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ARE UNITED STATES AIRLINES PREPARED TO HANDLE
IN-FLIGHT MEDICAL EMERGENCIES?
I. INTRODUCTION
Soaring over the Atlantic Ocean at 40,000 feet, you suddenly find
yourself having trouble breathing and you feel a tightness in your chest. You
know these are symptoms of a heart attack. You think to yourself, this
cannot be happening to me, especially here, on an airplane and so far from
a hospital. You hope that if your condition is serious that the airline is
equipped to handle a life-threatening situation. However, as your family
soon discovers, it is not.
This situation does happen and could happen to you. "Each year, an
unknown number of U.S. airline passengers dies not as the result of a crash
or a fire, but because the medicines and equipment that might have saved
their lives were not on board the plane."' "Roughly one out of every 10,
airline passengers will experience an in-flight medical emergency.^2 In
1996, 10,471 in-flight medical emergencies were reported in the United
States alone, which^ is^ an^ average^ of^ twenty-nine^ emergencies^ per^ day.^3
However, accurate statistics on in-flight medical emergencies and deaths do
not exist because airlines are not required to report them. 4 The Federal
Aviation Administration^5 (FAA) only requires air carriers to report in-flight
1. John (^) Crewdson, CardiacArrest at 37,000 Feet, CHI. TRIB., June 30, 1996, § 2, at 1.
- Douglas (^) W. Nelms, One in a Million: As the Number of Medically (^) At-Risk PassengersContinues to Increase, (^) so Do the Odds of Having an In-flight Medical Emergency, AIR TRANSPORT WORLD, Oct. 1, 1997, at 82. (^) This statistic is based on a Lufthansa report and is considered the industry's "best guess" figure. See id. 3. See Susan Okie, CardiacArrest in the Air-Without (^) the Tools to Cope, WASH. POST, Jan. 15, 1998, (^) A01, A6. Heart disease accounted for 1,020 of the emergencies reported. (^) See id. From 1994-1996: American Airlines recorded some 4,800 in-flight (^) medical emergencies of all types, including (^) those not attended by physicians. If American's experience is similar to other airlines, there could have been (^) more than 12,000 such emergencies aboard (^) U.S. commercial airlines last year [19951-an average of 32 a day, or more than 10 times the estimate produced (^) by the FAA's 1986- study. John Crewdson, How Many (^) People Die on Airplanes? We're Interested in Aircraft Accidents, Not HeartAttacks, an FAA Official (^) Says. Airline, FAA Data Woefudly Incomplete, CHI. TRm., June 30, 1996, § 2, at 9. 4. See Judy Foreman, If You Get Sick In-flight, (^) Friendly Skies Can Turn Ugly: Flight Crews Aren't Trained (^) to Deal with Medical Emergencies, BOSTON GLOBE, Dec. 22, (^) 1997 (visited Sept. 18, 1998) http://www.tdo.com/features/health/stories/1222/index.htm. 5. One of the responsibilities of (^) the FAA is to improve and maintain safety standards for airlines, (^) which includes safety rulemaking. See generally 14 C.F.R. (^) § 121 (1998).
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medical emergencies whenever a death occurs, 6 an aircraft is diverted, or when the onboard medical kit is used. 7 It is shocking to report that "[i]n an era when airline computers keep track (^) of passengers' meal and seating preferences and the number of miles they fly, neither the Federal Aviation Administration nor the airlines can say how many people get sick on this country's airplanes or even how many die. "^8 There is disagreement among experts as to the scope of in-flight medical emergencies. Some experts believe that the number of emergencies is relatively small, while others believe that the number of people who die on flights each year is much greater than the number that die in airline crashes. 9 Regardless of which statistic is accurate, in-flight medical emergencies, including deaths, are a significant problem and are frequently overshadowed by spectacular airline crashes.^10 As air travel becomes less expensive and more accessible, the number of people expected to fly will increase; therefore, the (^) problem of in-flight medical emergencies will likely increase as well. Boeing, a major aircraft
manufacturer, estimates that air travel will rise seventy-five percent by
2006." l^ If more people are flying in general, more "medically at-risk" passengers will also fly.' 2 In addition, more "at-risk" passengers will be
6. "[M]any airlines discourage an official declaration of death until after a passenger's body has been taken from the plane." Crewdson, supra note 3, § 2, at 9. With larger aircraft having several flight attendants available, CPR can be performed until the plane lands and a medical official can pronounce the passenger dead, and the airline will not have to record the death onboard. See Okie, supra note 3, at A6. Also, airlines do not have to provide any follow-up information on medical emergencies. See id. 7. See Linda L. Martin, The Shock that Revives, Bus. & COM. AVIATION, June 1, 1997, available in 1997 WL 10773863. 8. Crewdson, supra note 3, § 2, at 9. 9. See Tamar Nordenberg, Air Aid: Medical Kits Reach New Heights (visited Sept. **28,
- <** http://www.fda.gov/fdac/featuresl1998/198_air.html >. "Published news reports. . suggest that as many as 350 people a year die from in-flight medical problems... [which is] a lot more than the number of deaths from plane crashes, which range from a handful per year to more than 250, according to the National Transportation Safety Board." Foreman, supra note 4. "What the industry does not say is that commercial aviation is so safe that more passengers may die, on average, from in-flight medical emergencies than in aircraft accidents." Crewdson, supra note 3, § 2, at 9. "[A]ir travel in the U.S. is so safe that passengers are now more likely to die of an acute midair illness than in a crash." Crewdson, supra note 1, § 2, at 1.
