Aviation Medical Assistance Act of 1998
A Review for the One Health Academy
Woody Davis, MD, JD, FCLM
The views expressed in this presentation are those of the Presenter
and do not necessarily represent those of the United States
Government including the Federal Aviation Administration
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March 11, 2010
CNA Analysis & Solutions
Nobody Gets Closer…
To the People
To the Data
To the Problem
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March 11, 2010
Company Profile
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Not-for-profit
Across government
Over $100 million in revenues
Over 600 professional staff
– 70% PhD’s
– 92% with advanced degrees
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March 11, 20103
Primary Capability Areas
Acquisition
Exercises and Training
Logistics
Operations Analysis and
Field Engagement
Regional Security
Concept Development
and Program Evaluation
Policy Analysis
Resource and Workforce
Management
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March 11, 20104
Projects CNA is Currently Supporting at FAA
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Sector Design and Analysis Tool
(SDAT)
Offload Metrics
Airports Geographical Information
System (GIS)
Temporary Flight Restriction (TFR)
Builder
ICAO Standards
Digital NOTAMs
NASR Tool Development
Business Process Analysis
Enterprise Architecture
Ad hoc analysis
SysOps Budget development
Operational Support and Analysis to
FAA Crisis/Emergency/Security
Response Efforts
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ISO 9001-2000 Quality Management
System (QMS) Certification
Aeronautical Information Exchange
Model (AIXM)
Operational Evolution Program
NAS Strategy Simulator
User Request Evaluation Tool (URET)
Traffic Management Advisor (TMA)
Aeronautical Information Management
/ System Wide Information
Management (AIM/SWIM)
NextGen Program Support
NextGen Air Traffic Policy and
Strategy Development
Agency Policy Development
Acquisition Support
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March 11, 2010
Aviation Medical Assistance Act of 1998
[Pub. L. 105-170, 49 USC 44701, April 24, 1998]
Background
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US Airline Emergency Medical Equipment
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March 11, 2010
Passenger Travel Predictions
• (US enplanements)
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–
–
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1997 - 599 million enplanements
1998 - 614 million enplanements
2009 - 704 million enplanements
2030 - est. 1.2 billion enplanements
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March 11, 2010
Rationale
• Aging Population
– U.S. Census Bureau Estimates
Population, All Ages
1997
2005
2015
2025
267,645
285,981
310,134
335,050
(in 1,000s)
Median age (yrs.)
Mean age (yrs.)
15 to 44 years
65+ years
85+ years
34.9
36
36.6
37.2
37.3
38.4
38
39.5
44.78%
12.74%
1.44%
41.76%
12.65%
1.71%
39.26%
14.69%
2.00%
38.59%
18.49%
2.10%
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March 11, 2010
American Heart Association
• “Chain of Survival”
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Early Access
Early CPR
Early Defibrillation
Early Advanced Cardiac Care
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March 11, 2010
Approximately
360,000 Americans
every year, typically
those 41-65 years old,
suffer cardiac events.
