Exhausted after a night shift on a busy hospital ward, Dr Vishwaraj Vemala fell asleep almost as soon as he boarded his flight to India, only to be nudged awake by his mother a few hours later telling him there was ‘a problem’.
As he woke up, Dr Vemala, a liver specialist at Queen Elizabeth Hospital Birmingham, spotted a fellow passenger, sweating profusely, rush to the back of the plane where he then fell forward into the arms of a member of the cabin crew.
Dr Vemala jumped up to help but the initial signs did not look good. ‘I checked his pulse but there was none, and I realised he’d had a cardiac arrest,’ says Dr Vemala.
This would be a medical emergency wherever it occurred, but at 35,000ft and hours away from an airport it was especially difficult.
We’ve all seen it in films, and some will have witnessed it first-hand… that moment during a flight when the call goes up: ‘If there is a medical professional on board can they make themselves known to the cabin crew’
Dr Vemala shouted for the crew to bring the plane’s medical kit and defibrillator. He needed to shock the man’s heart to get it pumping again.
Even for Dr Vemala it was a challenging situation. ‘I’m a liver physician but have worked in intensive care for five years, too, and regularly dealt with cardiac arrest. But in hospital I’d have a team, monitoring equipment and trained nurses. Here I was on my own.’
He got the patient’s heart beating again but lacked the vital equipment needed to check that the man didn’t deteriorate, so had to borrow equipment from passengers, including a blood-pressure monitor and a glucose monitor. He also attached an Apple Watch to a laptop, using it as a makeshift electrocardiogram (ECG) to check the electrical activity of the man’s heart.
Dr Vemala would have to work to keep the 43-year-old patient alive for five hours – during which time he used the defibrillator once more to kickstart the man’s heart again after he had another cardiac arrest.
But by the time they were able to make an emergency landing at Mumbai that afternoon in November 2022, the patient was awake and talking.
‘He was telling me he had a three-year-old daughter in the UK and was travelling to Goa to visit family,’ says Dr Vemala. ‘It made me all the more glad I could help.’
An ambulance was waiting on the runway. ‘As he was taken away he had tears in his eyes,’ says Dr Vemala. ‘It was extremely emotional for us all.’
We’ve all seen it in films, and some will have witnessed it first-hand… that moment during a flight when the call goes up: ‘If there is a medical professional on board can they make themselves known to the cabin crew.’
Whether or not anyone comes forward – and what emergency equipment the plane carries – can make the difference between life and death.
When Natasha Ednan-Laperouse had a serious allergic reaction on a flight to Nice in 2016 there was no way for her to receive the urgent medical care she needed, and she later died in hospital.
And midair medical emergencies are not uncommon due to the sheer number of people taking flights – currently more than four billion passengers a year globally.
What’s more, factors caused by flying mean that many people become unwell in the air. And they won’t all have the happy ending of Dr Vemala’s patient.
According to Resuscitation Council UK, an estimated 1,000 people worldwide die during commercial flights each year.
While the classic story involves an emergency tracheotomy being performed using a ballpoint pen, the most common problems are feeling faint or lightheaded; sickness and diarrhoea; breathing issues and neurological conditions such as strokes and headaches, according to a review in The American Journal of Emergency Medicine in 2021.
But there can be a multitude of other reasons that people fall ill on a flight, says Dr Paulo Alves, global medical director of aviation health for MedAire, which provides access to doctors during health emergencies for onboard crew.
Simply being at an airport and getting through security can be stress-inducing, and ‘stress can push up pulse and blood pressure, making the heart work harder than normal’, he explains.
Eight-year-old Raven Norfolk, pictured with her parents Phoebe and Mark, had a seizure while travelling back from a week in Alicante earlier this year
Dr Vishwaraj Vemala, a liver specialist at Queen Elizabeth Hospital Birmingham, spotted a fellow passenger, sweating profusely, rush to the back of the plane where he then fell forward into the arms of a member of the cabin crew
‘Then altitude makes the air less dense, meaning there is less oxygen available to be breathed in and used by the body.’
This may just make some feel faint or lightheaded and, for most people, won’t cause harm. ‘But for those with a lung or heart condition that already makes the body work harder to get enough oxygen around the body, this dip in oxygen could worsen their symptoms and even lead to a heart attack,’ he continues.
And then there are the random accidents. Dr Alves witnessed a man smash his head on a TV screen suspended over the aeroplane aisle, which saw him require first aid. Someone may also burn themselves as a result of spilling hot drinks, for example.
Caring for those who fall ill at 35,000ft brings a whole host of challenges – including the fact that a plane is a cramped and busy space with little privacy and limited equipment, says Dr Ian Mollan, a consultant occupational medicine physician.
He knows more about it than most, having been on a plane when the call for help went up five times during a 25-year medical career. The worst occasion, he says, was ten years ago when he went to help a man who was barely conscious, sweating and ‘as pale as a ghost’.
Initially, Dr Mollan feared that the passenger, who was in his 40s and travelling alone in business class from Sydney to Munich, was having a heart attack.
