Epinephrine devices – known as EpiPens though that’s only one brand of such devices – dispense epinephrine to people experiencing anaphylaxis. A new lobby is asking Congress to require airlines to carry such devices on all flights. (Photo
2016 Getty Images
In July, when Matt Faraco, a 26-year-old from Atlanta, noticed his hands beginning to swell and his throat beginning to close while on a flight to Israel he didn’t know that he was experiencing the onset of anaphylactic shock. He’d never before had trouble with the kind of allergies that can cause such a life-threatening reaction.
Now Faraco owes his survival to a celebrity TV and YouTube Doc, Dr. Mike Varshavsky, who People magazine in 2015 dubbed “The Sexiest Doctor Alive.” Varshavsky happened to be on the same plane and responded to flight attendants’ call for a physician’s help. The right medicine to treat anaphylaxis – epinephrine – was immediately available to him because it is part of the plane’s “enhanced” medical kit. But it could only be administered by a licensed doctor or by another trained medical personnel working under the direction of a doctor via the plane’s radio. Thus, had Varshavsky or some other medical professional not been on the plane Faraco may well have died anyway.
The event happened just weeks after Rob Houton, a long-time lobbyist in Washington, D.C., had begun putting together a plan to form a new activist group with the aim of getting Congress to require all commercial aircraft to begin carrying pre-packaged epinephrine injection devices that anyone, not just doctors and medical personnel, can administer. Houton, whose 10-year-old daughter Catherine has dealt with a severe and potentially deadly peanut allergy all her life, formed the Coalition for Lifesaving Epinephrine Access and Responsibility (CLEAR) earlier this year after a series of well-publicized cases of anaphylaxis events aboard commercial airliners.
“Alexa Jordan, a Harvard student, went into anaphylactic shock on May 15 onboard a Southwest Airlines flight,” Houton said. “She survived, and we met shortly thereafter. And that’s where this effort to get Congress to act got started.”
There’s no hard data on how many cases of anaphylaxis occur aboard U.S. airlines each year. Carriers typically keep some such records, but there’s no standardized way for tracking and reporting that data for public consumption. So, it’s hard to know exactly how many passengers a year are affected by this medical issue, or how many flights are in some way disrupted as a result. But there’s little doubt that it’s a growing problem in flight simply because it’s a growing problem on the ground.
“There are 32 million Americans, 5.6 million of them children under age 18, who suffer from food allergies. And more than 40% of those children with food allergies have had cases of anaphylaxis. And for reasons that aren’t fully understood yet the number of people, particularly children, who have these potentially deadly allergies has nearly quadrupled in recent years,” he added. “It’s a real issue.”
One of the biggest problems they face, Houton explained, is that when they travel they sometimes forget to bring – or simply don’t have – epinephrine devices that can be quickly jabbed into their thighs to deliver a dose of medicine that will counter the anaphylaxis. Additionally, though it’s rare, sometimes airline passengers like Faraco, who have no known history of allergies and anaphylaxis, will experience such an event onboard a commercial flight. Not only do they not have an epinephrine device – commonly called an EpiPen even though that’s just one brand of epinephrine devices – with them, they typically can’t even tell fellow passengers, or flight attendants what’s happening to them. That means it’s up to flight attendants or any medical professionals who happen to be onboard and who respond to the event to diagnose the problem and deliver the medicine.
Houton, and fellow veteran lobbyist Jennifer Bell, who just signed on as CLEAR’s executive director, have begun work trying to educate members of Congress and the public about the nature and size of the problem.
“Our target is to get a mandate (that airlines carry epeniphrine devices in their medical kits) included in the next piece of legislation reauthorizing the Federal Aviation Administration, which is coming up in 2020,” Bell said.
In recent history FAA reauthorization bills have taken several years to get passed because they’ve become contentious matters that break down not just along party lines but along regional and philosophical lines as well. As a result, Congress has used multiple continuing resolutions that keep the FAA operating short-term by pushing the expiration date of the old FAA-authorizing legislation out several months at a time.
