Airlines Gear Up for Medical Emergencies

The Pan Am flight to San Francisco was about an hour out of London when Dr. Richard Selby, a Santa Ana neurologist, heard a flight attendant ask if there was a physician on board.

A man in his 60s had collapsed, unconscious, in the aisle six rows behind Selby.

Within seconds, Selby, a British nurse and an emergency room doctor from San Jose, were at the side of their stricken fellow passenger. In examining the cold and clammy man, Selby determined that although he still had a heart beat, his pulse was faint.

“His pupils were reactive, which would indicate to me his brain was still functioning,” Selby recalled. “At that point I determined he either had a seizure or was in a diabetic coma.”

Looking through the man’s belongings for clues, Selby found insulin and a diabetic test kit.

Selby got a drop of blood from the man by sticking him with one of his syringe needles, then applied the drop of blood to a test tape in the kit which measures blood sugar levels by color change.

“We then decided it was a hypoglycemic diabetic coma--his blood sugar had dropped to very low levels,” Selby said. “The problem was we had to get sugar into him.”

It was then that Selby discovered what countless other physicians have learned when they have responded to an in-flight medical emergency: Beyond a basic first-aid kit, which consists primarily of bandages and ammonia inhalants, U.S. airlines are not equipped to deal with most medical emergencies.

Situation Changing

That situation, however, is about to change.

Beginning Aug. 1, a new Federal Aviation Administration ruling will require that all U.S. airlines carrying 30 or more passengers be equipped with an expanded medical kit. This kit, according to the FAA, must contain equipment and supplies for treating such medical emergencies as acute allergic reactions, angina (chest pain due to an insufficient blood supply to the heart), insulin shock and hypoglycemic diabetic coma.

Had Selby had such a kit, he could presumably have treated his in-flight patient almost as effectively as most hospital emergency rooms where, Selby said, “he would have been given 50% glucose and water intravenously, and he would have been awake in minutes.

“But without the IV,” Selby added, “he could die or sustain severe brain damage.”

In the case of Selby’s flight in March, however, ingeniousness made up for the shortage of emergency medical supplies.

“We took Coca-Cola and packages of sugar and one man--a Kiwi farmer from Northern California--stood there continuously stirring that solution,” said Selby. “The problem was getting it into the man because he was comatose and not swallowing.”

Failing to get a swallow-reaction, Selby took the double rubber tubing off one of the stereo earphone sets, sliced it in half and inserted the tube through the man’s mouth into his stomach.

Selby first tried to get the liquid down the tube by using the headset’s ear piece as a funnel. When that failed, he said, he used an insulin syringe to push it down the tube.

“His (the patient’s) blood sugar was zero on the test kit, so we knew he didn’t have much time,” Selby said, adding that he remained in constant touch with the plane’s captain, who was prepared to land in Iceland if necessary.

As it turned out, the plane did not have to divert to Iceland, a costly maneuver that would have required dumping the plane’s fuel before landing.

“We were able to test the man’s blood sugar with his test kit. After getting two zero readings, we started to detect glucose in his blood, and we continued the treatment,” said Selby. “By the second hour he regained consciousness and was talking. . . . The man actually walked off the plane to meet his daughter.”

Despite the happy ending, the experience left Selby feeling “frustrated and concerned” about public safety on board airlines. “I don’t think people realize when they go on a plane that there’s nothing there,” he said.

Over the years, the airline industry has been opposed to carrying more fully equipped medical kits--which would contain surgical instruments, controlled substances and other major medical supplies--on board passenger planes. Such kits, the airlines argue, would not only be expensive but could lead to misuse and potential liability. And, they maintain, cases of passengers becoming seriously ill are extremely rare. Furthermore, “a noisy airline cabin is not the place to perform an accurate diagnosis,” says Thomas Tripp, manager of technical information for the Air Transport Assn., the trade and service organization for scheduled U.S. airlines.

“We’ve always considered the airlines to be a 500-mile-per-hour ambulance . . . that the first course of action should be to divert the airline and put the passengers on the ground,” Tripp said. “Anywhere in the United States, we can put a passenger into the hands of trained emergency personnel within 20 minutes at the most.”

Selby, however, is not the only physician concerned about the lack of emergency medical supplies on board airlines.

Dr. Vicki Hufnagel, a Los Angeles gynecologist, was on a flight when a pregnant woman started having contractions. “They brought out their kit, and it had aspirins and bandages in it,” she said. “They just didn’t have anything. I mean a role of gauze is not going to help you.”

