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Emergency Medical Equipment On Board German Airliners Jochen Hinkelbein, MD, DESA,∗† Christopher Neuhaus, MD,†‡ Wolfgang A. Wetsch, MD,∗† Oliver Spelten, MD,∗† Susanne Picker, MD,§ Bernd W. Böttiger, MD, DEAA,∗ and Birgit S. Gathof, MD§ Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany; † Working Group “Emergency Medicine and Air Rescue,” German Society of Aviation and Space Medicine, Munich, Germany; ‡ Department of Anesthesiology, University Hospital of Heidelberg, Heidelberg, Germany; § Transfusion Medicine, University Hospital of Cologne, Cologne, Germany ∗
DOI: 10.1111/jtm.12138
Background. Medical emergencies often occur on commercial airline flights, but valid data on their causes and consequences are rare. Therefore, it is unclear what emergency medical equipment is necessary. Although a minimum standard for medical equipment is defined in regulations, additional material is not standardized and may vary significantly between different airlines. Methods. German airlines operating aircrafts with more than 30 seats were selected and interviewed with a 5-page written questionnaire between August 2011 and January 2012. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted another three times by e-mail and/or phone. Descriptive analysis was used for data presentation and interpretation. Result. From a total of 73 German airlines, 58 were excluded from analysis (eg, those not providing passenger transport). Fifteen airlines were contacted and data of 13 airlines were available for analysis (two airlines did not participate). A first aid kit was available on all airlines. Seven airlines reported having a doctor’s kit, and another four provided an “emergency medical kit.” Four airlines provided an automated external defibrillator (AED)/electrocardiogram (ECG). While six airlines reported providing anesthesia drugs, a laryngoscope, and endotracheal tubes, another four airlines did not provide even a resuscitator bag. One airline did not provide any material for cardiopulmonary resuscitation (CPR). Conclusions. Although the minimal material required according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in the provision of additional material. The equipment on most airlines is not sufficient for the treatment of specific emergencies according to published medical guidelines (eg, for CPR or acute myocardial infarction).
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n the year 2012, approximately 2.5 billion persons worldwide traveled by commercial airline transport,1 – 3 and approximately 175 million were transported by air in Germany.4 Although airline travel is safe, individual factors in passengers (eg, age or preexisting diseases) as well as the number of passengers aboard larger aircraft1 and long-distance flights1 make emergencies increasingly more likely. Other studies have suggested that the frequency of in-flight emergencies is rising.5 In-flight medical emergencies often occur in commercial airline operations, but detailed data on their Corresponding Author: Jochen Hinkelbein, MD, DESA, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener St 62, Cologne 50937, Germany. E-mail: [email protected] © 2014 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2014; Volume 21 (Issue 5): 318–323
incidence, causes, and consequences remain limited, and are scarcely investigated scientifically, or even published.2,6 – 8 Some recent studies reported the incidence of in-flight emergencies to be one event per 14,000 to 39,600 passengers.8 – 10 A minimum standard for medical emergency material is defined by European as well as German regulations.11 Thus, all commercial aircraft have to be equipped with a first-aid kit (FAK) that all cabin crew members are trained to use. The FAK is suited to cover most minor illnesses (eg, nausea, headache, or dyspepsia). In addition, for aircraft with at least 30 seats, a (special) medical kit is required which can be used by competent personnel [eg, doctor’s kit (DK)].7 The contents may be enhanced according to the special requirements of the companies or by suggestions from their medical advisors.
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The aim of this study was to gather and analyze data on the (emergency) medical equipment provided by different German airlines that operate aircraft with at least 30 passenger seats. Materials and Methods There are several national (German), European, and international regulations related to provision of medical equipment in commercial aircraft.2 For the purpose of this study, European regulations for the commercial operation of aircraft (EU-OPS) were considered. An FAK is required at least once on each commercially registered European aircraft according to EU-OPS 1.745.11 EU-OPS 1.755 stipulates that additional emergency equipment is required only in aircraft with at least 30 seats11 without defining in detail what material is considered essential. To evaluate the usefulness of the material, European or international medical guidelines for the treatment of specific emergencies were applied [eg, cardiopulmonary resuscitation (CPR) and myocardial infarction]. Data Collection German airlines with aircraft having at least 30 seats (EU-OPS1.755) were selected from the German Federal Aviation Authority (LBA; http://www.lba.de). Airlines with solely cargo/air-freight operations and those without any scheduled passenger transport [eg, executive flights for very important persons (VIPs) or industrial companies] were excluded from the analysis (Figure 1). The selected airline operators received a five-page written questionnaire between August 2011 and January
Figure 1 Screening, selection, and inclusion process (http:// www.lba.de); 73 German airlines were identified and 15 airlines were appropriate for analysis. Thirteen airlines returned information for analysis. *Two airlines refused to participate or did not answer.
