TravelByte #39: Anticipating the Unexpected: Responding to In- Flight Medical Emergencies


Have you ever volunteered to help during an in-flight medical emergency (IME)? Not long ago I was called upon to assist during an international flight from NYC to Santo Domingo DR.  I was the only health professional who responded to the crew call, and while everything turned out just fine, I was dismayed at the lack of emergency protocols, equipment, and supplies on this U.S. carrier.

In this blog I share my experience and highlight an excellent article that may help any of us when called upon to assist an airline passenger with a medical emergency.

About two hours into a 4.5 hour flight, the crew asked for assistance with a woman complaining of chest pain. The passenger was an Italian citizen in her mid- twenties who was very agitated, gasping for breath and clutching her chest. She was traveling on her honeymoon with her new husband. She spoke only Italian; he knew very minimal English. Neither spoke Spanish and no one else on the plane spoke Italian. After a quick assessment, I determined that the passenger was not experiencing cardiac problems, but rather was having a full- blown panic attack and needed close monitoring to keep her seated. Periodically she would scream loudly that she wanted the plane to land immediately and then would rise from her seat and try to rush to open the cabin door. For the first 15 minutes of this event, I was asked several times if the pilot should divert the plane to another island. (Needless to say, fellow passengers vetoed loudly any suggestion that the plane go off course, delaying their arrival in the DR.)  To calm the passenger and prevent a safety issue, I chose to sit with the new bride and distracted her by looking at her wedding album for the remaining 2 hours of the flight. She pointed; I smiled. Occasionally the crew would ask if I wanted to sedate the passenger with small bottles of alcohol. I declined for many reasons, including the fact that I could not get an answer to my questions about her pregnancy status. Upon arrival at the airport, I was given several documents to complete. Despite the crew’s reports that fear of flying, alcohol- related agitation, and panic attacks were quite common, none of the documents included these diagnoses. The document was skimpy; cardiac c/o were the only options. I had to write out my account of the incident in full.

How did it all end? Well, as soon as we landed, the passenger became another person entirely. She changed into a different dress, applied makeup, and went down the ramp smiling. She hugged me as I tried to emphasize to her husband the importance of the note I had written out for him. It detailed what had happened on the flight and strongly encouraged that she be evaluated and possibly premedicated before they took their next flight in three days- a 12 hour non-stop back to Rome. It included my email address, if needed by a physician or the authorities for further information.

According to the Federal Aviation Administration, in-flight medical emergencies occur approximately in 1 out of every 604 flights. To address this need, the FAA requires that airlines store emergency medical kits, but with a minimum of items (see Arnot, 2020). Some carriers supplement that list, but I found nothing in the kit that was useful for this encounter. For example, I could have used a large size Bp cuff for my initial assessment, but none was available.

U.S. health providers are protected by the so-called Good Samaritan provision of the Aviation Medical Assistance Act and components of the Montreal Convention when responding to a medical emergency on a U.S. airline.  There is no U.S. legal obligation to respond; some European countries do require licensed clinicians to volunteer when called upon. Airline crews are not trained for medical emergencies, as the crew on this flight reminded me several times. And although they were very limited in what they could do in this situation, all of the crew was very appreciative and supportive of my efforts.

Thinking back on this experience, I decided to research the literature to learn more about IMEs and how best to respond. I am not trained in emergency care and I was certainly nervous initially.

Here I share one JAMA review article that I now have on my smartphone- just in case- and that I commend to our members. Other relevant articles are listed at the end of this blog.