“On all the flights I’ve been on, there usually are other physicians on board,” said Dr. Edward Austin, a Century City pediatric surgeon. “But you feel helpless not having the medications and the instruments” to use in an emergency.

Presumably, with the new FAA-mandated medical kit on board, physicians who encounter in-flight medical emergencies will not feel quite so helpless.

The medical kit, which the airlines must carry by Aug. 1, in addition to the required basic first-aid kit, will include a stethoscope, blood pressure cuff, airways (rubber tubes that go into the mouth or nose to keep the airway open), syringes, dextrose injection (sugar water for raising blood sugar levels), epinephrine and diphenhydramine hcl injection (both are used for treating acute allergic reactions) and nitroglycerin tablets (for angina).

As originally proposed by the FAA, the medical kit also would have included scalpels and other surgical supplies, in addition to morphine and other drugs. But those items were deleted because of concerns expressed by both the airlines and the American Medical Assn. over security and possible misuse.

Although the AMA hails the expanded medical kit as “a great improvement over the currently required first-aid kit,” many doctors feel that the new FAA-mandated kit falls short of being adequate.

“It’s a step in the right direction, but it’s certainly not as far as we want it to go,” said Dr. Mitchell Karlan, a Beverly Hills cancer surgeon, who is president of the Los Angeles County Medical Assn. and a member of the AMA House of Delegates.

Karlan maintains that, among other items, the new airline medical kits also should contain Ambu bags (a respiratory device that assists breathing), endotracheal tubes (a tube that goes into the trachea to help the person breathe), a laryngoscope (an instrument that permits the endotracheal tube to be inserted), IV solution and a more adequate supplemental oxygen supply--”the two-liter oxygen (tank) they have on board is hardly enough to get a balloon to blow up,” he said.

Karlan, who has been involved in four in-flight cardiac emergencies in which he administered CPR and closed-chest massages, believes the airlines have an obligation to their passengers.

“If they’re going to take the responsibility of transporting American citizens, they’ve also got to take the responsibility of having appropriate equipment and medications available for the most common medical emergencies that can occur on board.”

Con Hitchcock, legal director of the Aviation Consumer Action Project in Washington, which has been lobbying for an expanded medical kit since 1980, agrees.

“We’re pleased the FAA has recognized that there is a problem, but we’re disappointed that the agency did not go further and require additional equipment or drugs,” he said. “Their concerns, I think, are overstated as evidenced by the fact a number of foreign airlines use these type of kits, apparently without problems.”

Hitchcock noted that the FAA ruling requires the airlines to report all in-flight medical emergencies for the next two years, which, he said, “might provide additional evidence for strengthening the kits and putting more equipment in if the need is indicated.”

In the past, airlines have not been required to report in-flight medical emergencies. As a result, there are no precise statistics on exactly how common they are.

FAA spokesman Fred Farrar said, however, that they “are very infrequent.” According to Farrar, it has been estimated that 21 in-flight deaths occur each year, and about 10% of these might have been prevented if the new medical kit had been on board. (Hitchcock said projections made by an airline industry lobbying group estimate that 50 to 100 people die in flight each year).

The FAA ruling requiring the new medical kit does not address the question of liability. Two bills are currently pending in the House of Representatives and one in the Senate containing so-called Good Samaritan clauses, which would relieve physicians and others of liability for treating ill or injured passengers. The Senate bill, sponsored by Sen. Barry Goldwater, was passed by the Senate in February but has not been acted on in the House.

The FAA ruling also leaves unanswered the question of who should have access to the expanded medical kits, which will cost about $100 apiece.

Speaking for the FAA, Farrar said, “Our expectation is that flight attendants and flight crew members should not be using the kit. To use the kit would force them to make a diagnosis, which they’re not qualified to do.”

Ross Rubin, an attorney for the AMA, said, “I think inherent in our support of the kit is that the equipment be made available only to those qualified to handle the situation.”

Still, the FAA’s lack of direction on the matter has some flight attendants concerned.

“None of us are trained to give injections and to make that kind of a medical decision,” said Kathleen Pengra, a Western Airlines flight attendant from Fountain Valley. “I think most of us wouldn’t be willing to do it without a lot of training and a lot more money to take the risk of being sued.”

Matt Finucane, director of air safety and health for the 23,000-member national Assn. of Flight Attendants, said “the flight attendants do not anticipate they will be using the kit--they will turn it over to qualified, properly identified medical personnel.”

Finucane points out, however, that even if an airline’s policy is to turn the medical kits over only to properly identified medical personnel, unanswered questions remain.

