I’m on an airplane, and the announcement comes: If there are any physicians on the flight, please identify yourself to the flight attendant. I tense up, counting to 10, giving all the adult emergency room doctors and cardiologists who I am sure are snoozing around me a chance to ring their little call buttons or rush to the rescue. Then comes the announcement again. I undo my seatbelt and identify myself as a pediatrician, and brace for what I’m sure will be an elderly patient in the throes of a heart attack.
A 2018 review found that an in-flight emergency occurs approximately once every 604 flights, with the most common involving adults fainting — or feeling faint — or gastrointestinal, respiratory or cardiac problems.
Some years ago, Dr. Alexandre T. Rotta responded to a request for a doctor to come look at a sick passenger on a trans-Atlantic flight. The patient was an infant, and Dr. Rotta, who is the chief of the division of pediatric critical care medicine at Duke University Medical Center, thought, “no problem, this is what I do all day.” But as he examined a feverish baby with mottled skin, he found he couldn’t hear anything through his stethoscope because of the white noise, and couldn’t feel the baby’s pulses because of the vibration of the airplane.
The baby got better when they brought down the fever, but Dr. Rotta began to wonder, “What would it feel like for an adult practice physician to be taking care of this child, or me taking care of an adult?”
After he found himself in exactly that position, doing CPR on a woman who had turned blue on another trans-Atlantic flight, who fortunately started breathing again, Dr. Rotta became interested in in-flight medical emergencies, and most especially in the question of what kinds of problems come up for children in flight.
He began collaborating with Dr. Paolo M. Alves, the global medical director of aviation health for MedAire, a company that fields calls from airplanes where medical emergencies are unfolding. From inside a hospital in Phoenix, Dr. Alves said, emergency medicine doctors talk to whoever is up in the air with the patient. “We’ve been helped by pediatricians, dentists, veterinarians,” he said, as well as by doctors who treat adults and are as out of their depth when the patient is a baby as I am with the elderly.
Most recently, in a study published in July in the Annals of Emergency Medicine, Dr. Rotta and Dr. Alves and their co-authors reviewed the records of 11,719 in-flight medical events involving children younger than 19, for which those caring for the child on the airplane had used ground-based support. Of those, 76.1 percent happened on long-haul flights, and 82.9 percent were taken care of on the flight — that is, the child didn’t need additional medical attention after landing.
Most of the problems were related to nausea and vomiting, fever and allergic reactions. Among other things, the consultants on the ground can advise if a decision has to be made about diverting the flight; of the cases in that study, only 0.5 percent required a special landing.
In an earlier collaboration, the same research group reviewed 81,000 medical emergencies between January 2010 and June 2013 and found that just under 10 percent of them involved children, and there were 10 pediatric fatalities. In 2014, they published a review of the in-flight fatalities. Four of the 10 children who died had pre-existing medical problems, and in some cases were traveling for medical evaluation or treatment.
For children with pulmonary or cardiac problems, Dr. Rotta said, the atmosphere in an airplane can be stressful, dry and with a lower than usual oxygen concentration.
There were also four lap infants — children under 2 traveling without seats of their own — without any known medical problems who died in flight, and Dr. Rotta warned that people on airplanes often ignore the sleep safety precautions that they practice at home. “On long-haul flights, with the window shades down and the lights off, a passenger will wake up and notice their infant is dead next to them, whether there was the equivalent of SIDS or a parent rolled over and asphyxiated the child,” he said. It has also been suggested that the lower oxygen concentration may predispose some infants to disordered breathing and put them at risk for SIDS, he said.
In a separate study, published in 2016, they identified 400 cases of children suffering injuries in flight, Dr. Rotta said. “These were kids that boarded a plane healthy.” Though such injuries were relatively rare, the children who got hurt were disproportionately lap infants. Some got hurt in turbulence, and others suffered burns from spilled hot liquids, with meal service a time of particular danger. “At home, you would never pass a hot cup of soup or a hot meal over your infant,” Dr. Rotta said.
Many were injured by objects falling from overhead bins or by service carts passing in the aisle. “We’ve had several kids who had fingers crushed, arms crushed,” Dr. Rotta said.
It makes sense that the risk of such injuries is higher if children are seated on the aisle, Dr. Alves said. “Children should fly in the middle seat or window seat.”
Dr. Sherif M. Badawy, an attending physician in the division of hematology oncology at Lurie Children’s Hospital in Chicago, responded to an appeal for help on a flight from Istanbul to Chicago and found himself caring for a 17-month-old who was having trouble breathing.
When he asked what medications and equipment were available, Dr. Badawy was offered an asthma medication in an inhaler — the child would have to cooperate to take it — and a single bottle of oxygen, good for a couple of hours at most. The emergency equipment available on the flight was also not suited to a child, with no face mask or endotracheal tube of the right size.
In a 2018 article, Dr. Badawy argued for better preparedness for in-flight emergencies in children. “If parents really started asking these questions,” Dr. Badawy said, the airlines would respond. “It is your right as a customer to have the safest experience possible.”
So how do we keep our kids safe in the air? “Parents should carry aboard in their carry-on luggage medications in pediatric formulations,” Dr. Alves said.
Dr. Rotta would like to see infants in safety seats approved by the Federal Aviation Administration, rather than in laps. “Do not carry your lap infant, because bad things can and do happen, do not co-sleep with your child on long-haul flights,” Dr. Rotta said. “Don’t pass hot beverages, don’t seat the child in an aisle seat, have the child secured at all times.”
And if your child seems ill, go ahead and ask for help — and know that the people who come to help, high up in the sky, now have people down on the ground, looking over their shoulders.