When a medical emergency occurs on a plane, it "sets in motion a high-altitude calculation with human lives in the balance,"—and airlines often have on-the-ground medical consultants ready to weigh in, helping pilots "bypass" suggestions from onboard medical professionals to divert the flight, Ivan Levingston reports for Bloomberg.

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When an emergency occurs

A medical emergency happens on one out of every 604 flights, but few—0.3%—are fatal, according to a 2013 study in the New England Journal of Medicine. Overall, the study found about 7% of medical emergencies lead to a diversion—which the International Air Transport Association, an airline trade group, estimates can cost between $10,000 and $200,000 per diversion.

Jose Nable, an assistant professor of emergency medicine at MedStar Georgetown University Hospital and co-author of a 2017 paper on in-flight emergencies, said, "It's fairly expensive to divert an aircraft, and so a captain has to take into account a whole host of issue."

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So what happens when a medical emergency occurs?

Elise May, manager of inflight safety and regulatory compliance for Southwest Airlines explained that, in the event of an emergency, flight attendants are trained to protect themselves first, then page for a medical professional onboard. Flight attendants also may be trained in basic first aid. For instance, May said Southwest flight attendants have basic care skills.

The medical professional may decide that it would be in the patient's best interest for the plane to divert its course, but whether to divert is left up to the pilot and dispatcher—and it's not one that they take lightly, Levingston reports.

Help from the ground

To help pilots and dispatchers with that decision, airlines contract with medical consultants on the ground, such has MedAire Inc. and STAT-MD. On Southwest flights, May said, flight attendants have iPads that contain manuals and headsets to contact medical consultants on the ground.

Companies like MedAire, which is based in the ED of Banner-University Medical Center Phoenix, and STAT-MD, which is staffed by doctors from the University of Pittsburgh, help pilots decide whether a medical emergency warrants a diversion, taking the decision out of the hands of potentially "nervous and out-of-their-element doctors in the sky," Levingston writes.

May, of Southwest, said the decision to divert is "dependent a lot on our medical consultant and what they feel is the danger of the situation." She added, "There's all sorts of things to take into consideration."

Paulo Alves, the global medical director of aviation health for MedAire, said that doctors "tend to recommend diversions more than we do, because … onboard they don't want to assume the long-term responsibility."

Similarly, T.J. Doyle, the medical director for STAT-MD, said that doctors are "going to revert to divert." He added that medical professionals on board "should be a data-gatherer and a procedure-doer" and not "a decision-maker."

Most providers, Levingston writes, are bound by their Hippocratic Oath and are ready to help onboard flights when needed. For instance, Meera Shah, who helped revive a woman passed out on a plane last year, said she feels a moral obligation to help when an emergency occurs. "Ethically, I feel like there is this responsibility for me to intervene," she said. "What if I wasn't there? I always think about that."

But for some, having someone else weigh in on how to proceed with the flight might come as a relief, Levingston reports.

For instance, Scott Schoifet, an orthopedic surgeon, in 2006 was asked on a flight from Japan to New York whether it was safe to continue flying when a fellow passenger experienced chest pain. He said, "It was stressful first because they're looking at me like, 'What do you want to do?'" He added, "I can't make this decision. There's 350 people on the plane." Schoifet examined the woman and continued to monitor her until the plane was able to make a stop in Detroit, and continued on its journey from there.

Legal challenges

However, the process is not without its controversies, Levingston reports. United Continental Holdings, the parent company of United Airlines, is facing a lawsuit over its handling of a passenger's medical emergency. In the suit, the passenger Lewis Christman alleges the airline ignored a doctor's advice to land and failed to contact on-ground medical consultants when Christman suffered acute pancreatitis on a flight from Chicago to Rome. 

"Obviously, there is a significant cost to landing the plane," Christman's lawyer David Axelrod said. "We're looking for all the information about this incident, where my poor client is doubled over in pain and he's vomiting and they're not landing this plane."

Erin Benson Scharra, a United Airlines spokesperson said the company is looking into Christman's claims, but declined to comment on the airline's diversion practices (Levingston, Bloomberg, 5/30).

Trying to not get sick? The germs on a plane—and how to avoid them

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