Survival can be as
high as 90 percent
(in certain
circumstances) if
defibrillation is
provided during the
first minute after
collapse
The most common
form of death from a
cardiac event is
“ventricular fibrillation”
which is treatable with
defibrillation
For every minute that
defibrillation is
delayed, survival falls
about 10 percent,
dropping below 50
percent after 6
minutes
Defibrillation is usually
more effective than
CPR in sustaining life
in certain situations
Statistically, survival
after out-of-hospital
cardiac arrest
increases by 33
percent when
emergency medical
services arrive with
cardiac defibrillators
within 8 minutes
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March 11, 2010
Automatic External Defibrillators
• Available since early 1980s
• First approved by FDA for U.S. airline use in
1996
• Several Manufacturers
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March 11, 2010
Automatic External Defibrillators
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Portable
Easy to use
Limit operator decisions
Automatically interpret heart rhythm
Automatically determine if shock is needed (whether
rhythm is VF)
• Advise operator to shock if necessary
• AED records ECG
– Can be analyzed by cardiologist
– Possible to review incident
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Statute Rationale
• Increased Travel by more Passengers
• Aging Population
• In-flight environment among worst for suffering a
serious medical event  Cardiac Events
• No modifications to FAA regulations since 1986
requiring First Aid Kits and “ Doctor Only Kits”
• AED carriage required enhanced EMKs and training
(e.g., CPR) in addition to First Aid Kits
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Rationale Continued
• No AED
• Only basic crewmember emergency training
– illness, injury, or abnormal situations
– familiarization with the First Aid Kit
• First Aid Kit plus “Doctor Only” Medical Kit
• No Good Samaritan provisions
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Enhanced Medical Kit
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FAA Response to the Aviation Medical
Assistance Act of 1998
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Act Directed FAA
• Evaluate:
– Equipment required to be carried in air carrier EMKs
– Emergency medical training required of flight attendants
• Collect data (for 1 year) on: in-flight medical
emergencies that result in death or threat of death and
any such information as necessary to determine whether
AED’s should be carried on board air carriers 7500 lbs or
more and
• Issue:
– An NPRM to require enhancements (120 days after the data
collection)
– A recommendation to Congress for legislation
– A notice to explain why action not necessary
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Good Samaritan Provision
• Good Samaritan provision included to limit
from liability:
– Air carriers (in obtaining or attempting to
obtain the assistance of a passenger in
an in-flight medical emergency)
– Individuals (in providing or attempting to
provide assistance in an in-flight medical
emergency)
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March 11, 2010
FAA determined that there would be no
FAA requirement for certificated airports
to have AEDs.
SEE:
NOTICE OF DECISION (65 FR 35971)
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Data Results
• Data collection conducted July 1, 1998 to
June 30, 1999:
– “In-Flight Medical Event Report” /1-page
checklist (OMB approved)
– ATA distributed the forms and collected input
for the FAA on a quarterly basis
– Up to 15 different ATA-member airlines,
carrying approx. 85% of U.S. domestic airline
passengers contributed data
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Reporting ATA-member carriers
• AED’s and enhanced medical kits carried at time of survey
– Alaska
– Aloha
– America West
– American
– Continental
– Delta
– Hawaiian
– Midwest Express
– Northwest
– Southwest
– United
– UPS
– US Airways
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108 total reported deaths
• 97 deaths on aircraft:
 Cardiac
 Respiratory
 Cancer
 Loss of Consciousness
 Unknown cause
• 11 deaths not on aircraft:
 Cardiac (jetway)
 Cardiac (terminal)
 Cardiac (other)
 Cancer (jetway)
 Unknown cause (jetway)
64
9
4
1
15
3
5
1
1
1
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March 11, 2010
Data Collection Results
• Airline Data collection results reported to FAA:
– 188 total death or threat-of-death incidents
 177 events occurred on aircraft, either in flight, at the gate, or
while taxiing
(an average of 44 events every quarter on the aircraft;
approximately 3 per week)
 10 events in the jetway or in the terminal
 1 event in a taxicab
• Other reports in literature:
– Inflight medical emergencies occur at a rate of 20 to 100 per
million passengers, with a death rate of 0.1 to 1 per million
– The precise incidence of inflight medical emergencies is
unknown. There is no uniform or required reporting system, and
flight crews do not routinely report minor medical incidents that
do not require ground support.
