“Does anyone have an epinephrine auto-injector or antihistamines?” On two different flights within a year, Dr. Kimberly Blumenthal walked the aisles of a plane, polling passengers to see if anyone had medication for an allergic reaction in progress.
On each of these flights crossing ocean, airline crews told the Massachusetts General allergist that the plane didn’t carry epinephrine auto-injectors. Each crew also failed to mention that planes do have emergency medical kits. These are meant to contain vials and syringes with both allergic and cardiac concentrations of epinephrine.
But at 30,000 feet in the air, Blumenthal would have far preferred an epinephrine auto-injector to use. Each of the patients recovered under her care, but the physician found the situations unacceptable. “Both times I had to walk up and down the aisles asking passengers if they had the medications I needed. It is not OK,” she says.
Blumenthal joins a growing number of doctors who have reported to Allergic Living situations in which epinephrine wasn’t available in an in-flight allergic emergency. Or alarmingly, the airplane was not carrying it in a dosage suited to an allergic reaction. In the confines of an aircraft, doctors are having to troubleshoot cardiac vials and devices, sometimes even having to jerry-rig a way to inject.
From the patient’s perspective, anaphylaxis in the air is a scary health episode, as we’ll hear later in this article from a father. Matt Luptak of Ohio was shocked to learn there were no epinephrine auto-injectors in the medical kit of a plane that he and his child were aboard. In this separate incident, doctors scrambled to help his 11-year-old suffering anaphylaxis.
“There has been no event more terrifying in my life than being helpless to save my daughter,” said the man, who is trained as a medic and served in the U.S. Navy.
Why Aren’t ‘Best Practice’ Drugs in Kit?
In response to one of my tweets about airplanes missing epinephrine, Texas physician Dr. Shubhada Hooli said that, like Blumenthal, she resorted to crowdsourcing passengers for auto-injectors on a transatlantic flight. She gave a patient in anaphylaxis the one dose of epinephrine contained in the emergency medical kit (EMK).
However, he began having a biphasic (or secondary) reaction, which requires more epinephrine. “Fortunately, we collected EpiPens from other passengers,” the doctor wrote, and the passenger recovered.
It just should not be this hard. It is simply not logical for airlines to rely on a medical professional being on every flight. Doctors should not have to poll passengers for lifesaving medications, or troubleshoot and jerry-rig in the skies. They should be provided with an organized EMK that has the basic “best practice” medications available.
In addition, flight crews need training on allergic reactions and the swiftness with which they can progress. They need education on the urgency to offer physicians the medical kit, and let the doctor decide whether it’s needed. We have the correct tools; it is vital we use them for the best possible outcome.
Trouble with ‘Borrowed’ Medication
The first incident Blumenthal took charge of occurred in December 2021, on a JetBlue flight from Boston to Nassau. The other was in June 2022 aboard Delta; she was on her way home from a vacation in Greece.
On the latter flight, a 20-year-old woman with a tree nut allergy had eaten the airline’s meal and began reacting. Blumenthal stepped forward to help, and soon crowdsourced for an adult auto-injector. A man with allergies offered his two (which were expired), plus his child’s current junior version.
Yet Blumenthal told me she felt uneasy using someone else’s auto-injector. Afterall, this was their lifesaving medicine. She was glad to have the injectors in case things turned worse. But as an experienced allergist, she decided to first use her own antihistamines with the young woman. “Undoubtably if I had an auto-injector given to me by the airline, I would have used it.”
The passenger stabilized on the antihistamines alone. For an allergist she says, “anaphylaxis is not complicated; the stressful part is not having the right tools.” She notes that a physician without her background probably would not feel as comfortable.
On the Nassau flight, Blumenthal helped a 10-year-old having an allergic reaction. Luckily, on this day, she was carrying EpiPen Jrs, and she was able to get antihistamines from other passengers.
Epinephrine on Planes: May Be Missing
The Federal Aviation Administration (FAA) told Allergic Living that epinephrine in vial format “must” be stocked in the emergency kit. Once a kit is opened, a medical kit supplier explained that it is meant to be sent back to its supplier so used drugs will be replaced. Yet, I am reporting on too many incidents where the concentration used for an allergic reaction is not in the EMK at all.
A prime example is the nerve-racking experience of Dr. Mike Varshavski. In 2019, he had to troubleshoot an epinephrine vial in the dosage for a heart attack. The dosing was dangerously wrong for a passenger who was in the grip of severe anaphylaxis. The physician, known widely as Dr. Mike, told me that if medications such as auto-injectors are missing, “you’re essentially leaving the medical professionals to battle a fire without water.”
