Dr. Celine Gounder has volunteered five separate times to handle medical emergencies on board an aircraft while traveling as a passenger. On one international flight, she struggled to care for an obese, diabetic passenger who appeared to be having a heart attack.
She couldn't hear his blood pressure with the manual cuff provided by the crew because of the loud airplane noise, and without the assistance of a nurse, she had trouble inserting an IV to give him fluids. Gounder, who is an infectious disease specialist, stayed up the whole night holding the man's oxygen as his blood pressure plummeted.
And once the plane landed, she and her would-be patient were the last off the plane and no medical teams were at the gate to assist.
"I was furious," Gounder told ABCNews.com. "The most frustrating thing is the airlines never give you feedback as to what happened. They may not even know themselves, and you are sort of left hoping the person made it through and if what I did was right or wrong."
"In some ways, it's not fair. They are relying on our good will. And it's not just our good will -- it's an imposition." -- Dr. Celine Gounder
In a 2013 article she wrote for The Atlantic, "Medical Emergencies at 40,000 Feet," she says, in general, the airlines are "unprepared" for the most serious incidents.
Medical emergencies happen 1 in every 604 flights, according to a 2013 study published in the New England Journal of Medicine. And about 75 percent of the time, a doctor, nurse or paramedic on board must deal with the passenger in distress.
Just last weekend, a Delta Air Lines flight from Seattle to Atlanta was diverted when a 16-year-old boy with cerebral palsy died of a heart attack on board. According to the Atlanta Constitution, the teen, whose name was not released, was traveling with family and headed home to Georgia for the holidays.
The incident happened about 30 minutes after take-off when the boy went into cardiac arrest, according to registered nurse Dan Goslin, who responded to the call from the crew. He told ABC's Atlanta affiliate WSBTV that he and a doctor and midwife assisted, but could not revive the teen.
The Federal Aviation Administration (FAA) only requires that the airlines report a death or a flight diversion because of a medical emergency, and those incidents are rare, say experts.
Of the 2.75 billion passengers who fly on commercial airlines annually worldwide, only one third of 1 percent ended in death, according to the NEJM study.
Researchers analyzed nearly 12,000 calls to the University of Pittsburgh Medical Center, one of two ground communication hubs that provide physician advisors when an emergency happens in flight.
Those calls represented 744 million airline passengers from five domestic and international airlines from five domestic and international airlines from 2009 to 2010.
The majority of cases (37 percent) involved fainting; other medical emergencies included respiratory (12 percent) and nausea or vomiting (9.5 percent). Aircraft diversion happened in 7.3 percent of the flights.
The NEJM study was co-authored by Dr. Christian Martin-Gill, assistant professor of emergency medicine who works at the communications center.
There, physicians advise about 20 major airlines on how to treat a patient or whether to divert a flight or organize medical treatment on landing via satellite telephone or radio. The center operates 24/7 and handles about one consultation an hour or about 8,500 a year.
"It happens more frequently than you think," Martin-Gill told ABCNews.com. "Flight crews are trained in CPR using defibrillators and are trained in using on-board medical equipment. Each flight they are required to have a medical kit and on-board oxygen."
About one-fourth of emergencies are handled by the flight crew, who are trained in basic first aid.
"Most medical emergencies are relatively minor and handled with the kit and do not require diversion of the plane," he said. "The most common emergency is someone is light-headed -- known as syncope. With simple hydration and lying down, they improve rapidly."
The FAA requires that all major commercial U.S. airlines have on board medical kits that include an automated external defibrillator (AED), which can be used to shock the heart back to normal rhythm.
Medications in the on-board kits must include a non-narcotic pain killer; IV fluids for dehydration or low blood pressure; an antihistamine to treat allergic reactions; an inhaler for asthma; aspirin and nitroglycerin for a heart attack; IV dextrose for low blood sugar; epinephrine for allergic reactions or asthma; and atropine, and lidocaine as an adjunct to CPR. The kits must also contain a stethoscope and a manual blood pressure cuff among other supplies.
Martin-Gill concedes that some airlines are better equipped than others. One relatively common occurrence is nausea and vomiting and his study showed that the rate of diversion is lower when nausea medicine is available.
But he argues, "The vast majority of emergencies can be handled well with the equipment on board. In our experience, the kits cover most of the situations encountered on the aircraft."
Right now all three major airline associations are working with medical experts to revise recommendations for those kits.
One, the Aerospace Medical Association, hopes to have new guidelines ready for 2014. The last review was in 2003, according to Executive Director Jeffrey Sventek.
The organization advises the airline industry on medical emergencies and provides online publications for the lay person who has questions about their medical condition before they travel.
"We have got to do something because we feel very responsible to the public to provide a safe and healthy environment," said Sventek. "Americans are doing a lot more international travel and are exposed to more infectious diseases. There are myriad issues surfacing because of our mobile population."
He said the association "didn't disagree" with Gounder's observations that doctors sometimes need more expertise when volunteering on a flight.
"Not every doctor is trained in every specialty -- very few are," Sventek said. "You throw them inside an aircraft and with individuals with different circumstances."
"Some medical kits are lacking or some doctors didn't know there were experts on the ground made available through radio communication," said Sventek.
But, he adds, "Frankly, I think the airlines do a pretty good job of it," he said. "Medical folks who step forward to volunteer do a tremendous job."
Dr. Michael Gerardi, a former flight surgeon and pilot who is now director of pediatric emergency medicine at Morristown Medical Center in New Jersey, said every time he takes a flight, he identifies himself and tells the crew not to be afraid to wake him if there is an emergency.
"Emergency physicians rush to the patient on planes when these things occur," he said. "It is our nature, our DNA, and we are masters of improvisation."
He said emergencies happen when people with pre-existing medical conditions ignore their symptoms in anticipation of a flight.
"They get a maybe a TIA ( transient ischemic attack) or chest discomfort," he said. "It's a trip of a lifetime and they've got to get to that wedding. They don't eat or don't sleep and worry about the TSA lines and neglect their symptoms. Something is prone to happen."
Alcohol and use of sedatives to sleep can also cause medical problems, he said.
Sometimes doctors on board who have sub-specialties are hesitant to help out, said Gerardi. "They are totally out of their environment and feel the liability or risk, even with the good Samaritan laws. And if a patient dies, there is paperwork. They put a blanket or pillow over their head."
Still, Gerardi concedes, the medical kits are "pretty Spartan."
He agrees with Gounder that in addition to broader IV capabilities, the airlines should have a glucometer to measure blood sugar and access to sedatives.
"You see people go bizarre on airplanes," he said. "It would be good if we could knock them out and put them to sleep. … People with psychiatric issues need not be duct-taped to a chair."
Gounder said while most doctors are happy to assist, they are on vacation, too.
"In some ways, it's not fair," she said. "They are relying on our good will. And it's not just our good will -- it's an imposition."
One of her colleagues flew from Sri Lanka through London and almost missed a connecting flight because she was helping a passenger in distress. "She almost missed her connection and it was a big deal. ... We give [our help] because it is our duty and responsibility to care."
In the very least, Gounder said she wished she had known there were ground-based medical services the flight attendants could have contacted to help her deal with some of the passengers she volunteered to help. And maybe a little more positive reinforcement.
"One of the flight attendants on a flight from India to Frankfurt gave me a bottle of champagne," she said. "What am I supposed to do, drink the entire bottle before I go through customs? It didn't make any sense.
"It would have been nice to get a meaningful thank you letter -- recognition of what you did and an update."