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eganist

With regards to the kit which was not aboard the plane, I have a few quick questions from anyone in the know.

Missing were:

- Aspirin

- Nitroglycerin

- Masks

- Fluid cleanup kits

- Airways

I'm assuming the latter three are one-time-use. I'm assuming the former two have expiration dates. Does anyone have info on how often these items might be used aboard flights and/or actually reach their expiration dates?

I'm asking specifically to see how much money is saved by not stocking up and simply assuming that the resulting lawsuits and fines are cheaper than keeping kit stocked. I simply can't attribute this kind of neglect to human error. Someone has to have done the math on this.

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The medical kits in the US are usually quite extensive [1] (and even more so on long-haul flights into Europe), and I've never heard of someone running into a half-stocked one before. Often airlines will carry more than one so that if the first one gets used (even if one item from it gets used), they still have a second one on board to meet the letter of the FAA mandate. From the FAA: "If the air carrier elects to have only one AED and one EMK on board, if that AED is inoperative or that EMK is incomplete, the aircraft may not be dispatched."

Most of the meds have an expiry date of at least a year. Most airlines contract with someone like Banyan who handles supplying and refilling/recertifying the medical kits.

[1] https://www.acep.org/Clinical---Practice-Management/Emergenc...

The list of mandatory supplies is longer than that; those were probably just the ones this particular doctor was looking for. As of April 12, 2004 the FAA requires an emergency medical kit containing 25 specific items (https://www.law.cornell.edu/cfr/text/14/part-121/appendix-A).

Given the general markup on anything certified for use in aviation, I suspect the cost is on the order of $1000 / year / plane; my guess is that the EMK had been used and not restocked rather than Delta deliberately understocking medical supplies.

That is essentially as bad. They're running an airline - a business predicated on checking everything when you land a plane. Not restocking life-saving emergency medical items after use is inexcusable.

Not defending them but it could be possible the plane had a quick turnaround and the crew in charge of checking failed. I've had flights where they didn't even get the cleaning or catering crew in.

Honestly if a flight is that tight to schedule they should just delay to make sure everything is right.

If you're a FA and the emergency medical kit gets used on the flight, I imagine you would remember that when the plane lands. Forgetting that you had an emergency on board and not restocking the kit takes an incredible amount of thoughtlessness.

It could also have been pillaged by a drug addict. The check list may be "Check the medical kit is in board", and only checking the contents every 10 flights. Quite a low probabiliy that this happens together with a myocard problem and a problematic flight attendant, though.

> the crew in charge of checking failed

What other checks might have been missed? Fuel? Flap-setting? Doors are closed?

Cleaning and catering are not legal requirements to ensure the safety of the flight, unlike FAA-mandated equipment.

It's probably not "rechecking" but having it replaced once it's used (it's obvious to the crew when that happens)

And maybe there's a periodic recheck, but not every rotation

> checking everything when you land a plane

And critically, before you take off. This is what checklists are for.

This instantly brings to mind contract beacons in performer's agreements with facilities.

Checking for green M&Ms is a lot easier than individually inspecting grounding for all electrical work.

If the med kit's being shorted or overlooked, what else is?

I responded to a few in-flight emergencies on international flights. Each airline has its own idea of what should be in the emergency kit, and there really no standards/regulations that I am aware of.

Aspirin is easy to ask for from other passengers. Same with Nitro : either the patient IS known for angina, and usually has his own, or he's not, and I would not suggest giving nitro "just in case" with the disastrous side effects it can have.

Airways are mostly useless.

Are you in the US? The FAA has a strict set of minimum medical equipment for each flight with a flight attendant. [1][2]. European regulations require a lot more but don't actually apply to most flights in Europe as they only require an EMK for flights going more than 60 minutes from any airport. Even then, it seems like many European airlines carry a lot more than their American counterparts, though less than the ICAO recomendations [3]

[1] https://www.law.cornell.edu/cfr/text/14/part-121/appendix-A

[2] http://www.faa.gov/documentLibrary/media/Advisory_Circular/A...