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March 11, 2010
Limitations
• No method of confirming that all events were
recorded
• Multiple variations of the form were submitted
• Limited data form used to reduce burden
• Non-medically trained personnel likely
completed the form, accuracy
may be an issue
• Forms sometimes incomplete
• Events sometimes difficult to categorize
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AED Usage
• Average age of passengers: 62
• 17 reported events where passengers
administered at least 1 shock
• 4 possible saves
• 19 reported events of AED “not available” with
death outcome reported
• CPR performed: 82 events
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March 11, 2010
Emergency Medical Kit Usage
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Nitroglycerin used 6 times (already required)
Epinephrine used 6 times (already required)
IV Saline used 1 time (not currently required)
Atropine used 1 time (not currently required)
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March 11, 2010
What the data tells us
• In-flight medical events occur, although relatively
infrequently
• Certain medical interventions might change the
outcome of certain events
• Death occurs on air carriers
• AED’s possibly resulted in a positive outcome for
4 reported events; possibly could have changed
the outcome for 19 events where they were
reported “not available”
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March 11, 2010
Summary of FAA Decision
• Carry one AED on board each airplane weighing 7,500 lbs. or more
and serviced by at least one flight attendant
• Require initial and recurrent (every 24 months) training for flight
attendants on AED usage and in CPR
• Require initial training for pilots on the location of the AED and its
instruction set
• Enhance EMKs to include the following medications:
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Oral antihistamine
Aspirin
Bronchodilator
- Non-narcotic analgesic
- Atropine
- Lidocaine
• Enhance EMKs to include the following equipment:
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IV administration kit
(alcohol, sponges, tape, tape scissors, tourniquet)
An ambu bag w/ 3 masks
CPR masks
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March 11, 2010
Airlines
• All US certificated Domestic airlines that require at least flight
attendant have since 2005 been required to have certain
equipment and trained flight attendants to meet the requirements
of 49 CFR part 121, subpart X (sections 801, 803, 805). (Excerpts
follow)
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March 11, 2010
Sec. 121.801 Applicability
• This subpart prescribes the emergency medical
equipment and training requirements applicable to all
certificate holders operating passenger-carrying
airplanes under this part. Nothing in this subpart is
intended to require certificate holders or its agents to
provide emergency medical care or to establish a
standard of care for the provision of emergency medical
care.
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Sec. 121.803 Emergency medical equipment
•
(a) No person may operate a passenger-carrying airplane under this part
unless it is equipped with the emergency medical equipment listed in this
section. (b) Each equipment item listed in this section-- (1) Must be
inspected regularly in accordance with inspection periods established in the
operations specifications to ensure its condition for continued serviceability
and immediate readiness to perform its intended emergency purposes; (2)
Must be readily accessible to the crew and, with regard to equipment
located in the passenger compartment, to passengers; (3) Must be clearly
identified and clearly marked to indicate its method of operation; and (4)
When carried in a compartment or container, must be carried in a
compartment or container marked as to contents and the compartment or
container, or the item itself, must be marked as to date of last inspection. (c)
For treatment of injuries, medical events, or minor accidents that might
occur during flight time each airplane must have the following equipment
that meets the specifications and requirements of appendix A of this part:
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March 11, 2010
Sec. 121.805 Crewmember training for in-flight
medical events
•
(a) Each training program must provide the instruction set forth in this
section 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. (b) Training
must provide the following: (1) Instruction in emergency medical event
procedures, including coordination among crewmembers. (2) Instruction in
the location, function, and intended operation of emergency medical
equipment. (3) Instruction to familiarize crewmembers with the content of
the emergency medical kit. (4) Instruction to familiarize crewmembers with
the content of the emergency medical kit as modified on April 12, 2004. (5)
For each flight attendant-- (i) Instruction, to include performance drills, in the
proper use of automated external defibrillators. (ii) Instruction, to include
performance drills, in cardiopulmonary resuscitation. (iii) Recurrent training,
to include performance drills, in the proper use of an automated external
defibrillators and in cardiopulmonary resuscitation at least once every 24
months. (c) The crewmember instruction, performance drills, and recurrent
training required under this section are not required to be equivalent to the
expert level of proficiency attained by professional emergency medical
personnel.
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March 11, 2010
Appendix A to Part 121--First Aid Kits
2. Except as provided in paragraph (3), each approved first-aid kit must contain at least
the following appropriately maintained contents in the specified quantities:
Adhesive bandage compresses, 1-inch ............................... 16
Antiseptic swabs .................................................................. 20
Ammonia inhalants .............................................................. 10
Bandage compresses, 4-inch................................................ 8
Triangular bandage compresses, 40-inch.............................. 5
Arm splint, non-inflatable ....................................................... 1
Leg splint, non-inflatable ........................................................ 1
Roller bandage, 4-inch.......................................................... 4
Adhesive tape, 1-inch standard roll........................................ 2
Bandage scissors .................................................................. 1
3. Arm and leg splints which do not fit within a first-aid kit may be stowed in a readily
accessible location that is as near as practicable to the kit.
