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Will the Federal Aviation Administration (FAA) finally mandate that airlines carry EpiPens in their emergency medical kits, or continue to put passengers' lives at risk? That's the question at the heart of three senators' recent letter to the FAA, which we wholeheartedly support, given the anaphylactic allergies of several of our clients and in our own family.
While it's easy for those without allergies to not care as much, there are at least a couple reasons why it makes sense to want the FAA to mandate that airlines carry EpiPens:
1. Anaphylactic Allergies Can Affect Someone Who Was Never Previously Allergic
Take my husband, who has an anaphylactic allergy. He had plenty of exposure to the allergen in question throughout his childhood, with no issues whatsoever. Then, out of the blue, in his twenties, he had an anaphylactic reaction that landed him in the hospital. Without the prompt administration of epinephrine he would have died. To this day he must carry an EpiPen with him everywhere, as he still has that allergy.
Or take a child who has never had an allergic reaction, so his parents or guardians don't carry an EpiPen, yet the child goes into anaphylaxis on a flight, with no hospital-level emergency medical attention available. This is what happened to a ten-year-old on an American Airlines flight in 2018. He ate a single cashew, then started to go into anaphylaxis, with chest pains and labored breathing. American Airlines of course didn't have an EpiPen on board, only vials of epinephrine that would have required careful measuring and injection by a licensed medical professional. This takes extra time that an actual medical emergency often doesn't have. The nurse that volunteered to help told the flight crew that they needed an EpiPen; two fellow passengers volunteered theirs, although one didn't work. The second one fortunately did, saving the child's life. If the passenger hadn't provided this EpiPen, the child would have died.
First-time anaphylaxis on a flight has even happened to a doctor, who was lucky enough to be treated by another doctor on her flight. If he or someone like him hadn't been on the flight, she might not have survived.
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2. Reduce Suffering and Potentially Avoid a Flight Diversion
Even if you have misplaced confidence that an anaphylactic reaction could never happen to you or someone you care about, as a passenger, you should want to reduce the patient's suffering and potentially avoid a flight diversion. In the case above where the child's first ever anaphylactic reaction was on a flight, the flight from Aruba to New York was nearly diverted to the Dominican Republic, but thanks to the child's positive reaction to the EpiPen, it continued to New York, where they were met by emergency responders. That said, because EpiPens buy time to get to a hospital or emergency medical care for monitoring and potential additional administration of further epinephrine), in other cases, particularly on longer flights, the flight will need to divert so the patient can get to a hospital. An example is a 2022 United flight from San Francisco to Singapore diverted to Hawaii due to a deadly peanut allergy. Prompt administration of an EpiPen, however, can not only save the patient's life but also significantly reduce the patient's suffering and symptoms.
Here's the letter to the FAA from Senators Elizabeth Warren, Chuck Schumer, and Edward Markey, urging the FAA to mandate that airlines carry EpiPens:
“At least one in fifty adult Americans are at risk of experiencing a life-threatening anaphylactic allergic reaction at some point in their lives. In the event of an anaphylactic reaction, medical experts overwhelmingly agree that an immediate injection of epinephrine is the recommended first line of defense against further complications. While epinephrine may be administered through a traditional injection by a trained medical professional, auto-injector devices are commonly used in emergency situations and offer a quick-to-use, pre-measured method that a layperson can use to immediately administer the necessary treatment.
Having an epinephrine auto-injector available is especially crucial in a setting like an airplane, where emergency medical personnel may not be present or immediately available. Under FAA rules, airlines are required to stock emergency medical kits on any flight requiring a flight attendant. These kits must include specific medical equipment for use in an emergency. But the current FAA rules – last updated in 2004 – do not include epinephrine auto-injectors as part of the required contents. Numerous passengers have reported life-threatening emergencies involving travelers experiencing anaphylactic reactions who were fortunate enough to be on flights with trained medical personnel, or who were able to use auto-injectors that fellow passengers happened to have on hand and were able to provide. These travelers were fortunate, but we cannot continue to rely on good fortune to protect the 2.9 million passengers on every one of the 45,000 daily airline flights in the United States.
The FAA has, in the past, required that flights include a number of single dose ampules of epinephrine (which would be injected by syringe in the case of emergency). However, these ampules are designed to be used primarily in the event of a cardiac emergency. For these ampules to be useful in an anaphylactic emergency, a trained medical professional would need to be on board to properly measure the correct dosage and administer the injection. The glaring gap in FAA’s regulations disregards the widely-accepted guidance by medical professionals who stress the importance of epinephrine auto-injectors in treating anaphylaxis, and puts airline passengers at risk.
Following the enactment of the FAA Reauthorization Act of 2018, the Aerospace Medical Association, having conducted an FAA-commissioned review of existing emergency medical kits, recommended that auto-injectors be included in the regular contents of each kit, among other suggested contents. However, the FAA has not initiated a rulemaking to apply this recommendation. Airlines are clearly capable of meeting this standard, should FAA require it. In fact, certain airlines stated they independently elected to provide auto-injectors on flights, but it is impossible to determine whether these airlines are consistently adhering to these voluntary commitments –and there is nothing that prevents them from dropping them altogether.
We urge you to amend the current standing regulation to require that epinephrine auto-injectors be included in the emergency medical kit of every flight, as well as engage in regular review of medical kit requirements. We ask that you provide us with a staff-level briefing within 30 days on this matter, and we thank you for your consideration of this request to ensure the safety and health of passengers across our nation’s skies.”
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As a 25 year First Responder, I have no qualms whatsoever about asking airlines to have an EpiPen (or comparable, such as an Auvi-Q) on board, much like the requirement to carry AEDs. That said, I want to also issue caution, and note that careful requirements for training must be in place, as an overdose or misapplication epinephrine can have negative consequences as well, to include rapid changes in blood pressure, heart rate and even heart rhythms. Additionally, while your article suggests an EpiPen administration could avoid a flight diversion, this is really untrue. Any administration of Epi should be… Read more »