- See John Crewdson, Ill in the Air? Don't Count on FastLanding, CHI. TRIB., Aug. 4, 1996, § 1, 1 at 15. Hundreds of U.S. airline passengers die every year because life-saving drugs and medical equipment were not onboard the plane. (^) See id. In some cases, passengers die because the planes carrying these sick passengers do not land immediately. _See id.
- See_ Nelms, supra note 2, at 82.
- See id.
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additional expenses incurred in an emergency landing,' 8 airlines are looking for more ways to handle in-flight medical emergencies.' 9 The concern of in-flight medical emergencies^ has^ prompted^ the^ U.S. government to take steps to address^ the^ issue.'^ The federal^ government^ has realized that its more than decade-old regulations regarding airline preparation for in-flight medical emergencies are^ inadequate.^2 '^ On^ April^ 24, 1998, President Clinton signed into law the Aviation Medical Assistance Act.' This Act directs the FAA to review its existing regulations regarding the required equipment to^ be^ carried^ in^ emergency^ medical^ kits^ on commercial aircraft and the training requirements^ of^ flight^ attendants^ who use the equipment. 23 The Act requires^ the^ FAA^ to^ begin^ a^ rulemaking process to modify the^ existing regulations^ as^ a^ result^ of^ the^ reevaluation.' It also^ requires^ the^ FAA^ to^ make^ a^ determination^ whether^ to^ mandate defibrillators as part of the emergency medical equipment on^ airplanes and in airports throughout the country.' The^ Act^ also^ requires^ the^ airlines^ to make a good faith effort to report emergencies and deaths so that the FAA can get a more accurate^ idea^ of^ the^ scope^ of^ the^ problem.^
26
Some issues involved in deciding what equipment and medication to carry on commercial airlines are: (1) the cost of advanced medical equipment on each plane; (2) whether the patient should^ be^ treated^ during flight or on the ground; and (3) the liability to the airlines and safety^ of^ the passengers on the aircraft if sharp medical instruments^ and^ drugs get^ into^ the wrong hands.2 7^ Some medical groups^ have^ warned^ the^ FAA^ that^ certain drugs and devices, if misused, "could do more damage than good." 2 The FAA must also take into consideration electronic interference when deciding
- Airlines can incur costs of hundreds of thousands of dollars if^ a^ plane^ must^ make^ an emergency landing. See Foreman, supra note 4. The pilot may have to dump fuel to avoid the dangers of landing the plane with full tanks. See id. Also, the^ airline^ may^ have to^ put delayed passengers in hotels or on other airlines^ to^ get^ them to^ their^ final^ destinations.^ See id.
- See id.
- See generally Bryon L. Dorgan, President Signs Dorgan-FristDefibrillatorBill: FAA Will Reevaluate the Need for Life Saving Medical Equipment Aboard^ Commercial Aircraft, Gov'T. PRESS RELEASES, Apr. 28, 1998, availablein 1998 WL 7323216. 21. See id.
- Aviation Medical Assistance Act of 1998, Pub. L. No. 105-170, 112 Stat.^ 47 (to be codified at 49 U.S.C. § 44701).
- See id. § 2.
- See Dorgan,^ supra^ note^ 20. 25. See id.
- See Aviation Medical Assistance Act of 1998, Pub. L. No. 105-170,^ § 3,^112 STAT. 47, 47-48 (to be codified at^49 U.S.C.^ §^ 44701).
- See Ericson, supra note 16.
- Okie, supra note 3, at A6.
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what type of medical equipment to require (^) onboard commercial aircrafts. 29 "Any electronic medical equipment carried onboard (^) an aircraft must be certified free from any potential for electronic (^) interference with flight instruments or aircraft controls. " The purpose of this note is to evaluate the current (^) FAA regulations on in-flight medical emergencies for U.S. carriers and (^) compare these regulations to those of (^) the European Union according to several standards such as: (1) the minimum emergency medical equipment required (^) onboard; (2) the minimum training (^) requirements for flight attendants; and (3) the extent of liability of the airline, crewmembers, (^) and any medically-trained passenger who assist during an in-flight medical emergency. Part II will give a brief background of commercial (^) aviation in the United States and how it has evolved into the mega industry it is today. Part III sets forth (^) the current U.S. regulations (^) promulgated by the FAA. Part IV explains how commercial aviation in the European Union is regulated (^) and sets forth the laws (^) that currently govern the European Union. Part V compares U.S. and European Union (^) regulations. Part VI provides several recommendations to the FAA for upgrading the medical equipment required (^) on all U.S. commercial (^) airlines and the training given to flight attendants to deal with these problems. Also, (^) Part VI offers a recommendation for the type of action needed to allow a crewmember or (^) other passenger to aid a sick passenger (^) without having to worry about a lawsuit for misdiagnosing or treating the passenger while (^) in the air.
