Two years ago, I wrote in Allergic Living about what appeared to be a turning point for passengers at risk of anaphylaxis.
After years of advocacy by physicians, patients and allergy organizations, Congress directed the Federal Aviation Administration (FAA) to update the contents of airline emergency medical kits. The FAA Reauthorization Act of 2024 singled out the emergency treatment of anaphylaxis as a priority for the airline regulator to address through new rules.
Like many in the food allergy community, I believed we were finally on the path toward bringing airline emergency medical preparedness into the 21st century. Yet today, the act’s two-year deadline has passed. We are still waiting.
The delay is not what concerns me most. What concerns me is that the words the FAA ultimately chooses will determine whether this becomes one of the most significant advances in airline medical preparedness in decades. Or, whether little changes at all.
Section 368 of the FAA Reauthorization Act of 2024 directs the FAA to determine whether airline emergency medical kits include “appropriate medications and equipment that can practicably be administered” for anaphylaxis. Those words matter.
In 2024, many people, including me, read that language and assumed it pointed toward modern, easy-to-use epinephrine devices. But over the past two years, it has become clear that this language is open to interpretation. Congress did not prescribe a specific delivery system, leaving it to the FAA to determine in its rulemaking how those words will be put into practice.
FAA’s Rule on Epi: Which Approach?
The issue is not whether airplanes should carry epinephrine. Currently, airlines in the U.S. are supposed to carry epinephrine in vial form in their emergency medical kits (EMKs). The question is what Congress intended by “appropriate medications” and “practicably administered.”
Does that language recognize the realities of treating anaphylaxis inside an airplane cabin? In these confines, time is critical, space limited, turbulence may be present, and knowledge of weight-based dosing is needed to treat younger children. It might seem obvious that the “appropriate” solution for an EMK is for an easy-to-administer epinephrine auto-injector or nasal spray.
However, might the FAA conclude that because a qualified medical professional can administer epinephrine from a vial with a syringe, today’s EMKs already satisfy Congress’s requirement?
Those are two very different conclusions. That is why the FAA’s forthcoming Notice of Proposed Rulemaking matters so much.
It’s also why the Asthma and Allergy Foundation of America and my No Nut Traveler nonprofit requested a meeting with FAA leadership before publication of the Notice of Proposed Rulemaking. Our goal is to ensure that the agency hears directly from physicians, researchers and patient advocates before the agency’s interpretation of Congress’s language is reflected in the proposed rule.
While the proposed rule will later be subject to public comment and congressional oversight, the FAA’s chosen language will establish the framework going forward.
‘Battling a Fire With No Water’
Over the past years, my reporting for Allergic Living has documented doctors and nurses describing challenges when responding to in-flight emergencies. Current FAA regulations require U.S. airlines to carry epinephrine in vial form in their EMKs. Yet many health professionals have spoken to me of finding incomplete or difficult-to-use emergency medical kits.
For instance, there was Dr. Andrea Merrill’s transatlantic experience working with an emergency kit with deficiencies that included no epinephrine. She found no vial, simply no epi, period. Her 2022 post on X went viral.
That same year, orthopedist Dr. Samara Friedman only found a cardiac epinephrine device (called a Bristojet) in the EMK. Fortunately, she had the skills to jerry-rig it to treat a young woman suffering nut anaphylaxis.
Meantime, Dr. Mike Varshavski’s memorably described to me that doctors in the skies were being left to “battle a fire without water”. He’d stepped up to help a patient experiencing life-threatening anaphylaxis. (The man had eaten red meat before the flight and was later diagnosed with alpha-gal syndrome.)
Nurse Kellie Hopkins will never forget assisting a 10-year-old having a first-time severe allergic reaction to a cashew. She got the crew to call out to passengers for an epinephrine auto-injector. There wasn’t time to look up the child’s dose when using a vial.
Or consider how the FAA exempted airlines from replenishing certain medications during drug shortages. The record demonstrates that ambiguity in emergency preparedness has real-world consequences.
In Varshavski’s case in 2019, aboard a transatlantic flight, he found only the cardiac concentration for epinephrine in the EMK. He recalled having to calculate and adjust the dose, otherwise his patient’s “heart could have stopped.”
Varshavski’s fire analogy remains relevant. The question is not whether physicians can improvise – it’s whether they should have to.
Pre-Boarding and Reaction Prevention
Airline safety for passengers with food allergies depends on two equally important pillars: prevention and preparedness. Prevention includes consistent airline policies, comprehensive crew training, clear communication and allowing passengers enough time to clean their seating areas before boarding is complete.
Before pre-boarding was recognized as an accommodation, I often found myself rushing through crowded boarding lines trying to clean my son’s seating area before time ran out. For most travelers, a dirty tray table is unpleasant. For someone with a food allergy, it can be life-threatening.
Preventive measures remain inconsistent. Earlier this year, the Department of Transportation recognized food allergy as a disability. Yet in doing so, it limited pre-boarding protections to passengers with peanut and tree nut allergies. Of note, a study out of Northwestern University found 70 percent of passengers reporting that an airline promised accommodations that were not honored.
No safety system assumes prevention is perfect. Aircraft carry oxygen, defibrillators and fire extinguishers because emergencies still happen. Food allergy preparedness should follow the same philosophy. When prevention fails, the emergency medical kit becomes the safeguard.
FAA’s Rule on Epi: Words Matter
Senator Tammy Duckworth has championed improvements to airline emergency medical kits since 2019. Her interest was sparked by an Illinois constituent’s “terrifying experience” on a flight in which she’d used her own epinephrine auto-injector. She received no further assistance as symptoms returned.
The senator wants to ensure airline EMKs are equipped with the tools needed to respond to anaphylaxis, including advocating for easy-to-use epinephrine.
This week she told me: “It’s past time for the FAA to ensure these life-saving emergency medical kits are ready to meet the needs of fliers and save lives.”
The FAA stands at a crossroads. Congress has recognized that anaphylaxis deserves specific attention. Physicians have repeatedly described the challenges of treating allergic emergencies aboard planes. Incidents continue to demonstrate why prevention alone cannot eliminate all risk.
The rulemaking notice will determine what “appropriate medications and equipment that can practicably be administered” means. That distinction will influence airline emergency preparedness for years to come.
As the FAA readies its rulemaking, the request of AAFA and No Nut Traveler to meet with the agency is pending. We remain hopeful its leadership will hear directly from physicians and patient advocates before finalizing its proposed rule.
Air travel has always been built upon layers of safety. For serious medical conditions, we do not rely solely on prevention. We prepare for the emergencies we hope never occur.
The FAA has an opportunity to ensure that airline emergency medical kits reflect today’s standard of care, not yesterday’s. For millions of passengers and for the medical professionals who may be called upon to save their lives – the words chosen in this rule will matter.
Lianne Mandelbaum is Allergic Living’s airlines correspondent, and the founder of NoNutTraveler.com.
Related Reading:
MD Ignites Debate: Why No Auto-Injectors, Other Drugs in Plane Medical Kits?
Lawmakers Learn Urgent Need for Auto-Injectors on Planes
