This discussion was recorded on July 11, 2022. This transcript has been edited for clarity.
Robert D. Glatter, MD: Welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Today, we have a distinguished panel joining to discuss important issues surrounding emergency medical kits (EMKs) on domestic flights in the United States.
Here to discuss this important topic is Dr Andrea Merrill, a surgical oncologist at Boston Medical Center, along with Dr Amy Ho, an emergency medicine physician and senior vice president/chief of clinical informatics for Integrative Emergency Services in Dallas, Texas. Also joining us is Lianne Mandelbaum, founder of No Nut Traveler and an airline correspondent for Allergic Living magazine.
Welcome, everyone.
Amy F. Ho, MD, MPH: Thanks so much for having us, Rob.
Glatter: My pleasure. Thank you for joining.
Dr Merrill, I'd like to start with you. A recent tweet you posted became a hit on the internet, receiving nearly 500,000 likes and 57,000 retweets as you assisted a passenger with a medical emergency in flight going toward Europe.
What you found in the medical kit was really concerning. I'm going to let you discuss this in detail and what you did exactly to help support this patient.
Andrea L. Merrill, MD: An hour or two into the flight, they announced that there was a medical emergency. They asked if there are any medical professionals on board. I ran up along with two other physicians and they handed us what they told us was the EMK, which was a red bag. I've never been in a medical emergency on an airline before. I looked inside the kit, and I wasn't sure what to expect.
We needed to take a blood pressure, and the blood pressure cuff came in three pieces. They were all wrapped in plastic. We had to take them out of the plastic and assemble the blood pressure cuff, which took some time. Then we had to take a manual blood pressure and use a stethoscope that they had, which was a disposable stethoscope. I know most people out there probably don't use these disposable stethoscopes. You can barely hear anything in an office, and there's no chance that you can hear anything on an airplane.
Obviously, you could take a palpable blood pressure, but to really have something useful, if you need to take repeated measurements, you need to be able to take a good blood pressure, and it was just really impossible.
They didn't have a pulse oximeter. It would have been good to have a glucometer in this situation. They didn't have one in the kit. I was curious, so I asked if they had an EpiPen, because one of the doctors said they didn't carry it. They confirmed that they don't carry an actual EpiPen autoinjector. It was pretty bare-bones what was in there. Luckily, the passenger was okay. We didn't need much more, but I was pretty surprised at what was and what was not in there. Had we really needed to do something emergently, I felt like we would have been unprepared.
Glatter: Was the flight attendant able to help you in a way that you felt was useful or supportive at the time that you were fumbling through to get the right equipment that you needed to take care of this patient?
Merrill: They were standing nearby. Since tweeting (and many other people like Dr Ho and Lianne have replied to me), I've learned that they have other medications on the plane. Some of them could have been useful, but they didn't offer that, and I didn't know to ask for the other medication kit.
I've also learned that they often can connect you with medical professionals on the ground that they work with, and that wasn't made an option. Potentially, it was because the passenger was doing well, and they thought the situation was handled. They didn't ask us, and they didn't offer these services to see if we needed them.
Basic In-Flight First Aid Kit vs Emergency Medical Kit
Glatter: Amy, I want to bring you into this. In this situation — and you're well familiar with this — there's a basic kit and a more advanced kit. I'll let you delve into that to the point that Andrea was discussing.
Ho: I'm an ER doctor. I've responded to a couple of medical emergencies, and part of my training in residency was in-flight medicine where you flew in a helicopter. You learned all about preparedness, and we used to have to run our supplies daily to make sure we had everything.
When I started looking in this topic a few years ago — after just coming out of an emergency just like Dr Merrill was talking about — we realized that there are four categories of supplies that are required. There's an automated external defibrillator (AED), an oxygen tank, a first aid kit (which is a really basic kit), and then there's something called an EMK, which is the emergency medical kit. That is a sealed kit. It's only supposed to be given to people who are qualified for it, which is why you end up having to ask for it.
The Federal Aviation Administration (FAA) has publicly available a list of what's in that kit. A couple of years ago, they asked for help from some of the medical associations to revamp that kit. That being said, the current kit requires some basic airway equipment for adults and pediatrics. It requires basic intravenous (IV) equipment, a blood pressure monitor, a stethoscope, some cardiac drugs (like 1:10,000 epi[nephrine], atropine, lidocaine, nitro[glycerine], and aspirin). It requires bronchodilators, antihistamines, and pain medicines.