II. BACKGROUND
Regularly-scheduled (^) passenger and express carriers began operating in the mid-1920s. 3 ' "The premier carrier to offer sustained (^) service was Western Air Express, which began its Salk [sic] Lake City-to-Los Angeles route on May 23, 1926."32 In 1926, little (^) thought was given to in-flight medical emergencies. Flying (^) was basically for the wealthy and adventurous and was (^) mainly domestic in nature. Between 1926.. .and 1993 the industry grew from 6, passengers flying 1 million passenger miles a year-and paying a dollar a mile (in 1993 dollars) for the speedy but cramped new service-to nearly half a billion passengers flying nearly a (^) half
29. See In-FlightMedical Kits, 1997: Hearing Before the Subcomm. on Aviation of (^) the House Comm. on Transp. and Infrastructure, (^) 105 1 Cong. 146 (1997) (statement (^) of the Air Line Pilots Association) [hereinafter In-Flight Medical Kits].
- (^) Id. 31. See I MYRON J. SMITH, JR., THE AIRLINE BIBLIOGRAPHY: (^) THE SALEM COLLEGE GUIDE TO SOURCES ON COMMERCIAL AVIATION 13 (1986). 32. Id.
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Bargmann v. Helms that the Federal Aviation Administration had authority to institute rulemaking pursuant to its statutory^ mandate^ of^ regulating "safety." (^48) The issue in (^) Bargmann was whether (^) the FAA possessed (^) the
statutory authority to institute rulemaking to upgrade the quality of first-aid kits currently carried onboard commercial aircraft.^49 The^ FAA^ said^ it^ lacked the "power, under its^ mandate^ to^ regulate^ 'safety'^ in^ the^ Federal^ Aviation Act of 1958, to require commercial aircraft to carry medical equipment designed to treat health problems that^ 'occur'^ in^ flight^ but are^ not^ 'caused by' flight."' The court disagreed, holding that "the FAA has the statutory authority to proceed with a rulemaking on the subject should it deem such action advisable on the merits."5^ The^ court^ emphasized^ that^ the^ FAA^ does not have to require such equipment, simply that the FAA has the authority to do so. 5 ' Bargmann demonstrates that the FAA does have the authority to require airlines to^ carry^ equipment^ necessary^ to^ handle^ in-flight^ medical emergencies. After Bargmann was decided, the FAA set out requirements for large commercial aircraft^ to^ carry^ emergency^ medical^ kits.^53 Besides^ setting minimum standards for safety equipment^ required^ onboard^ the^ aircraft,^ the FAA promulgates regulations for^ airlines^ to^ follow^ when training^ flight attendants on safety-related issues.' However, the question still remains whether or not those regulations and standards are enough to^ meet^ today's in-flight medical needs." Some U.S. airlines have taken action beyond the FAA's minimum standards in order to make^ flying^ a^ safer^ experience^ for^ their^ passengers.^56 In November 1996, the FAA approved the use of biphasic external defibrillators' (devices^ to^ treat sudden cardiac^ arrest),^ and^ that^ same^ month, American Airlines became the first U.S. carrier to install defibrillators, which it placed only on its international aircraft. 58 In 1998, shortly after
- See Bargmann v. Helms, 715 F.2d 638 (D.C. Cir. 1983). See also Ericson, supra note 16.
- See Bargmann, 715 F.2d^ at^ 638.
- Id. at 638-39.
- Id. at 639.
- See id.
- See 14 C.F.R. § 121.309(7)(d)(ii) (1998).
- See generally 14 C.F.R. § 121.417 (1998).
- See generally Nelms, supra note 2.
- See id. See also Airlines^ Adding^ Defibrillators,^ supra^ note^ 13.
- See Aaron Howard, RN, HeartAttack at 30, 000 Feet, NURSEWEEK/HEALTHWEEK, Apr. 3, 1998 (visited Nov. 21, 1998) <http:lwww.nurseweek.comlfeatures/98-4/rescue .html >. 58. See Nelms, supra note 2, at 84.
