Anaphylaxis Over Ocean: MD Finds No Epinephrine Vial in Plane Kit

Is there a doctor on board? Yet again, we come across a story of an emergency 30,000 feet up in the air, and a physician faced with an in-flight medical kit that lacks vital medications.

In this case, there was no epinephrine in a dose suitable for anaphylaxis, as a passenger suffered a nut allergy reaction over the Atlantic Ocean.

The Federal Aviation Administration (FAA) assured Allergic Living in July 2022 that airplanes must carry epinephrine for anaphylaxis except in times of shortage. However, in this incident, again, it just wasn’t there. What was there? Epinephrine in a cardiac syringe device and, most fortunately, a physician with the skills to troubleshoot.

This dramatic story unfolded on June 22, 2022. The 20-year-old passenger decided last minute to join her parents on a trip to Italy. Their flight was sold out, so they booked their daughter on a different flight from Newark’s airport, which departed around the same time.

According to the doctor who treated her, the young woman accepted the airline’s chicken meal, wrongly assuming nuts would never be an ingredient of an in-flight meal. But as her throat began to feel itchy, she checked the label and saw “chicken with cashew” in small print. The woman is allergic to cashew. In that moment, she also had the awful realization that she’d left her auto-injectors with her parents.

A nurse was the first to answer the flight attendants’ call for medical assistance. She gave the passenger two doses of Benadryl. However, 15 minutes after the second antihistamine, the woman was feeling increasingly unwell. She asked for a doctor, and Dr. Samara Friedman, a pediatric orthopedist, stepped up to help.

Luckily for the patient, Friedman is also the mom of a 17-year son with food allergies. She recognized potential symptoms of anaphylaxis – throat tightness, very runny nose – and decided epinephrine was needed right away.

No Epinephrine in Allergy Dosage

In an interview, Friedman told me that the emergency medical kit (EMK) on this flight was organized in a fold-up panel style. There was a list of medications, in very tiny print. It did help in locating the epinephrine. However, the only epinephrine found was in a box, containing a device called a Bristojet. The device, meant for IV use in cardiac distress, includes a glass cylinder containing epinephrine at the concentration 0.1 mg per mL.

This EMK had no standard epinephrine vials at the anaphylaxis dosage and no auto-injectors.

Friedman’s family had three epinephrine auto-injectors with them, due to her son’s allergies. But her son would be eating many meals in Italy, and it wasn’t clear whether they could refill his prescription there. So, she was reluctant to use one of them in this situation. (On a past trip, he had needed his auto-injectors.)

Still, she told me that if no workable solution could be found for the young patient, her plan was to use her son’s auto-injector and deal with the consequences in Italy. But the crew told her that, in order to use a borrowed auto-injector, the airline’s policy required that the plane contact the airline’s ground medical provider.

There was a problem: the crew could not reach ground support – perhaps because of the flight’s location over the ocean. Friedman says: “I like to take a picture of the flight path. I just added the red dot on the eastern edge of North America, which is approximately where we were when the flight attendant approached me.”

In my reporting on airlines and allergies, I have been told that medical support on the ground is always available in an emergency. But Friedman said it wasn’t the case, at least in those urgent moments.

Jerry-Rigging a Solution

While unfamiliar with the Bristojet device at her disposal, Friedman says her orthopedic training helped her to troubleshoot. She told me she had to “stick the individually wrapped needle and syringe directly into the cylinder of epinephrine.” Because she knew the dosage in auto-injectors, she was aware of the concentration and dilution volume to treat an allergic reaction.

It was challenging, but she injected the young woman. She stabilized, and the plane avoided the need for an emergency diversion.

Flight map photo: emergency began over ocean.

Allergic Living recently shared the harrowing experience of Dr. Mike Varshavski, who also found no allergic concentration of epinephrine in an airplane EMK while over the ocean. He had come forward to treat a patient in first-time, severe anaphylaxis.

We have previously reported that cardiac and allergic epinephrine are “required” EMK items. However, the airlines have successfully lobbied for exemptions from carrying these and other medications at times of shortages. Yet, there is no current shortage of epinephrine – the FDA recently confirmed this to me. Meanwhile, the FAA says the airlines must stock these medications when they are, in fact, available.

So I ask, why on Friedman’s transatlantic flight was the required epinephrine for the allergic concentration in vial form missing? Why do testimonials from a growing list of medical professionals suggest planes are in the air without certain required medications?

This begs these questions. Who monitors the EMKs and makes sure medical kits replenished? Are the airlines self-policing? The answers remain unclear.

Call for Auto-Injectors in Kits

Friedman’s expertise is as a pediatric orthopedist. I asked her: if she had not been a food allergy parent, would she have recognized an allergic reaction in progress? She somberly told me there was a good chance she would not have recognized this was anaphylaxis, especially as the woman had no hives. (Hives are commonly associated with an allergic reaction, but not everyone gets them.)

Due to experience with her son, Friedman was knew the signs of early anaphylaxis and the correct dose of epinephrine. She agreed this was a fortunate coincidence, preventing a progression of anaphylaxis, and the need for an emergency landing.

Friedman is of the view that epinephrine auto-injectors should be standard in all EMKs. “Every medical professional would know how to use an auto-injector and, unlike vials, even a layperson could be instructed.”

In my role as an airlines accommodations advocate, I often make presentations on traveling with food allergies, and must comment on the food this young woman ate. I always recommend not accepting the airline meal. While this passenger missed the label, traces allergen exposures can also occur. The catered food is prepared in huge kitchens, and cross-contact protocols are anything but clear. My advice is to bring your food.

Some people in the food allergy community don’t think epinephrine in EMKs is a big concern. After all, they always carry their own. However, I would stress a few things: we are human and mistakes happen, such as epinephrine being misplaced (as in the young woman’s case). Plus, some allergic passengers will require more doses of epinephrine than they carry.

Friedman is diligent, yet even she ran into an allergy issue. She once gate-checked her bag because there was no more overhead space, forgetting the auto-injectors were in that case.

The food allergy epidemic continues to grow, and Allergic Living has reported on first-time reactions happening on a plane. I have long advocated for best practice medicines for anaphylaxis (an epinephrine auto-injector) to be required on all airlines.

Given the current situation, it is likely that a preventable anaphylaxis death will occur on a plane, simply because the FAA is not requiring planes to carry the best practice medications to treat an allergic reaction. This is utterly unacceptable, and the time for action is now.

Lianne Mandelbaum is Allergic Living’s airlines correspondent, and the founder of NoNutTraveler.com.