You are totally right, Dr Merrill; it does not have like a pulse oximeter or a glucometer because the airlines will sometimes crowdsource those from other passengers. That being said, this is the bare minimum of what you are required to have. Many airlines can and do add more, usually at recommendation of their med control, which could be an academic center or a corporate occupation medicine group. You'll see that there's some variation because of that.
Glatter: Right. I think what you're saying, Amy, is very important in that there are gradations. If medical personnel, such as an EMT, a nurse, or a physician, is available and is comfortable, they can ask for that kit if they're aware of it. It's important to be aware that you just don't get that advanced kit upfront, especially in an allergic type of situation or emergency, if someone is having a cardiorespiratory issue, a GI issue, you name it.
Lianne, let me bring you into this because of your experience as a journalist in this space. There's a disconnect here, in that the kit itself has not been formally updated by the FAA in over 16 years. There's a reason behind this, and I want you to get into this.
Lianne Mandelbaum: The FAA last issued a circular on this in 2006 and formally updated the kit in 2004. We have to look at what's happened in the world since then. I can speak from my expertise as a food allergy advocate. Between 2007 and 2017, we had a huge increase by 377%, and that is actual emergency room claims that were filed.
These medication kits, at a minimum, should have an easy-to-use autoinjector. Part of my job has been to collect testimonials both from allergic families and from physicians, and there are a couple issues with the vials. First, and most importantly, they don't necessarily have to be there because the airlines have been granted an exemption for five medications, including among them the allergic concentration of epinephrine. You may find, and several physicians have reported to me (more than several actually), that they've found either no epinephrine or only the cardiac concentration, and no autoinjector. Then you are really stuck with no usable medication.
Crowdsourcing is great, but what if you're an allergic family traveling out of the country and you have two autoinjectors and you give up your autoinjector, and then you get to France and go out for a meal and only have one with you? There's that to consider.
There's the issue of vials cracking. I have a physician who told Allergic Living that there was turbulence and the vial cracked and he split open his hand. There are so many issues with that.
The other thing is there's a lack of crew awareness just like you were saying as far as the EMK, but even more so on training. They think the autoinjector, or the vials of epinephrine, are magic and that they're going to work. Time is of the essence. You really need the autoinjector if something is going to go south very quickly.
There's a well-known case on British Airways where a young girl died. She had ingested something from the ground that had unlabeled sesame in it. They asked the crew for the EMK and they got it. It was a junior doctor, and I'm not quite sure what that means in the UK. He had just gotten his license. The father had already administered two autoinjectors, and she was dying. They asked the crew to draw up two more vials of epi and the crew said, "We're not trained to do that." There actually was an autoinjector on the plane, and that was the saddest part. British Airways voluntarily carries them, but the crew didn't know. It's not just the medical kit. The crew has to know what to give the physicians when they need it. There's such a lack of training and a disconnect.
We've also seen stories where physicians can't find what they need quickly because these kits are so disorganized. We have so many issues surrounding these kits. The FAA just needs to step in because you cannot leave it airline to airline, medical provider to medical provider. It needs to be a standard list so that passengers are safe up in the air. There's just no excuse.
Glatter: Part of it is that they claim there are ongoing shortages. That's the rationale given for not having these medications. Amy or Andrea, is there research about these shortages? How can we somehow address this? We all know that there are medications shortages in working at the hospital. That's a given.
When you fly, there should be a standard. It's not a flying hospital, but it's a place where hundreds of people are gathered for many hours. We need to have standards in place, equipment in place, and things that protect the public. Amy, I'll start with you.
Ho: In 2019, there was a review with the Aerospace Medical Association, who brought in the American Pediatric Association that focused on the things that need to be added to this kit. The EpiPen was absolutely on it for both adults and pediatrics.
One of the major issues isn't necessarily a shortage, but number one, it's expiration. All these medications will expire within about a year or so. It's recommended that the kit is reviewed, these are changed out, and so on, but it doesn't always happen, like Lianne's mentioning.
Number two is costs. We all know EpiPens are extremely expensive. The 1:1000 (1 mg/mL) ampoule of epi is very cheap along with the syringes, but Lianne is totally right. There's no training by the flight attendants for it. They do go through a preliminary training where there is no physician related to that training. Their role is really just to know that it's there and hopefully give it to someone on board, which is absolutely not ideal and can be dangerous.
EpiPen Autoinjector vs Epinephrine Ampoules and Syringes
Ho: Here is an EpiPen trainer, and they all basically look like this. All you have to do, if someone's going into anaphylactic shock, is pull the blue safety and then hold it against someone's thigh for about 3 seconds.
Dr Ho demonstrates using an EpiPen autoinjector.