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placing defibrillators on only its international aircraft, 9 American^ Airlines equipped all its aircraft with defibrillators. 6 They^ also enhanced^ the^ on- board medical kit^ by^ adding more^ prescription^ medicines^ to^ treat^ cardiac arrest, epileptic seizures, asthma, bronchitis, psychosis, anxiety, nausea, vomiting, motion^ sickness,^ and^ postpartum bleeding.^
(^61)
Although the FAA has not updated commercial airline^ regulations^ for in-flight medical^ equipment^ for^ twelve^ years,^ many^ airlines,^ such^ as American, are initiating the much-needed changes. 62 Shortly^ after^ American Airlines upgraded their equipment, Delta, United and Alaska Airlines followed suit.^63 Regardless of the FAA ruling, in the near future, many^ U.S. carriers are expected to do the^ same.^6 "^ Other^ carriers^ across^ the^ globe have carried defibrillators and enhanced emergency medical kits for^ years,^ setting a high standard in the industry.' Virgin Atlantic^ Airways^ and^ Qantas,^ the Australian airlines, have^ carried defibrillators for^ the last^ three years.^66 Cathay Pacific Airways based in Hong Kong and Air Zimbabwe also^ carry
- In June 1997,^ American^ Airlines^ added^ defibrillators^ to^ its^ overwater fleet^ to help treat sudden cardiac arrest.^ See^ American Airlines'^ Purchaseof^ Heart^ DefibrillatorsJustified on Safety Alone but^ Could^ Also^ Limit Liability,^ WORLD^ AIRLINE^ NEWS,^ Apr.^ 4,^ 1997, available in 1997 WL^8541644 [hereinafter^ American^ Airlines'^ Purchase^ of Heart Defibrillators]. See also American Airlines: American Airlines Equips InternationalFleet^ with Defibrillators, M2 PRESSWIRE, July 2, 1997, available in 1997 WL 11937470 [hereinafter American Airlines: American Airlines Equips]. On May 1, 1998, American started adding automatic external defibrillators and enhanced medical kits on its^ domestic flights.^ See American Adds Defibrillators,EnhancedMedical^ Kits^ to^ Domestic^ Fleet,^ AVIATION^ DAILY, May 1, 1998, at 193 [hereinafter American Adds^ Defibrillators].^ See^ also^ John^ Crewdson, Medical Gear^ Upgrade^ Lets^ American^ Airlines^ Keep^ Pace^ Defibrillators,Drug^ Kits^ Will^ Be Added to its Domestic Flights, CHI. TRIB., Jan. 14, 1998, § 1, at 3 [hereinafter^ Crewdson, Medical Gear^ Upgrade].^ During^ an^ American^ Airlines^ flight^ from^ Texas^ to^ Mexico, passenger Robert Giggey became the first person^ to^ be^ successfully^ saved^ from^ cardiac^ arrest with the^ use^ of^ a^ defibrillator^ onboard the^ airline.^ See^ John^ Crewdson,^ DefibrillatorAboard Jet Saves Cardiac Victim, Prr. POST-GAZErE, Feb. 22, 1998, at^ A3,^ available^ in^^1998 WL 5235033 [hereinafter^ Crewdson,^ DefibrillatorAboard^ _Jet].
- See American Adds Defibrillators,supra_ note 59, at 193.
- See Crewdson, Medical Gear Upgrade, supra note 59,^ § 1,^ at^ 3.^ See^ also^ American Airlines: American Airlines Equips,^ supra^ note^ 59;^ American^ Adds^ Defibrillators,supra note
- See Crewdson, DefibrillatorAboard Jet, supra note 59,^ at^ A3.
- See CNN Financial Network, Fly the Healthy^ Skies^ (Aug.^ 3,^ 1998) http://europe.cnnfn.com.fntraveler/9808/03/biztravel. See^ also^ Delta^ Equipping^ Fleet with Defibrillators, AVIATION DAiLY,^ Jan.^ 15,^ 1998,^ at 84.^ See^ also^ Crewdson,^ Defibrillator Aboard Jet, supra note 59, at A3.^ See^ also^ Renewed^ Interest^ for^ Defibrillators^ Aboard Aircraft, AIR SAFETY WEEK, Mar. 9, 1998, available^ in^^1998 WL^7199991 [hereinafter _Renewed Interest].
- See_^ DefibrillatorAboard^ Jet,^ supra^ note^ 59,^ at^ A3.
- See^ id.
- See John Crewdson, Hong^ Kong^ Carrier^ is^ Latest^ to^ Add In-flight^ Defibrillators, CHI. TRIB., Feb. 28, 1997, § 1, at 3.
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to develop clear and comprehensive procedures to cover in-flight medical emergencies. 7 n "Some flight attendants have first aid training. However, they are neither legally obligated nor^ licensed^ to^ handle^ passengers' medical^ needs." During a flight attendant's initial training, the FAA requires "[e]ach training program... [to] provide... emergency training ... with respect to each airplane type,^ model,^ and^ configuration,^ each^ required^ crewmember,^ and each kind of operation conducted, insofar as appropriate for each crewmember and the certificate holder. "^9 Emergency training must provide, among other things, an orientation to "[f]irst aid equipment and its proper use ... [and] [i]llness, injury, or other abnormal situations involving passengers or crewmembers to include familiarization with^ the^ emergency medical kit."' Each crewmember must demonstrate the use of each type of emergency oxygen^ system on the^ aircraft^8 '^ and^ must receive instruction^ in respiration and hypoxia.1 The majority of time during flight attendant training is spent on emergency evacuation drills.' Although flight attendants are well trained to handle an evacuation, they usually are given only minimal instruction to handle a heart attack, an epileptic seizure, or any other illness or injury that may arise unexpectedly during flight." The reason they are not given extensive training on medical emergencies could be because they are not required^ to^ perform^ emergency^ care^ on^ their^ passengers. United States commercial airlines are classified as "common carriers"
airplane or on the ground. Id.
