Flying helped people create an interesting collection of catch phrases- truisms and sage-sayings. Among the most-salient is this old favorite: “Better to be on the ground wishing you were up there- than up there wishing you were on the ground.” Pilots of my acquaintance tend to bring this up during discussions with another pilot they feel might soon be in the position of wishing they were ‘down here’. The advising ...

Dave Higdon  |  01st May 2009
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Dave Higdon
Dave Higdon

Dave Higdon is a highly respected, NBAA Gold Wing award-winning aviation journalist who has covered all...

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Training- Judgment Rule When In-Flight Crisis Strikes

Flying helped people create an interesting collection of catch phrases- truisms and sage-sayings. Among the most-salient is this old favorite: “Better to be on the ground wishing you were up there- than up there wishing you were on the ground.”

Pilots of my acquaintance tend to bring this up during discussions with another pilot they feel might soon be in the position of wishing they were ‘down here’. The advising pilots often take the view that the at-risk aviator fails to see the true risks ahead – one who sees the signs- knows the signs are there- but then fails to read them.

Then pilots often back up their position with by paraphrasing a movie line: “tomorrow is another day and it (the destination) will still be there…”

A different yardstick- however- applies for passengers. They generally depend on the judgment of the flight crew concerning whether to fly that day or at that time. Yet if you consider the actual scope of the phrase “in-flight emergency” you’ll probably realize that not all emergencies in-flight involve any safety-of-flight issues but safety-of-people problems.

That’s when the savvy- experienced- thoughtful traveler puts into play knowledge and training they may have learnt from other places to help the situation.

In-Flight Medical Emergencies
Knowing exactly the extent to which medical emergencies occur is difficult to determine. Data collection varies even among highly regulated and data-dense commercial airlines- let alone private aircraft operating absent the hefty reporting requirements of the common carriers.

That said; we know medically urgent things happen. Often the malady suffered is no more rare or life-threatening than air sickness or its close companion- motion sickness – the kind that people get only when without a horizon or ground reference. On other occasions- serious crises have arisen- requiring quick action; occasionally- the event is an in-flight death.

Among the sources of information confirming some of what we know anecdotally to be happening are reports from trade association and pilots’ reports to employers. One source for confirming information came recently from the open-access journal Critical Care- which reported results of research on two airlines by teams from two universities- the University of Bochum in Germany and the University of California- Los Angeles (UCLA).

According to a report from Medical News Today (http://www.medicalnewstoday.com/articles/136616.php)- the researchers learned early on how sparse useable data was; 27 of 32 carriers approached lacked the data requested- two declined to participate and one possessed data unusable to the researchers. But among the remaining two unidentified carriers- the teams found 10-189 incidents to analyze. Fainting was the most-frequent event reported (5-307 of the incidents reviewed – or a massive 53.5 percent).

Second place went to stomach problems- with 926 events- or 8.9 percent of the total- and third place belonged to cardiac events at 509- or 4.9 percent of the total.

The study’s authors noted- “Surgical illnesses accounted for a minor percentage of all on-board emergencies. There were 47 cases of thrombosis (0.5%)- 27 appendicitis cases (0.25%) and just one case of gastrointestinal bleeding (less than 0.1 %). There were two births and 52 deaths'.

Even though the study’s sample is relatively small – remember- only two of 32 carriers participated – the ranking and number of cardiac events points toward the reason why airlines and corporate aircraft operators increasingly carry advanced emergency medical equipment on board. But the presence of equipment on the aircraft you use means little unless someone knows (a) where to find it and (b) what to do with it when they fetch it.

First- know your airplane
Veteran flyers blessed with a single source of air travel – a one-plane fleet- fractional-share holder- jet card or regular charter repeat user – have no excuse for not knowing some fundamentals about the airplane on which they fly.

For example- at some time preparing for the first flight of the day- someone on the crew should brief passengers on some fundamental facts about the aircraft – whether it’s your buddy who flies the company plane only part time between stints in Accounts- or a full-time professional pilot you’ll see only once every few missions.

