TABLE I. EMERGENCY MEDICAL KIT ITEMS USED IN FLIGHT
IN 2,293 APPLICATIONS (..UGUST 1986 - JULY 1988)

Kit Items Reports of Use Percentage of Total
Kit Applications
Sphygmomanometer 1724 73.2%
Stethoscope 1723 75.1%
Nitroglycerin Tablets (10) 227 9.9%
Syringes (3) (as necessary for administration) 142 6.2%
Needles (6) (as necessary for administration) 139 6.1%
Diphenhydramine (2 ampules) 37 2.5%
Epinephrine (1-1000,2 ampules) 56 24%
Dextrose (50%, 50 cc) 41 1.8%
Oropharyngeal Airways (3 sizes) 36 1.6%

Designations reflect actual specifications of kit content. For kit items with multiple subelements, the
reports of use do not permit a determination of exact numbers or sizes of subelements actually

deployed.

of 2,322 reports of ME’s were received for analysis
(1,016-year I; 1,306-year II), with the medical kit
being used in all but 29 cases (3-year I; 26-year I).
A iotal of 33 in-flight deaths were recorded over the
2 years (9-year I; 24-year II), with only one death
representing crewmember death (secondary to air-
craft structural failure and resultant physical trauma).
When applied, the medical kit content utilization
renged from approximately 75% for the stethoscope
and sphygmomanometer, to less than 2% for the
injectable dextrose. The accompanying table por-
trays detailed utilization rates. The medical provider
was documented as a physician in approximately
85% of all 2,293 uses of the medical kit, with
registered nurses and emergency medical techni-
cians providing an additional 8% of coverage, and
the remaining 7% distributed primarily to the “un-
known” category, with a host of varied medical
professionals helping in scattered instances.

The 2,322 reports were scanned for overlapping
medical symptoms, medical signs, and even spe-
cific disease entities. The most common presenting
symptom was pain (280 reports: 29-year I; 151-

year II), of which chest pain was the most prevalent
complaint (205 reports: 95-year I; 110-year II). The
most common presenting sign was unconsciousness
(241 reports: 123-yearI; 118-year II). The next three
most prevalent presentations included shortness of
breath (137 reports: 62-year I; 75-year I); nausea
and/or vomiting (154 reports: 54-year I; 100-year
II); and various myocardial (heart) references (97
reports: 49-year I; 48-year I). These are not exclu-
sive presentations: for example, a few cases have
been recorded as presenting with chest pain and
shortness of breath, a fairly common clinical combi-
nation that can be etiologically associated with
cardiac, pulmonary, and even other organ disease.

Two hundred forty-seven emergency reports,
were accompanied by at least partial medical history
and a few details on diagnosis and treatment. Inthese
247 cases, there were 158 (76-year I; 82-year 11) with
medical history that was directly orind:rectly related
to the presenting in-flight event; these cases range
from relatively obvious sequences as known diabetics
orallergy-prone individuals having insulin or allergic
reactions, respectively, to less direct associations,


UTILIZATION OF EMERGENCY MEDICAL KITS
BY AIR CARRIERS

Introduction

The Department of Transportation Emergency
Medical Equipment Requirements Rute of January
9, 1986, mandated a period of 24 months (August
1986-Juty 1988) during which all air carriers flying
under Federal Aviation Regulation, Part 121, would
monitor medical emergencies and use of the pre-
scribed medical kits (2). The discussion section
within the rule projected that “an analysis of the
Tesults atthe termination of the reporting requirement
in 2 years will provide the FAA with information on
medical emergencies occurring in flight so that any
necessary changes can be made to the medical kits,
training of personnel, or related matters.”

Although the reporting requirements called for
a description of how the medical kit was used, by
whom, and the outcome of the medical emergency,
they permitted the individual records, or a sum-
mary thereof, to be submitted to the air carrier's
Principal Operations Inspector in the FAA, and the
guidelines further permitted wide latitude in the
level of detail contained within either individual or
summary formats. The resulting heterogeneous data
base was made available to Office of Aviation
Medicine’s Civil Aeromedical Institute staff to as-
sist with summary .:bulations (3, 4) and, wherever
possible, to extract the salient lessons leamed from
this data base.