- See id.
- Mayo Clinic, supra note 14. The FAA does not require crews to learn CPR, but some carriers still provide CPR and other medical training. See Foreman, supra^ note^ 4.
- 14 C.F.R. § 121.417(a) (1998).
- 14 C.F.R. § 121.417(b)(2)(ii), (b)(3)(iv) (1998).
- See 14 C.F.R. § 121.417(c)(2)(i)(C) (1998).
- See 14 C.F.R. § 121.417(e)(1), (2) (1998). Hypoxia is the lack of oxygen to the brain or a "[d]^ eficiency in the amount of oxygen reaching bodily tissues." THE AMERICAN HERITAGE DICTIONARY 634 (2d College ed. 1985). Hypoxia occurs during decompression of the aircraft and must be treated immediately with oxygen. See AMERICAN TRANS AIR, INC., FLIGHT ATTENDANT INFLIGHT^ MANUAL,^ ch.^ 5,^ at^9 (Mar.^ 30, 1997).^ The "time^ of^ useful consciousness" is the duration from the start of hypoxia until the decline of a person's constructive performance. See id. The approximate time of "useful consciousness" is 45 seconds at 30,000 feet and 18 seconds at 40,000 feet. See id.
- See generally 14 C.F.R. § 121.417 (1998). Emergency evacuation training consists of knowing the location, function, and operation of emergency equipment. See id. § 121.417(b)(2)(i)-(iv). Flight attendants are trained to operate emergency^ exits^ in^ order^ to evacuate an aircraft during an emergency landing on land, as well as deploy rafts and evacuate during a water ditching. See id. § 121.417(b)(2)(i), (iv). They are trained to put out fires onboard the aircraft and handle hijacking, bomb threats, and other unusual^ situations.^ See^ id. § 121.417(b)(3)(ii), (v).
- See id. § 121.417(a)(3)(iv).
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and are not required to provide emergency care for their passengers. Consequently, when a medical emergency occurs on board an aircraft, flight attendants, who are in immediate (^) charge of the safety and welfare of the passengers, have several (^) options. They can deal with the problem themselves, they can ask for the assistance of any medically trained passengers on board, or they can "radio patch" to medical personnel on the ground. In addition, they can recommend (^) to the pilot, who always has final responsibility,' that the aircraft land at the nearest airport, or they may request that emergency medical personnel meet the aircraft on arrival. 6 In light of these options, a flight attendant should have enough training and equipment (^) to feel confident in handling an in-flight medical emergency.
IV. EUROPEAN UNION LAW: JAA STANDARDS
In Europe, the fifteen members of the European Union belonging to the Joint Aviation Authorities s7^ (JAA) enacted, in April 1998, requirements regarding medical emergencies on airplanes which are similar to the requirements the FAA is seeking to implement in 1999.8 Recent deregulation has created a need to harmonize (^) civil aviation among the European communities.' Before deregulation, each community acted under
85. Although the captain of an aircraft is in complete command (^) of her plane, the reality is, a decision to land for medical reasons involves so many extra costs to the airline that the dispatchers and its medical department are usually a part of the decision-making process. See Crewdson, supra note 10, § 1, at 14. Extra costs include dumping fuel in order to avoid damage to the landing gear, paying extra landing and servicing fees, overtime for flight crews and rescheduling passengers' flights. See id. "United's pilot handbook contains the admonition that any captain considering an emergency medical landing is 'strongly advised' to contact both United's dispatchers and the airline's medical department 'before dumping fuel, diverting or (^) otherwise compromising available options.'" Id. Part 121 of the Federal Aviation Regulations contains emergency provisions which state that "[iln an emergency situation... (^) [requiring] immediate decision and action[,] the pilot in command may take any action that he considers necessary under the circumstances." 14 C.F.R. § 121.557(a) (1998). For information relating to emergencies on supplemental air carriers and commercial operations, see 14 C.F.R. § 121.559 (1998). 86. See Richard 0. Cummins (^) & Jessica A. Schubach, Frequency and Types of Medical Emergencies Among Commercial Air Travelers, 261 JAMA 1295 (Mar. 3, 1989). 87. The 15 members of the European Union that are part of the Joint Aviation Authorities are Austria, Finland, Sweden, Spain, Portugal, Germany, Italy, United Kingdom, France, Netherlands, Greece, Belgium, Denmark, Ireland, and Luxembourg. See The 15 Member States (visited May 11, 1999) <http://ue.eu.int/en/info/15states.htm >. 88. See Barry James, In Europe, Crews Trained to Cope with Trouble, INT'L. HERALD TRIB., Jan. 16, 1998, at 4. "National governments are responsible for airline safety in Europe, and they approve and monitor aircraft or equipment." Id. 89. See 1998 O.J. (C 214) 37, arts. 1.2-1.3. See also Europe Opens Up the Skies to Competition, EUROWATCH. Apr. 18, 1997, available in LEXIS, EURCOM Library, EURWCH File. On April 1, 1997, the European airline industry completed its final stages
