In the Air, Health Emergencies Rise Quietly

March 13, 2008 -- The death of an American Airlines passenger during a flight from Haiti to New York last month has cast a spotlight on the growing number of medical emergencies on commercial jets, a trend that largely has escaped public notice because airlines aren't required to report such incidents.

The clearest picture of the problem comes from MedAire, an Arizona-based company that provides emergency medical advice to airlines that carry nearly half of the 768 million passengers on U.S. flights each year. A MedAire analysis, done at USA TODAY's request, indicates the rate of medical emergencies aboard commercial flights nearly doubled from 2000 to 2006, from 19 to 35 per 1 million passengers.

The increasing rate of medical incidents, health and aviation analysts say, partly reflects a collision of two factors:

• The rising number of older passengers as the 79 million baby boomers begin entering retirement but continue traveling habits established when they were younger.

• Flights that go farther and last longer than was typical several years ago. In a sample of 11 airlines served by MedAire, the average length of a flight rose from 1,233 miles in 2000 to 1,347 miles in 2006.

Medical crises are the force behind a rising number of emergency landings, says Joan Sullivan Garrett, MedAire's chairman.

"If you are ill, an airplane is the worst place to be," says David Stempler, president of the Air Travelers Association. "You are trapped at 35,000 feet."

Airlines and industry groups such as the Air Transport Association have mostly resisted revealing details about medical emergencies, saying such information is hard to collect and can be misinterpreted. And because airlines aren't required to file such reports, more is known about in-flight emergencies involving animals than humans. The Department of Transportation requires airlines to report animals' deaths on commercial flights; last year there were 14, the DOT says.

The death of Carine Desir on an American Airlines flight from Haiti to New York on Feb. 22 raised questions about how airlines handle medical emergencies. Desir's family has questioned whether the airline responded quickly enough with oxygen to save her.

The airline says its own review of the incident found the crew did all it could to help Desir. The New York medical examiner later found Desir died from complications of heart disease and diabetes.

MedAire says passengers with diabetes, seizure disorders and heart and respiratory ailments account for 23% of in-flight deaths and 29% of medically related flight diversions.

A USA TODAY analysis based on a variety of sources offers a fuller picture of in-flight medical incidents:

• There are more deaths from in-flight medical emergencies than from airline accidents. Since Jan. 1, 2003, there have been 95 passenger fatalities from airline accidents, according to the National Transportation Safety Board. MedAire reports that 219 passengers have died on the U.S. flights it analyzed during the same period. The company says the actual number is probably much higher because it tracks fewer than half of all U.S. airlines.

• In cases in which MedAire had information about the age of passengers with medical emergencies, those 51 and older accounted for 83% of 63 in-flight deaths in 2006. That age group accounted for 59% of 550 medical-related flight diversions in 2006.

• Airline industry trade groups such as the Air Transport Association (ATA) and the Regional Airline Association say in-flight medical emergencies are rare. But USA TODAY found it is common for emergency personnel to meet a plane carrying a sick passenger.

The newspaper obtained 911 dispatch data from 10 agencies that operate major airports. Eight agencies reported that crews were sent to help a very sick passenger at least once a week. The airports include some of the nation's busiest, such as Los Angeles International and Dallas-Fort Worth International.

• Medical emergencies can affect safety. The newspaper found 559 reports filed from 1998 to 2006 into a NASA safety incident database where crews logged events concerning in-flight illnesses. In 25% of the cases, crews said responding to medical emergencies led to abnormal flying situations, such as diverted jets landing overweight because of excess fuel and sometimes blowing tires, or getting approval to fly faster than regulations allow.

• Communication difficulties sometimes make it difficult for doctors on the ground to help passengers in distress. Because airlines removed many phones from cabins and secured cockpit doors after the 9/11 terrorist attacks, information usually has to be relayed by intercom from the back of a plane to the pilots, who then pass it along to doctors on the ground.

Not being able to communicate directly with flight attendants or others at the side of a stricken passenger makes it harder for doctors on land to give timely advice, says David Streitwieser, MedAire's medical director. He supervises a team of emergency physicians at a call center in Phoenix. "With chest pain, it's almost impossible to do with any certainty."

Some airlines are using satellite radios on flights over the Pacific Ocean and putting headsets in the cabin that flight attendants can use to speak with doctors on the ground, Garrett says.

Medical specialists say a key to ensuring adequate care aboard commercial flights is having a complete picture of what incidents are occurring among passengers. Collecting such data is important from a public health standpoint, says David McKenas, former medical director for American Airlines. "Data surveillance is key in trying to reduce disease in any kind of environment, and airlines just happen to be one unique environment."

