In five years as a family physician, Dr. Trish Penner has answered two in-flight calls for doctors on board. Most recently, she volunteered her services on a charter flight from Mexico to Winnipeg, Canada, where she lives. Penner and a nurse on the flight helped a man in his 30s with chest pain. They gave him aspirin, took a family history and sat with him for part of the trip. The other time Penner pitched in, the sick passenger had alcohol poisoning. Because the plane had already begun its descent, she wasn’t allowed to get up and treat him herself. From her seat, she told flight attendants what to do, talking them through each vitals check until the plane pulled into the gate. 

Each year, thousands of medical emergencies happen at 30,000 feet in the air. One in every 604 flights involves a reported emergency, which translates into 44,000 yearly emergencies worldwide, according to a recent large-scale study on in-flight emergencies published in the New England Journal of Medicine. The actual number could be higher, since there’s no standardized, industry-wide reporting system.

No one wants to picture themselves sitting in the aisle of a 747, getting an unplanned checkup as passengers look on. But it’s useful to know which health conditions can be exacerbated by air travel and what to expect if you ever need medical attention during a flight — who might be caring for you, what training they’ve received, and what they can actually do for you at cruising altitude. With help from airline reps, doctors and flight attendants, here’s an inside look at in-flight medical care.

The most common emergencies 

Dr. Curtis Huynh was flying home from a family vacation in Hawaii when a flight attendant came over the loudspeaker, asking for a doctor. Huynh, a physical medicine and rehab doctor from Las Vegas, raised his hand.

In the lavatory, Huynh found an elderly man who was groggy and gasping for air. “I knew something was really wrong,” he says. Together, he and a flight attendant helped the man out of the bathroom and started performing CPR. “My guess was he’d had a heart attack,” Huynh says. “I didn’t have a good sense that he was going to make it.”

Ultimately, an ER doctor and paramedic on board also pitched in, but the man died before the plane could divert. When it comes to mid-air medical emergencies, cardiac arrest is rare but dangerous: It occurs only 0.3 percent of the time, yet accounts for 86 percent of all in-flight deaths, according to the NEJM study. The most common in-flight problems, according to the study, are fainting or feeling dizzy and lightheaded (37 percent), respiratory symptoms (12 percent) and nausea or vomiting (10 percent).

Penner says there are limits to how much you can help in the air, regardless of the emergency. Even basic medical equipment, such as a stethoscope, can be hard to use due to ambient noise. “You want to be helpful and make sure everybody stays alive,” Penner says. “But we don’t have all the resources we need to make appropriate medical decisions. It’s really doing medicine with one hand tied behind your back.”

Health problems can flare up in the air

Air travel can tax the body and aggravate existing conditions, mainly due to air pressure. Cabins are pressurized, but not necessarily to sea level, meaning passengers experience high altitude for hours. The air also isn’t as moist as it is on the ground.

Patients with heart failure are more likely to experience respiratory distress, anxiety, stress, difficulty breathing, leg or feet swelling, fatigue or blood clots during air travel, according to one study. 

If you have respiratory or cardiovascular issues, it’s a good idea to speak with your doctor about strategies to help prevent in-flight medical crises. One option for patients who rely on supplemental oxygen is to use a portable, battery-powered oxygen concentrator during flights to increase O2 levels up in the air.

Who’s allowed to help?

When flight attendants put out a call for medical professionals, they’re happy to have a variety of licensed providers respond, including MDs, nurses and physician assistants, says SkyWest flight attendant Kelley McMahon. During her nearly 13 years in the air, McMahon has helped with two in-flight heart attacks. She isn’t required to ask for credentials, she says.

Each airline makes its own policies on how to select qualified volunteers and whether to require proof of identification or expertise. Southwest Airlines representative Ro Hawthorne says the airline reviews medical credentials before allowing a volunteer to assist. Credentials might include a driver’s license with an MD designator, a U.S. Drug Enforcement Administration card, a nursing license, a paramedic ACLS card, or a business card that matches the name on a driver’s license. Japan Airlines keeps a registry of physician passengers whom flight attendants can call on for assistance. 