Methods

Only limited data points were uniformly
abstractable from all the in-flight medical emergency
reports. One could minimally define the total number
of reporting airlines, the total number of in-flight
deaths, the total number of airlines with medical kit
usage, the frequency of diversions for medical rea-
sons, the frequency of use of specific items in the
new medical kit, and the type of medical provider.
The summary data should be used with the caveat
that the level of missed, incomplete, or even faulty
data provided by individual airlines could not be
evaluated by CAML.

Another level of analysis incorporated a review
of those airline submittals that were voluntarily
accompanied by extended case reports, sometimes
even full copies of the materials completed by the in-
flight health care provider responding to the emer-

gency. Approximately 30% of the carriers reporting
in-flight medical emergencies provided this type of
data transmitial, but the total cases with such detail
fepresented only about 10% of the total caseload.
Nonetheless, these case materials provide better
insight into such parameters as medical conditions
predisposing to the in-flight event, the actual pro-
gression and outcome of the medical event, the
specific items of medical kit usage, as well as the
registered complaints and suggestions Ly the in-
flight care provider and flight crew directed at im-
proving the existent medical kit and emergency
response.

A final Jevel of analysis in this review addresses
representative non-FAA data sets that treat the issue
of medical kit usage and improvement. We feel
these, and future, contributions of the interested
aeromedical community will be very useful, espe-
cially since it is among the largest carriers that most
of the useful clinical data reside, data that were often
not available to the FAA in the terse summaries
adequate to the regulatory reporting requirements
provided by the airlines. The enabling regulation
defining the kits had a projected 10-year vclidity,
although mandatory reporting to the FAA was re-
quired for only two years. Now that the FAA lacks
regulatory access to the kit usage data as of August
1, 1988, the airlines with medical departments will
be even more critical to the ongoing evaluation of
the kits.

Finally, since the data were provided to the Civil
Aeromedical Institute in sets covering full year
experiences (August 1986-July 1987 [yearI}; August
1987-July 1988 [yearI1]), we will retain the separation
of data summaries by year and by overall total, but
would immediately cauticn that, although the con-
trasting of year I and year II data permits some
relevant comparison and speculation, the paucity of
data does not merit any statistically meaningful
analysis for trends.

. Results

During the 2-year monitoring period, 42 airlines
(18-year I; 24-year II) identified instances of medical
emergencies (ME), while 62 airlines (30-year I; 32-
year Ill) specifically reported no in-flight ME. A total


such as passengers on multiple cardiovascular
medications who encountered exacerbation of chest
pain or shortness of breath. The most prevalent
predisposing or related histories in these 247 cases
were cardiovascular (27%), endocrinological (6%),
gastrointestinal (5%), obstetric-gynecological (4%),
pulmonary (4%), neurological (4%), and allergic
(3%). Single reports included such examples as an
antecedent spider bite and a hisiory of AIDS.

The same pool (247) of cases permitted some
insight into the degree of satisfaction the medical
care providers had with the medical kit. Six providers
decrizd the quality of the sphygmomanometer and
stethoscope with such verdicts as “too cheap and
useless,” “piece of junk,” “leaking,” “too small,”
and “inoperative” for the sphygmomanometer, and
comments such as “came apart,” “hard to hear,” and
“piece of junk” for the stethoscope. Additional
improvements requested in the nonmedication area
included better airway equipment (2) and electro-
cardiogram (EKG) support (2). Of more minor
nature were individual requests for alcohol wipes
for cleansing and rubber gloves for the protection of
the provider.