Russell Rayman, executive director of the Aerospace Medical Association, the primary medical advisers to the airlines, says he has tried to create a database of medical emergencies, but airlines have not cooperated. "Airlines don't want to tell anybody about their medical problems in flight," he says. "There is no public affairs value in that at all."

Airlines resist disclosure

In September, USA TODAY sent a survey to every major airline's chief executive officer — a total of 60 — asking them how often in-flight medical emergencies occur, how many passengers die and how the airlines train and equip crews to deal with such emergencies.

A few airlines responded: Express Jet, Sun Country and Virgin Atlantic gave some details on the number of medical emergencies they experienced, how they train flight attendants, and the equipment they carry on board beyond federal requirements.

Then the ATA, the industry's trade association, stepped in. "Nobody is going to complete the survey," spokesman David Castelveter said. "We've spoken with them about it, and that is where we are going to draw the line."

Through the ATA, airlines collectively described their reasons for not releasing information: "Data are not kept in this format; records are not readily accessible; information is proprietary or protected by privacy policies; or time and resource constraints prevent us from preparing a meaningful response."

The industry's stance often has made it difficult for families of those who die during flights to determine what happened, says Craig Goldenfarb, a lawyer in West Palm Beach, Fla., who is representing a family in a suit against US Airways.

Court records have become a key source of information about in-flight medical emergencies. Some families have alleged that automated external defibrillators (AEDs) failed to function properly. Such devices shock a quivering heart back to a normal beat.

Each airline must equip its planes with working AEDs, but federal rules allow jets with inoperable ones to make a few flights until a replacement can be found.

The Federal Aviation Administration requires various medical equipment, medication and training for all carriers. Besides oxygen and AEDs, required supplies range from bandages and gloves to aspirin and heart medications. Some airlines — including American, Virgin Atlantic, British Airways and Qantas — say they provide more than the minimum.

American, for example, carries drugs not required by the FAA — but called for by doctors who have come to the aid of passengers on flights — to treat seizures, diabetes and persistent vomiting. American also says it provides more portable oxygen bottles than required.

The most common medical crisis in flight is neurological, which can range from a fainting spell to a seizure to a stroke. Last year there were 5,837 calls about neurological emergencies to MedAire, and those led to 266 emergency diversions. Sometimes pilots are close enough to their destination airport — or they think that a suitable airport with qualified medical help is too far away — so they determine that continuing the scheduled flight is the best option.

A pilot's decision on whether to divert his aircraft in an emergency can be one of life and death, says Enrique Leira, assistant professor of neurology at the University of Iowa College of Medicine. Leira has taught new pilots what questions to ask flight attendants to determine quickly whether a passenger has had a fainting spell or a stroke that needs immediate intervention to save the brain. He says having more data from airlines would help "improve outcomes."

Doctors know that the airline cabin causes a strain on the body, one that healthy people tolerate without much difficulty. Cabin air can be very dry. People in fragile health can become dehydrated. The airline cabin is pressurized, but it is a lower air pressure than at sea level, meaning less oxygen reaches the brain.

"The in-flight environment is plausibly more conducive to stroke than on the ground," Leira says. But without data, he says, it's impossible to say for sure.

Defending the airlines

Stempler says passengers have to take some responsibility to ensure they're fit to fly, making sure, for example, that their medications are within reach.

Chris Chiames, a former US Airways executive who heads the Sudden Cardiac Arrest Association in Washington, D.C., defends the airlines. "The reality is, airlines are doing a better job responding to medical emergencies than any other segment of the community," Chiames says. "Airlines have thousands of people trained in first aid and CPR. They have equipment nearby. They are actually a role model here."

Linda Campbell, a nurse, has worked at American Airlines for more than a decade, pulling together information about medical emergencies from pilots, flight attendants and passengers. She says the data are used to help train and equip flight attendants. During a crisis, she says, crews "can't call 911. They are 911."

Shawn Lynn, who recently retired from American Airlines, celebrated a 10-year anniversary last month. On Feb. 18, 1998, she was the first U.S. airline flight attendant to save a passenger on a jet with an AED. The airline has saved 81 lives since then.

Lynn notes that a crew is alerted to a medical emergency by four rings of the aircraft's chime. "When you hear the four bells, it's a sobering moment," she says. "We have to continue to train and keep up on current medical procedures. Saving one life is worth it."

Contributing: Stephanie Armour, Priya Raman, Susan O'Brian, Robin Hilmantel and Jessica Calefati