Federal Air Regulations require the crew of an aircraft to brief passengers on some basics- and to assure they use some of them. It’s very much similar to the little lecture we’d all recognize as the standard safety briefing of a cabin attendant of a commercial carrier. Passengers are required to be told when and how to use the seat belts and shoulder harnesses; if and when they can smoke – a rarity- but it happens sometimes; the location and operation of the main cabin door and emergency exit. This is all routine information.

As a smart passenger- you should take it upon yourself to know these important points- even if your buddy from Accounts fails to tell you – because he thinks you’re smart enough to know already.

Above and beyond the basics…
These days- corporate aircraft increasingly carry equipment to aid in other emergencies- including those that can’t wait on the 20 minutes or more a high-flying business jet needs to descend from high in the flight levels- slow down and land.

You need to know the location of any first-aid kit on board. A well-equipped kit could help you gather symptoms to radio to help on the ground- provide tools to help perform CPR on heart-attack or breathing-crisis victim- or even provide aspirin to administer to a heart-attack victim. A thermometer- blood-pressure cuff- bandages- possibly even medications for allergy reactions or splints for broken bones also are a must.

You should know where to find hot water- if available at all; and where to locate the ice- in the event it is needed for a cold pack or to chill a liquid. The storage sites for blankets and pillows can also be useful to know should someone on board – even yourself – suffer a medical emergency in-flight.

The Ultimate Threat: Cardiac Issues
Another modern piece of medical gear increasingly found in contemporary corporate aircraft is something called the AED - Automatic Electronic Defibrillator. Anyone older than 10 has seen hundreds- maybe thousands of such instances on television and in movies; the medical staff urgently arrives with the Defibrillator after determining a cardiac event of some sort is in progress.

Someone rips open the victim’s shirt or blouse and starts Cardiac Pulmonary Resuscitation (CPR) until the doctor gets the ‘paddles’ ready with a daub of gel- places them opposite one another on the victim’s chest- screams “Clear!” and pushes a button that sends a jolt of electricity coursing through the afflicted’s chest. If all works well- the heart resumes a normal rhythm and all’s well that ends well.

Of course- that same procedure could have the opposite effect if used on someone not experiencing cardiac issues. Thus- technology and its geniuses gave us the AED which serves as a combination heart monitor- diagnostician and therapy deliverer. You really need know only where it’s stored on the airplane to get started; instructions for use are printed right on the machine.

You open the devise and remove the two pads that sense heartbeat and rhythm and- if needed- deliver the shock; place the adhesive pads on the victim to match the drawing in the instructions and turn on the machine.

Depending on the model- it should first determine whether there’s a heartbeat and- if so- whether it’s strong and normal. If the brain of the machine senses the pulse as somehow abnormal- it warns the operator of the impending shock and delivers the jolt automatically – then returns to sensing mode to gauge the patient’s response to the treatment.

Little to no further human intervention is needed while the machine stays on-line and monitoring the patient. And those instructions cover both normal-function info and details on how to quickly troubleshoot a problem. If the unit doesn’t sense a complete circuit- or has another issue- a trouble indication will point you toward a check list that shows how to resolve the issue.

But- ultimately- act – and act quickly!

The important points to remember: First- as stressed already- you should know where such equipment is located; then act quickly if someone seems to be having a heart attack or other cardiac problem. Whenever issues of heart function arise- time is of the essence.

If the problem arises after leveling off at cruise altitude- the suddenly ailing passenger will be a long time seeing a medical professional- regardless. Fast action by passengers or crew could make the difference. Consider the following.

Time is Not on your side…
When an emergency or crisis situation requires the flight crew to make a new decision- two distances immediately come into play. Of course- the most-obvious issue to resolve is finding an alternate destination. So the question becomes- where is the closest suitable airport?

