Death at 35,000 Feet: The Dirty Little Secret of Every Airline

New York (VINNEWS/Rabbi Yair Hoffman) Right now, as this article is being read, someone is dying on an airplane. They are dying in a padded seat, at cruising altitude, surrounded by two hundred strangers and a crew of flight attendants who were handed a first-aid kit that has not been meaningfully changed since 2004. And the truth is that the item that could have saved that person costs less than in-flight headphones.

A medical emergency happens on roughly one out of every 600 flights. Newer studies put it closer to one in 200. Either way, with billions of people flying each year, that adds up to thousands of emergencies every single year. 

The most common problem is fainting, which makes up about a third of all cases. Trouble breathing and nausea come next. Most passengers recover from these before the plane even lands. But some don’t.

When someone dies on a plane, it is almost always the heart. In the largest studies, sudden cardiac arrest causes close to 90 percent of all in-flight deaths, even though it is only a tiny fraction of emergencies. The people who die are usually older — the median age is about 70.

Cardiac arrest and stroke are also the events most likely to force a plane to make an emergency landing. One large review of nearly twelve thousand emergencies recorded 36 deaths, most of them happening in the air before the plane could land — roughly one death every month, from just five airlines. Across the whole industry, the real number of in-flight deaths runs from dozens to well over a hundred every year.

Here is the point that should trouble anyone: the event most likely to kill you in the air is not the event the medical kit is best prepared to handle. A kit built only for the common, mild problems will fail at the exact moment a life hangs in the balance.

What Planes Already Carry

A member of my shul where I was the Rav, was a top administrator at the Federal Aviation Administration — the agency that writes the rules for airlines.  I know that the FAA does require a sealed Emergency Medical Kit on every large U.S. passenger plane, plus a defibrillator and a basic first-aid kit. The medical kit is not empty. It holds a blood-pressure cuff, a stethoscope, breathing tubes, a hand-squeezed breathing bag with masks, a bag of IV fluid, gloves, needles, and a small set of drugs: injectable adrenaline, an antihistamine, aspirin, a painkiller, and a few heart medicines.  But those requirements are long outdated. 

But the problem is not what is in the kit. The problem is what is missing, and what only comes in adult sizes, and what the rules simply refuse to require. Below is a list of what could and should be added — and how little each item costs. (There should also be a good Samaritan law or a doctor that can be called too, but that is beyond the scope of this article.) 

Six Additions Every Plane Should Be Required to Carry

(If any medical doctor has more suggestions please contact the author)

1. An adrenaline auto-injector (like an EpiPen), in adult and child sizes. A severe allergic reaction — to a peanut, a bee sting, a shellfish dish — can close a person’s throat in minutes. The kit already has adrenaline, but only in a glass vial that a responder must draw into a syringe by hand, in bad light, on a shaking plane, with a real chance of measuring the wrong amount. An auto-injector is a simple spring-loaded pen: press it to the thigh and it delivers the exact right dose in one second. A flight attendant can use it even if no doctor is aboard. Every kit should carry one adult pen and one child pen. Cost: about $100 to $400 for a two-pack of the generic version.
2. Naloxone (Narcan) for drug overdoses. Opioid overdoses now happen everywhere, and a plane is no exception — whether from a passenger’s own medication or something worse. Naloxone is a nasal spray that reverses an overdose within minutes. If you spray it into someone who turns out not to be overdosing, it does no harm at all. It is now sold without a prescription and sits in police cars, schools, and libraries across the country. There is no good reason it is not on the plane. Cost: about $40 for a nasal-spray dose.
3. A pulse oximeter to measure oxygen. This is a small clip that slips onto a fingertip and, in seconds, shows how much oxygen is in a person’s blood. It matters enormously in the air, because the cabin is pressurized to feel like you are on a mountain 5,000 to 8,000 feet high — there is already less oxygen than on the ground. When a passenger says they can’t breathe, this cheap little clip turns a guess into a real answer, and tells the responder whether the person needs oxygen right now. Cost: about $15 to $50.
4. A glucometer to check blood sugar. Low blood sugar can look exactly like a stroke, like drunkenness, or like fainting — and it is instantly fixable once you know that’s the problem. Here is the strange part: the kit already contains sugar (dextrose) to treat it, but nothing to test for it. That is like packing the cure and leaving out the way to know when to use it. Blood sugar below 54 can cause a diabetic coma and so can blood sugar above 600. (Kits do not have insulin but that may be understandable for a number of reasons.) A glucometer is a tiny meter and a test strip that reads blood sugar from a single drop. Cost: about $20 to $40 for the meter; strips cost pennies.
5. A rescue airway device to keep breathing open. When a person is unconscious, the tongue can block the airway and cut off air. The current kit’s simple tubes are not enough for a serious case. A rescue airway — doctors call it a supraglottic airway, such as an i-gel — is a soft device that slides into place in seconds and holds the airway open. It is far easier to use than the breathing tube doctors place in a hospital, and during a long emergency landing or a heart-attack rescue, it can be the difference between air getting in and not. Cost: about $10 to $30 each; a few sizes should be stocked.
6. A wider set of basic medicines and supplies. A few cheap, long-lasting additions would cover the gaps. An anti-nausea medicine (such as ondansetron) treats the one-in-ten emergencies involving vomiting — which matters, because bad vomiting is one of the things most likely to force a plane to land. A tube of glucose gel treats low blood sugar in someone awake enough to swallow. A steroid pill (such as prednisone) helps with severe allergic and asthma attacks. And — remarkably — the rules require IV fluid but never actually require the small plastic tubes (catheters) needed to get that fluid into a vein. A complete IV kit finally lets the crew use the fluid that is already on board. Cost: each item roughly $5 to $25; an IV kit about $5 to $15.

