When a New York woman died aboard an American Airlines flight returning from Haiti last month, her death raised concerns among passengers about the level of medical treatment available at 9,000m.
An inquiry is still under way in the death of Carine Desir, 44, aboard American's Flight 896 on Feb. 22, but it has already prompted airlines and passengers to review the current protocol.
What happens if a passenger has a heart attack onboard? How well-equipped is the plane? What kind of training does the flight crew have?
Medical emergencies happen on planes more often than you might think. MedAire, a Phoenix company that provides cabin crews with medical advice, received 17,084 in-flight calls last year. Most were minor in nature, involving fainting or an upset stomach.
But 649 planes were diverted for medical reasons and 97 people died onboard, according to the company, which advises 74 commercial carriers, including Continental, JetBlue and Virgin America.
"We fly more than a quarter-million people a day on average, which would easily fit a medium-size city," said Tim Smith, a spokesman for American. "Just about anything that can happen on the ground can and will happen on an aircraft."
So how prepared are the airlines for medical emergencies? It depends on the carrier. The Federal Aviation Administration's rules are pretty thin: Planes are required to be equipped with a first-aid kit, a defibrillator and, for all but the smallest planes, an emergency medical kit that includes a stethoscope, needles, epinephrine and an intravenous set.
But beyond being trained in basic CPR, and being drilled every 24 months on how to use a defibrillator, flight crews aren't required to know much more than where the medical equipment is kept. A 2006 FAA advisory states, "Flight attendants should not be expected to administer medications or to start IVs."
Candace Kolander, a flight attendant and the health coordinator at the Association of Flight Attendants, said: "Although we have the equipment onboard, the reality is we aren't trained as medical hospital personnel. In reality, it's minimal first aid."
Attendants can open a first-aid kit to dole out bandages, and they can administer oxygen and use the defibrillator. But they are not supposed to use the stethoscope and syringes, or even administer aspirin without the direction of a medical professional. Rather, they are typically instructed to call upon medically trained volunteers from the cabin.
So, in the event that a medical crisis strikes in the sky, passengers are generally at the mercy of who happens to be onboard.
"People think they have the same resources in the air as they do when they call 911, and it's just not that way," said Joan Sullivan Garrett, the founder of MedAire. "They're ignorant of the fact that there are many challenges of flying outside of their control."
What happens, for example, if a passenger experiences cardiac arrest? Getting the passenger to a hospital may seem like the obvious priority, but which hospital and how are tough questions: Should the plane be diverted to the nearest airport? Is that runway long enough? Is it faster to proceed to the planned destination? How urgent is the condition?
These weighty decisions are ultimately left up to the pilot.
Although the FAA doesn't require it, most US airlines contract with companies like MedAire or medical institutions like the Mayo Clinic for medical counsel from doctors on the ground for flight attendants and pilots - albeit remotely. Some go further: American has its own in-house doctors who provide medical direction to flight crews.
But no matter how knowledgeable the doctor, the medical care is limited by distance.
"We're often getting the story told to us from the passenger, maybe to the flight attendant, maybe to us," said David Claypool, a medical director at the Mayo Clinic Medical Transport, which advises Northwest Airlines and other clients. "We're working on experience and gestalt."
Perhaps better medical judgment can be deployed before the plane takes off. For instance, if gate agents notice that a passenger in the boarding area is in distress, coughing uncontrollably or writhing in pain, they can alert their airline and consult with on-call medical professionals to determine whether the passenger poses a risk. A passenger with full-blown chicken pox, for example, may be denied boarding.
But there is a flip side to empowering flight crews to play the role of public health officials. Discrimination lawsuits, for example, have been threatened against airlines that ejected passengers with HIV.
It's also generally up to the crew to make the difficult decision about what to do with a body in the event of a death onboard. Last year, a first-class passenger on a British Airways flight from New Delhi to London woke up to find himself sitting near a corpse. The airline later said that an elderly woman from the economy section had died after takeoff, and the body was moved to first class, where there was more space for family members of the deceased to grieve with more privacy.
Some airlines offer more training and carry more medical equipment onboard than others. American, for example, has offered defibrillators onboard since 1997, long before the government required airlines to carry them.
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