My experience as a flight attendant traveling the world opened my eyes. When I look back at this experience as an LLM graduate of the University of Minnesota Law School, I find it shocking. My first question is: Do you think your life can be measured by the price you pay for an airline ticket? People would like to say it should not. Unfortunately, my experience working as a flight attendant proved to me that it is. While airplane crashes make headline news, more people die from cardiac arrest mid-flight. The equipment that could save lives is not mandatory across international borders. This should make headline news.
I joined a low-cost carrier based in the United Arab Emirates in 2007. It was one of the fastest-developing airlines in the Middle East. It was popular because of its low cost. I completed many training courses required by the General Civil Aviation Act (GCAA1), including safety, security, and first aid, before getting on board to work as a licensed flight attendant. The first aid training was the hardest. I had to memorize all the signs and symptoms of disease that frequently occur during flight and how to deal with them as a first aider. I spent a considerable amount of time practicing Cardiopulmonary resuscitation (CPR2) After passing the battery of tests, I was permitted to work as a flight attendant. After one year of work as flight attendant, one of our passengers died on board due to a heart attack. This had an immense impact on me emotionally. While CPR was administered during flight and upon landing, the passenger did not survive. As I became more senior, the incident vanished from my memory. There were so many flights and so many passengers; it all become a blur to me.
After flying with a low-cost carrier for two and a half years, I had the good fortune to join one of the premier airlines in the world. It was famous for its luxurious flight and expensive first-class suites and was often ranked best in class by Skytrax3.
Like the low-cost carrier, I had to take the training courses before I was able to begin my employment. However, it was easier this time because I found the safety and security procedures to be very similar, since both companies operated flight with Airbus aircrafts. The part that was remarkably different was not necessarily the training related to safety and security but, rather, the equipment. While items like the First Aid Kit and Emergency Medical Kit (“EMK”4) were similar5, it was the other life-saving medical equipment that was remarkably different.
First-Class Medical Support at 39,000 Feet vs. Budget Low-Cost Carriers
The most interesting part was the service of remote emergency response centers. A state-of-the-art telemedicine monitor that includes an automated blood pressure cuff, glucometer, thermometer, capnometer, and pulse oximeter could transmit information (including digital picture and video) to a ground-based physician. The device provides on-screen, step-by-step instruction on how to use the diagnostic features, enabling even the flight attendant to provide essential medical monitoring. The airline company always encouraged us to use this medical service for passengers because it was much more effective, even though it was substantially more expensive.
The second major difference was the medical equipment known as the Automated External defibrillator (“AED.”6) Although I was trained to administer CPR on both carriers, the luxury airlines trained their flight attendants to properly administer the AED. This equipment is much more effective in saving the lives of heart attack passengers than CPR. According to the American Heart Association, the survival rates of cardiac arrests that occur outside of hospitals nearly doubles when the AED is administered in addition to CPR. I was reminded of the passenger who died on board on the previous airline. I couldn’t stop thinking about how the passenger might have survived if the low-cost carrier had had the AED machine and the service of a remote emergency response center on board. Is the benefit of a low-cost ticket the price we pay for the airline to not invest in life-saving medical devices?
