Features  / 01.13 /

Doctor NRST

In an emergency, find a place to land first

air emergency

Photography by Chris Rose

On April 2, 2012, an 81-year-old pilot became unconscious while flying a twin-engine airplane. His 80-year-old wife, in the right seat, radioed the ground. Another airplane was launched to fly beside her and talk her through the landing, which she had to accomplish on one engine as the other one had run out of fuel. The wife survived with minor injuries, although the husband died.

On March 27, 2012, a JetBlue pilot in command of a flight from New York to Las Vegas had a mental breakdown. After being ejected from the cockpit, he had to be restrained by passengers. The airplane made a safe although unexpected landing in Amarillo, Texas.

On March 9, 2012, an American Airlines flight attendant had a mental collapse shortly before takeoff and had to be restrained by passengers and crew.

Private pilots carry a medical certificate along with their pilot certificate. They’re screened pretty well to make sure they are physically and mentally capable for the responsibilities of flying. There are rules in commercial aviation, such as cockpit crews not eating at the same time to avoid the potential of disabling food poisoning. So medical emergencies involving cockpit or cabin crew are exceedingly rare.

Rare, but not unknown. And medical issues involving passengers are much more common than most people expect. More than 22,000 times in 2011, air crews called an emergency room that specializes in in-flight medical emergencies. That’s an average of more than 60 times a day. Every day. What do you do when you are a mile above the nearest ambulance?

IS THERE A DOCTOR ON BOARD? I was on a late-night flight from Amsterdam to Minneapolis, in the very last row so I could be near the coffee and conversation in the galley. After dinner, as everyone settled in to a movie or fitful sleep, a flight attendant’s voice came over the PA system. “Attention, everyone,” she said, “we have a medical emergency on board. If there is a physician on board, please make yourself known to the cabin crew.”

Two or three people stood up. A flight attendant removed a metal case from a panel in the galley wall, and they all moved forward. Whispers of “heart attack” and “seizure” and “epilepsy” and “diabetes” jumped the aisles, but no one really had a clue.

There was a gathering near an exit row, but no panic. No one screamed. After a while, the doctors returned to their seats, and the crew re-stowed the case. The patient was fine—or fine enough. There was a bit of gallows humor from the cabin crew, and some debate about whether or not a seal had been broken on the case, but the weather was clear and Minneapolis was waiting.

On the ground, however, I couldn’t stop wondering. In a coffee shop, I stopped another pilot. “What do you do?” I asked. “What are the rules for a medical emergency? How do you decide between returning, continuing, diverting or something else?” More important, I wondered, what I would do if a passenger in my rented Cessna 172 suddenly had a medical emergency?

COMMERCIAL AVIATION. Because no one knew how the general population would take to flying, the first commercial flight attendants were registered nurses. That idea quickly proved itself unwarranted, but because of the sheer number of bodies in the sky, medical emergencies on commercial flights are not uncommon. As the flying population ages, the problems become more diverse.

Airlines are not required to keep or publish data about medical emergencies in flight. However, the website for the British Medical Journal, in a 2000 article, states, “The commonest reasons for diversion in a recent U.S. study were cardiac incidents (28 percent), neurological problems (20 percent), and food poisoning (20 percent). Other reports have cited severe and uncontrollable pain or bleeding; major injury with shock; impending birth; and uncontrollable mental disturbance.”

MedLink, a service of MedAire Inc., handles more than 22,000 in-flight air-to-ground medical advisory calls annually—22,594 in 2011. More than 65 commercial airlines as well as private owners, fractional owners, and a good many Fortune 100 companies pay a membership fee and then have access to doctors practicing in the emergency department of Banner Good Samaritan Medical Center, a Level I Trauma Center in Phoenix, Arizona. According to Heidi MacFarlane, vice president of strategic development, and Erin Mitchell, manager for marketing and corporate communications, the calls run the range from questions about medications to how to handle a sudden cardiac arrest. Thirty-seven percent of the 2011 calls were regarding neurological/neurosurgical issues. Twenty- five percent concerned gastrointestinal questions. Nine percent relayed respiratory concerns, while only 7 percent involved cardiac issues and only 3 percent involved psychiatric problems. Other issues that prompted a call included allergies, orthopedics, ENT, infectious diseases, and trauma.

