Medical emergency in the skies

After a rash of in-flight medical incidents, Bess Manson asks just what happens when things go awry at 30,000ft.

Heart attack, allergic reaction, stroke – there’s never a good time to fall ill, particularly when you’re 30,000ft up, flying over the open ocean, thousands of miles from anywhere. Up here, dialling 111 for help is not on the cards. But life is unpredictable, and crises do not adhere to a schedule. With several recent reports of in-flight medical emergencies, you wonder, just what happens when things go awry midair?

It’s reassuring to know airlines have a robust system set up for an in-flight medical drama. Such events are a relatively common occurrence, according to Tim Robinson, pilot and president of the New Zealand Air Line Pilots’ Association (NZALPA).

Robinson, a first officer, who has been an international airline pilot for 26 years, says he has had around 30 in-flight emergencies during his career, dealing with anything from heart attacks and allergic reactions to serious cases of meningitis.

It can cost airlines in the millions to divert a plane, so much will be done to avoid this.

HELP ON THE GROUND

Most airlines have access to specialist medical advice on the ground, both in-house and from on-call medical services that can be reached any time from anywhere, using satellite phones.

Air New Zealand uses MedLink, part of MedAire, a USbased service that offers medical advice to more than 100 airlines in 140 languages with a database of emergency medical response teams at more than 5000 airports.

When a medical emergency happens, it is the flight crew that start the chain of action.

After alerting the captain, a call will go out asking if there is a doctor or someone with medical training among the passengers.

With the help of crew, who all have first aid training, and possibly a medically trained passenger, symptoms are relayed to the medical expert on the ground, who then works on a diagnosis. With new technology it’s possible to send photos or videos of the patient back to the ground-based personnel to help them assess their condition.

The MedLink ground staff will have full details of the flight, so are able to make an assessment on the next course of action based on the condition of the patient, where the aircraft is and how far it has to go.

Should the pilot decide to divert, the MedLink team would determine the most appropriate airport and organise onthe-ground local emergency services to meet the aircraft.

But in any situation the responsibility and the safety of the aircraft and its passengers rests with the pilot in command.

Air New Zealand’s policy is that you have to have a very good reason to stray from the advice given by MedLink, says Robinson.

‘‘Under the New Zealand Civil Aviation Act the ultimate responsibility rests with the captain, who is in situ with all the information. When considering a diversion, the captain will look at factors such as how close the diverted airport is, what the weather is like, the length of the runway, what medical facilities are available at the divert destination.

‘‘It’s very rare for the captain to [act] outside the medical advice, but they may have compelling reasons to do so.’’

COUNTING THE COST

The life of the patient is of the highest priority and everything will be done to save that person, says Robinson.

‘‘Commercial factors are a secondary priority. When we talk about life and limb, commercial factors such as whether you can refuel at the unscheduled stop, if passengers are going to be inconvenienced

or whether it’s going to cost the company money, are a consideration but not the primary consideration.’’

But there’s no getting away from the fact that the costs of a diversion can be sky-high. They will vary hugely, depending on where you divert to, and whether the plane can refuel and leave immediately after the patient has been offloaded.

If an aircraft cannot be refuelled quickly, or the crew don’t have enough duty hours to see them through to the intended destination, requiring passengers to be put up in hotels, then it becomes a significant cost to the company, possibly running into the millions.

The costs of a diversion to the airline is quite complex, as it depends on the jurisdiction of the airport to which the plane is diverted, says aviation expert Irene King. ‘‘Different countries have different rules for passenger compensation or no compensation, as the case may be.’’

INCIDENTS ON THE UP

In 2018, the International Air Transport Association (IATA) estimated that about 38.1 million flights will have operated worldwide, up from 36.4m in 2017. Commercial airlines will have carried just over 4.3 billion passengers on scheduled flights.

With some long-haul flights now spanning more than 17 hours, the increase in the number of flights and our ageing population, the instance of in-flight medical emergencies is set to increase. Air New Zealand requires a medical certificate from people with more serious known medical conditions. Those with pre-existing medical conditions might be more susceptible to the cabin conditions – altitude and the issues associated with the length of flights.

Longer flight durations subject passengers to longer exposure to relative hypoxia (an insufficient intake of oxygen), which may also have a greater effect on older passengers.

But the grey dollar is worth a lot to airlines – increasingly – and the risks elderly passengers pose have to be weighed against this, says Robinson.

Some people fly when they shouldn’t, he adds. ‘‘There’s a bit of a ‘she’ll be right’ attitude out there, with people thinking they have booked their flight, paid for it so they’re going to go even if they have the flu or a bad cold. Passengers have got to take responsibility and manage their own risks.’’

ONE IN 604

It’s difficult to estimate how often medical events occur during a flight, because airlines are not required to report these incidences, says Jose Nable, an assistant professor of emergency medicine at MedStar Georgetown University Hospital and co-author of a 2017 paper on in-flight emergencies.

Based on data from a groundbased communications centre that gives medical consultation service to airlines, medical emergencies happen in about one in every 604 flights. Of those, 875 planes (7.3 per cent) were diverted to another destination. But this figure was likely to be underestimated as many medical events may be handled on board without involving a groundbased consultation centre.