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to the internationally recommended standards" 1 and the superior training practices of the industry."0 EU sources (^) contend that the JAR-OPS standards are sufficient to ensure a high level (^) of safety in the industry. 3 Under JAR- OPS standards, "[a]n operator shall ensure that medical and first aid (^) training includes: (1) [i]nstruction on first aid and the (^) use of first-aid kits; (2) [f]irst aid associated with survival training and appropriate hygiene; and (3) [t]he physiological effects of flying and with particular emphasis on hypoxia." ° Regarding (^) safety equipment, the JAR-OPS states that an airline "shall ensure that each cabin crew member is given realistic training on, and demonstration of, the location and use of safety equipment including. .. [f]irst-aid kits, their contents and emergency medical equipment."'5 Airlines must also ensure that recurrent training, which occurs every twelve months, includes a section on "[f]irst aid and the contents of the first-aid kits."" 6 One of the differences between the Federal Aviation Regulations (FARs) and (^) the Joint Aviation Regulations (JARs) is that additional crewmembers are assigned to specialist duties under the JARs. 107 In the European Union, airlines can utilize additional crewmembers (^) who are solely assigned to specialist duties' 08 to which other requirements (^) of the JAR-OPS are not applicable." (^) One of the specialist duties listed in the JAR-OPS is medical personnel." 0 In the United States, each crewmember (^) must meet the requirements of the FARs, regardless of whether they have a specialized duty."' In the European Union, cabin crews are given advanced first aid training. This training is an orientation to the physiology of flights including an emphasis on hypoxia.I" European Union cabin crews are also trained to handle other medical emergencies, including choking, stress reactions, allergic (^) reactions, hyperventilation, gastro-intestinal disturbance, air sickness, epilepsy, heart attacks, strokes, shock, diabetes, emergency
101. The Convention on International Civil Aviation (^) "provides for implementation of the measures necessary to ensure the safe operation of aircraft[s]." 1991 O.J. (L 373) 4. This Convention (^) was signed in Chicago on December 7, 1944. See id.
- See 1998 O.J. (C 214) 37, art. 2.2.
- See 1991 O.J. (L373) 4.
- JAR-OPS 1 Subpt. 0, § 1, App. I to JAR-OPS 1.1005, 1.1005(e).
- JAR-OPS 1 Subpt. 0, § 1, App. I to JAR-OPS 1.1010, 1 1.1010 (h)(12).
- JAR-OPS 1 Subpt. 0, § 1, (^) App. 1 to JAR-OPS 1.1015, 1.1015(b)(5).
- See JAR-OPS (^1) Subpt. 0, § 2, IEM OPS 1.988.
- "The additional crew members solely assigned to specialist duties to whom the requirements of Subpart 0 are not applicable include the following: (^) i) Child minders/escorts; ii) Entertainers; iii) Ground engineers; (^) iv) Interpreters; v) Medical personnel; vi) Secretaries; and vii) Security staff." JAR-OPS 1 Subpt. 0, § 2, IEM OPS 1.988, (^11) 1.988(i)-(vii).
- See id. 110. See id. I 1.988(v). 111. See 14 C.F.R. § 121.417(a) (1998).
- See JAR-OPS 1 Subpt. 0, (^) § 1, App. 1 to JAR-OPS 1.1005, 1.1005(e)(3).
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childbirth and asthma. ' Cabin crews are given basic first aid and survival training which includes care of the unconscious, bums, wounds and fractures, and soft tissue injuries. 4 First-aid training must also include practical cardio-pulmonary resuscitation (CPR) by each cabin crewmember in the airplane environment on a specifically designed dummy." 5 Contrary to the JAA, the FAA does not mandate CPR by crewmembers." 6 To maintain high safety standards, the training programs, facilities, and training organization must be duly approved by the Member State and the JAA. 1 7^ They must also be given formal recognitior.'^8 However, the process for approval and recognition is left to the Member States themselves. " Another mandatory standard in the European Union that is not a regulation in the United States is medical examinations of cabin crewmembers.^1 Each cabin crewmember receives an initial medical examination or assessment and periodic re-assessments.' 2 ' These examinations are to be conducted by, or under the supervision of, a medical practitioner acceptable to the Joint Aviation Authority.^22 The Authority mandates that (^) the operators maintain a medical record for each cabin crewmember. "3 Each crewmember must be in good health, free from any physical or mental illness which might lead to incapacitation or the inability to perform cabin crew duties, have normal cardiorespiratory function, a normal central nervous system, adequate visual acuity with or without visual correction, adequate hearing, and normal function of the ears, nose, and throat." 2 Keeping crewmembers healthy is important in ensuring that they have the strength and ability to perform all of their necessary duties, including assisting sick passengers.
- See JAR-OPS 1 Subpt. 0, § 2, IEM to App. I to JAR-OPS 1.1005, 1.1015 & 1.1020, l(b)(i)-(xii). See also James, supra note 88, at 4.