[3] http://www.sciencedirect.com/science/article/pii/S1477893910...

I'm in Canada.

That being said, I've review your first link, and I'm not impressed.

* Sphygmonanometer = useless. You can't hear fuck. Just taking the pulse is accurate enough in life or death circumstances.

* Stethoscope = almost useless. You can't hear fuck. Might want to use to confirm a suspicion of pneumothorax.

* Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though

* CPR mask. If he's coding in the plane, he's dead.

* Saline solution, 500 cc. As good as two glasses of (holy) water by mouth.

* Protective nonpermeable gloves or equivalent. Good ! Should have at least four of those.

* Analgesic, non-narcotic, tablets, 325 mg = Tylenol. Who cares

* Antihistamine injectable, 50 mg. Why ??? Not more potent than any cheap oral antihistamine.

* Bronchodilator. Good

* Epi. Good. But they should not have two different concentrations to confuse people.

* Lidocaine. Have no idea why anyone would want that.

> Sphygmonanometer = useless. You can't hear fuck.

A systolic pressure is still a useful datapoint. If you want to get a diastolic pressure, see if you can't track down a paramedic (a modern widebody jet isn't much louder than the back of a rig).

> Stethoscope = almost useless. You can't hear fuck.

See above...

> Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though

Most people don't know how to use any of this stuff... That's why they page for a doctor...

> Saline solution, 500 cc. As good as two glasses of (holy) water by mouth.

That's enough to make a difference for a preload sensitive heart failure pt.

> Analgesic, non-narcotic, tablets, 325 mg = Tylenol. Who cares

Someone in pain?

> Lidocaine. Have no idea why anyone would want that.

As an antiarrhythmic, I'm sure. A "hail mary pass" at best, but worth a shot, I guess.

>> Airways, oropharyngeal. Most people don't know how to use those. Might be useful, though

> Most people don't know how to use any of this stuff... That's why they page for a doctor...

In Australia we teach OPAs in Advanced First Aid (not the first aid certification that most people get, but it's a component of the training that workplace first aid officers at any large business must undertake). I'm not sure whether flight attendants are required to undergo that training but it would not be unreasonable to make them.

Of course, as you say, when you can page for a doctor...

> Sphygmonanometer = useless. You can't hear fuck. Just taking the pulse is accurate enough in life or death circumstances.

Seems like a digital blood one would be fine?

> Antihistamine injectable, 50 mg. Why ??? Not more potent than any cheap oral antihistamine.

No more potent, but faster acting, no? Seems like a good idea for anaphylactic shock?

Antihistamines will not reverse anaphylaxis. If the patient has progressed to anaphylactic shock, they need epinephrine (and you might as well give them the half liter of fluid in the kit as well).

> but faster acting, no?

Not really. Even regular tablets begin to act in 20 min, even faster with the sublingual ones.

> Seems like a good idea for anaphylactic shock?

A very bad one, actually. Some people might want to give an antihistamine first (completely useless in anaphylaxis, by the way), and see what happens, instead of going straight to epi.

When you cannot know the provider's experience, its better to assume for the worse, and give one, and one only choice = EPI.

I don't quite trust a digital BP cuff. Airplanes aren't really loud at all. I've done vitals in the middle of louder crowds or in the back of a rig.

Anaphylaxis is only treatable with epi and fluids.

Nitroglycerin has a fairly short half life and doesn't love being exposed to air. Aspirin like any drug has a shelf life but not an unusually short one. Masks etc are going to have an expiration but unless the package is damaged are likely fine. Airways being invasive require closer management. Tetracycline is one of the few drugs that I am aware of that most practitioners will not use past expiration because of reports in the literature that old tetracycline caused kidney damage.

There are well defined SOPs in healthcare for when a sealed kit is opened. It is taken out of service, restocked, QCd, and returned to service. There was no mention of O2 administration in this article but the oxygen kit also requires routine checks and maintenance.