No systematic recommendations for medica-
tion upgrades were detected, with separate and
isolated requests being registered for diazepam,
atropine, naloxone, “oral antihistamine,” and
“antiemetic.” In two more complicated cases,
lidocaine, atropine, and more syringes were re-
quested in one, while in the second (with five
physicians providing care), dilantin, bicarbonate,
lidocaine, and saline were requested, in addition to
a request for an on-board EKG.

The situations surrounding the 33 deaths might
seem the optimal environments within which to do
a selective evaluation of medical kit efficacy (or
failure); unfortunately, the finai reports donot permit
this analysis. We estimate that approximately 48%
of the 33 deaths were apparently related to cardiac
etiology, 6% to accidental causes, another 6% to
terminal cancer consequences, 3% to an ailergic
etiology, 3% to AIDS, and the remaining 33% to
unknown reasons.

The final section within Results will now re-
view representative individual airline studies of
their own ME cases.

A separate analysis of all kit usage on United
Airlines (1) during the period August 1986-July

1987 identified 362 uses on 361 flights. Even with
extended data tracking efforts, postflight outcome
data from the patient or other source were available
on only 144 cases. The authors concluded that
multiple medication additions were unnecessary,
but felt the current kit could be improved by includ-
ing a bronchodilator.

An unpublished review by Dr. David Millett of
Eastern Airlines estimated the costs of the utilized
production kits (at about $58 per kit) and the average
costs of kit refurbishment (at about $33 per kit)
during the first year of use as more than covered by
the savings from the approximate 50% reduction in
unscheduled landings for medical reasons noted in
the same first year.

Discussion

. Although only two years of data were available
for review, the pattem of medical kit item usage in
emergencics was very similar in the first and second
years. The 26% increase in numbers of cases in the
second year, and the 166% increase in deaths from
year I to year If seem dramatic but may represent
nonstatistically relevant variance. After all, these
deaths t a minuscule proportion of the ap-
proximate 450,000,000 annual passenger
enplanements.

The 2,322 in-flight emergencies equate to
slightly over 3 cases per day across all Part 121
carrier operations. Physicians responded to at least
85% of these emergencies. High frequency recurrent
complaints about kit adequacy were not obtained
during the two-year monitoring period, but kit as-
semblers and purchasers should assure consistent
quality of the heavily-used stethosccepes and
sphygmomanometers, and (because of the prevalent
Presenting symptoms and signs) the kit’s medical
content might selectively be expanded to include
analgesics, antiarrhythmics, antiemetics, and
bronchodilators. Even without expansion, the kit
content should be publicized to all interested phy-
sicians in advance of flight participation.

The high frequency of related or predisposing
medical histories for the actual in-flight events, and
the varied specialties and skill levels of the re-
sponders, indicate the potential benefit to be gained
in allowing medically concerned passengers to
Tegister their problems, and also interested doctors
to register their willingness to provide standby care,
in advance of actual flights.


u
+

-.* : (1)

AD-A234 784

DOT/FAA/AM-91/2 Utilization of
Emergency Kits by
Wallop De 2st Air Carriers

J.R. Hordinsky
MH. George

Civil Aeromedical Institute

Federal Aviation Administration
Oklahoma City, Oklahoma 73125

March 1991

Dr

A Peed Final Report

This document is available to the public through
the National Technical Information Service,

Springfield, Virginia 22161.

@

U.S. Department
Of Transportation
Federal Aviation
Adrainistration

91 4 25 678



As expected, some of the more clinically seri-
ous presentations might have been helped with a
more complete medical kit (e.g., wider range of
cardiovascular diagnostic and treatment modali-
ties). Even if we ascribed all deaths to cardiovascular
etiologies (and they were admittedly not), and pre-
pared for this eventuality, on average only one in-
flight death occurs in Pari 121 carrier traffic every
23 days. To be of assistance to this population, one
would need to provide both a more suphisticated kit
and amore sophisticated user of same; it is not just
a matter of having more on-board crewmembers
knowledgeable in basic first aid and CPR.

