No plane should take off without an EpiPen onboard

Aug 18, 2023

By Lindsey UlinAug. 1, 2023

I was in seat 20C on a flight home this March, when I felt my throat closing. Minutes earlier, hives had appeared on my face and chest. As a physician, I knew exactly what these symptoms meant: anaphylaxis, a severe allergic reaction so precipitously fatal that putting a breathing tube down someone’s throat is sometimes necessary.

What I needed was an epinephrine autoinjector, also known as an EpiPen, but neither the airplane emergency medical kit nor any other passenger had one. The kit did have a glass vial of epinephrine, but without someone to safely administer it with a syringe it was useless. My family helplessly watched me struggle to breathe. We were still 30 minutes from landing.

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I’m alive today because another physician happened to be on my flight and knew how to safely give epinephrine from the glass vial stocked in the kit. But if this happens to you or your loved ones on a flight, you might not be so lucky. The Federal Aviation Administration must require airlines to include epinephrine autoinjectors in their emergency medical kits to save passengers’ lives.

An estimated 32 million Americans have food allergies, and each year 200,000 of them require emergency medical care. Adults can develop new allergies, as I did, though my trigger still remains unknown.

Anaphylaxis, a severe allergic reaction, is a life-threatening medical emergency and has to be treated with epinephrine as soon as possible. The glass vial of epinephrine planes carry is hard to use, and administering it safely involves multiple time-consuming steps that require medical knowledge.

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But anyone can use epinephrine autoinjectors, which take less than 10 seconds to give and commonly come with instructions, making them a safer and more practical treatment for inflight emergencies. My nearly fatal story can happen to anyone and may have a worse ending if epinephrine autoinjectors or a clinician is not onboard.

I was lucky there was epinephrine in any form onboard at all. The FAA allows planes to fly without a complete emergency medical kit onboard due to exemptions they’ve granted to airlines since 2016. A complete emergency medical kit, defined and last updated by the FAA almost 20 years ago, contains a minimum of 25 instruments and multiple lifesaving medications including epinephrine (but only in a vial form), atropine, dextrose, and lidocaine.

But airline lobbying groups or individual airlines can apply for an exemption “for use during temporary supply shortages.” Those “temporary” exemptions last for four years and can then be renewed. It’s true that epinephrine autoinjectors were in shortage beginning in 2018. The FDA tracks drug shortages online and a search for epinephrine autoinjectors shows the status as resolved which, by its definition, indicates “a situation in which the market demand is covered and no supply issues are anticipated by the manufacturers.”

As a physician, it is highly concerning that in the letter granting the 2016 exemption epinephrine is described as “a medication mainly used for cardiac resuscitation,” with no mention of anaphylaxis or allergies anywhere in the entire 13-page document. Perhaps an accurate and complete understanding of the emergency uses of epinephrine should be considered before asserting that not including it any form onboard “would not adversely affect safety.” I know from professional and personal experience this is an untrue and dangerous policy that puts all of us at risk.

The true motivation behind airlines pursuing these exemptions is likely cost, as a glass vial of epinephrine, like the one of my flight, retails for about $5, while an epinephrine autoinjector can cost up to a couple of hundred dollars. If you flew Frontier Airlines in June or July of 2017, your trip may have been one of almost 800 during which 11 of their planes flew with incomplete emergency kits that did not have any epinephrine, atropine that treats slow heart rates, or both onboard. The FAA threatened a $474,000 penalty against Frontier Airlines for continuing to fly with incomplete emergency medical kits after this was discovered, but it eventually granted it an exemption as it was not included in the airlines represented in the 2016 request.

Perspective and commentary from experts around the world

Crowdsourcing for lifesaving medications like epinephrine autoinjectors and hoping someone onboard will have had medical training is not a safe or acceptable emergency preparedness strategy. The FAA must update its emergency medical kit requirements to include epinephrine autoinjectors immediately. Too many lives are at stake in waiting for the current exemption to expire next year or worse, risking it being renewed for another four years.

The FAA’s authorization expires in September. The Federal Aviation Administration Reauthorization Act of 2023 offers a perfect opportunity to update the requirements for emergency medical kits.

Until the FAA requires epinephrine autoinjectors to be included in commercial airlines’ emergency medical kits, we all take a grave risk of losing much more than our luggage each time we fly.

Lindsey Ulin is an internal medicine resident physician at Brigham and Women’s Hospital in Boston.

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