You’re cruising at 35,000 feet, the seatbelt sign is on, and suddenly…
“Is there a doctor on board?”
In-flight medical emergencies (IMEs) are relatively common events, occurring in approximately 1 in 600 commercial flights. With increasing air travel, healthcare professionals are more likely to be called upon to assist during a flight. It is a uniquely challenging pre-hospital experience in an unfamiliar environment, with limited resources and altered physiology of cabin pressure. It is therefore useful to have a systematic approach to differentiate the various common presentations in an IME.
Contents
Medico-legal Concern
You heard the request and felt compelled to help. As you are going to volunteer, you remember you’ve just enthusiastically gurgled down a generous serving of in-flight wine (or was it two?) After a brief reflection, you deem yourself unfit and decide your skills are better redirected to enjoying the in-flight entertainment.
You are absolutely right, as you are at risk of misconduct! The best practice of medicine does not differ from in-land practice. You should always act within your competence and capabilities.
Legal liability is often the main concern for healthcare professionals when volunteering in an IME. The legal consideration varies across different airlines and their respective jurisdiction. Here are the key principles to note according to the General Medical Council and the International Civil Aviation Organisation:
- There is no legal obligation to respond to an IME in the UK, only an ethical expectation.
- Airlines generally welcome any medical help – physicians, physician assistants, nurses, advanced nurse practitioners, and paramedics.
- Act within your competence and identify with your real name and profession. No further personal information is needed.
- Always seek patient consent and document clearly using the resources available.
- You do not lead a decision to make an emergency landing – the final decision is made collaboratively between the captain, cabin crew, and ground-based medical support.
- Most countries have Good Samaritan protections, and litigation against help is very rare if the person acted in good faith, within competence, and with no resultant gross negligence.
Tip: If you are travelling on a US-operated airline, the Aviation Medical Assistance Act will cover you from any medicolegal issues if you volunteer to assist during an in-flight medical emergency.
The In-Flight Environment: What makes it different?
Understanding the unique physiology and logistics of flight is essential before addressing specific conditions. Cabin pressure is equivalent to an altitude of 6,000 to 8,000 feet. As such, arterial oxygen saturation is expected to fall to around 90-93% in healthy individuals. The difference in pressure causes expansion of trapped air due to barotrauma, eventually worsening some conditions such as pneumothorax, bowel obstruction, sinus or ear diseases. Most commercial aircraft carry a basic first aid kit, an enhanced emergency medical kit, an automated external defibrillator, and supplemental oxygen. However, content may vary by jurisdiction. Due to the limitations in physical space and resources, all airline medical emergencies are communicated to ground-based medical services, who will liaise with the pilot and the crew and assist the clinician in real time.
Common In-Flight Medical Emergencies
The following is a list of the most common in-flight medical presentations according to the literature:
Syncope and Presyncope
In-flight syncope and pre-syncope are the most common presentations. They are usually benign, often resulting from dehydration, prolonged immobility, or a vasovagal response. Passengers may report dizziness, nausea, sweating, or visual dimming before a transient loss of consciousness. Causes include vasovagal, dehydration, orthostatic hypotension, hypoxia, and alcohol. Management includes lying supine with leg elevation, loosening of tight clothes, administration of supplemental oxygen (if indicated), encouraging fluid intake if alert, and monitoring blood glucose level.
Gastrointestinal
In-flight gastrointestinal conditions commonly include nausea, vomiting, diarrhoea, and abdominal pain, often related to motion, anxiety, or foodborne illness. More serious causes, such as gastroenteritis, peptic ulcer disease, or even early appendicitis, should be considered. Management usually comprises antiemetics, oral hydration and supplemental oxygen if indicated. It is important to consider red flag symptoms such as fever, persistent vomiting, localised or severe abdominal pain, peritoneal signs and gastrointestinal bleed as they may influence the decision to divert the flight.
Chest Pain and suspected cardiac event
In-flight chest pain may arise from benign causes such as musculoskeletal strain or reflux, but serious conditions like acute coronary syndrome (ACS), arrhythmia or pulmonary embolism must be considered. It is therefore essential to take a focused history and examination to ascertain the likely cause of chest pain and communicate promptly with the ground-based medical team. Consider initiating treatment such as aspirin in suspected ACS, glyceryl trinitrate (if blood pressure permissible), oxygen supplement and analgesia.