2012 to be returned via postal mail or electronically. Besides pre-packed and required emergency medical material, drugs, medical devices, wound material, and other medical equipment were queried. General questions concerning equipment lists or analysis of medical incidents were also presented. If no reply was received within 4 weeks, the airlines were contacted again (up to three times) by e-mail and/or telephone and requested to complete the questionnaire. Data Analysis and Presentation Data for different airlines were presented anonymously to ensure data safety (presentation only with numbers). All data were entered into a spreadsheet for tabulation and calculation of descriptive statistics (Microsoft® Office Excel® 2007 SP3 MSO, Redmond, WA, USA). Provided drugs/intravenous (IV) medications were categorized on the basis of their suitability to treat different emergencies according to published medical guidelines. For CPR, guidelines from the European Resuscitation Council (ERC 2010),12,13 and for myocardial infarction, the current guidelines from the European Society of Cardiology (ESC) were used.14,15
Results Airlines and Response Rate From a total of 73 airlines, 58 were excluded from the analysis: 40 airlines operated aircraft with less than 30 seats, and another 18 airlines were excluded because of their solely cargo/charter operations or termination of service in 2010/2011 (Figure 1). Fifteen airlines were contacted initially and requested to complete the survey. “DC Aviation GmbH” refused to participate because of company policy and “Private Wings” did not respond. Information was received from 13 airlines resulting in a response rate of 87% (13/15). For further analysis, data of these 13 airlines were considered 100%. Seven airlines (53.8%) provided short-distance (regional) flights only (Table 1). Pre-packed Material An FAK (according to EU-OPS) was provided by all airlines. Seven airlines (53.8%) reported having a DK and four airlines (30.8%) provided an “emergency medical kit” (EMK) which was packed non-standardized. Two (15.4%) airlines (both operating only short-distance flights) reported having no other pre-packed material apart from the FAK and also no IV drugs. Except for two airlines providing long-haul flights, all stated that they equipped each aircraft identically (Table 1). Twelve airlines also provided a list of the required material as well as a short description of how to use and when to use different drugs. J Travel Med 2014; 21: 318–323
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Table 1 Exemplary drugs and medical equipment depending on the type of operations (n = 13). Data are presented as (relative) percentages Airlines with long-distance Airlines with operations, short-distance flights only, n = 7 (ie, 100%) n = 6 (ie, 100%) Medical kits FAK Emergency medical kit or doctors’ kit available Aircraft equipped identically Drugs and medication Myocardial infarction (all drugs available) IV access Emergency medical equipment CPR equipment ECG/AED Resuscitator bag Anesthesia equipment Surgical material Ground medical consultation offered Analysis of medical emergencies
n = 7 (100%) n = 5 (71.4%)
n = 6 (100%) n = 6 (100%)
n = 7 (100%)
n = 4 (66.7%)
n = 0 (0%)
n = 3 (50%)
n = 3 (42.9%)
n = 5 (83.3%)
n = 3 (42.9%) n = 1 (14.3%) n = 3 (42.9%) n = 1 (14.3%) n = 2 (28.6%) n = 3 (42.9%)
n = 6 (100%) n = 3 (50%) n = 6 (100%) n = 5 (83.3%) n = 5 (83.3%) n = 4 (66.7%)
n = 3 (42.9%)
n = 3 (50%)
AED = automated external defibrillator; CPR = cardiopulmonary resuscitation; ECG = electrocardiogram; FAK = first aid kit; IV = intravenous.
Drugs and Medication A wide variety of medication is provided by airlines to handle medical in-flight emergencies. Therefore, the provided materials were rated on their suitability to handle different categories of in-flight emergencies. For example, ibuprofen, aspirin or paracetamol tablets as well as paracetamol supp. could be used for “pain treatment” and it was not essential to have all of them on board. If one of them was available, the category “pain” was filled. Six airlines (46.2%) reported providing some oral medication against pain, and seven airlines (53.8%) had burn gel (Table 2). In addition, nine airlines (69.2%) provided tablets or suppositories to cure fever and some medication against allergies (eg, tablets, fluid, and gel). Ten airlines (76.9%) provided some kind of medication medication against nausea and vomiting. For treatment of hypertension, nine airlines (69.2%) had at least one IV drug available. Five airlines (38.5%) provided specific IV drugs for the treatment of hypotension (eg, etilephrine). Anesthesia and Surgical Procedures Eight airlines (61.5%) reported having IV-access material for medication or infusion. While six airlines (46.2%) reported providing anesthesia drugs, laryngoscopes, and endotracheal tubes, another four airlines (30.8%; all operating short-distance only) did not J Travel Med 2014; 21: 318–323
Table 2 Availability of drugs; altogether, n = 13 airlines responded to the survey
Drug for … /against … Pain Fever Nausea and vomiting Ear/eye problems Cardiac arrhythmia Myocardial infarction Respiratory problems Agitation Cardiopulmonary resuscitation (CPR) Hypertension Hypoglycemia Allergy Anesthesia
Yes (n)
No (n)
No report (n)
6 9 10 8 9 3 10 9 9 9 9 9 5
0 0 0 0 0 7 0 0 1 0 0 0 1
7 4 3 5 4 3 3 4 3 4 4 4 7
n = number
provide even a resuscitator bag (Table 1). Six airlines (46.2%) provide IV medication for anesthesia induction (eg, lysthenone and midazolam) but none of the airlines reported providing ketamine or a qualified opioid to maintain anesthesia. Six airlines (46.2%) reported having surgical material such as sewing material, scissors (n = 5; 38.5%), and scalpels (n = 4; 30.8%). Eight airlines (61.5%) also provided material for immobilization, bandage, or wound dressing. Medical Devices for Specifically Severe Emergencies Altogether, four airlines (30.8%) offered the facility to diagnose ventricular tachycardia (VT)/ventricular fibrillation (VF) for CPR by an electrocardiogram (ECG) and/or automated external defibrillator (AED) (Table 1). On the contrary, four other airlines (30.8%, all providing short-distance flights only) did not provide any material for CPR. Four airlines (30.8%) did report not providing adrenaline. Nine airlines (69.2%) had atropine (up to 3 mg) available. Three airlines operating long-distance flights (23.1%) provided all the required drugs for the in-flight treatment of acute myocardial infarction (AMI; ie, nitro-spray, heparin, aspirin, and anti-arrhythmics), but no airline reported having morphine. Seven airlines (53.8%) had at least some drugs for AMI therapy. Ground Medical Consultation To improve in-flight safety and handling of emergencies, some airlines provided the facility of consultation (eg, radiotelephony or satellite communication) for pilots, cabin crew, or even medical personnel.3 Seven airlines (53.8%) reported providing this service, whereas three (23.1%) did not (no answer, n = 3). Quality Management Six airlines (46.2%) reported analyzing medical emergencies regularly, whereas three (23.1%) intentionally did not.
