Big Thoughts for Little Children….From 30,000 Feet

By Peter Antevy, MD – I’ll admit that I am one of those people whose mind is always working. My wheels are constantly spinning. The content in those wheels fluctuates between my family, work, new ideas, etc.

So last week as I was en route to the NAEMSP national conference in San Diego and the plane reached the 30,000 foot cruising altitude, there I was…left with my thoughts, Wifi…and two active infants in the row in front of me (thank you Southwest Airlines!)

The irony was that as we elevated beyond 10,000 feet and I reconnected to the world (thank you to whoever invented in-flight Wifi), the first email in my inbox was the link to an article about the lacking resources in medical kits for pediatric-specific emergencies on airplanes.

It was written by a pediatric emergency physician, current CEO of the American Academy of Pediatrics and former Commissioner of Health for the Commonwealth of Virginia, Karen Remley MD, MBA, MPH. While there were many parts that made me nod emphatically in agreement as I was reading, this sentence really struck a nerve.

“While most of my experiences responding to the call for a doctor during a flight have been for ill adults, occasionally I am called on to help a child. I particularly remember one late evening flight where a toddler with a very high fever began having a seizure. There were no child-sized medications or equipment available for me to help this child breathe and receive medicine to stop the seizure.”

All I could say to myself, was, “But why?” As I looked up at the two infants in the next row I reminded myself that any ability to help them would be significantly limited due to the limited resources available to me.

Through the years I have personally been called to help passengers on planes (adults and children) with things ranging from stroke to childbirth, an Ebola scare (my wife loved that one) and severe ear pain. I’ve placed AED pads (for continuous monitoring) and have had to use the emergency medical kit (EMK) while on board. The paucity of pediatric equipment and medications in the kit was disheartening. Unfortunately, like so many things in pediatrics, a bad outcome forced a change.

This past year legislation was introduced – the Airplane Kids in Transit Safety (KITS) Act – in Congress, “that would require the Federal Aviation Administration (FAA) to review the contents of emergency medical kits and update them to include appropriate medications and equipment for children if deficiencies are found.”

Sadly, the FAA hasn’t been required to update medical kits since 2004. Why isn’t it standard for all aircraft to have these crucial materials on board? It seems so obvious and more importantly, fixable.

Now I’m going to go into the weeds a bit here and dig into the specifics of what’s in the EMK currently. If that’s not your thing (and I promise I’m not offended), here’s what you need to know, and then you can skip to my summary…there’s a huge disparity in what’s on board these planes we take our kids on and what NEEDS to be on there to ensure the best possible outcomes in an emergency situation.

Ok, for those of you staying with me for this part, here we go.

This table, located on the US Government Publishing Office’s website, lists the contents of the currently required EMK: The official statement is that “as of April 12, 2004, at least one approved emergency medical kit that must contain at least the following appropriately maintained contents in the specified quantities:”

Starting from the top, there needs to be a pediatric sized blood pressure cuff (sphygmomanometer). One could always get a rudimentary systolic BP by palpating one at the radial artery, yet having a pediatric sized BP cuff is more appropriate. Next, the kit only has one pediatric sized oral airway yet has 2 adult airways (large and small). This ratio needs to be flipped and then some. The pediatric airway can accommodate oral airways of 4 different sizes (0,1,2 and 3).

Next, the needles need to be addressed. It is not clear whether these are catheters or needles, yet my inclination is that these are catheters. If so, then needles must be added so that medications can be administered intramuscularly. The syringes are available and appear to be suitable for medication administration.

The remainder of the list includes medications. The oral tablets include analgesics and antihistamines, both of which should be provided as a liquid for pediatric administration (ibuprofen, acetaminophen and diphenhydramine). The injectables (atropine, dextrose, epinephrine and lidocaine) can be used in pediatrics yet the dose will depend on patient’s weight.

I would consider the addition of an antiepileptic medication such as midazolam with a mucosal atomizer device for easy intranasal application. A certain addition should be Ondansetron (available as an oral dissolving tablet) and can be easily administered to adults or children of any age. A bronchodilator is on the list yet a spacer must be included in order to provide the medication to a pediatric patient in respiratory distress. Lastly, the consideration should be made for oral glucose (paste) for hypoglycemic children and adults.

What about AED’s? We need to be sure that all AEDs have pediatric pads along with the standard adult pads. Here is what is listed on the same USGPO website.

This is another case of the system being broken when it comes to the most vulnerable population, our children. My team has worked tirelessly over the past 5 years to rethink a pediatric resuscitation standard of care that was built on principles that have since evolved and desperately require a reset. My passion is fueled by the notion that we, as physicians, as constituents and as parents, need to do everything we possibly can to change the things that matter most. Substandard quality and archaic safety standards should not, and cannot be tolerated.

While there are committees of pediatric physicians looking at how to improve emergency medical kits, I want to hear your input. Whether you are a parent, uncle, great aunt, legislator or medical provider, your thoughts count. Let us know what you think should be included in the next version of the EMK for airplanes. And you can also contact your local congressman to tell them YOU want to see these changes made. Just visit http://m.house.gov/representatives/ and find your representative.

Thankfully we landed safely in San Diego and the overhead announcement for a doctor did not happen. As I walked off the plane behind the parents and their children (still screaming), I knew there was one thing I had to do….buy a pair of noise cancelling headphones for my next flight!