That's what delivers the medication. Once you hear that click, you've delivered the medication. Fairly easy. How I think about this analogously is similar to intranasal Narcan. It's very simple to use.
In contrary, what the airlines have required via the FAA and the EMKs, is an ampoule of epinephrine, which usually looks something like this. This one is not epinephrine, but it's usually a glass bottle. You have to snap off the ampoule, and then you need a syringe. The smallest syringe the FAA requires is a 5-cc syringe, which is what I have here. You draw up only about half to 0.3 mg or mL, and that's a tiny amount. Even as I'm moving this on the camera, you can barely see it because it's only about 0.3 mL.
Dr Ho demonstrates using an ampoule and a 55-cc syringe.
You have to have a blunt film needle to draw up the epinephrine out of the ampoule, and then you switch it to an actual injection needle. Again, this all requires medical training, many pieces that you have to find in the kit, and then finally you give it to the passenger.
Dr Ho displays a blunt film needle (shown in pink) and packaging of an injection needle.
Obviously, a large amount of medical skill is needed in an already stressful situation that people may or may not have the training for.
Merrill: Plus, if you're doing it in the aisle, usually there are many people around you, or there may be turbulence. You can't really steady your hand to draw it up or to open the ampoule. It's hard enough to lean over someone to try to get on a blood pressure cuff. I can imagine that trying to draw that up would be a little bit challenging.
Glatter: Going through this, it's apparent to me that there must be stricter regulations, not just domestically but internationally. Getting everyone on the same page is exceedingly difficult. There are economic issues, supply line chains, and trying to arrive at this.
There's no database of in-flight medical events that exists in the US or internationally, where you could enter incidents of what happened and outcomes to help with research. In fact, Dr Donald Yealy's publications in 2018 in JAMA and 2013 in The New England Journal of Medicine talk about the rarity of such in-flight medical events. In fact, allergic reactions are so low in this data from 2008 to 2012, it was only about 1.3% that were allergic reactions. Most included syncope, presyncope, GI [issues], cardiac issues, and things of that nature. Knowing that it's rare to have anaphylaxis, that's what they're quoting. These data are not up-to-date. We need to update the database to make sure that we have an accurate picture of how often anaphylaxis or severe allergic reactions happen. Lianne, I'll let you comment on this.
Mandelbaum: Let's start by circling back to the FAA. The plane has to make an emergency landing or diversion for an actual report.
I had an ER nurse who actually specialized, just like what you did, Amy, in the helicopters. She did not feel comfortable in a moment. It was a 10-year-old's first reaction to a cashew in the air, and she did not feel comfortable calculating the dose from the syringe into [the pediatric [dose]. She did crowdsource, and she did get an EpiPen. This is someone completely experienced.
I also reported that Dr Shah quite recently had an emergency up in the air, and he and another physician came up to help. The other physician was a urologist, and didn't know how to titrate the different concentrations. Dr Shah told me he took time from treating the patient to show this person how to do it because he said if the wrong concentration was used, it would be a problem.
We aren't getting these reports. They're not required. Nobody's collecting them. If the plane doesn't make an emergency landing or somebody else's autoinjectors used (or I know people who used their own autoinjector), they don't want to bother the staff, because often you are taunted if you have an allergic reaction. I collect many testimonials where people have been mocked, taunted, or harassed by flight crew, so they use their autoinjector in the bathroom. I know several people who have done that, unfortunately, and those don't go into reports either.
There's absolutely no way we're keeping track of these events. In fact, I was part of a coalition to put autoinjectors on planes. It was a bill that didn't pass. I think part of the reason it didn't pass is that it included a provision for a Government Accountability Office (GAO) report on these reactions. I don't think that they want these reactions tracked.
The FAA has the ability to change this now. In 1984, Ralph Nader's group sued them because they wanted to update the EMKs. The court came back and said, "No, you're wrong. You actually have purview." They said that the FAA does have purview and they can update the kit. Yet, we sit here after these recommendations have come in related to including the autoinjectors. We sit here, and nothing happens. It's quite confounding to me.
Ho: That was the December 2018 review. The review actually happened in 2019, and there was a piece of legislation that said, "Hey, we need to review this," and hence they outsourced it to the Aerospace Medical Association. That being said, you are totally right, Lianne. The reporting is not standardized.
There is some reporting mostly just because there's med control. Like I mentioned, med control is often outsourced to private companies. It's often with academic emergency centers, where they'll take a call just like you take an EMS telemetry call. I did those in residency as well, and that's where they will see that there's events happening in flight, and the New England Journal of Medicine article that Dr Glatter is talking about was a review of a med control for an academic center.