The doctors on the ground have access to the airline database regarding medical equipment on board and guide the cabin crew through whatever medical procedures are necessary. If a diversion is the best option, they can advise which alternate destination has the most immediate and appropriate level of care for the situation.

GENERAL AVIATION. But what about those of us who fly low and slow, who take friends and coworkers for rides, who don’t have a cabin crew or a flight nurse to help if someone gets sick? Motion sickness is the most common medical challenge a passenger in a private airplane will face. And there is a little bag in the airplane (or at least there should be) that does not solve the issue but will accommodate the symptoms very nicely.

There are stories, urban legends perhaps, that hint at larger issues. A 98-pound Air Force flight instructor has to reach over and break the nose of a hulking cadet who has a panicked death-grip hold on the stick. A purse strap had to be wrapped around the hands, arms, and neck of a passenger to get them off the controls.

Still, more serious medical issues can arise at any time, in any place, with anyone. It could be a panic attack, a heart attack, a seizure, or something as simple as choking. Just like imagining what might go wrong with the engine helps us plan for the emergency we hope will never happen, imagining what might go wrong with the friend in the next seat helps us plan for the best course of action.

Tim Meyer is the director of emergency air transport for Sanford Health Systems in Fargo, North Dakota, and oversees a fleet of fixed wing and helicopter medical aircraft. His passengers are, by definition, in the midst of a critical medical situation. However, he says, “We are never in a situation where we have a passenger who might interfere with piloting the aircraft because we have medical staff on board. We have flight paramedics and flight nurses on every flight.”

Meyer is also a pilot. Because of his experience with air ambulances, I asked him to imagine what might happen if a passenger in a small airplane had a sudden issue. “It’s possible,” he said, “if the passenger was having some type of seizure, they might stretch and stand really hard on the rudder pedals. It’s possible they might bang against the door and pop it open. Anything’s possible.”

The advice is pretty simple. No matter what the medical emergency may be, you cannot help the person until you are on the ground. If you are flying you cannot perform the Heimlich maneuver or CPR. This isn’t a matter of law. It’s a matter of fact. If your passenger has fainted, you have no idea why. It could be nothing at all. It could be serious. The “golden window” for a patient with sudden cardiac arrest is between six and 10 minutes.

“The important thing,” Meyer says, “is that a passenger with a medical issue is going to take your attention away from flying the airplane. Remember the three-step thing we all learn first—aviate, navigate, communicate. You have to fly first. Just land the airplane.”

Just as a Coast Guard rescue swimmer sometimes has to dunk or strike a panicked person in the water in order to facilitate the rescue, you might have to take drastic measures to get someone who has grabbed the controls to let them go. It’s a pretty sure bet that whatever you do for the person next to you will be easier to fix than a crashed airplane.

AIR TRAFFIC CONTROL. Should the pilot of a private aircraft declare an emergency if there is a medical issue? From the FAA operations point of view, an emergency is an emergency—it doesn’t matter if it’s mechanical or medical. The whole purpose of declaring an emergency is to gain access to the most immediate and efficient help and clearance possible. According to Robin Mugavero, air traffic manager in Fargo, North Dakota, once a pilot declares an emergency, ATC will do whatever the pilot wants. Depending on the situation, the pilot can turn back, land immediately, or proceed to a destination. It doesn’t matter if the airplane is a commercial flight or a Cessna 150. Once you say you have a problem, ATC’s job is to get you down safely. ATC does not give medical advice.

NRST. You cannot attend to a passenger and fly any airplane at the same time. It’s that simple. Hit the NRST button (nearest airport). If you’re flying in an area with a tower, which means a fair bit of traffic, declare an emergency. Land at the very first strip. It doesn’t matter where. If a town is big enough for an airport it is probably big enough for some type of emergency service. There is going to be an EMT, a first responder, a county sheriff, or a medically trained volunteer fire department if not a full-size ambulance service. Dialing 911 on a cellphone will bring at least one of these right to the door of your airplane. You do your passenger the very best service by landing.

W. Scott Olsen is an English professor at Concordia College in Moorhead, Minnesota.