In-Flight Emergencies: A Review

Christian Martin-Gill, MD, MPH, Thomas Doyle, MD, MPH and Donald M. Yealy MD

JAMA December 25, 2018   Volume 320, Number 24, pages 2580-2590

  • The most common IMEs are syncope or near syncope, GI, respiratory and cardiovascular symptoms
  • Diversion of aircraft occurs in 4.4% of IMEs
  • The number of IMEs may be underrepresented in the available data and may be as high as 260 to 1420 IMEs daily worldwide
  • Cabin pressurization (typically pressurized to 5000- 8000 ft), prolonged sitting, and dry cabin air impact passenger physiology. These environmental changes alone can promote respiratory and cardiovascular effects.
  • The article includes a list of the minimum emergency medical kit items as required by the FAA (Table 3) and notes the need for: standardization of equipment and kit location within the aircraft, and the addition of pediatric equipment, pulse oximetry, naloxone, antibiotics and a major analgesic.

In addition to a “General Approach to an IME -Clinical Assessment and Management” section, the authors provide a very useful series of 16 boxes that outline “Initial Assessment” and “Management and Expected Course” for some of the most common IMEs (e.g., syncope, GI illness, seizure, trauma, allergic reactions, obstetric emergencies, cardiac arrest). As example:

Management of In-Flight Medical Emergencies: Syncope, Gastrointestinal, Respiratory, Cardiovascular, Strokelike, and Seizure

Note: In this article the authors frequently mention that airlines often, or routinely, contract with on- the- ground medical services for assistance with IMEs, decisions about diversion, and support for volunteer HCWs in the cabin. I was never told of any ground support by this flight crew and the crew wanted me to make the decision to divert, “the captain says we have to decide within 15 minutes or we lose the opportunity to land as we will then be over the Atlantic. What do you want to do?”

If you ever find yourself in a similar situation, do ask about the availability of contract medical services that can support in-flight volunteers.


Of special value to travel health nurses, the article speaks to prevention of IMEs. All passengers should be encouraged to hydrate often and eat scheduled meals and snacks. Low humidity and pressure changes in the cabin coupled with exhaustion increases the risk for dehydration and syncope.  The authors go on to say:

“Physicians and nurses assisting flight travel plans for patients with chronic medical conditions should consider and educate patients on the effects of cabin altitude, need for routine medications, and potential occurrence of medical emergencies. “ 

In the pretravel visit, travel health nurses often focus on the risks at destination. This article reminds us to also address any relevant issues of air travel as well. Travelers should bring necessary medications in carry-on, not checked luggage, and never anticipate that the airline will provide all required drugs or equipment in the event of an emergency (including diabetic medications, sufficient oxygen supply, or epinephrine).

Other relevant articles on this topic:

Arnot, M. What’s inside an airplane’s medical emergency kit? Retrieved July 30 from

Epstein, Catherine R, et al. “Frequency and Clinical Spectrum of in-Flight Medical Incidents during Domestic and International Flights.” Anaesthesia and Intensive Care, vol. 47, no. 1, 13 Feb. 2019, pp. 16–22.

Peterson, D. C., Martin-Gill, et al. (2013). Outcomes of Medical Emergencies on Commercial Airline Flights. New England Journal of Medicine, 368(22), 2075-2083.

Kesapli, Mustafa, et al. “Inflight Emergencies During Eurasian Flights.” Journal of Travel Medicine, vol. 22, no. 6, 2015, pp. 361–367., doi:10.1111/jtm.12230.

U.S. G.P.O. Public Law 105 – 170 – Aviation Medical Assistance Act of 1998 (1998) (enacted).

FAA. (2006). Emergency medical equipment (121-33B). Retrieved from

FAA. (2006). Emergency medical equipment training (121-34B). Retrieved from

Lufthansa. (n.d.). Doctor on Board. Retrieved from

Nable, J. V., Tupe, C. L., Gehle, B. D., & Brady, W. J. (2015). In-Flight Medical Emergencies during Commercial Travel. New England Journal of Medicine, 373(10), 939-945.

EASA. (2018). Carriage and use of Automatic External Defibrillators (2018-03). Retrieved from

Hinkelbein, J., Neuhaus, C., Wetsch, W. A., Spelten, O., Picker, S., Böttiger, B. W., & Gathof, B. S. (2014). Emergency Medical Equipment on Board German Airliners. Journal of Travel Medicine, 21(5), 318-323.