Recently, Allergic Living covered Dr. Samara Friedman’s experience in June 2022 handling an in-flight allergy emergency over the ocean. To treat her patient suffering a tree nut reaction, the orthopedic surgeon needed to jerry-rig a cardiac device called a Bristojet, which is for IV use. It contained epinephrine at the wrong concentration for anaphylaxis.
As passengers, we cannot necessarily rely on the airline medical kit to carry the allergic concentration of epinephrine. In 2020, the FAA quietly granted an airlines lobby group’s request to renew exemptions for five medications, including the allergic concentration of epinephrine. These exemptions are only meant to apply in times of shortage. There is no current epinephrine shortage. However, the stories of medical professionals’ issues with the EMKs in allergy emergencies continue to mount.
People with known allergies usually carry their own epinephrine, but mistakes happen. In Blumenthal’s case with the 10-year-old, the family had auto-injectors, but they wound up in their checked baggage. There needs to be epinephrine on board for those with known allergies and also, from a public health perspective, for those who do not yet realize they have an allergy.
A Child’s First-Time Reaction
There certainly can be anaphylaxis that’s completely unexpected. On Father’s Day 2022, Matt Luptak and his daughter boarded a Spirit Airlines airplane in Fort Lauderdale. The day before the flight, 11-year-old Sophia broke out in hives after she was bitten by no-see-um bugs in the Florida Keys. Her dad gave her Benadryl that evening. Then before the flight, he gave her an anti-inflammatory Advil gel cap, to ensure she’d be comfortable during the two-flight trip back to Ohio.
He told me that he noticed his daughter’s allergic reaction after takeoff. Her eyes began watering. This progressed to her eyes and lips swelling up and, most alarmingly, her breathing becoming labored. When Sophia said her throat “felt heavy,” Luptak immediately hit the call button and asked the flight attendant for an epinephrine auto-injector.
He recalls the attendant replying, “We don’t have those on board.” He found this shocking, and shouted to those nearby: “Does anybody have an EpiPen?” No one did. The flight attendant then made an announcement, asking if there was an epinephrine auto-injector on the plane. She also got no response. A doctor identified himself, looked at Sophia and told the attendant: “Get the oxygen now”. He also asked for a steroid dose pack (Medrol), but was told there was none.
Sophia had two puffs of an albuterol inhaler. A retired physician came up to assist and said her lung function was declining. MedLink, the ground medical support service, authorized the physician to use the epinephrine in the medical kit. But this wasn’t the end of the drama.
As in other cases we’ve reported on, the doctor told Luptak: “This is different administration and concentration, I have to figure it out.” He was concerned about the dosage. Finally the doctor was ready and wanted to put an IV catheter in Sophia’s arm, but could not find a usable vein. He attempted to put it in the girl’s hand, but the gauge was too big, and she began bleeding considerably from the attempts.
Luptak could see the terror in his daughter’s eyes. Finally, a smaller gauge was found, and medications were administered, and Sophia slowly began to recover.
Need for Epinephrine on Planes
Luptak is not certain of the cause of his daughter’s severe reaction. One of the doctors theorized it could have been the high level of histamine in her blood combined with a reaction to the Advil. What is more certain is the obvious difference an easy-to-use auto-injector would have made in treating progressing anaphylaxis in a timely fashion.
As passengers, we cannot expect a fully stocked hospital up in the air. But it is reasonable to expect basic medical kits to contain best practice medications and to be standardized. Stories from both passengers and physicians demonstrate that airlines should not have variation in their EMKs.
Senator Tammy Duckworth has told me: “We expect our planes to have safety equipment like seatbelts, and there’s no reason consumers shouldn’t have the same expectation for lifesaving drugs.”
Blumenthal bluntly points out that, we cannot save everyone who has an emergency in the air. For instance, some heart conditions are complex. But she thinks we can expect to save people who have an in-flight allergic reaction with an easy-to-use auto-injector. Sophia stabilized not long after she received epinephrine. It would have made so much more sense to have an auto-injector as the delivery method.
We are living in one of the most medically advanced countries in the world. So I must ask: How are we not giving physicians who step up to help in the air the proper medications to treat passengers? This is absurd. We have all the tools we need to make this happen. All we need is to bring medications in the EMK into the 21st century. The FAA has the power to make it happen.
Note: If you think the FAA needs to urgently review the contents of airline emergency medical kits and ensure access to epinephrine and auto-injectors on flights, please write to your member of Congress or your Senator. In calling for a review, you may wish to include links to this article, as well as to these ones:
• Why Your Plane’s Medical Kit May Lack Drugs Like Epinephrine
• Anaphylaxis Over the Ocean: MD Finds No Epi Vial in Plane Kit
Lianne Mandelbaum is Allergic Living’s airlines correspondent, and the founder of NoNutTraveler.com.