The biggest issue with airways is making sure the blade has batteries. Had a guy show up to a doc-in-a-box I was staffing and they had a full complement of tubes and blades, but no batteries. That is one time you really want batteries.

I doubt this is the result of any conscious optimization process. If it were, it would have been turned into a profit center - eg aspirin billed at $100/pill to the passenger who "requested" it. Who wouldn't want to get in on the hospitals' racket?

IIRC, passengers don't get to request anything. The kit stays closed, except for medical professionals. For good reasons - handing out meds likely entails liabilities, and no airline wants that.

That's why I put "request" in quotes. The patient is unable to request anything; the doctor is doing it on their behalf.

More likely: what's being optimised are cabin check proceedures between flights, or reporting cases / incidences of use. Possibly also raiding of supplies by parties with access -- cabin crew or cleaners would be highest on my list.

But the point remains: Delta initiated a 17h flight with a lethal head flight attendant and a half-stocked medical kit, and have failed to follow-up on the incident. I'd like to see the FAA's incident report.

Don't ask how I know this: Nitroglycerin tablets come in a tiny, sealed glass jar. It's a weird little container. So I wonder if it's short-lived in air / humidity. If so, then replacing it periodically might be the prudent thing to do.

Even at my workplace, which is a much more tame environment, somebody goes around and checks the contents of the first aid kits that are located around the buildings, periodically.

> tiny, sealed glass jar. It's a weird little container.

I believe that's referred to as an 'ampoule.'

https://en.wikipedia.org/wiki/Ampoule

Many whole aircraft have been lost to human error, most often outside the cockpit. I don't think it's too hard to believe as a reason for the medical kits not being restocked.

I don't know about nitoglycerin, but aspirin expiration dates aren't really "hard" ones; you can basically ignore them.

This might be true, but it also wouldn't surprise me if regulations said "replace expired items."

Some government agencies have saved a lot by holding onto "expired" medications.

http://www.wsj.com/articles/SB954201508530067326

Nice. I'm not sure I'd trust military research all that much given how the VA has to deal with the aftermath of defects in medical policies and research by the DoD, but hey at least someone's researching it.

VA hospitals generally support university research, not military research. The military has their own hospitals and more importantly their own field casualty care systems. Source: I am a physician researcher at a military medical center.

As far as trusting research, you can probably find a good solid reason to distrust any research. Whatever your politics you can probably find something you disagree with about any given funding agency. But in that case we should just revert to our Neanderthal selves and solve all of our problems with clubs. What you should be doing is thinking critically about the introduction and method section And comparing them to the results. If you're in the field, you should know the authors or at least something about them and their methods.

Some things - adrenaline comes to mind - have a very short time frame until expiration and frequently newer atock isn't available when ordered. I assume expired stock is often used.

Is medical nitroglycerin different than the explodey kind?

Chemically? No. It's just a very small amount (a few hundred micrograms), mixed with a lot of 'filler'.

The actual molecule is not.

In medical use you don't use pure nitroglycerin; you typically dilute it with other stuff. For example https://en.wikipedia.org/wiki/Nitroglycerin_(drug)#/media/Fi... shows that the IV solution is 40mg of nitroglycerin per 100 mL of solution, or about .04% by mass. I doubt it's very explodey.

Of course even if you want to explode stuff you normally don't use pure nitroglycerin either, because it's _too_ explodey. According to https://en.wikipedia.org/wiki/Dynamite#Form dynamite is 20-60% nitroglycerin nowadays. Still a lot more than 0.04%.

As my siblings are saying, the same molecule but different concentration. This is the reason why you should handle dynamite in gloves: otherwise you absorb nitroglycerin through skin, lower your BP and faint.

Dynamite is trinitrotoluene. Not nitroglycerin. Totally different biological activity.

Excuse me; I don't think so. TNT is trinitrotoluene. Dynamite is a mixture of nitroglycerin, absorbents, and stabilizers.

sounds like an IV PPI would have been highly useful here as well

Today I learned that planes carry nitroglycerin.

Yes, dozens of milligrams of the stuff...

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