Date: 201504
Local time of day: 1201-1800
Location: ZZZ.ARTCC, US
Light: Daylight
Aircraft: Large Transport
Operator: Air Carrier
Operating under: Part 121
Flight plan: IFR
Mission: Passenger
Flight phase: Cruise
Airspace: Class A ZZZ
ATC / advisory: Center ZZZ
Reporter organization: Government
Reporter function: Enroute
Reporter qualification: Air Traffic Control Fully Certified
Human factors: Time Pressure; Situational Awareness; Distraction; Confusion; Communication Breakdown; Troubleshooting; Workload
Anomaly: Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Illness / Injury
Detector: Person Air Traffic Control
When detected: In-flight
Result: Air Traffic Control Issued New Clearance; Air Traffic Control Separated Traffic
Contributing factors: Human Factors; Procedure
Primary problem: Procedure

Narrative: I was the controller working Radar. I did have a radar associate (RA) controller (two different individuals) during these events. The RA controller took a call from ZZZ; and when he hung up; he informed me that Aircraft X; in handoff status to me at the time; might be a medical [issue]. He stated that the ZZZ controller didn't have any more information; but that Aircraft X had mentioned that there was a situation on board; and would let us know if any assistance was required. Aircraft X checked on frequency; at which time I informed the pilot that I was aware that there may be a medical situation; and to please keep me informed of their status. The pilot of Aircraft X said she would do so. At this time; the Front Line Manager (FLM) in the area was informed that there might be something developing; but that it was not an [issue] yet.About eight minutes later; Aircraft X informed me that they were [in fact had] a medical [issue]; due to an unconscious passenger who had possibly become hypoglycemic; and who also was suspected to be under the influence of prescription painkillers. The aircraft was an arrival; on an appropriate STAR routing; but because the pilot had [a medical issue]; I issued Aircraft X a clearance from their present position direct to [the airport]. I then stated; 'ZZZ is landing north; expect vectors to final.' The pilot concurred. At that time; the FLM in the area was informed of the [medical issue] by the RA controller.Offline coordination was accomplished with the next sector that Aircraft X would enter. [Sector X]; a ZZZ low sector which primarily handles east departure traffic out of ZZZ. As we were not in a typically busy/complex time of day for departure traffic; the Radar controller concurred with our plan to send Aircraft X direct ZZZ; and stated that he would accomplish coordination with [TRACON]. Jet arrivals to ZZZ do not normally transit Sector X airspace. The FLM was standing between our two sectors and was aware of this development. The FLM stated; 'They're watching you up front'; and I understood that I was being monitored by the Operations Manager In Charge (OMIC) on a radar scope at the front of the control room.Aircraft X continued on a course direct ZZZ. Aircraft Y checked on to my frequency.About ten minutes later; my FLM took a phone call; and then returned to stand behind me. He stated; 'I need you to ask Aircraft X if they can accept a route direct [to a fix]; then direct [to ZZZ]; to go into the southeast arrival gate at the TRACON.' I told him that I didn't think that was a good idea; given that the aircraft had stated they had a medical [issue]; and that the passenger in distress had been unconscious for some time; with unknown complicating factors. I asked the FLM where this direction was coming from. The FLM told me that it was coming from the OMIC and the Air Traffic Manager (ATM). The ATM happened to be in the Control Room when this situation developed; and was monitoring me from the front desk; alongside the OMIC. I thought that it was unusual and inappropriate for the OMIC [and] ATM to be making decisions about a traffic situation; and told the FLM such. The FLM then stated that there was also a desire from the Traffic Management Unit (TMU) at [the TRACON] for Aircraft X to enter their airspace in an appropriate arrival gate. I was told that 'he will fit in better' and 'TRACON won't have to vector him as much; he would get vectored a lot if he went in the east departure gate'. The FLM also mentioned that TMU was concerned about Aircraft X conflicting with departure traffic; despite the fact that there were very few departures coming out the east departure gate at that time; due to arrival delays that morning.As requested by management (my FLM); I asked Aircraft X if they could accept the routing change. The pilot concurred; and I issued the new clearance to ZZZ. I made a radar handoff to Sector X. The FLM informed the Radar controller of the new route; and told him about an altitude restriction that Aircraft X would need to meet at [the fix].Aircraft Y [had] a medical [issue]. The pilot stated that they had a passenger who was experiencing chest pains; and requested 'direct ZZZ with NO DELAY' (emphasis mine). As with Aircraft X; I cleared Aircraft Y direct ZZZ. I told the FLM that I had a second medical [issue]; and gave him the details I had at the time.I switched Aircraft X to Radars frequency. I waited a couple of minutes; then coordinated offline with the Radar controller about Aircraft Y's situation. I then began a radar handoff to Radar; and when it was accepted; I switched Aircraft Y to Radars frequency.The FLM approached me and asked; 'Did you give that Aircraft Y the route yet?' I replied in the negative; and told the FLM that Aircraft Y was already talking to Radar. The FLM then informed the Radar controller of the need to issue Aircraft Y the route over [a fix]. When the FLM returned