Emergency Medical Kits are essential to saving airline passengers, but doctors say regulations are outdated

(InvestigateTV) - In a 255-character tweet in June of last year, a surgical oncologist who had just assisted in a medical emergency on a plane pleaded with an airline to update its medical kits.

“I just assisted in a medical emergency in the air,” the doctor tweeted. “Your medical kits need a glucometer, epi pen (sic), and automatic blood pressure cuffs - it’s impossible to hear with a disposable stethoscope in the air. Please improve this for passenger safety!”

Her tweet went viral, with more than 54,000 retweets and 470,000 likes in the months that followed.

Dozens of doctors echoed her concerns in comments, where they shared personal stories of assisting with an in-flight emergency with a sometimes-limited medical kit.

Some recalled challenges using disposable stethoscopes and manual blood pressure cuffs, while others urged airlines to add more life-saving items into their kits.

In 2004, the Federal Aviation Administration updated its 1986 rule requiring airlines to place an automated external defibrillator (AED) and update a kit containing basic medical supplies that’s required on all planes with at least one flight attendant and a maximum capacity of more than 7,500 pounds.

In that guidance, the FAA listed 25 life-saving items emergency medical kits, “commonly called EMKs,” are required to have. Among other things, the list includes a stethoscope, aspirin, a blood pressure cuff, and epinephrine to treat allergic reactions. Notably, the rule does not require the kits to contain an EpiPen, an auto-injectable device that delivers epinephrine.

That list hasn’t been updated in nearly two decades.

While leaving the first aid kits the same, the FAA in 2019 did update its guidance on items that are needed or recommended during the flight attendant’s safety demonstration before each flight, like making flight attendants stand near exits without disrupting passengers from watching video demonstrations.

While the FAA does not allow airlines to leave out any of the 25 items required for the EMK, they do have the option to add other life-saving items. Some have opted to add a pulse oximeter and the overdose reversal drug Narcan.

But an InvestigateTV analysis of doctors’ experiences with the EMKs found contents vary widely, oftentimes leaving doctors and other medical professionals with limited or outdated equipment.

‘Absent or incomplete’

Dr. Leo Nissola, a medical doctor and the chief scientific officer at FirstBio Research, knows how critical those moments can be while aiding a passenger 30,000 feet in the air, sometimes hours away from a medical facility.

He has first-hand experience with medical emergencies on flights, aiding in at least five over his career. He said that whenever that call has come, he hasn’t always had what he’s needed.

“In my experience, all 100% of the times that I’ve asked for those kits, they were either absent or incomplete,” Nissola said. “I think the kits are usually outdated, the ones I’ve come across, and could definitely use some improvement.”

In a recent flight from San Francisco to Hawaii, Nissola aided in a medical emergency where a child was experiencing a high fever. He said when he asked for the kit, he couldn’t find anything he could use to measure the child’s body temperature.

“There was nothing to help me assess the health of that individual and understand if we needed to turn around the plane,” Nissola said. “There was pretty much nothing to measure the child’s temperature, there was no oximeter.”

Emergency medical kits are not required to carry a thermometer, something Nissola thinks the FAA should change. In addition to requiring a thermometer, Nissola has urged the federal agency to require a glucometer, an oximeter, and an EpiPen.

“There was obviously no EpiPen, which is one of the most important items you should have on the plane,” he said.

Dr. Amy Faith Ho is an emergency medicine physician raised in Austin, TX.

During her time in medical school, Ho found an interest in health policy through her work with medical organizations.

Like Nissola, she too has assisted in medical emergencies on a handful of flights while traveling for leisure.

“The first time I saw this kit, I was astonished that they didn’t have something as basic as a glucometer, which is a blood sugar monitor,” Ho said. “Because one of the most common things that can happen to someone on a plane or while traveling is their blood sugar gets a little too low and maybe gets too high and that can cause a lot of issues.”

While Ho has not actually had to use items from a plane’s EMK on a passenger, she agrees with other doctors’ assertions that the kits need updating.

“Unfortunately, with where we are in addiction and the opioid crisis, opioid overdoses are a commonality that we see,” Ho said. “And so having naloxone on hand could really save a life in case someone has an overdose on the plane.”

Lack of uniformity

The standard FAA-approved emergency medical kit includes medications to treat pain, allergic reactions, and cardiac conditions. Some airlines also include medications for nausea and seizures, InvestigateTV found.

But medical professionals interviewed by InvestigateTV said they would like to see other medications, like amiodarone, which treats life-threatening arrhythmias, and glucagon for low blood sugar, required for the kits.