Emergency Medical Equipment in Airliners
Seven airlines provided a standardized form for liability exclusion (no answer, n = 2). Furthermore, seven airlines provided a gift for travelers who offered in-flight medical consultation while two airlines did not (no answer, n = 4). Discussion In this study, the contents of emergency medical equipment aboard commercial German airline carriers with more than 30 seats were analyzed. To our knowledge, there are no studies published specifically on equipment aboard for German airlines carriers. The main finding of this study was that all airlines are equipped as required in the specific regulations. However, there was a wide variation in additional medical equipment aboard German carriers with some questionably useful material. While some airlines were excellently equipped to handle even severe emergencies (eg, CPR) according to present medical guidelines, others were equipped marginally, suggesting that they could handle only minor cases properly. Airlines providing long-distance flights were equipped more extensively compared with airlines operating only short-distance flights only (Table 1). Congruently, Sand and colleagues have found that medical flight kits vary extensively in European aircraft.6,16 These authors interviewed 32 European airlines (both low-cost and full-service carriers; response rate, 37.5%).16 In contrast, the response rate of this study was quite high (87%), allowing a more representative interpretation of the data. Medical Kits The percentage of minimally equipped airlines (15.4%) is congruent with the results from Sand and colleagues.16 Although European and not German airlines were investigated in their study, the percentage of minimally equipped airlines was nearly identical to that of this study. Managing Specific Emergencies Regarding the doctoŕs kit, even more variety was reported (Table 2). As data on in-flight emergencies are scarce,1,2,6,8 it is not possible to adequately qualify the usefulness of the material provided. Unfortunately, no international database on in-flight medical emergencies exists yet.1,2,8 However, lack of denominator data is common in aviation,17,18 and can prohibit further evaluation of the required material. Notwithstanding, it is known that physicians are available on more than 80% of flights experiencing in-flight emergencies.1 Therefore, having adequate medical equipment is of great importance. Cardiac events are the most common problems during airl travel.7,8,19 Qureshi and colleagues7 reported, from an analysis of 177 in-flight emergencies in the UK, that exacerbation of preexisting medical problems accounted for the majority of in-flight medical
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emergencies (65%) whereas newly emerging medical problems were significantly infrequent (28%). Of the preexisting problems, respiratory disorders (21%), cardiovascular problems (14%), and abdominal problems (10%) are the most common. However, new medical problems other than syncope (91% of n = 140) are rare.7 Syncope was the most common in-flight medical problem,3,6,7,19,20 followed by gastrointestinal disorders (8.9%) and cardiac conditions (4.9%). More specifically, myocardial infarction (22.7%), apoplexy (11.3%), and epileptic seizures (9.4%) were the most common causes of a flight diversion. A standardized, international database on in-flight medical emergencies could improve preventive strategies by assisting pre-flight medical assessment.6,21 Treatment According to Guidelines Cardiac arrest has an incidence of 1 per 5–10 million passengers.1 Up to 89% of patients with sudden in-flight cardiac arrest suffer from VF/VT.22 – 24 The early use of AEDs improves survival in patients suffering from VF and VT.13,25,26 The number of lives lost as a result of cardiac arrest has been estimated to be as high as 1,000 per year in International Airlines Transport Association (IATA) carriers.24,27 Whereas an AED is required by law on board US and other international airlines,27 it is not necessary in European aircraft, even though it is sometimes available28 (Table 1). However, early defibrillation can be initially successful in up to 91%24 of cases. The in-flight use of an AED can result in 33% to 55% survival to hospital discharge, which includes the 22% to 89% patients with VF/VT.22,23,27 In this study, 50% of long-distance airlines were found to provide an AED compared with 14.3% of short-distance airlines (Table 1). However, when rating these data according to the ERC guidelines 2010 for CPR,12,13 a large discrepancy is found with this study: only 30.8% of airlines carry an ECG and/or an AED. On the contrary, the same percentage of airlines (30.8%) does not provide any useful material even for CPR (all short-distance airlines). According to the guidelines, CPR cannot be performed adequately in more than two thirds of all aircraft because emergency medical equipment and drugs are far too limited. Although an ECG/AED or CPR equipment may be considered unnecessary in short-distance operations, it may take an aircraft more than 20 min to land at the next airport even in these operations. Another point of interest was the treatment of patients with AMI according to the current guidelines.14,15 Only three airlines (23.1%; all long-haul flights) provided all the drugs required for the in-flight treatment of AMI. However, seven airlines (53.8%) had at least some drugs for AMI therapy. Usefulness of the Material and Curiosities After analysis of our data, it remains unclear why some airlines provide large doses of some specific drugs (eg, succinylcholine 500 mg, atropine 6 × 0.5 mg, 50 mL J Travel Med 2014; 21: 318–323