- See JAR-OPS 1 Subpt. 0, § 2, IEM to App. I to JAR-OPS 1.1005, 1.1015 & 1.1020, 1(c)(i)-(iv). 115. Seeid. (d). 116. See Okie, supra note 3, at A6. 117. See 1998 O.J. (C 214) 37, art. 2.2. 118. See id. 119. See id.
- See JAR-OPS I Subpt. 0, § 1, JAR-OPS 1.995, 1.995(a)(2). See also 1998 O.J. (C 214) 37, art. 2.1. 121. See JAR-OPS 1 Subpt. 0, § 1, JAR-OPS 1.995, 1.995(a)(2). (3). 122. See JAR-OPS 1 Subpt. 0, § 2, AMC OPS 1.995(a)(2), 1 1. 123. See id. 2. 124. See id. 3(a)-(g).
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While the United States is just beginning (^) to adopt standards to safeguard the in-flight health of passengers on U.S. airlines, one European carrier is looking for ways to (^) become the industry leader in caring for sick passengers.^1
36
In an era when foreign [outside Europe] airlines are searching for ways to improve their in-flight medical care - British Airways is developing a system that will transmit electrocardiograms via satellite to emergency physicians on (^) the ground - U.S. airlines are not required to carry even a thermometer or a bottle of aspirin. 37
British (^) Airways, Lufthansa, Air France, Qantas and Alitalia, like most airlines in Europe, carry^ medical^ kits^ no^ bigger^ than an^ ordinary^ suitcase.^
3 8
These kits are stocked with most of the same cardiac drugs found in hospital emergency rooms (^) and include medications for seizures, pain relief, narcotic overdoses, psychotic behavior^ and^ drugs^ to^ stop^ postpartum^ hemorrhaging.^
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Many of those kits also contain extraordinary medical equipment such as umbilical cord clamps for use during childbirth." (^4) By contrast, in 1994, Trans World Airlines (TWA) flight attendants who assisted in a birth during flight used shoelaces to tie the mother's umbilical cord because an umbilical cord clamp was^ not^ available.'^
Most foreign airlines are better equipped to safeguard the health of their passengers than U.S. carriers. For example, "British Airways' medical kit contains nearly 90 items, including 30 drugs-10 of which, among them (^) a narcotic painkiller, can be administered by flight attendants if there is no physician aboard."143 In addition, many foreign airlines carry endotracheal tubes and bag-valve-masks (used to assist respiration).'" Air Canada follows the European philosophy for safeguarding the health of its air travelers and carries most of the same drugs and devices as the European carriers."' s^ Considering these higher standards, it is not surprising that nearly all major foreign airlines disagree with the (^) FAA's approach of limiting the ability of commercial airlines to handle medical situations that
- See Crewdson, supra note 73, § (^) 2, at 6.
- Id.
- See id.
- _See id.
- See id._
- See id.
- See generally id.
- Id. § 2, at 6. 144. See Crewdson, supra note 1, § 2, at 2.
- See Crewdson, supra note 73, § 2, at 6.
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IN-FLIGHT MEDICAL EMERGENCIES
arise during flight." The United States, unlike Canada, has not followed the European carriers and fails to carry advanced medical kits onboard their aircraft to assist in saving lives. 47 Currently, the FAA must determine whether the United States (^) will carry advanced medical equipment and medication like European carriers or stand by the outdated philosophy that, when safeguarding the health of passengers, "less is more.-' Legislation is necessary to provide airlines, crewmembers and medical volunteers immunity from prosecution for attempting to save a person's life during flight. 1 4 9^ "So-called 'good Samaritan' laws, which give legal protection to health professionals who offer emergency assistance on the ground, do not apply in the air, a potential disincentive for going to the aid of a fellow passenger."" 0 Good Samaritan statutes have been in existence for nearly fifty years.' These laws resulted from perceptions that potential rescuers would ignore highway accident victims due to the fear of liability.' The legislators envisioned a simple answer to the problem when they enacted statutes "creating immunity (^) from civil (^) liability for those who (^) volunteered in (^) medical
emergencies. " However, modem emergency medical systems did not exist during the 1950s and 1960s when most of these laws were passed." Before advanced emergency medicine existed, society greatly relied upon individuals to provide care to injured persons in accident situations.' 55 Today, each state and the District of Columbia have Good Samaritan laws. 156 The majority view is to provide immunity for Good Samaritans assisting an injured person regardless of his or her medical background, while the minority of states only extend immunity to individuals (^) with medical training."'7 The two purposes of Good Samaritan laws are (1) "encouraging
- See id.
- See id.
- See id.
- See In-Flight Medical Kits, supra note 29, at 147. 150. Foreman, supra note 4. 151. See Bridget A. Burke, Note, Using Good Samaritan Acts to Provide Access to Health Carefor the Poor: A Modest Proposal, 1 ANNALs HEALTH L. 139, 140 (1992).
- See id.
- Id.
- See id. 155. See id. 156. See id.
- See id.