to me; I told him that the passenger aboard Aircraft Y was possibly experiencing a cardiac event; the pilot had an [issue]; and the pilot had specifically (likely after hearing Aircraft X's new route) requested direct ZZZ with 'no delay'. I told him that 'no delay'; to me; means that I send that aircraft direct to the destination airport; and accomplish coordination to ensure that everything goes smoothly. Further; I explained to him that in situations like these; minutes may make a difference as to the long-term health and well-being of the passenger in distress. I feel that it's irresponsible of me to force/convince a pilot to take a specified route; strictly because the TRACON feels that the route will make their job easier. If an aircraft in distress (or one containing a passenger in distress) is to be afforded right of way over all other aircraft; why is TRACON's workload even a consideration?I am concerned that I do not understand the chain of command as well as I previously thought. I understand that I am to follow the direction of my FLM unless it is a violation of the 7110.65; or unless it would produce some other illegal/dangerous situation. In no way was I trying to be insubordinate during this situation. Previous to this; in my years as a Certified Professional Control (CPC); emergencies (whether medical; mechanical; etc.) were handled in the way I was attempting to handle these: coordinate with the intervening ZZZ sectors and TRACON East Departure sector for a direct arrival. I had never; not once; been given an 'unable' in response to that type of situation. Things were always handled quickly and professionally; as a collaborative effort between controllers at the two facilities. We controllers were trusted to do our jobs; and to assess what workload we could handle. In all my previous experiences; management's role was contained to coordination with other management. Previously; my FLM's let me work and coordinate as I saw fit. I have never had the ATM and OMIC trying to dictate what I do with an aircraft [in distress]. The ATM and OMIC are not operationally current; and I don't feel comfortable taking control instructions from them. Also; I don't understand why TMU needed to get involved in the way that they did. I understand that there had been arrival delays that morning; and that there was reasonable arrival demand at the time. I have never worked at the TRACON and can't speak for their procedures; but I assume that when the East Departure controller accepts an unusual arrival situation; it is then their task to work things out with the internal arrival sectors. The ultimate question I have is; who has the final say? If the pilot (specifically Aircraft Y) requests; and his is supposed to be the final word; as Pilot in Command (PIC); then why are we trying to go around his stated desires?I am concerned that there may be a management attitude of 'a medical [issue] isn't a real [issue]'. My FLM; at one point during this situation; made a comment that Aircraft X hadn't said anything about 'no delay'; hadn't asked to be expedited; etc. By my personal standards; an [issue] is an [issue]; whether medical; mechanical; etc. If there were no concern on the pilot's part for the passenger in distress; why would he declare an [issue]? I treat a medical [issue] the same way I would treat an airplane that was on fire. I'm not qualified to discern what medical conditions may be less critical than others; so I treat every declaration of a medical [issue] as an aircraft that needs to get on the ground as soon as possible. I think that if either of the airplanes here had in fact had a fire; or some other critical issue; the management or TMU response would have been much different. I see that as irrational; if a passenger's life may be in danger; shouldn't we treat that the same way as 200 passengers lives being in danger?Further; I am deeply concerned about the apparent disregard for the well-being of passengers who may experience a medical [issue] while on board an aircraft in Center's airspace. I feel that the culture at Center; and the prevailing attitude of management and TMU personnel; is that we controllers are to do whatever TRACON wishes; regardless of the workload or cost to us. In this case; doing as TRACON asked could potentially have come at a huge cost to the passengers in distress.I recommend an exploration of changes to the 7110.65; such as defining a medical [issue]; and adding the definition of a medical [issue] in [the 7110.65]; as well as recommendations for handling such. I recommend emphasizing that an [issue] is an [issue]; regardless of its nature; if the pilot feels that it is critical.I recommend clarification in the 7110.65; as well as the AIM; as to who has the final authority on the operation of a flight.I recommend changes at the local level; in terms of the SOP and various LOAs; that clearly lay out who may issue control instructions to an aircraft; as well as contingency plans for emergency situations. i.e.; in an [issue]; can/should TMU override a pilot's stated desire to proceed direct ZZZ?I recommend development of 'best practices' (route/altitude guidance) for jets in distress to use (if possible) if they need to enter [TRACON] airspace through a departure gate (i.e.; direct [to a fix]; direct ZZZ; at or below 12;000 feet; for the East Departure gate).




Synopsis: Controller reports of a medical issue which is coordinated to be direct the airport. Management while observing; lets it be known to the Controller that direct a fix direct the airport would be better for the TRACON. The Controller disagrees and states the aircraft is distress. Discussion ensues about managements part in the movement of distressful traffic.