Airlines can augment their medical emergency kits without seeking the FAA’s approval. However, that has led to inconsistencies from airline to airline due to a lack of mandated guidance by the FAA on items that can be used to supplement EMKs.

In 2019, the FAA asked industry leaders to help review the current contents of medical kits used on commercial flights.

The guidance document proposed by the Aerospace Medical Association Air Transport Medicine Committee suggested adding things such as a battery-operated blood pressure reader and auto injectors for epinephrine such as EpiPens when “available and cost-effective.”

InvestigateTV reached out to the FAA about changes to EMKs. The agency provided the following statement:

“A commercial flight cannot take off without a complete, sealed Emergency Medical Kit. Airlines must regularly inspect all equipment, including the emergency medical kit. If the seal of an emergency medical kit is broken, and any item is used, the entire kit must be replaced before the next flight departs. U.S. air carriers typically carry two emergency medical kits to ensure they have a sealed one for the next flight.

“The FAA is reviewing the emergency medical kit requirements based on input from the Aerospace Medical Association (AsMA). Because changing kit contents requires rulemaking, the FAA has issued guidance with recommendations of additional items to include.”

‘An aging population’

In January, the Department of Transportation recorded more than 562,000 domestic flights, an increase from the same month the year prior.

A 2018 Journal of American Medicine Association (JAMA) study estimated an in-flight emergency occurs on approximately one in every 600 flights. Experts said that is likely a conservative number due to limited data.

In a Freedom of Information Act request submitted to the FAA, InvestigateTV asked for records of all medical emergencies that occurred on domestic flights over the past five years.

The agency provided a summary of just over 400 incidents, with a spokesperson characterizing the list as “incomplete” because the FAA only collected data when it was “absolutely warranted, mandated, and/or invited.”

No other government agency tracks in-flight medical emergencies.

A fifth of the incidents provided by the FAA involved passengers. The rest were comprised of cabin crew and flight attendants.

In one instance, a passenger broke their leg after encountering turbulence during the flight.

In other emergency summaries, passengers experienced chest pain, vomiting or nausea, or respiratory or cardiovascular issues.

“People live into their seventies, eighties, and nineties and if you have medical conditions certainly you shouldn’t have to be afraid of flying,” Dr. Avital O’Glasser said. “I think (updating the kits is) absolutely crucial. Just extrapolating from other medical data, we have an aging population.”

O’Glasser is an internal medicine physician and an associate professor of medicine at Oregon Health & Science University. She said she has responded to at least half a dozen in-flight medical emergencies during her 16-year career as a physician.

During one such event on a United Airlines flight, she came across an “enhanced emergency medical kit.”

She tweeted out the picture of the color-coordinated sheet that included Narcan.

“In the heat of the moment, when you’re trying to stabilize a patient at 30,000 feet, like not having to dig through something, but having very clear, organized…this is there, this is color-coded,” O’Glasser said. “These are the doses we have; it gave me just so much peace of mind that I could do my job as smoothly as possible.”

That kit was made by MedAire, a company that provides airline crews with support, training, telemedicine, and equipment.

The company provides emergency medical kits that include more than what the FAA requires for 16 airlines around the world.

Dr. Paulo Alves is the company’s global medical director for aviation health. His role includes looking at in-flight emergency data as well as helping prepare and assemble medical kits.

He’s also been involved in 25 in-flight emergencies.

“Most airlines in the country, what they carry in the kit, is actually well beyond the minimum requirements prescribed by the FAA,” Alves said.

Alves led the 2019 task force created by the FAA to review what new items need to be in these kits.

“The FAA is actually the government agency responsible for enforcing the medical kits and controlling the medical kits, but they don’t define the contents of the medical kits,” Alves said.

While he’s encouraged the FAA has provided airlines with updated guidance per the committee’s recommendations, he’s concerned the changes won’t be universally accepted until it’s mandated by the government.

New Hampshire Sen. Jeanne Shaheen and North Dakota Sen. John Hoeven sent a letter in 2019 to the FAA urging it to “require opioid overdose reversal drugs, such as naloxone, in the emergency medical kits carried by passenger airlines.”

Doctors, flight attendants, and crew members encourage passengers to do the following before flying:

• Carry an EpiPen if you’re prone to allergic reactions
• If you are diabetic, carry your insulin and glucometer
• If you are traveling with a sick child or you don’t feel well, consider postponing your trip

“If you are a patient, and you are traveling, please, please, please, make sure that you keep any of your life-saving medications with you. Do not check it. Do not put it in your luggage,” Ho said.

If you are a doctor, airlines suggest carrying your credentials when accessible in case your assistance is needed on a flight.

InvestigateTV reached out to all U.S. airlines for comment on their EMKs. To see the full statements, please read below:

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