Rules that Govern What Medical Equipment Must be On Board
Requirements regarding medical equipment on board, including AED and Medical Kit, vary depending on the country. Unfortunately for international travelers, the legislation that mandates AED machines on aircrafts worldwide is spotty at best. Many countries don’t require them at all, despite the considerable number of cardiac arrests that occur midflight each year. The FAA7 requires all American commercial airlines weighing 7,500 pounds or more and serviced by at least one flight attendant to carry an AED and an enhanced emergency medical kit. AED use during the commercial flight environment has been validated as safe and effective.8 However, the AED machine is not mandatory on airplanes flying within European airspace. There is no strict requirement for operators, only a recommendation based on the result of a risk assessment. Some countries, like Ghana, make AED mandatory, but only partially. The Ghanaian Civil Aviation Authority requires that aircrafts with passenger configurations of greater than 100 passengers should carry at least one AED on flight segments lasting more than 5 hours; extended range operations; and other flight operations where alternate airports may not have adequate emergency medical facilities. Furthermore, it clearly states that the carriage of AED for other flights should be determined by operators on the basis of a risk assessment that takes into account the particular needs of the operations.9
Moreover, all United States airlines are required to carry the standard kit, and many supplement its contents with additional equipment and medication. There are, however, no international regulations requiring a complete kit to be available overseas. The International Air Transport Association (IATA10) does not regulate the contents of emergency medical kits of international airlines, though it does endorse the Aerospace Medical Association’s (AsMA)11 recommendations12. An international study that evaluated the medical kits used by 32 European airlines revealed a high degree of variability; several kits were evaluated to be inadequate to administer emergency care.13
Are You Safe at 39,000 Feet?
The price of an airline ticket varies, not just between First Class and Economy but even among Economy fares. Most passengers don’t realize that an expensive air ticket would provide not only a higher quality meal but also better medical equipment. I can’t say conclusively that an expensive air ticket guarantees you better medical services with state of the art medical equipment on board. What I can say, at least from my experience, is that higher-cost airline companies spend a lot of money to offer better medical services, such as a remote emergency response center and AED. These devices also require a considerable yearly investment in maintenance. While it is difficult for passengers to find out what medical equipment is available on board before paying for an air ticket, you can only assume that the more you pay, the greater the likelihood you will receive better medical services on board. In other words, if you are flying somewhere in Europe or southeast Asia on a budget airline, it is highly possible that your flight will not come equipped with certain life-saving medical device, like an AED. Since there are no mandatory requirements under IATA across international airspace borders, travelers should beware. While I believe that all travelers should be equal and receive the highest level of medical treatment available, without legal mandates, the economics of air travel will determine if you die on flight. This sounds harsh, but it is the brutal reality. While the media is obsessed with scaring the public about airplane crashes, it should instead focus more on the lack of standards related to medical equipment on board flights. This is a more likely threat than airplane crashes, which rarely occur. Your life shouldn’t depend on which airline you fly and whether or not the carrier invested in certain life-saving medical equipment. Safety must be mandatory.
- General Civil Aviation Act
- Cardiopulmonary resuscitation
- Skytrax (originally known as Inflight Research Services) is a United Kingdom – based consultancy which runs an airline and airport review and ranking site. Skytrax conducts research for commercial airlines, as well as taking surveys from international rate cabin staff, airport, airlines, airlines lounge, in-flight entertainment, on-board catering, medical equipment and several other elements of air travel.
- Emergency Medical Kit
- First aid kit contains only basic equipment, such as bandages and pain killer and the EMK which was envisioned by the FAA to be more of doctor’s kit, provides a considerable range of emergency pharmaceuticals and devices that EMT-Intermediates and paramedics would be familiar with.
- An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm. AEDs are used to treat sudden cardiac arrest (SCA). SCA is a condition in which the heart suddenly and unexpectedly stops beating.
- Federal Aviation Administration
- Use of automated external defibrillators by a U.S. airline.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL, Ramaswamy K, Barbera SJ, Hamdan MH, McKenas DK
N Engl J Med. 2000 Oct 26; 343(17):1210-6.
- Advisory Circular AC 06-300
- International Air Transport Association
- the Aerospace Medical Association
- Equipment stocked in “emergency medical kits” is not mandated by any international aviation body, although the International Air Transport Association (IATA), the Aerospace Medical Association (AsMA), and the International Civil Aviation Organization (ICAO) have agreed upon standardized recommendations
- Emergency medical kits on board commercial aircraft: a comparative study. Sand M, Gambichler T, Sand D, Thrandorf C, Altmeyer P, Bechara FG Travel Med Infect Dis. 2010 Nov; 8(6):388-94.