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dopamine, and glucose 40% 100 mL). One explanation could be that these airlines provide special intensive care unit (ICU) transportation facilities [eg, patient transfer compartment (PTC)] and, therefore, carry a larger quantity of drugs. Concerning CPR of patients, four short-distance airlines (30.8%) did not report providing adrenaline although it is included in multiple international guidelines for CPR.12,29,30 Another nine airlines (69.2%) still had atropine (up to 3 mg) available, even though it is no longer recommended for CPR12,29,30 by the medical guidelines. One airline for short-distance flights still provided ammonium smelling ampoules for minor circulation problems. Another airline provided “anti-AIDSgloves.” Limitations Several limitations of this study have to be noted: First, not all the airlines contacted (response rate, 87%) returned a response. However, compared with other studies,16,19 this percentage was quite high. Second, data were reported by the airlines, but they could not be validated. Third, the information provided by the airlines may have covered some specific aircraft and not the complete fleet. It is at least conceivable that there may be an inter-aircraft variation in emergency equipment within the same company. The same may apply to different flight paths and duration of flights (one aircraft for both short- and long-distance flights). However, most airlines equip all aircraft identically. Fourth, on an evidence-based level, information on what emergency equipment is required on board an aircraft is scarce, that is, specific information about the incidences and causes of medical problems of patients. Unless a valid standardized data base is made available, this question cannot be answered. Conclusions All the airlines analyzed carry the complete material for medical emergencies as required by European aviation regulations. However, there are significant differences in the material provided additionally at the discretion of the airlines: some of the drugs provided (eg, dopamine, atropine, and etomidate) are no longer recommended even in ground-based emergency medicine. However, to treat common and severe medical emergencies adequately (eg, CPR and myocardial infarction), it is helpful to provide medication as required by international medical guidelines. In this context, some of the airlines are insufficiently equipped to deal with severe in-flight medical emergencies (eg, CPR), the reason perhaps being that the specific material is not necessarily required according to European aviation regulations. To conclude, emergency medical equipment should be standardized and up to date to ensure proper J Travel Med 2014; 21: 318–323
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treatment of in-flight emergencies. A database can be helpful to record and analyze relevant in-flight emergencies. Acknowledgments We thank Lisa Tauszig for her corrections in the manuscript. We would like to thank the airline companies that participated in this study: Air Berlin PLC & Co. Luftverkehrs KG; Augsburg Airways; Avanti Air; Cirrus Airlines; Condor Flugdienst GmbH; Contact Air Flugdienst GmbH & Co. KG; Eurowings GmbH; Germania Fluggesellschaft mbH; Germanwings; Lufthansa (incl. Lufthansa Cityline); TUIfly; WDL Aviation; and XL Airways Germany. Declaration of Interests None of the authors have a conflict of interest with material mentioned in this study. There is also no or indirect relationship between any of the authors and the airline companies reported. This study was supported by a grant from The German Society for Aviation and Space Medicine (DGLRM). References 1. Graf J, Stüben U, Pump S. In-flight medical emergencies. Dtsch Aerztebl Int 2012; 109:591–602. 2. Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009; 373:1067–2077. 3. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med 2013; 368:2075–2083. 4. Statistisches Bundesamt. 2011: 9,3 Millionen mehr Flugpassagiere als 2010 [in German]. 2012. Available at: https://www.destatis.de/DE/PresseService/Presse/Press emitteilungen/2012/02/PD12_059_464pdf.pdf?__blob= publicationFile. (Accessed 2012 Apr 7) 5. Dowdall N. Is there a doctor on the aircraft? Brit Med J 2000; 321:1336–1337. 6. Sand M, Bechara FG, Sand D, Mann B. In-flight medical emergencies. Lancet 2009; 374:1062–1063. 7. Qureshi A, Porter KM. Emergencies in the air. Emerg Med J 2005; 22:658–659. 8. Hinkelbein J, Spelten O, Wetsch WA, et al. Emergencies in the sky: in-flight medical emergencies during commercial air transport. Trends Anaesth Crit Care 2013; 3:179–182. 9. Cummins RO, Schubach JA. Frequency and types of medical emergencies among commercial air travellers. JAMA 1989; 261:1295–1299. 10. Ruskin KJ, Hernandez KA, Barash PG. Management of in-flight medical emergencies. Anesthesiology 2008; 108:749–755. 11. Europäische Union. VERORDNUNG (EG) Nr. 859/2008 DER KOMMISSION vom 20. August 2008 zur Änderung der Verordnung (EWG) Nr. 3922/91 des Rates in Bezug auf gemeinsame technische Vorschriften und Verwaltungsverfahren für den gewerblichen Luftverkehr mit Flächenflugzeugen. Amtsblatt der Europäischen Union. 2008 Sep 20;L254:1–238
Emergency Medical Equipment in Airliners 12. Nolan JP, Hazinski MF, Billi JE, et al. Part 1: Executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment tecommendations. Resuscitation 2010; 81S:e1–e25. 13. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation 2010; 81:1219–1276. 14. Hamm CW, Bassand JP, Agewall S, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2999–3054. 15. Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2008; 29:2909–2945. 16. Sand M, Gambichler T, Sand D, et al. Emergency medical kits on board commercial aircraft: a comparative study. Travel Med Infect Dis 2010; 8:388–394. 17. Hinkelbein J, Dambier M, Glaser E, Landgraf H. Medical incapacitation im cockpit: Inzidenz, Ursachen und Folgen. Flugmed Tropenmed Reisemed 2008; 15:14–19. 18. Hinkelbein J, Neuhaus C, Schwalbe M, Dambier M. Significant lack of data in aviation accident analysis. Aviat Space Environ Med 2009; 88:77. 19. Sand M, Bechara FG, Sand D, Mann B. Surgical and medical emergencies on board European aircraft: a retrospective study of 10189 cases. Crit Care 2009; 13:R3.