It doesn’t help to land at the first available airport if the heart-attack or stroke center is nearer a different airport. So the decision must take into account finding a runway that’s suitable for the aircraft and with the closest facilities suitable for the victim’s medical crisis.

The other distance of concern is a vertical question: how high is the airplane? And how fast can it descend? These issues factor into the distance you may have to fly- which may help you put patient and facilities closest together. Regardless- that altitude translates into time before any landing anywhere occurs.

Consider the factors: A business jet flying at FL510 – 51-000 feet above sea level- or almost 10 miles up – would need 15 minutes to get on the ground if it could descend at 5-000 feet per minute without suffering damage; none really can.

At a still-rapid 3-000 feet per minute and keeping airspeed below the redline limit- a jet at FL510 needs 16 minutes to burn off 48-000 feet- then another few minutes to get the airplane slowed to landing speed and onto the ground- then to where an ambulance can meet – so figure more than 20 minutes from when the decision is made.

Many airplanes will need longer due to operational limitations or distance from a suitable runway. Now responsibility for making these command decisions rests solely with the aircraft crew – and that’s responsibility enough to warrant the passengers carrying some of the load by being able to help ailing cabin mates.

Breathing Easy
Do you also know where the aircraft stores its emergency oxygen equipment? No- not that to be used in the unlikely event of a loss of cabin pressure. That system can’t leave the flight deck for the pilots- and any aft-cabin gear should be automatic. We’re talking about emergency medical oxygen- which may be called for in a variety of medical crisis in the cabin.

Applying oxygen should be considered almost immediately- some clinicians say- because a medical issue in an aircraft cabin is already working with an oxygen issue – low cabin pressure. Think about it for a moment. Business turbine aircraft generally all employ pressurization in the cabin for the comfort and safety of the people on board.

Without- oxygen masks would be required above about 12-000 feet – and aircraft would be limited to cruising at altitudes far lower than today’s high-flying jets can go. But in the majority of pressurized aircraft- the system provides a cabin altitude equivalent to 8-000 feet above sea level- occasionally below – but sometimes as high as 10-000msl.

Even healthy people can suffer a decline in pulse-oxygen saturation at such pressure altitudes; heavy smokers and people with other respiratory issues can suffer oxygen-saturation levels low enough to impact how they feel and perform.

Compound the cabin altitude issue with an illness related to respiration or heart- and the need for good pulse-oxygen levels becomes critical. First-aid kits increasingly provide a pulse oximeter to show a victim’s blood oxygen saturation. Turn it on- put the little close-pin type clamp on a finger and watch the read-out. Any reading below 90 percent is a significant cause for concern.

To use most emergency medical oxygen systems- put the mask on the patient- open the tank valve- then adjust the regulator to the desired flow to get the pulse-oximeter to read as close as possible to 100 percent.

In the meantime- communicate to the flight crew that the victim needs professional medical attention.

Be your own best friend
Air crew and frequent aircraft users really have no excuse for ignorance of any medical gear carried on their usual aircraft.

The path to enlightenment may be no more complicated than finding the on-board equipment so you can look up manufacturer’s info and learn how it’s supposed to work.

Many corporations offer opportunities for staff to training on medical equipment like AEDs- on techniques like CPR- and on general knowledge like that available from Red Cross first-aid training. A long-time benefit of Bombardier’s annual business aviation Safety Standdown (www.safetystanddown.com) has been the hands-own training in this area.

The training also includes lecture work on other travel-health concerns. For example- the instructors stress how frequent travelers and air crew need to wear or carry information on any medications they require and any allergies to be avoided in the event they need help from a co-worker or stranger.

If given the opportunity to attend hands-on classes in AEDs and CPR- or general travel-medical training- take it and apply yourself. The life you save may be your own- thanks to your ability to guide the person tending you when stricken; it may be a family member that fate puts in front of you.

Or it may be that boss who’ll have to remember the life-saving gesture at all the right moments…


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