There are some data out there, but you are both right, hitting the nail on the head that there is no standardized way for all of this. That being said, flight attendants will absolutely take people's information. They'll ask for your medical license often because they want to be able to leave a report on what happened. Some med controls will actually reach out to physicians on board that assisted to ask, "What can we do that's better?"
Merrill: They did take all my information down, and a nurse from the airline did call me a few days later to follow up on the incident.
Mandelbaum: That was because the kit was cracked. There were also instances where the person goes into anaphylaxis. I have several testimonials where a patient is stabilized, but they're met with an ambulance on the ground. Because they didn't open the EMK and the patient received the injection in the ambulance, that is not considered an in-flight incident. We've got incidents like that. There are so many variables.
It's very hard to get a data sense of what's going on. Obviously, in the United States alone, we've got 1 in 13 kids, or about two students per classroom We've got 48% of adults that have food allergies develop them as adult-onset. Airlines are still serving the most potential trigger foods for these adults, which are tree nuts and shrimp. They're still serving it.
They've got to come into the 21st century and have the right tools on board so that we have a positive ending here. The doctors that are called up, we've got to give them the right tools. It's not that they're not available. The American Heart Association lobbied really hard for defibrillators to be put on planes. We need all the medical societies to come to agreement on these other medications (eg, autoinjectors) to be put on planes. If you're going to come up in answer to an emergency, you should have basic medical kits updated to reflect what's going on in society today. It just makes sense.
Not Comfortable Treating a Patient on a Plane? Your Options
Glatter: One thing I wanted to hit on is that there are many physicians and nurses that are specialized, and they may not feel comfortable handling all types of emergencies in air. Let's be honest: If you're a dermatologist, a psychiatrist, or someone who hasn't had resuscitative patient care, it can be daunting. You want to help, you want to be there. If you're not trained and not really proficient because you haven't reeducated yourself on some of this, being called in the midst of hundreds of people to act can be daunting. I think that's important to understand that there's a need to step forward, but also you have to be proficient at what you're doing.
Merrill: That is a really good point. Like I have never had to draw up epinephrine to give to someone having an allergic reaction. It's just not something I've ever encountered. I'm a surgical oncologist treating breast cancer and thyroid cancer. If there was ever a situation, I was probably in an emergency room or somewhere else where we work in teams. In medicine, there are many other people helping and doing things, but you don't have that in the plane. You really need everything to be streamlined, more automatic, and easier to use when you're in a stressful situation.
You're also not expecting an emergency, so you're not really in that frame of mind that you're about to treat someone. You're on your way to vacation, enjoying yourself, and then suddenly there's a medical emergency. It's a different frame of mind than what we're doing every day for work.
Glatter: Absolutely. Amy, would you want to add anything further?
Ho: I want to reiterate what Dr Merrill said. Coming from the medical world, it's important to remember you have a team. That is what we learn in medicine. When you're on an in-flight emergency, the airline attendants are your crew. Like I said, they do have some basic training, but they're obviously not a nurse or a medical technician.
Your crew is also other passengers who may volunteer. If it's a syncope and you have a cardiologist right there, maybe they're going to be more helpful. Also, remember that there is medical control. Every airline has to have med control on the ground so you can defer. Of course, if you're a physician and you are on vacation and you've had a couple drinks, there's never anything that says that you have to respond to this. Always assess what your skills are and what your own capacity is in that moment. Help if you can because it's probably the right thing to do. If you're not in a place to do it, there is a backup.
Glatter: One thing is that the medical control has the ultimate authority about what to do. The ground-based medical physician can tell the pilot either to divert or not. The person treating the patient doesn't have the final say. I found that very interesting that although you're the person in charge of the resuscitation, the decision to land or divert is made by the ground-based physician, which was concerning.
Dr Merrill, you didn't have any interaction, you said, with ground-based medical control.
Merrill: Yeah, they didn't offer it. Again, maybe because the passenger luckily was doing well and the situation seemed handled. I didn't know until I tweeted and received responses that that was even an option.
Ho: If a physician responds or if medical personnel respond on board, they won't always call med control. Just remember that, and you can absolutely ask for it.
Mandelbaum: There are some cases when there's no med control. In that case that I told you where there was the death, it was a shorter flight, and they didn't have the radio length. They're not all connected.
I also wanted to add that it's not just epinephrine that is exempt right now, and the FAA renewed exemptions for five medications. We just found out that it was quietly renewed (Senator Duckworth's office), and it's atropine, dextrose, lidocaine, and both vials of epinephrine.
What kind of situations could you guys envision with those other drug shortages not being there? I mean, this is not bad allergies anymore. This is a public safety issue.