323 20. Springings DC, Davies PTG. In-flight medical emergencies. Lancet 2009; 374:1063. 21. Ruskin KJ. In-flight medical emergencies: time for a registry? Crit Care 2009; 13:121. 22. Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med 2000; 343:1210–1216. 23. Brown AM, Rittenberger JC, Ammon CM, et al. In-flight automated external defibrillator use and consultation patterns. Prehosp Emerg Care 2010; 14:235–239. 24. ÓRourke MF, Donaldson E, Geddes JS. An airline cardiac arrest program. Circulation 1997; 96:2849–2853. 25. Nichol G, Stiell IG, Laupacis A, et al. A cummulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1999; 34:517–525. 26. Koster RW, Baubin MA, Bossaert LL, et al. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2010; 81:1277–1292. 27. O’Rourke RA. Saving lives in the sky. Circulation 1997; 96:2775–2777. 28. Bertrand C, Rodriguez Redington P, Lecarpentier E, et al. Preliminary report on AED deplayment on the entire Air France commercial fleet: a joint venture with Paris XII University Training Programme. Resuscitation 2004; 63:175–181. 29. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation 2010; 81:1305–1352. 30. Field JM, Hazinski MF, Sayre MR, et al. Part 1: Executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010; 122:S640–S656.
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Emergency Medical Equipment On Board German Airliners Jochen Hinkelbein, MD, DESA,∗† Christopher Neuhaus, MD,†‡ Wolfgang A. Wetsch, MD,∗† Oliver Spelten, MD,∗† Susanne Picker, MD,§ Bernd W. Böttiger, MD, DEAA,∗ and Birgit S. Gathof, MD§ Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany; † Working Group “Emergency Medicine and Air Rescue,” German Society of Aviation and Space Medicine, Munich, Germany; ‡ Department of Anesthesiology, University Hospital of Heidelberg, Heidelberg, Germany; § Transfusion Medicine, University Hospital of Cologne, Cologne, Germany ∗
DOI: 10.1111/jtm.12138
Background. Medical emergencies often occur on commercial airline flights, but valid data on their causes and consequences are rare. Therefore, it is unclear what emergency medical equipment is necessary. Although a minimum standard for medical equipment is defined in regulations, additional material is not standardized and may vary significantly between different airlines. Methods. German airlines operating aircrafts with more than 30 seats were selected and interviewed with a 5-page written questionnaire between August 2011 and January 2012. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted another three times by e-mail and/or phone. Descriptive analysis was used for data presentation and interpretation. Result. From a total of 73 German airlines, 58 were excluded from analysis (eg, those not providing passenger transport). Fifteen airlines were contacted and data of 13 airlines were available for analysis (two airlines did not participate). A first aid kit was available on all airlines. Seven airlines reported having a doctor’s kit, and another four provided an “emergency medical kit.” Four airlines provided an automated external defibrillator (AED)/electrocardiogram (ECG). While six airlines reported providing anesthesia drugs, a laryngoscope, and endotracheal tubes, another four airlines did not provide even a resuscitator bag. One airline did not provide any material for cardiopulmonary resuscitation (CPR). Conclusions. Although the minimal material required according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in the provision of additional material. The equipment on most airlines is not sufficient for the treatment of specific emergencies according to published medical guidelines (eg, for CPR or acute myocardial infarction).
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n the year 2012, approximately 2.5 billion persons worldwide traveled by commercial airline transport,1 – 3 and approximately 175 million were transported by air in Germany.4 Although airline travel is safe, individual factors in passengers (eg, age or preexisting diseases) as well as the number of passengers aboard larger aircraft1 and long-distance flights1 make emergencies increasingly more likely. Other studies have suggested that the frequency of in-flight emergencies is rising.5 In-flight medical emergencies often occur in commercial airline operations, but detailed data on their Corresponding Author: Jochen Hinkelbein, MD, DESA, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener St 62, Cologne 50937, Germany. E-mail: [email protected] © 2014 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2014; Volume 21 (Issue 5): 318–323
incidence, causes, and consequences remain limited, and are scarcely investigated scientifically, or even published.2,6 – 8 Some recent studies reported the incidence of in-flight emergencies to be one event per 14,000 to 39,600 passengers.8 – 10 A minimum standard for medical emergency material is defined by European as well as German regulations.11 Thus, all commercial aircraft have to be equipped with a first-aid kit (FAK) that all cabin crew members are trained to use. The FAK is suited to cover most minor illnesses (eg, nausea, headache, or dyspepsia). In addition, for aircraft with at least 30 seats, a (special) medical kit is required which can be used by competent personnel [eg, doctor’s kit (DK)].7 The contents may be enhanced according to the special requirements of the companies or by suggestions from their medical advisors.
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The aim of this study was to gather and analyze data on the (emergency) medical equipment provided by different German airlines that operate aircraft with at least 30 passenger seats. Materials and Methods There are several national (German), European, and international regulations related to provision of medical equipment in commercial aircraft.2 For the purpose of this study, European regulations for the commercial operation of aircraft (EU-OPS) were considered. An FAK is required at least once on each commercially registered European aircraft according to EU-OPS 1.745.11 EU-OPS 1.755 stipulates that additional emergency equipment is required only in aircraft with at least 30 seats11 without defining in detail what material is considered essential. To evaluate the usefulness of the material, European or international medical guidelines for the treatment of specific emergencies were applied [eg, cardiopulmonary resuscitation (CPR) and myocardial infarction]. Data Collection German airlines with aircraft having at least 30 seats (EU-OPS1.755) were selected from the German Federal Aviation Authority (LBA; http://www.lba.de). Airlines with solely cargo/air-freight operations and those without any scheduled passenger transport [eg, executive flights for very important persons (VIPs) or industrial companies] were excluded from the analysis (Figure 1). The selected airline operators received a five-page written questionnaire between August 2011 and January
Figure 1 Screening, selection, and inclusion process (http:// www.lba.de); 73 German airlines were identified and 15 airlines were appropriate for analysis. Thirteen airlines returned information for analysis. *Two airlines refused to participate or did not answer.