“I think at some point,” he said, “people may find themselves in an ethical dilemma where, let’s say a carrier says, ‘Give this only to a properly identified doctor,’ and someone says, ‘I’m a doctor, but I have no ID,’ and you have a person who looks like he’s dying on you. What are you going to do?

“A similar dilemma might be that a carrier says, ‘Give this only to a doctor,’ and someone says, ‘I’m a paramedic, and I’ve worked for 10 years handling cases like this.’ Do you give the kit to the person if you have someone in bad shape?”

But, Finucane added, “it’s better to have some ethical dilemmas than have 50 to 100 people die in flight and no possibility of helping them.”

Pan Am spokesman James Arey said the debate over “whether or not to have expanded medical kits on board” has been going on through 60 years of commercial aviation.

“Generally speaking,” he said, “while there are one or two airlines that have more elaborate medical kits on board, 95% of the airlines believe the most efficient and best course of action is to land at the nearest point and get the person professional help with professional equipment rather than relying on Good Samaritan procedures.”

Judy Curtis of El Toro, a flight attendant for Flying Tigers who serves as central safety and health chairman for the Assn. of Flight Attendants, said she became convinced of the need for a medical kit after a man complained of severe chest pains during a two-hour flight between the Philippines and Okinawa.

Without an expanded medical kit on board, Curtis said, the three military doctors who responded to her call for assistance were able only to give the passenger oxygen. Fortunately, she said, the plane landed in Okinawa an hour later, and the man was met by an ambulance.

“I still don’t know the outcome for this man,” she said, “but if it had happened on the next phase of our trip--a nine-hour flight--I don’t know if he would have made it.”

Janice Northcott, in-flight services safety manager for United Airlines, said United started a test program using advanced medical kits on select overwater flights to Hong Kong and Tokyo in 1982.

But the kits, which included injectable drugs and some surgical instruments, were not used with great frequency and were never used to save a life, she said.

As for the FAA-mandated medical kit, Northcott said United plans to keep it locked in the cockpit and make it available to properly identified medical professionals.

“You’ve got to really try it,” she said. “The best experience is to get a lot of airlines and see how effective the kits are.”

(United Airlines, which pioneered stewardess service in 1930, originally required all stewardesses to be registered nurses. The idea of having women tend to the comfort of passengers was proposed by a nurse named Ellen Church, who became one of United’s “original eight” stewardesses. United’s nursing requirement, which the airline felt would help give the new passenger service an air of professionalism, stayed in effect through World War II, although the airline continued to require one flight attendant-registered nurse to be on board its Honolulu service until the advent of jet service in the early ‘60s.

(In 1980, Cornelia Peterman Tyson of Corona del Mar, one of the “original eight,” told a reporter that she thought having a nurse on board “was a psychological thing more than anything. At that time it was unusual to fly, and many people were afraid to fly. I think the passengers, knowing we were nurses, had great confidence in us if ever anything happened.”)

Dr. U.A. Sexton, regional flight surgeon for the FAA in Los Angeles, said in-flight medical emergencies are usually a matter of “poor planning” on the part of the passenger.

“If he’s taken appropriate care of himself, it should never occur,” said Sexton, who advises passengers “to be sure you have the medication you need on your person, not in your baggage. The diabetic should carry readily available sugar, the guy with chest pains supposedly should have his own nitroglycerin with him. . . . “

“Most of the people who died (in-flight) knew they were very ill, and that’s the reason they were being transported,” Sexton added. “The guy who suddenly dies from a heart attack is a relatively rare event.”

In addition to carrying all their medications with them on board, passengers should keep a brief medical history in their wallet, especially if they’re traveling alone or with someone not familiar with their medical history, Selby advises.

And personalized medical identification bracelets or necklaces, he added, “are very valuable.”

Despite their infrequency, in-flight medical emergencies do occur. And when they do, the AMA’s Rubin said, “physicians continue to come forward regardless of Good Samaritan (legislation) status.”

Indeed, for Karlan the question of liability isn’t a concern.

“You really don’t give a damn about that kind of stuff when there’s a patient in an emergency,” he said. “You can talk to most doctors, and they’ll tell you somewhere along the line they’ve been on a flight where there’s been a problem they’ve been involved with. It’s very seldom there will be a call for a physician where you won’t get two or three or four who show up immediately.”

As for Selby, who has responded to three in-flight medical emergencies over the years, there’s no question he would do it again.

“Sure,” he said, “that’s why I became a doctor. You can’t ignore those things.”