However, he quickly realised there was another cause. The passenger was able to tell him that while on a stopover in the Middle East, he had lost a significant amount of blood while on the loo.
‘This suggested he had an internal bleed in his bowel, which could still have been haemorrhaging, causing a potentially dangerous loss of blood,’ says Dr Mollan.
The passenger was starting to enter a state of shock – a life-threatening condition caused by there being insufficient blood to carry oxygen around the body. His heart rate was starting to climb as the body worked harder to push what blood was left to his organs.
Dr Mollan raced to get a needle from the plane’s onboard medical kit into the veins in the back of the patient’s hand, before the veins started to collapse (as they can with shock).
‘I was relieved once these were in,’ says Dr Mollan, ‘as intravenous access gets harder the more unwell a patient becomes, as the blood vessels in the limbs contract as the body shuts down and focuses on blood supply to the organs.’
Dr Mollan’s quick-thinking meant that the minute the plane touched down in Munich 20 minutes later, the medical crew who rushed on board could start emergency treatment en route to hospital. The patient’s life was saved.
Dr Mollan, who is also an aeromedical expert (dealing with conditions affecting air-crew that arise from flying) based at RAF Brize Norton, was on hand when a pregnant woman went into labour on a flight to South Africa a week after her due date, too.
‘She was breaking the international guidelines on flying in pregnancy at that point, and she started to have contractions over north Africa,’ he says.
‘What’s more, she was having a breech baby, so it was going to come out feet-first – which means a higher chance of problems during the birth.
‘Thankfully, we were able to get her a crew bunk, and we made her comfortable, gave her some paracetamol and monitored her until we landed as planned.’
But what about the kit needed for more major emergencies? According to regulations, UK airlines have to carry medical kits that include a stethoscope, syringes and needles, urinary catheters and tubes that can be inserted into the throat if someone stops breathing.
Some airlines also carry a defibrillator like the one Dr Vemala used. They should also have a range of drugs including adrenaline, pain relief, drugs to stop seizures, sickness and heart problems, and antihistamines for allergic reactions.
But the cabin crew won’t necessarily know how to use any of these things, or be allowed to administer drugs. The crew do receive first-aid training and learn life-support skills such as cardiopulmonary resuscitation (CPR).
They will also have access to a basic first-aid kit – which is why having a doctor on board can make a world of difference.
Even then, the equipment available will be limited. Not only did Dr Vemala have to borrow a blood-pressure monitor from a passenger as he was battling to save his patient on the way to India, the drip on the plane also lacked a digital monitor.
This normally measures how much medication is flowing into the patient – so Dr Vemala had to instruct the cabin crew on how to count the drops dripping through per minute to ensure this was enough to keep the patient’s blood pressure stable.
Dr Vemala believes that cabin crew need a better understanding of what’s in the medical kit and how to use it.
‘The cabin staff were incredible and followed every instruction I gave to the letter,’ he says. ‘But airline staff are only trained in basic life support and aren’t often taught how to use the tools in the medical kit. As well as this they need to know vital signs to assess if someone is getting better.’
Working mid-flight can be anxiety-inducing even for doctors, says Dr Mollan. ‘You’re generally working alone, in very small spaces, with a whole load of people in close proximity,’ he says.
‘Due to the background noise on a plane it’s almost impossible to hear anything with a stethoscope, which is one of the tools that we normally use to listen to people’s heart or their breathing.
‘There could also be a language barrier with the passenger. And you only have what happens to be in the plane’s kit.’
And some doctors may not want to get involved in a medical emergency when they are travelling as passengers – ‘particularly if we have enjoyed an alcoholic drink’, says Dr Mollan. ‘It would be reckless as a doctor to be treating people if you weren’t completely sober.
‘As a doctor you’ve got a duty of care to provide Good Samaritan activities, but you may not be covered for it from an insurance perspective, so you could face litigation if the patient was to come to harm. It’s a very tricky area legally.’
In the case of a severely ill passenger, the emphasis is usually on keeping them going until the plane can land at a nearby airport. This isn’t always straightforward, however.
At that point the minutes can feel like hours, say Phoebe and Mark Norfolk, who had the ‘terrifying’ experience of watching their eight-year-old daughter Raven have a seizure while travelling back from a week in Alicante earlier this year.
As she was walking back from the loo, Raven suddenly dropped to the floor, her legs and arms twitching violently. Her eyes rolled upwards and she was unresponsive for five minutes – ‘it was absolutely terrifying’, says Phoebe, 28, a full-time mother from Leeds.
‘The cabin crew put out a call for any healthcare professionals on board and two women – a GP and nurse – came up to help.
‘The whole thing was utterly overwhelming, the plane was full and there was little room to move. You don’t know what to do in these situations.’
Raven was diagnosed with a rare form of epilepsy aged two, which causes myoclonic-atonic seizures – where bursts of unusual brain activity lasting seconds make her neck muscles twitch, meaning Raven nods her head briefly.
