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Aviation Medical Assistance Act of 1998 A Review for the One Health Academy Woody Davis, MD, JD, FCLM

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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Aviation Medical Assistance Act of 1998 A Review for the One Health Academy Woody Davis, MD, JD, FCLM

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  1. Aviation Medical Assistance Act of 1998A 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

  2. CNA Analysis & SolutionsNobody Gets Closer…To the PeopleTo the DataTo the Problem

  3. Company Profile • Not-for-profit • Across government • Over $100 million in revenues • Over 600 professional staff • 70% PhD’s • 92% with advanced degrees 3

  4. Primary Capability Areas Acquisition Exercises and Training Logistics Operations Analysis and Field Engagement RegionalSecurity Concept Development and Program Evaluation PolicyAnalysis Resource and Workforce Management 4

  5. Projects CNA is Currently Supporting at FAA • 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 • 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

  6. Aviation Medical Assistance Act of 1998[Pub. L. 105-170, 49 USC 44701, April 24, 1998]Background

  7. US Airline Emergency Medical Equipment

  8. Passenger Travel Predictions • (US enplanements) • 1997 - 599 million enplanements • 1998 - 614 million enplanements • 2009 - 704 million enplanements • 2030 - est. 1.2 billion enplanements

  9. Rationale • Aging Population • U.S. Census Bureau Estimates

  10. American Heart Association • “Chain of Survival” • Early Access • Early CPR • Early Defibrillation • Early Advanced Cardiac Care

  11. Automatic External Defibrillators • Available since early 1980s • First approved by FDA for U.S. airline use in 1996 • Several Manufacturers

  12. Automatic External Defibrillators • 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

  13. 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

  14. 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

  15. Enhanced Medical Kit

  16. FAA Response to the Aviation Medical Assistance Act of 1998

  17. 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

  18. 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)

  19. FAA determined that there would be no FAA requirement for certificated airports to have AEDs. See:Notice of Decision (65 FR 35971)

  20. 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

  21. 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

  22. 108 total reported deaths • 97 deaths on aircraft: Cardiac 64  Respiratory 9  Cancer 4  Loss of Consciousness 1  Unknown cause15 • 11 deaths not on aircraft:  Cardiac (jetway) 3  Cardiac (terminal) 5  Cardiac (other) 1  Cancer (jetway) 1  Unknown cause (jetway) 1

  23. 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.

  24. 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

  25. 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

  26. Emergency Medical Kit Usage • 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)

  27. 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”

  28. 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: • Oral antihistamine - Non-narcotic analgesic • Aspirin - Atropine • Bronchodilator - Lidocaine • Enhance EMKs to include the following equipment: • IV administration kit • (alcohol, sponges, tape, tape scissors, tourniquet) • An ambu bag w/ 3 masks • CPR masks

  29. 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)

  30. 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.

  31. 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:

  32. 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.

  33. 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.

  34. 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.

  35. 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: • Be stored in the passenger cabin. • 2. Meet FAA Technical Standard Order requirements for power sources for electronic devices used in aviation as approved by the Administrator. • 3. Be maintained in accordance with the manufacturer's specifications.

  36. 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 § 264regulations. • 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

  37. 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

  38. Tempus 1C Health Monitoring System

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