2012 to be returned via postal mail or electronically. Besides pre-packed and required emergency medical material, drugs, medical devices, wound material, and other medical equipment were queried. General questions concerning equipment lists or analysis of medical incidents were also presented. If no reply was received within 4 weeks, the airlines were contacted again (up to three times) by e-mail and/or telephone and requested to complete the questionnaire. Data Analysis and Presentation Data for different airlines were presented anonymously to ensure data safety (presentation only with numbers). All data were entered into a spreadsheet for tabulation and calculation of descriptive statistics (Microsoft® Office Excel® 2007 SP3 MSO, Redmond, WA, USA). Provided drugs/intravenous (IV) medications were categorized on the basis of their suitability to treat different emergencies according to published medical guidelines. For CPR, guidelines from the European Resuscitation Council (ERC 2010),12,13 and for myocardial infarction, the current guidelines from the European Society of Cardiology (ESC) were used.14,15
Results Airlines and Response Rate From a total of 73 airlines, 58 were excluded from the analysis: 40 airlines operated aircraft with less than 30 seats, and another 18 airlines were excluded because of their solely cargo/charter operations or termination of service in 2010/2011 (Figure 1). Fifteen airlines were contacted initially and requested to complete the survey. “DC Aviation GmbH” refused to participate because of company policy and “Private Wings” did not respond. Information was received from 13 airlines resulting in a response rate of 87% (13/15). For further analysis, data of these 13 airlines were considered 100%. Seven airlines (53.8%) provided short-distance (regional) flights only (Table 1). Pre-packed Material An FAK (according to EU-OPS) was provided by all airlines. Seven airlines (53.8%) reported having a DK and four airlines (30.8%) provided an “emergency medical kit” (EMK) which was packed non-standardized. Two (15.4%) airlines (both operating only short-distance flights) reported having no other pre-packed material apart from the FAK and also no IV drugs. Except for two airlines providing long-haul flights, all stated that they equipped each aircraft identically (Table 1). Twelve airlines also provided a list of the required material as well as a short description of how to use and when to use different drugs. J Travel Med 2014; 21: 318–323
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Table 1 Exemplary drugs and medical equipment depending on the type of operations (n = 13). Data are presented as (relative) percentages Airlines with long-distance Airlines with operations, short-distance flights only, n = 7 (ie, 100%) n = 6 (ie, 100%) Medical kits FAK Emergency medical kit or doctors’ kit available Aircraft equipped identically Drugs and medication Myocardial infarction (all drugs available) IV access Emergency medical equipment CPR equipment ECG/AED Resuscitator bag Anesthesia equipment Surgical material Ground medical consultation offered Analysis of medical emergencies
n = 7 (100%) n = 5 (71.4%)
n = 6 (100%) n = 6 (100%)
n = 7 (100%)
n = 4 (66.7%)
n = 0 (0%)
n = 3 (50%)
n = 3 (42.9%)
n = 5 (83.3%)
n = 3 (42.9%) n = 1 (14.3%) n = 3 (42.9%) n = 1 (14.3%) n = 2 (28.6%) n = 3 (42.9%)
n = 6 (100%) n = 3 (50%) n = 6 (100%) n = 5 (83.3%) n = 5 (83.3%) n = 4 (66.7%)
n = 3 (42.9%)
n = 3 (50%)
AED = automated external defibrillator; CPR = cardiopulmonary resuscitation; ECG = electrocardiogram; FAK = first aid kit; IV = intravenous.
Drugs and Medication A wide variety of medication is provided by airlines to handle medical in-flight emergencies. Therefore, the provided materials were rated on their suitability to handle different categories of in-flight emergencies. For example, ibuprofen, aspirin or paracetamol tablets as well as paracetamol supp. could be used for “pain treatment” and it was not essential to have all of them on board. If one of them was available, the category “pain” was filled. Six airlines (46.2%) reported providing some oral medication against pain, and seven airlines (53.8%) had burn gel (Table 2). In addition, nine airlines (69.2%) provided tablets or suppositories to cure fever and some medication against allergies (eg, tablets, fluid, and gel). Ten airlines (76.9%) provided some kind of medication medication against nausea and vomiting. For treatment of hypertension, nine airlines (69.2%) had at least one IV drug available. Five airlines (38.5%) provided specific IV drugs for the treatment of hypotension (eg, etilephrine). Anesthesia and Surgical Procedures Eight airlines (61.5%) reported having IV-access material for medication or infusion. While six airlines (46.2%) reported providing anesthesia drugs, laryngoscopes, and endotracheal tubes, another four airlines (30.8%; all operating short-distance only) did not J Travel Med 2014; 21: 318–323
Table 2 Availability of drugs; altogether, n = 13 airlines responded to the survey
Drug for … /against … Pain Fever Nausea and vomiting Ear/eye problems Cardiac arrhythmia Myocardial infarction Respiratory problems Agitation Cardiopulmonary resuscitation (CPR) Hypertension Hypoglycemia Allergy Anesthesia
Yes (n)
No (n)
No report (n)
6 9 10 8 9 3 10 9 9 9 9 9 5
0 0 0 0 0 7 0 0 1 0 0 0 1
7 4 3 5 4 3 3 4 3 4 4 4 7
n = number
