In May 2016, Lewis Christman was flying from Chicago to Rome when he suffered a bout of acute pancreatitis. He curled into a fetal position on the floor. He spent the next seven hours in agony while the plane flew on. The next three months, he spent in hospitals.
This month, Christman sued , accusing United Continental Holdings of ignoring a recommendation from a doctor on board to divert the flight and failing to contact medical consultants on the ground. It was another round of bad publicity for United and one that draws scrutiny to how U.S. air carriers treat passengers in distress and the pressure to keep flights in the air.
"Obviously, there is a significant cost to landing the plane," said David Axelrod, Christman's lawyer. "We're looking for all the information about this incident, where my poor client is doubled over in pain and he's vomiting and they're not landing this plane."
A medical emergency sets in motion a high-altitude calculation with human lives in the balance. While pilots are the ultimate decisionmakers, airlines have earth-bound medical consultants that help bypass on-board volunteers -- reducing expensive emergency landings, but with the potential of providing expert decisions in real time.
Christman's suit seeks information about the incident from Phoenix-based MedAire Inc., which provides in-flight medical advice to more than 100 airlines. Company spokeswoman Mandy Eddington declined to comment on the lawsuit or any relationship with United.
Paulo Alves, MedAire's global medical director of aviation health, said in an interview before the suit was filed that his company provides help from doctors with extensive experience. Just 1.6 percent of flights in which MedAire is called are diverted. He said airlines see the value in bypassing medicos who happen to be aboard.
"If the model was not financially interesting for them, then they wouldn't hire us," Alves said. "Doctors, they tend to recommend diversions more than we do, because of course they don't want to assume the long-term responsibility."
A medical emergency occurs once every 604 flights and 7.3 percent led to diversions, according to a 2013 New England Journal of Medicine study. It also found that 0.3 percent of emergencies on planes end in deaths.
"It's fairly expensive to divert an aircraft, and so a captain has to take into account a whole host of issues," said Jose Nable, an assistant professor of emergency medicine at MedStar Georgetown University Hospital and co-author of a 2017 paper on in-flight emergencies. Perry Flint, a spokesman for the International Air Transport Association airline trade group, said his organization estimates that a diversion can cost anywhere from $10,000 to $200,000.
Erin Benson Scharra, a United Airlines spokeswoman said the company is investigating Christman's claims, but declined to speak further about medical diversions or consultants it employs.
Companies like MedAire, housed in the emergency unit of the Banner-University Medical Center Phoenix, play a key role in diversion decisions. STAT-MD Inc., which offers a similar service and uses doctors from the University of Pittsburgh, works with around 20 national and international air carriers. It says it reduces landings that would otherwise be recommended by nervous and out-of-their-element doctors in the sky.
"They're going to revert to divert," said T.J. Doyle, the medical director for STAT-MD. "The medical volunteer should be a data-gatherer and a procedure-doer. They should not be a decision-maker."
The emergencies encountered by medical professionals on flights vary in severity. Internal medicine doctor Gina Jabbour of New York revived an elderly woman who fainted after using the bathroom. The flight continued on schedule and Jabbour was rewarded by a flight attendant with "secret cookies."
Scott Schoifet, an orthopedic surgeon, was dozing on a flight from Japan to New York in 2006 when he was awakened to help a fellow passenger with chest pain. Flight attendants asked Schoifet whether it was safe to continue flying.
"It was stressful first because they're looking at me like, 'What do you want to do?"' Schoifet said. "I can't make this decision. There's 350 people on the plane."
He checked in with the woman for the rest of the flight until she disembarked at a stop in Detroit, and then the plane continued on.
This month, a Delta Air Lines passenger passed out before takeoff at Fort Lauderdale's airport. The person was treated by none other than Surgeon General Jerome Adams, who was traveling from Florida to Mississippi for a discussion on the opioid epidemic. The plane was still on the tarmac, and Adams helped evaluate the traveler, who ended up going to the hospital.
Medical emergencies on planes set in motion a chain reaction. Elise May, the manager of inflight safety and regulatory compliance for Southwest Airlines, said flight attendants first protect themselves. Then they page for a medical professional on board. Southwest's flight attendants are trained in basic care, and are equipped with iPads that have manuals and headsets to contact ground-based consultants.
The decision on whether to divert is ultimately made by the pilot and dispatcher, but it is "dependent a lot on our medical consultant and what they feel is the danger of the situation," May said. "There's all sorts of things to take into consideration."
Doctors are protected by a federal law that protects air carriers and individuals from liability while providing assistance in the air. But the Hippocratic oath remains their lodestar.
"Ethically, I feel like there is this responsibility for me to intervene," said Meera Shah, a New York doctor who helped revive a woman passed out on a plane this year. "What if I wasn't there? I always think about that."
(This story has not been edited by NDTV staff and is auto-generated from a syndicated feed.)