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IN-FLIGHT MEDICAL EMERGENCIES
be saved. Advanced emergency medical kits and first aid^ training^ for^ flight attendants are even more essential for an airline than carrying a raft and training flight attendants on water-ditching procedures,' 67 which all U.S. carriers are required to do.' 68
A. Mandatory Reporting of In-FlightMedical Emergencies is Needed to Show the Scope of the Problem
Because airlines are not required to report in-flight medical emergencies, it is difficult to fully understand the problem. It is important to analyze what problems U.S. carriers face and to then make recommendations accordingly. Although the European Union and Australia have upgraded their medical equipment onboard aircraft, what is good for other countries is not always good for the United States. It is also important to learn from other countries and not just follow in their footsteps. By defining an in-flight medical emergency and then requiring U.S. airlines to report these emergencies to the FAA, the FAA can determine what emergencies occur most frequently without having to merely speculate. This mandatory process of reporting in-flight medical emergencies would allow the FAA to obtain concrete information before making drastic changes that could cost airlines millions of dollars. Once the types of medical emergencies that are most likely to occur onboard are determined, the FAA can plan its attack accordingly. The situation should be evaluated continually and changes made over time. It is important to understand that just because British Airways carries certain medical equipment does not mean the same equipment is important for a U.S. carrier (^) to have onboard. Different countries have different lifestyles, diets, and habits, and therefore, they also have different medical problems. Once it is known from which medical ailments Americans truly suffer, U.S. airlines can predict what conditions to treat during flight and carry the necessary equipment.
B. Requiring Passengers to Disclose Potentially Life-threateningIllnesses Priorto the Day of Departure
Besides requiring airlines to report in-flight medical emergencies, the FAA should require passengers to report potentially life-threatening illnesses to the airline before the day of departure, possibly even when they purchase
167. A water-ditch is an emergency landing made in the water. Flight attendants are required to learn the equipment and procedures for ditching. See 14 C.F.R. § 121. (b)(3)(iii) (1998). 168. See id. § 121.417(b)(2)(i).
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IND. INT'L & COMP. L. REV.
their ticket.69 This would allow the airlines to make special provisions for that passenger's care if an emergency arises. 7 ' "Passengers with diabetes mellitus, coronary artery disease, a history of recent^ surgery,^ asthma, emphysema, seizure disorders,^ and^ sickle^ cell^ disease^ would^ be^ most^ likely to be affected by^ air^ travel and,^ thus,^ a^ mechanism^ for^ notification^ of^ the airline should be instituted for people with such illnesses."
C. Emergency Physicians' FirstAid Kit Wish List
MedAire,172 which provides an emergency medical hotline^ for^ airlines that subscribe^ to^ their^ services,^ has^ developed^ an emergency^ physicians'^ first aid kit wish list."m This list includes items that^ would^ assist^ in^ identifying^ the immediate threat to the patient's health and stabilizing the patient's condition until proper emergency medical care is available. 74 The items on the wish list include an automated blood pressure^ cuff^ and^ stethoscope,^ which^ are
- See Burton J. Glass, Letter to the Editor, In-flight Emergencies: Doc^ Riders^ in the Sky, 263 JAMA 233, 234 (1990).
- See id.
- Id.
- "MedAire was founded in 1986 with the mission of providing immediate expert medical support to people facing medical emergencies^ in^ remote locations^ -^ whether^ they were on land, in the air or^ at sea."^ Medical^ Kits^ on^ Commercial^ Aircraft,^ supra^ note^ 132,^ at
- MedAire's clients are located in more than 36 countries, with British Airways^ announcing recently that they will become the newest airline to use MedLink's services. See id. See^ also British Airways Looks to MedAire for Support in Managing In-Flight Medical^ Emergencies, Bus. WIRE, April 22, 1998, available in WL EURONEWS Database.^ In^ the^ aviation industry, MedAire's most well known service is its 24-hour emergency medical hotline service called MedLink. See Medical Kits^ on Commercial^ Aircraft,^ supra^ note^ 132,^ at^ 70. Anytime a^ client^ has^ a^ medical^ situation^ on^ board^ their^ aircraft, no matter where in the world they are^ flying,^ they^ can contact,^ via satellite^ or^ standard^ air-to- ground voice/data communication services, the MedLink Communications Center and talk^ directly and^ immediately^ to^ one^ of^ [MedLink's]^16 board certified emergency physicians.
MedLink is based within the emergency department of^ Good^ Samaritan Regional Medical Center, Phoenix, Arizona, a Level I Trauma Center, which gives.., emergency physicians additional access to^ specialists^ in more than^45 fields of medicine as well as a certified regional poison control center. Medical Kits on Commercial Aircraft, supra note 132, at 70. The physicians who answer these calls assist non-medical personnel in^ collecting data, helping^ the victim^ and^ stabilizing crisis situations. See id. Because of MedLink, many airlines reduced their number^ of diversions for in-flight medical emergencies by^ more^ than^ 90%^ within^ the^ first^ year^ of^ service with MedLink. See id. Currently, MedLink takes approximately 150 calls^ a^ month.^ See^ id. at 71.
- See Medical Kits on Commercial Aircraft, supra note 132,^ at^ 72-74.
- See id. at 72.
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