request for medical assistance: nothing. The term “Rheumatologic Emergency” may well be an oxymoron. Suffice to say that I chose my area of medicine, a cognitive and sciency niche, in part because making emergency interventions does not so much fit my personal style. Every other time I have been in this scenario, in a restaurant, on another flight, at high holiday services, someone else, presumably more qualified and certainly more willing, has come forward. This time, after a few minutes, an attendant made a second announcement. My wife-to-be, Robin, looked over at me as I resigned myself and slipped my shoes back on. Another attendant approached me as I made my way aft. Peeking over the seats, I could see that the gentleman looked less pale. With wishful thinking, I at that point diagnosed him with a syncopal episode – I really did not want it to be anything else. I identified myself as a “pediatric rheumatology fellow” to the attendant. I was not a board-certified anything at that point. I produced a flimsy, non-laminated card from my wallet which identified me as someone with restricted privileges to prescribe drugs through a training program at Children’s Hospital Boston. It looked like it easily could have been a photocopy.
I identified myself to the couple and asked if they would not mind if I sat in the open seat between them. I figured that if it was an anxiety-related situation, it would be best to stay down below seat-level so that the gaping stares of the other passengers would not make matters worse. They told me that he had suddenly and briefly lost consciousness in mid-conversation. The guy was initially disoriented but was now coming around. He had no significant medical problems. They had been drinking prior to the flight as well. I asked him if he would not mind if I checked his pulse and he offered his clammy hand. The pulse was slow, regular, and steady. I was relieved that it was not a fast or irregular pulse that would shoot my benign diagnosis out of the water. I clumsily put on a cheapo stethoscope offered by the flight attendant. From what little I could hear, there was a heart, it was beating slowly and steadily. Done. That was the extent of my diagnostic evaluation.
Just as I was about to begin reassuring folks that the gentleman had passed out and was going to be OK, a woman, a new addition to the group, asked me if I wanted to put the Automatic External Defibrillator (AED) on the patient. While I was talking and listening, the woman had made her way back from the front of the plane (maybe first class?) and identified herself as an ICU nurse at MGH. My first thought was something to the effect of “Oh Shit.” My second was “Really, you are offering to help now?” The real heavy lifting that I did that evening was convincing the ICU nurse that the man was fine and that we did not need to prepare to defibrillate or cardiovert anyone. After some discussion, she lost interest and made her way forward. Don’t get me wrong, if there had been an actual emergency rather than a need for assessment and reassurance, I have no doubt that the ICU nurse would have been much more of service than me. I explained to the couple a little bit about vasovagal syncope and got them to chuckle a bit after hearing one of my own choice fainting stories (I have several). Crisis averted, I returned to my seat. The attendants thanked me. Although they asked me to write down my name and address, they did not comp me with anything (fine by me) and I did not hear anything from the airline.
In my short experience, the main barrier to responding in an emergency is getting over the realization that you might actually be the person most qualified to help. This was never the case in the hospital during my residency and is still not the case now. The brief medical interaction I had with that gentleman, fortunately limited, felt elemental and pure. We were in that situation together at 35,000 feet. I was the patient’s doctor, maybe the best available, with no supervising attending in the offing. I suspect for many physicians, the opportunity to come forward as a Good Samaritan on a flight is uniquely rewarding, an idealized version of a more typical health care encounter. That said, I’ll continue to wait a cautious interval before stepping into the aisle and answering the call.