Ho: If we're giving those medicines, honestly, those sound like a diversion. With atropine and cardiac epinephrine, those are all things where you're diverting and just trying to temporize.
Mandelbaum: What if you're over the ocean?
Ho: Absolutely. Good point.
Glatter: I wanted to talk to the group about having Narcan or naloxone in the kits, certainly related to withdrawals initially, but overdoses as well. Based on the data and persons I've spoken with, withdrawal is more common than an overdose. That said, I still think that's a basic medicine, based on our society now and the opioid crisis. Amy, I'll let you start with your thoughts on this.
Ho: I mentioned previously that I feel like the EpiPen vs an epi ampoule is analogous to Narcan intranasal vs Narcan as an ampoule. It's not required by the FAA, but it is, however, on certain airlines. When I started this pathway, I reached out to multiples airlines to ask what they voluntarily had added to their EMKs. American Airlines had Narcan intranasal. British Airways had Narcan IV as well as oral buprenorphine, which I found quite interesting. Delta had Narcan intranasal. It is available, but not standardized. Again, much discussion on the delivery mechanism, just like with epinephrine.
Mandelbaum: With all these medications, again, I just want to stress that there needs to be standard requirements set by some sort of competent oversight governing body, such as the FAA, but also globally. Not only do you not know what medicines are in what kits depending on what airline, you don't know when they've been refreshed. I reached out to several airlines for a story I was writing, and I couldn't get a consistent answer as to when it gets refreshed.
How are these testimonials from physicians making their way to me that they're over the Atlantic and opening up an unsealed kit with no epinephrine in it, or opening up a kit that says "No epi in kit" with the sticker, which was very recent? I also want to add that the US Food and Drug Administration (FDA) has told me at the current time, and at the time of this testimonial that I took, that there were no epinephrine shortages in the vials. I contacted the FAA and said, "Look, the FDA is telling me that there's actually no shortage." The FAA said, "Well, an airline must replenish when there's no shortage." We don't know who's overseeing this. Are the airlines self-policing?
Glatter: That's a good point. Some of the companies do have internal monitoring databases, and they do account for when a medicine is used, when it's out of stock, or when an ampoule has been broken. Apparently this is an internal process, but it's not anything that's reported. That's, again, the problem. That's where we stand. Dr Ho and Dr Merrill, would you want to add anything else?
Ho: No, I think that's a great summary that Lianne has. These do need to be standardized. The FAA rules do only apply to certain flights, but they will apply to most of our standard commercial flights. She's totally right that there are exemptions. I know some ER doctors that actually keep a little bit of a personal medical kit on them to help respond to these.
Merrill: Also, we shouldn't have to think to bring a medical kit with us when we're traveling because it's not available. When I'm on vacation, I want to be on vacation. Obviously, I want to help out if someone is sick or needs attention. I would hope that, in the air, when you're far away from an ambulance or other medical equipment, they would have something available to help stabilize someone until you can get to a safe place.
Mandelbaum: According to MedAire, what Amy was saying, the first aid kit and the EMK are both no-go items. If you don't have them, you're supposed to not be able to fly, which is why they have these exemptions. In case they don't have these medicines, the plane can still take off. The issue is, how long can they do this for without replenishing? We just don't know that. There's no oversight.
Glatter: I want to wrap up here and thank everyone for really a very informative discussion about this important topic. Hopefully, we can effect some change. Again, thank you all very much for joining me.
Robert D. Glatter, MD, is assistant professor of emergency medicine at Lenox Hill Hospital in New York City and at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.
Andrea L. Merrill, MD, is an assistant professor of surgery at the Boston University School of Medicine and a surgical oncologist at Boston Medical Center.
Amy F. Ho, MD, MPH, is an emergency physician, published writer, and national speaker on issues pertaining to healthcare and health policy, with work featured in Forbes, Chicago Tribune, NPR, KevinMD, and TEDx.
Lianne Mandelbaum is founder of No Nut Traveler and frequent media source on food allergy issues. She has been interviewed by the New York Times, Forbes, Allergic Living, Scientific American, the Wall Street Journal, and others. She was part of a team that collaborated on the right to pre-board US airlines as food allergy passengers under the Air Carrier Access Act (ACAA). This effort yielded a successful Department of Transportation ruling and the recognition that food allergy is considered a disability under the ACAA.
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Medscape Emergency Medicine © 2022
Cite this: Robert D. Glatter, Andrea L. Merrill, Amy F. Ho, et. al. Ever Treat a Patient on a Plane? Why Med Kits Need an Update - Medscape - Aug 05, 2022.
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