Add all of it together — the two auto-injectors, the naloxone, the oximeter, the glucometer, the rescue airways, the extra medicines, and the IV kits — and the total comes to only a few hundred dollars per plane. Spread across a plane that flies for decades and carries tens of thousands of people a year, the cost per passenger is less than a penny. One life saved, or one landing avoided, pays for the upgrade many times over.

Six Mitzvos Involved in Getting that Kit

For the Torah Jew, this is not only safety statistics and saving money. The obligation to preserve life is one of the pillars of the Torah.  Each of the following mitzvos bears on why stocking a proper medical kit is not a luxury but a duty.

VeNishmartem me’od b’nafshosaichem (Dvarim 4:9).. This is the mitzvah of protecting our health and our very well-being — the Torah’s command that a person guard his life and the lives entrusted to him.

Rak hishamer lecha (Dvarim 4:15).. Few have heard of this second mitzvah. The verse later on, “Rak hishamer lecha,” is understood by most Poskim to comprise an actual second, separate mitzvah (see Rav Chaim Kanievsky zt”l, Shaar HaTeshuvos #25) — to take special care.

V’Chai Bahem — “And you shall live by them” (VaYikra 18:5).. There is a third mitzvah in these words, from which Chazal derive the foundation of pikuach nefesh — that the mitzvos were given to live by, not to die by. If nearly the entire Torah steps aside for the sake of a single life, surely mere expense and inconvenience must step aside as well.

VaHashaivoso lo — “And you shall return it to him” (Dvarim 22:2).. There is a fourth mitzvah in Parshas Ki Saytzai, in the mitzvah of hashavas aveidah, returning a lost object. The Gemara in Sanhedrin (73a) includes within these words the obligation of returning “his own life to him as well” — making this verse the source for the mitzvah of saving a life. This, I believe, is the general mitzvah to which the Shulchan Aruch refers in Orach Chaim 325.

Lo Saamod Al Dam Rayacha — “Do not stand idly by your brother’s blood.”. There is a fifth mitzvah, a negative commandment, brought in Shulchan Aruch (Choshen Mishpat 426:1) and in the Rambam — not to stand idly by while another’s life is in danger. This includes oneself, and one’s spouse and children too, by leaving them bereft, chalilah.

Lo Suchal l’hisalaym — “You cannot shut your eyes to it” (Dvarim 22:3).. Finally, there is a sixth mitzvah, a negative commandment paired with the positive mitzvah of hashavas aveidah, in the verse that comes directly after it: “You cannot shut your eyes to it.” The Netziv (HaEmek She’eilah) refers to this mitzvah as well. One may not close his eyes to a danger he has the power to prevent.

The Bottom Line

The tools listed here are economical, they last for years, and are already used every day in ambulances, schools, and doctors’ offices across the country. 

As more people fly, and as we, the flying public grows older, the number of emergencies in the air will only rise. A plane is an isolated island — far from help, with long delays before a hospital is possible. The kit on board is the bridge across that gap. It should be a strong one. They are the minimum tools required to carry a life across the sky until real care is possible — and, for the Torah Jew, these six mitzvos demand nothing less.  

The author can be reached at [email protected]