Respiratory
In-flight respiratory conditions commonly include pulmonary embolism, exacerbations of asthma and chronic obstructive pulmonary disease, hypoxia related to reduced cabin pressure, and anxiety-induced hyperventilation. Initial management focuses on reassurance, positioning the patient upright, and administering supplemental oxygen if available. Beware of any underlying medical conditions and encourage passengers to self-administer their own bronchodilator where possible. In more severe cases, diversion may be required.
Neurological
In-flight neurological conditions include syncope, seizures, and acute events such as stroke. Syncope is often related to dehydration, immobility, or vasovagal episodes, while seizures may occur in individuals with known epilepsy or be provoked by hypoxia or fatigue. Initial management involves ensuring patient safety, maintaining airway patency, and placing the individual in the recovery position if unconscious. Supplemental oxygen should be administered if available, and check blood glucose if equipment is available. For suspected strokes, early recognition is crucial, and flight diversion may be necessary. Passengers with known neurological conditions should carry medications and relevant medical information when travelling.
A Systematic Approach
Remember, you are the extra hand, the clinical assessor – a translator of medical to human language.
- Approach the cabin crew in a calm and confident manner.
- Start by identifying yourself to the cabin crew – stating your name and medical profession.
- Gain the passenger’s consent and proceed to identify the passenger’s name and date of birth. If unconscious, seek collateral history wherever possible. If they are a minor, speak to their guardian if available.
- Follow the aviation protocol and ensure the patient is in a safe position – well strapped to the seat or rested on the floor.
- Ask the flight attendants for the first aid kit, emergency medical kit and automated external defibrillator (AED) if indicated. Flight attendants are certified in cardiopulmonary resuscitation and the use of an AED.
- Obtain a medical history and assess the ill passenger using the ABCDE approach (airway, breathing, circulation, disability, exposure) as per ALS protocol. Auscultation may be difficult due to aircraft noise, but aim to continuously monitor the vital signs.
- With the passenger’s consent, communicate findings with the crew member and pilot. Follow the airline protocol and ask for ground-based medical consultation for advice.
- Inquire about any available medications, especially in passengers with a known medical background.
- If it can be done safely, consider moving the ill person to an area with more space and privacy
- Notify the crew immediately if the passenger is suspected of having a communicable disease or is severely ill.
- Further decisions in management and flight diversion are made by the pilot and the ground-based emergency medical services.
- It is important to document your clinical encounter on specific airline forms if available and keep a copy for your own record.
A common question revolves around DNACPR. If a passenger has a DNACPR form with them, should the medical responder heed the DNACPR at the time of an in-flight emergency? The answer varies depending on which airline and territory you are in. Different airlines have different protocols for such matters. It is therefore imperative to follow the respective airline’s protocol and communicate with ground medical support for advice.
References & Further Reading
CDC Yellow Book [Internet]. Perspectives: Responding to Medical Emergencies When Flying; 2025 Apr [cited 2026 May 1]. Available from: https://www.cdc.gov/yellow-book/hcp/travel-air-sea/perspectives-responding-to-medical-emergencies-when-flying.html#cdc_report_pub_study_section_4-disclaimer
CDC Yellow Book [Internet]. Air Travel; 2025 Apr [cited 2026 May 1]. Available from: https://www.cdc.gov/yellow-book/hcp/travel-air-sea/air-travel.html
Chandra A, Conry S. In-flight Medical Emergencies. West J Emerg Med [Internet]. 2013 Sep 17 [cited 2026 May 14];14(5):499-504. Available from: https://doi.org/10.5811/westjem.2013.4.16052
FPnotebook [Internet]. In-Flight Medical Emergency; 2026 Jan [cited 2026 May 14]. Available from: https://mobile.fpnotebook.com/ID/Travel/InFlghtMdclEmrgncy.htm
Isakov A. UpToDate [Internet]. Management of inflight medical events on commercial airlines; 2025 Oct [cited 2026 May 14]. Available from: https://www.uptodate.com/contents/management-of-inflight-medical-events-on-commercial-airlines
If you liked this article, consider checking out: Pre-Hospital Management of Hypothermia
Written by: Dr Yun Yan Wong (FY2)
Reviewed by: Dr Callum Carruthers (GP with a special interest in Emergency Medicine, and responder with BASICS Scotland)