For such a heterogeneous traveling population,
it would seem prudent to offer those people with

known health concems or particular personal per-
ceptions of high risk for illness, and even death, a
choice of flights wherein designated professional
medical staff are traveling in standby (albeit con-
current passenger) status.

Because the final chapter of consensus building
on in-flight medical care has not yet been written,
we (within the FAA and the private sector) must
continue to explore alternatives for improvement.
Ongoing voluntary evaluation of in-flight health
care experience by individual carriers will be es-
pecially useful as evidence to support action. This
pooling of data will be needed to most efficiently
meet the joint FAA-industry mandate to refine the
“optimal” medical kit and applications.

References
1. Cottrell JJ. Inflight Medical Emergencies: One Year Experience with the Expanded Medical Kit.

JAMA 1989; 262; (12): 1653-1656.

2. Depastment of Transportation Federal Aviation Administration, Emergency Medical Equipment
Final Rule-14CFR, Parts 11 and 121. Fed. Reg. January 9, 1986.

3. George MH. Summary of Inflight Medical Emergency Reports, August 1, 1986 through July 31,
1987, Intemal Memorandum Report No. AAM-119-88-2.

4. George MH. Summary of inflight Medical Emergency Reports, August 1, 1987 through July 31,
1988, Internal Memorandum Report No. AAM-119-89-3.

UB. GOVERNMENT PRINTING OFFICE: 199 - 561-670/20839


NOTICE

This document is disseminated under the sponsorship of
the U.S. Department of Transportation in the interest of
information exchange. The United States Government
assumes no liability for the contents or use thereof.


Technical Report Documentation Page

T. Report Ne.

DOT/FAA/AM-91/2

2. Government Accession No.

3. Recipient's Catalog Ne.

‘4. Title and Subtitle

by Air Carriers

Utilization of Emergency Medical Kits

S. Report Date

March 1991

6. Performing Organization Code

7. Author's)

J. R. Hordinsky and M. H. George

8. Performng Organization Report No.

P. 0. Box 25082

9. Performing Orgonization Name and Address

FAA Civil Aeromedical Institute

Oklahoma City, Oklahoma

10. Work Unit No. (TRAIS)

TT. Contract or Gront No.

73125

12.

Washington, D.C.

BEES SE AvEst ion Hedicine
Federal Aviation Administration
800 Independence Avenue, S.W.
20591

3. Type of Report and Period Covered

4. Sponsoring Agency Cade

15. Supplementary Notes

resultant physical trauma).
physician was the provider in over 85% of the cases.
symptom was pain, with unconsciousness, impaired breathing, nausea and/or vomiting,
and various myocardial diagnoses the most common presenting sign (in descending
order of frequency). High frequency recurrent complaints about kit adequacy were
not noted during the two year monitoring period; there were scattered references
about the poor technical quality of the most frequently employed equipment; the
medical kit content might selectively be expanded to include analgesics,
antiarrhythmics, antiemetics, and bronchodilators.

1. VS 16° Department of Transportation Emergency Medical Equipment Requirements Rule
of January 9, 1986, mandated a period of 24 months (August 1986 - July 1988) during
which all air carriers flying under Federal Aviation Regulation, Part 121, would
wonitor medical emergencies and use of the prescribed medical kits. The reporting
airlines were to provide descriptions of how the medical kits were us2d, by whom,
and the outcome of the medical emergency.

During the two year monitoring period, a total of 2,322 reports of medical
emergencies were documented; these included 33 inflight deaths, with only one of
these representing a crew member (secondary to aircraft structural failure and
In the 2,293 actual uses of the medical kit, a
The most common presenting

a

oe

17. Key Words

Emergency Medicel Care
Medical Kits

Inflight Health Care
Air Lines

18. Distribution Statement

Document is available to the public
through the National Technical

Information Service,
Springfield, Virginia

22161

19. Security Clossil. (of this report)

Unclassified

WD. Security Classil. (of this page)

Unclassified

Zl. No. of Pages | 22. Price

7

Form DOT F 1700.7 (8-72)

Reproduction of completed page authorized

A