provide even a resuscitator bag (Table 1). Six airlines (46.2%) provide IV medication for anesthesia induction (eg, lysthenone and midazolam) but none of the airlines reported providing ketamine or a qualified opioid to maintain anesthesia. Six airlines (46.2%) reported having surgical material such as sewing material, scissors (n = 5; 38.5%), and scalpels (n = 4; 30.8%). Eight airlines (61.5%) also provided material for immobilization, bandage, or wound dressing. Medical Devices for Specifically Severe Emergencies Altogether, four airlines (30.8%) offered the facility to diagnose ventricular tachycardia (VT)/ventricular fibrillation (VF) for CPR by an electrocardiogram (ECG) and/or automated external defibrillator (AED) (Table 1). On the contrary, four other airlines (30.8%, all providing short-distance flights only) did not provide any material for CPR. Four airlines (30.8%) did report not providing adrenaline. Nine airlines (69.2%) had atropine (up to 3 mg) available. Three airlines operating long-distance flights (23.1%) provided all the required drugs for the in-flight treatment of acute myocardial infarction (AMI; ie, nitro-spray, heparin, aspirin, and anti-arrhythmics), but no airline reported having morphine. Seven airlines (53.8%) had at least some drugs for AMI therapy. Ground Medical Consultation To improve in-flight safety and handling of emergencies, some airlines provided the facility of consultation (eg, radiotelephony or satellite communication) for pilots, cabin crew, or even medical personnel.3 Seven airlines (53.8%) reported providing this service, whereas three (23.1%) did not (no answer, n = 3). Quality Management Six airlines (46.2%) reported analyzing medical emergencies regularly, whereas three (23.1%) intentionally did not.
Emergency Medical Equipment in Airliners
Seven airlines provided a standardized form for liability exclusion (no answer, n = 2). Furthermore, seven airlines provided a gift for travelers who offered in-flight medical consultation while two airlines did not (no answer, n = 4). Discussion In this study, the contents of emergency medical equipment aboard commercial German airline carriers with more than 30 seats were analyzed. To our knowledge, there are no studies published specifically on equipment aboard for German airlines carriers. The main finding of this study was that all airlines are equipped as required in the specific regulations. However, there was a wide variation in additional medical equipment aboard German carriers with some questionably useful material. While some airlines were excellently equipped to handle even severe emergencies (eg, CPR) according to present medical guidelines, others were equipped marginally, suggesting that they could handle only minor cases properly. Airlines providing long-distance flights were equipped more extensively compared with airlines operating only short-distance flights only (Table 1). Congruently, Sand and colleagues have found that medical flight kits vary extensively in European aircraft.6,16 These authors interviewed 32 European airlines (both low-cost and full-service carriers; response rate, 37.5%).16 In contrast, the response rate of this study was quite high (87%), allowing a more representative interpretation of the data. Medical Kits The percentage of minimally equipped airlines (15.4%) is congruent with the results from Sand and colleagues.16 Although European and not German airlines were investigated in their study, the percentage of minimally equipped airlines was nearly identical to that of this study. Managing Specific Emergencies Regarding the doctoŕs kit, even more variety was reported (Table 2). As data on in-flight emergencies are scarce,1,2,6,8 it is not possible to adequately qualify the usefulness of the material provided. Unfortunately, no international database on in-flight medical emergencies exists yet.1,2,8 However, lack of denominator data is common in aviation,17,18 and can prohibit further evaluation of the required material. Notwithstanding, it is known that physicians are available on more than 80% of flights experiencing in-flight emergencies.1 Therefore, having adequate medical equipment is of great importance. Cardiac events are the most common problems during airl travel.7,8,19 Qureshi and colleagues7 reported, from an analysis of 177 in-flight emergencies in the UK, that exacerbation of preexisting medical problems accounted for the majority of in-flight medical
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emergencies (65%) whereas newly emerging medical problems were significantly infrequent (28%). Of the preexisting problems, respiratory disorders (21%), cardiovascular problems (14%), and abdominal problems (10%) are the most common. However, new medical problems other than syncope (91% of n = 140) are rare.7 Syncope was the most common in-flight medical problem,3,6,7,19,20 followed by gastrointestinal disorders (8.9%) and cardiac conditions (4.9%). More specifically, myocardial infarction (22.7%), apoplexy (11.3%), and epileptic seizures (9.4%) were the most common causes of a flight diversion. A standardized, international database on in-flight medical emergencies could improve preventive strategies by assisting pre-flight medical assessment.6,21 Treatment According to Guidelines Cardiac arrest has an incidence of 1 per 5–10 million passengers.1 Up to 89% of patients with sudden in-flight cardiac arrest suffer from VF/VT.22 – 24 The early use of AEDs improves survival in patients suffering from VF and VT.13,25,26 The number of lives lost as a result of cardiac arrest has been estimated to be as high as 1,000 per year in International Airlines Transport Association (IATA) carriers.24,27 Whereas an AED is required by law on board US and other international airlines,27 it is not necessary in European aircraft, even though it is sometimes available28 (Table 1). However, early defibrillation can be initially successful in up to 91%24 of cases. The in-flight use of an AED can result in 33% to 55% survival to hospital discharge, which includes the 22% to 89% patients with VF/VT.22,23,27 In this study, 50% of long-distance airlines were found to provide an AED compared with 14.3% of short-distance airlines (Table 1). However, when rating these data according to the ERC guidelines 2010 for CPR,12,13 a large discrepancy is found with this study: only 30.8% of airlines carry an ECG and/or an AED. On the contrary, the same percentage of airlines (30.8%) does not provide any useful material even for CPR (all short-distance airlines). According to the guidelines, CPR cannot be performed adequately in more than two thirds of all aircraft because emergency medical equipment and drugs are far too limited. Although an ECG/AED or CPR equipment may be considered unnecessary in short-distance operations, it may take an aircraft more than 20 min to land at the next airport even in these operations. Another point of interest was the treatment of patients with AMI according to the current guidelines.14,15 Only three airlines (23.1%; all long-haul flights) provided all the drugs required for the in-flight treatment of AMI. However, seven airlines (53.8%) had at least some drugs for AMI therapy. Usefulness of the Material and Curiosities After analysis of our data, it remains unclear why some airlines provide large doses of some specific drugs (eg, succinylcholine 500 mg, atropine 6 × 0.5 mg, 50 mL J Travel Med 2014; 21: 318–323