In 1998, Congress passed a bill called the Aviation Medical Assistance Act to encourage medical professionals to volunteer. But it was just a legislative nudge; American healthcare providers flying on registered U.S. airlines aren’t legally obligated to help in an emergency. Many other countries, including Australia, France and Germany, do impose a legal obligation to assist.

What can airlines and flight attendants do?

The goal of mid-air medical care is to stabilize a sick passenger until they can get treatment on the ground. For U.S.-based airlines, the Federal Aviation Administration requires every plane to carry at least one automated external defibrillator, basic supplies like bandages and splints, and an enhanced medical kit with supplies like syringes, IV equipment, saline solution, aspirin, antihistamines, epinephrine and nitroglycerine tablets. Only medical professionals can open the enhanced medical kit, McMahon says. Some airlines supplement their kits. Delta Airlines says its emergency medical equipment on board exceeds the FAA’s minimum requirements.

Other countries have their own rules. In Canada, an AED is optional, and in Europe, the European Aviation Safety Industry doesn’t mandate airlines to stock defibrillators, though they’re recommended if an aircraft has more than 30 passengers and at least one crew member. British Airways includes items not commonly found on U.S.-based flights, like benzodiazepines, antibiotics and a suture pack including a disposable scalpel and a suture needle.

Penner stocks her purse with extra supplies in case she’s called on. She carries a stethoscope, aspirin, Ativan and a diagnostic book, since Wi-Fi in the air can be spotty. Other doctors say they’ve downloaded electronic versions of medical references to their smartphones, as well as apps like the Physician’s Desk Reference and drug interaction tables. 

All flight attendants are trained in CPR and first aid and know how to use AEDs. Flight attendant and author Heather Poole says initial flight attendant training usually lasts six to seven weeks for major carriers and covers medical emergencies. Once a year, she attends a one- or two-day session to review protocols. “I’ve had a couple passengers go unconscious in flight,” she says. “Thank God there were doctors on board to help.” 

What if there’s no doctor (or other pro) on board?

When a flight attendant’s call goes unheeded, they still have help, albeit from doctors on the ground. In addition to asking for physician assistance, most major airlines also contract with an airline consultation service, which lets pilots radio physicians for medical advice, which they can then relay to flight attendants. Some airlines provide in-cabin headsets so flight attendants can hear the advice themselves.

Backed by the resources of the University of Pittsburgh Medical Center, STAT-MD is one such service. Delta has partnered with STAT-MD for nearly 20 years, getting advice from physicians who are residency-trained and board-certified in emergency medicine. 

In all scenarios, the captain decides whether or not to divert a flight. In the NEJM study, 7.3 percent of the emergencies caused flights to divert. Captains can also request a priority landing to get a sick passenger care on the ground quickly. 

Perks for medical professionals

Medical personnel who help with in-flight emergencies don’t get paid, but they may get perks. While Penner and Huynh say they’ve never received anything, McMahon says professionals who help out often get rewarded with miles or vouchers for hotel stays.

One doctor got a bottle of wine and later received a voucher to spend at a tax-free shop during a future flight. Turkish Airlines runs a Smiling Doctors program; doctors who register and agree to assist during in-flight emergencies get perks like 5,000 miles for signing up and 1,000 miles if they fly at least once a year.

Improving the system

In a recent study, researchers argued for a standardized, industry-wide system to capture data on in-flight emergencies. Having a shared database, study authors said, would help inform decisions on what medical equipment is crucial and what extra training crew members might need. 

Others are pushing for emergency medical kits that would better support pregnant women and children. In 2018, the FAA reauthorization bill was signed into law. It included language directing the FAA to reevaluate whether its emergency medications and equipment standards meet the specific health needs of children and pregnant women. The FAA has yet to respond with guidance. So even with policies in place to reduce the challenges of practicing mile-high medicine, there’s still work to do.

In the meantime, you can talk to your doctor about flying-related health concerns and make sure you have whatever medications and supplies you need on board, as well as any vital health info that might be relevant to in-air treatment decisions. And if you or anyone else gets sick on a plane, remember that even if a healthcare provider is polishing off airline peanuts on a direct flight to paradise, the Hippocratic oath doesn’t take vacation. 

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