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March 11, 2010
Appendix A to Part 121--Emergency Medical Kits
Sphygmomanometer............................... 1
Stethoscope.................................... 1
Airways, oropharyngeal (3 sizes): 1 pediatric, 3 1 small adult, 1 large adult or equivalent
Self-inflating manual resuscitation device with 1:3 masks 3 masks (1 pediatric, 1 small adult, 1 large adult or
equivalent).
CPR mask (3 sizes), 1 pediatric, 1 small adult, 3 1 large adult, or equivalent.
IV Admin Set: Tubing w/ 2 Y connectors......... 1
Alcohol sponges............................ 2
Adhesive tape, 1-inch standard roll 1 adhesive.
Tape scissors.............................. 1 pair
Tourniquet................................. 1
Saline solution, 500 cc........................ 1
Protective non-permeable gloves or equivalent... 1 pair
Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes 6 necessary to administer required medications).
Syringes (1-5 cc, 2-10 cc, or sizes necessary 4 to administer required medications)
Analgesic, non-narcotic, tablets, 325 mg....... 4
Antihistamine tablets, 25 mg................... 4
Antihistamine injectable, 50 mg, (single dose 2 ampule or equivalent).
Atropine, 0.5 mg, 5 cc (single dose ampule or 2 equivalent).
Aspirin tablets, 325 mg........................ 4
Bronchodilator, inhaled (metered dose inhaler 1 or equivalent).
Dextrose, 50%/50 cc injectable, (single dose 1 ampule or equivalent).
Epinephrine 1:1000, 1 cc, injectable, (single 2 dose ampule or equivalent).
Epinephrine 1:10,000, 2 cc, injectable, (single 2 dose ampule or equivalent).
Lidocaine, 5 cc, 20 mg/ml, injectable (single 2 dose ampule or equivalent).
Nitroglycerin tablets, 0.4 mg.................. 10
Basic instructions for use of the drugs in the 1 kit.
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March 11, 2010
Appendix A to Part 121-- Automated External Defibrillators
At least one approved automated external defibrillator, legally marketed
in the United States in accordance with Food and Drug
Administration requirements, that must:
1. Be stored in the passenger cabin.
2. 2. Meet FAA Technical Standard Order requirements for power
sources for electronic devices used in aviation as approved by the
Administrator.
3. 3. Be maintained in accordance with the manufacturer's
specifications.
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March 11, 2010
In Conclusion
• First Aid kits are used; although infrequently; EMKs more frequently
but mainly stethoscope and blood pressure cuff. AED use occurs
but most recent reports indicate use on ground
• Diversions are still occurring: Rate of emergencies reported about 1
to 4 per 10,000 passengers with diversions (@$3000-$50,000)
approximately 200 per million flights or approximately 1 per 10
reported emergency.
• About three quarters of in-flight medical emergencies are managed
by cabin crew or passengers. Inflight medical support (e.g. MedLink)
common. Few if any reports under 42 USC § 264
regulations.
• The range of equipment and drugs on board varies but can be
extensive
• Medical personnel who volunteer to help the crew manage an
incident should remember to “do no harm” and practice within the
limits of their training and knowledge
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March 11, 2010
Etihad Adopts Telemedicine Technology
In April, Etihad Airways will begin introducing the Tempus IC health
monitoring system across its long- and ultra-long-haul fleet. In the event a
passenger develops a medical problem in flight, the Remote Diagnostic
Technologies (RDT) system enables crewmembers to gather vital
diagnostic information about the individual—such as blood pressure (see
photo), glucose readings and electrocardiograms— as well as to take
photographs.
The data, in turn, is transmitted to medical experts on the ground who could
advise the crew how best to treat the passenger until the aircraft lands and
the passenger can be transported to a medical facility. Etihad plans first to
deploy the system during the second week of April on all flights to the U.S.
and then roll it out across the remainder of the long-haul fleet. Basingstoke,
England-based RDT specializes in developing diagnostic device technology
for use by non-medical experts in remote locations, such as cargo ships and
oil rigs.
Aviation Week & Space Technology Mar 08 , 2010, p13
Tempus 1C Health Monitoring System
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March 11, 2010