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dopamine, and glucose 40% 100 mL). One explanation could be that these airlines provide special intensive care unit (ICU) transportation facilities [eg, patient transfer compartment (PTC)] and, therefore, carry a larger quantity of drugs. Concerning CPR of patients, four short-distance airlines (30.8%) did not report providing adrenaline although it is included in multiple international guidelines for CPR.12,29,30 Another nine airlines (69.2%) still had atropine (up to 3 mg) available, even though it is no longer recommended for CPR12,29,30 by the medical guidelines. One airline for short-distance flights still provided ammonium smelling ampoules for minor circulation problems. Another airline provided “anti-AIDSgloves.” Limitations Several limitations of this study have to be noted: First, not all the airlines contacted (response rate, 87%) returned a response. However, compared with other studies,16,19 this percentage was quite high. Second, data were reported by the airlines, but they could not be validated. Third, the information provided by the airlines may have covered some specific aircraft and not the complete fleet. It is at least conceivable that there may be an inter-aircraft variation in emergency equipment within the same company. The same may apply to different flight paths and duration of flights (one aircraft for both short- and long-distance flights). However, most airlines equip all aircraft identically. Fourth, on an evidence-based level, information on what emergency equipment is required on board an aircraft is scarce, that is, specific information about the incidences and causes of medical problems of patients. Unless a valid standardized data base is made available, this question cannot be answered. Conclusions All the airlines analyzed carry the complete material for medical emergencies as required by European aviation regulations. However, there are significant differences in the material provided additionally at the discretion of the airlines: some of the drugs provided (eg, dopamine, atropine, and etomidate) are no longer recommended even in ground-based emergency medicine. However, to treat common and severe medical emergencies adequately (eg, CPR and myocardial infarction), it is helpful to provide medication as required by international medical guidelines. In this context, some of the airlines are insufficiently equipped to deal with severe in-flight medical emergencies (eg, CPR), the reason perhaps being that the specific material is not necessarily required according to European aviation regulations. To conclude, emergency medical equipment should be standardized and up to date to ensure proper J Travel Med 2014; 21: 318–323
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treatment of in-flight emergencies. A database can be helpful to record and analyze relevant in-flight emergencies. Acknowledgments We thank Lisa Tauszig for her corrections in the manuscript. We would like to thank the airline companies that participated in this study: Air Berlin PLC & Co. Luftverkehrs KG; Augsburg Airways; Avanti Air; Cirrus Airlines; Condor Flugdienst GmbH; Contact Air Flugdienst GmbH & Co. KG; Eurowings GmbH; Germania Fluggesellschaft mbH; Germanwings; Lufthansa (incl. Lufthansa Cityline); TUIfly; WDL Aviation; and XL Airways Germany. Declaration of Interests None of the authors have a conflict of interest with material mentioned in this study. There is also no or indirect relationship between any of the authors and the airline companies reported. This study was supported by a grant from The German Society for Aviation and Space Medicine (DGLRM). References 1. Graf J, Stüben U, Pump S. In-flight medical emergencies. Dtsch Aerztebl Int 2012; 109:591–602. 2. Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009; 373:1067–2077. 3. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med 2013; 368:2075–2083. 4. Statistisches Bundesamt. 2011: 9,3 Millionen mehr Flugpassagiere als 2010 [in German]. 2012. Available at: https://www.destatis.de/DE/PresseService/Presse/Press emitteilungen/2012/02/PD12_059_464pdf.pdf?__blob= publicationFile. (Accessed 2012 Apr 7) 5. Dowdall N. Is there a doctor on the aircraft? Brit Med J 2000; 321:1336–1337. 6. Sand M, Bechara FG, Sand D, Mann B. In-flight medical emergencies. Lancet 2009; 374:1062–1063. 7. Qureshi A, Porter KM. Emergencies in the air. Emerg Med J 2005; 22:658–659. 8. Hinkelbein J, Spelten O, Wetsch WA, et al. Emergencies in the sky: in-flight medical emergencies during commercial air transport. Trends Anaesth Crit Care 2013; 3:179–182. 9. Cummins RO, Schubach JA. Frequency and types of medical emergencies among commercial air travellers. JAMA 1989; 261:1295–1299. 10. Ruskin KJ, Hernandez KA, Barash PG. Management of in-flight medical emergencies. Anesthesiology 2008; 108:749–755. 11. Europäische Union. VERORDNUNG (EG) Nr. 859/2008 DER KOMMISSION vom 20. August 2008 zur Änderung der Verordnung (EWG) Nr. 3922/91 des Rates in Bezug auf gemeinsame technische Vorschriften und Verwaltungsverfahren für den gewerblichen Luftverkehr mit Flächenflugzeugen. Amtsblatt der Europäischen Union. 2008 Sep 20;L254:1–238
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