‘But what happened on the plane that day was another level,’ says Phoebe.
This was a tonic-clonic seizure – caused by a sudden, intense burst of electrical activity in the brain.
Using the aircraft’s medical kit, the medics on board monitored Raven’s breathing, pulse and blood pressure.
Raven was diagnosed with a rare form of epilepsy aged two, which causes myoclonic-atonic seizures
‘They were worried because Raven remained unconscious after the seizure ended,’ Phoebe says.
‘It was terrifying and felt more scary knowing that we couldn’t just call an ambulance.’
Twenty minutes into the three-hour flight to the East Midlands, the plane was diverted to Barcelona.
Raven was just coming round as they landed and was helped into a waiting ambulance which took her to hospital. She was discharged an hour later.
Her doctors think that disruption to her daily medication while on holiday may have contributed to the seizure.
Her parents remain thankful that when the call went up for medical assistance, there were people on board the plane who were prepared to come forward to help Raven.
‘We are just so grateful,’ they say.Â
Has it put them off travelling? Says Phoebe: ‘Absolutely not.’
Additional reporting: Julie Cook
I’d passed out in the loo with sepsis, but a nurse on the plane saved my life
‘I didn’t even get a chance to thank the nurse or the cabin crew,’ says Sam
Cabin crew had to break down the loo door when Sam Wallace passed out on a flight home from a five-day holiday in Malaga.
Sam, now 30, initially thought food poisoning was to blame for the fact that he had spent 24 hours with an upset stomach. But on his umpteenth trip to the loo on the plane, ‘I closed the door behind me and everything suddenly went black’, he says.
When Sam, from Solihull, a manager at Aston University, didn’t return to his seat, his now ex-girlfriend banged on the door. After getting no answer, she went to find Sam’s wallet.
Sam suffers from paroxysmal nocturnal haemoglobinuria – a rare disorder in which red blood cells break apart prematurely. ‘It leaves me more at risk of infections,’ he says, ‘so I always carried a patient information card in my wallet’.
His girlfriend ran to show it to the cabin crew, who forced the loo door open and found Sam collapsed in a heap.
He recalls: ‘I was in and out of consciousness, but I heard a member of cabin crew go on the Tannoy and say, ‘Is there a doctor or nurse on board?’ ‘
Sam was laid out flat on spare seats at the front of the plane. ‘By now I was drenched with sweat yet cold to the touch,’ he says.
A nurse who was on the flight returning from a hen party came forward to help. She saw the dark red, blotchy rashes all over his body and Sam heard her say: ‘Sepsis.’
Sepsis is where the immune system overreacts to an infection, and it can be fatal. The nurse told the cabin staff she was certain that’s what Sam had and he needed urgent medical care.
‘The trouble was,’ says Sam, ‘we were only just crossing the Channel’ – and the plane was en route to Birmingham.
The crew alerted emergency services and an ambulance met the plane as it landed.
Paramedics immediately came on board, gave Sam an injection of strong antibiotics and blue-lighted him to hospital. ‘I didn’t even get a chance to thank the nurse or the cabin crew,’ says Sam. ‘Once I got to hospital, the rest is just blank.’
A major complication of sepsis can be the loss of limbs, as the body shuts down, reducing blood flow to the extremities. Sam was later told he’d been minutes away from losing his limbs, or even dying.
‘The quick-thinking cabin crew, the pilot, the nurse passenger and the ambulance saved my life,’ he says of the event in 2016. ‘I never got the nurse’s name, but if she’s reading this, I’d love to thank her in person.’
Julie Cook
How to avoid getting sick on a flight
There are steps that passengers can take to help protect themselves from health difficulties – and an important one is to not rush your meals, advises Dr Paulo Alves, global medical director of aviation health for MedAire, which provides access to doctors for advice during midair health emergencies.
‘Altitude makes gas expand by about 25 per cent, so simple things like eating quickly, which will make someone swallow more air, or having fizzy drinks, can lead to this gas expanding uncomfortably in the stomach,’ he says. ‘This can lead to abdominal pain, which can sometimes be confused with a more severe condition such as appendicitis.’
If you have a long-term condition, it’s crucial to plan ahead. ‘Always carry any medication you take in your hand luggage. Don’t put it in the hold – we see this so often,’ says Dr Alves.
If you take regular medication he suggests noting down when your dose is due as time zones can cause confusion. This can be problematic for those with diabetes, for example.
And check if medical approval is recommended before you travel, as might be the case for those who have recently had surgery or have uncontrolled chest pain, he says. He adds: ‘If you feel unwell don’t get on the flight. Don’t do it just because you’re desperate to get home – this could have consequences.’
He says we should all move our legs as much as possible on a flight to try to keep blood moving. Just raising and lowering your feet, keeping toes on the ground and circling your ankles for a few seconds every hour, can also help.
To cut the risk of accidents, he adds: ‘Avoid putting children in the aisle seat, as they could easily be hit by falling objects and service trolleys.’