While not ideal, Bell says if similar circumstances arise around the 2020 FAA re-authorization it’ll just give the fledgling CLEAR organization more time to enlist corporate and individual members and to educate and win the support of more legislators. It’ll also give CLEAR and its supporters in Congress more time to get an actual bill – which has yet to be written – and all the attendant details nailed down.
“It’s one thing to pass a mandate that airlines equip their planes with EpiPens,” Bell said. “It’s another to make sure the manufacturers can meet the demand, meet the standards that get set up, and that the airlines and individuals will have quick access to those mandated devices. We’ll be working on those and other practical issues, including Good Samaritan protection laws for those individuals and flight attendants who assist passengers in anaphylactic shock.
“We likely will follow what’s happening in schools,” she explained. “Every state now has laws requiring schools to stock EpiPens, though the rules vary widely. We’ll be looking at the best practices among those to see what will work best.”
This won’t be the first time that Congress has been asked to require airlines to carry epinephrine devices. A similar measure was floated back in 2015 but went nowhere.
Prior to the late 1990s epinephrine was not available in any form on commercial flights. But as part of its unilateral effort to place Automated External Defibrillators onboard all its planes American Airlines also created enhanced medical kits stocked with a wider array of medical instruments and medicines than ever before. Congress thereafter ordered the FAA to create new rules requiring all airlines to carry AEDs and the enhanced medical kits on their planes.
Dr. David McKenas, American’s chief medical officer at the time, and the driving force behind the introduction of AEDs and enhance medical kits to the airline world, said he and his team considered and rejected the idea of including epinephrine devices in those enhanced medical kits out of concern that they might be mistakenly administered to someone exhibiting symptoms similar to anaphylactic shock but who actually was experiencing some other serious medical issue.
“You could be giving them something that would make their situation worse,” McKenas said. “We consciously chose to make epinephrine vials, along with syringes and needles, a part of the kit because that way it would require a doctor or trained medical professional to be involved in determining what the patient was experiencing. I still would be hesitant even today making it possible for a non-professional to make that decision.”
McKenas said it’s always best for those who have such allergies to “be responsible and carry your own EpiPens, or carry EpiPens for your children traveling with you.” (Full disclosure, the author has partnered with Dr. McKenas on an up-coming book about the introduction of AEDs on commercial flights.)
But Dr. Richard Lockey, a distinguished professor at the University of South Florida’s College of Medicine and an expert in allergies and immunology, takes the opposite view. He admits that in rare cases it’s possible that a shot of epinephrine could make a patient wrongly diagnosed with anaphylaxis worse. But, he added, the benefits of epinephrine for someone in anaphylaxis and the rarity of someone exhibiting anaphylaxis-like symptoms resulting from some other cause makes having epinephrine devices onboard planes a good idea. Besides, epinephrine devices are calibrated to “underdose,” not overdose a patient experiencing anaphylaxis, he explained. While that’s typically enough to help the patient with anaphylaxis in most cases it would not be enough to do significant harm to a patient wrongly administered epinephrine.
“I think it would be helpful,” Lockey said. “Could an EpiPen hurt someone? Ninety-nine percent, ‘No.’ Now, if it were given to someone with really severe coronary artery disease it theoretically could hurt them. But that would be an extremely rare case, especially in an airplane (where someone with severe coronary artery disease is very unlikely to be). But in the other 99% of the cases it definitely could save the person’s life. At 30,000 feet you don’t have a good option. They could very well die before you get to a hospital and run lab tests to determine what the problem is.
“I understand the concern,” Lockey added. “But we live in a day and time when you can’t cover every potential exception or possibility. But if you can provide something that in 99% of the cases save lives or, at the least do no additional harm, then I would provide that. A needle and syringe with vials of epinephrine would be great for someone trained in this like me. But what if no trained doctor is on board, or there’s a doctor onboard but they’re not familiar with allergy and anaphylaxis issues?”
