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PLEASE NOTE: The following transcript is a portion of the official hearing record of the Committee on Transportation and Infrastructure. Additional material pertinent to this transcript may be found on the web site of the Committee at [http://www.house.gov/transportation]. Complete hearing records are available for review at the Committee offices and also may be purchased at the U.S. Government Printing Office.


U.S. House of Representatives,

Subcommittee on Aviation,

Committee on Transportation and Infrastructure,

Washington, DC.

    The subcommittee met, pursuant to notice, at 9:35 a.m. in room 2167, Rayburn House Office Building, Hon. John J. Duncan, Jr. (chairman of the subcommittee) presiding.
    Mr. DUNCAN. I will call the subcommittee to order and welcome all of the witnesses.
    I do first of all want to apologize. At our last hearing last week, I think we had about 20 Members here, but I'll be surprised if anybody shows up today because we were in session until about 3:30 this morning, and so I do appreciate the ones who are here.
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    We have witnesses today, and I think this will be a very fascinating hearing. We have witnesses today from Arizona, Texas, New Jersey, Connecticut. We also have Dr. Eric Donaldson from Qantas Airlines, who has traveled all the way from Sydney, Australia, and I certainly appreciate him coming all that distance to be here with us today.
    I want to especially thank our distinguished colleague, Congresswoman Barbara Kennelly, for taking time from her busy schedule to be with us. I did not know whether she would make it this morning, but she's here.
    Let me just say very briefly that the subcommittee has not reviewed the issue of medical supplies and equipment on airlines for some 13 years, and that's really the only time that Congress did look into it. At that time, 1984, there were a little over 300 million passengers a year flying on commercial flights in the United States. Today almost 600 million are flying, and the FAA estimates are that the number of passengers will increase to around a billion passengers a year 8 to 10 years from now.
    Obviously, I think one can conclude that medical in-flight emergencies certainly have increased. Hopefully, we can learn more about this today.
    In 1984, there were a number of legislative proposals considered in this subcommittee that would have required better medical kits, supplies, and equipment on airplanes. In fact, Senator Barry Goldwater, among others, introduced legislation in regard to this issue in the other Body during that same Congress.
    So in 1986, after much discussion, the FAA put in place regulations that augmented the first aid kit with a more-extensive medical kit and supplies and equipment for a large commercial carrier.
    Items required in the medical kits by the FAA in 1986 are the same items found in today's kits, with one exception—the addition of latex gloves. A list of these items is located in the memo provided to the subcommittee members.
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    We have several expert witnesses here with us this morning who will help us to understand the different types and number of occurrences of medical incidences and emergencies on aircraft and how these situations are handled. Just this past Monday night in my home town of Knoxville I had a man whose son is a USAir pilot who told me, not even knowing that we had this hearing coming up, that his son had recently had to land his plane on an emergency basis in Baltimore because a man had a heart attack on the plane and they cleared out the first-class passenger section. Fortunately, this man's life was saved by that emergency landing. But this is becoming an all-too-common occurrence.
    The AMA tells us that over 1,000 Americans suffer sudden cardiac arrest each day in this country. A 1988 study published in the ''Journal of the American Medical Association'' reported about 72 deaths each year on airplanes between 1977 and 1984; however, that number apparently has gone up to over 100, or possibly even higher, and there is some uncertainty about that at this time.
    We look forward to hearing from the witnesses and looking into whether some changes need to be made in the equipment and supplies that are carried on these planes, whether there needs to be more intensive and extensive training of airline attendants in first aid and in the handling of medical emergencies, and the whole ramifications of this entire issue.
    I do not believe that commercial air passenger airplanes should be or should have to become flying hospitals; however, I do believe that it is this subcommittee's responsibility to review this important issue and see if any changes need to be made.
    I now recognize the ranking member, Mr. Lipinski.
    Mr. LIPINSKI. Thank you very much, Mr. Chairman.
    Mr. Chairman, I have a long opening statement which I would like to have included in the record, without objection.
    Mr. DUNCAN. Without objection, so ordered.
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    Mr. LIPINSKI. Thank you very much. I simply want to say that this is a very, very interesting and important topic that we're going to be getting testimony on today, and I'm anxious to hear about it, so I will yield back the balance of my time so we can rapidly move to the witnesses. Thank you.
    [The prepared statements of Mr. Lipinski, Mr. Cramer, Mr. Costello, and Mr. Poshard follow:]

    [Insert here.]

    Mr. DUNCAN. We'll hear opening statements from any other Members at this time if they wish to make them. I'm surprised that we have this many Members here, since we got out so late.
    Mr. Blunt, do you have anything you wish to say at this time?
    Mr. BLUNT. Mr. Chairman, I think this is an important hearing. Certainly I'm grateful that the witnesses are here today, and I think I want to give them all the time we can. We're glad they're here and glad you've called this hearing today.
    Mr. DUNCAN. Thank you very much.
    Mr. Boswell?
    Mr. BOSWELL. Thank you, Mr. Chairman.
    I, too, appreciate this. We fly a lot, and I think probably every one of us has seen an emergency at one time or another on the airplane. I assumed wrongly that they probably already had some kits on there, so I guess that's what I get for not checking it out.
    But with the number of people flying, common sense tells me it's just the right thing to do, and so let's get at it and do it the best we can to fit the flying public and you folks in the industry that are providing the service and let's get it done. I think the people expect it and I think it's something we can do.
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    Mr. DUNCAN. Mr. Pease?
    Mr. PEASE. Mr. Chairman, I'm barely awake let alone coherent. I don't think I'll run the risk of a statement, except I am grateful for the opportunity to be here and I'll listen attentively.
    Mr. DUNCAN. Thank you very much.
    Ms. Johnson?
    Ms. JOHNSON OF TEXAS. Just briefly, Mr. Chairman. Thank you very much. I'm very interested in the hearing since I have a health background, and I do think that this is a very significant hearing, and I thank you for holding it and look forward to hearing the witnesses.
    Thank you.
    Mr. DUNCAN. Thank you very much.
    Dr. Cooksey, do you have any opening statements you wish to make?
    Dr. COOKSEY. Since I just got here, Mr. Chairman, I'd better listen for a while. But, as a physician, I'm interested in the issue and have discussed this issue, but I'll wait, I'll listen, try to learn.
    Mr. DUNCAN. All right. Thank you very much.
    Our first witness is one of the finest and most distinguished Members of this House, Ms. Barbara Kennelly from Connecticut. Ms. Kennelly, you may begin.

    Mrs. KENNELLY. Thank you very much, Chairman Duncan and Ranking Member Mr. Bill Lipinski. I want to thank you for this opportunity to speak on this issue that is so important to all of us—passenger safety during air travel.
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    I want to say a few words about this issue, and then I'd like to introduce my constituent, Mrs. Lynn Talit, who knows only too well why adequate medical supplies and equipment must be carried on board our commercial airlines.
    As a frequent traveler on our commercial airlines, I know how important safe air travel is; yet, every year, as you said, Mr. Duncan, passengers on United States airlines die in the air because the medicine or equipment that could have saved their lives was not on board the plane.
    Today we have the technology to deal with in-flight medical emergencies such as sudden cardiac arrest, but we do not require the airlines to train the flight crew to deal with medical emergencies and do what has to be done to make sure passengers are safe.
    In the event of sudden cardiac arrest, the key to survival is a rapid response. This includes immediate CPR and rapid defibrillation. It is vital that the flight crew be trained in CPR and the planes carry emergency medical equipment.
    Technology to deal with sudden cardiac arrest has come a long way, and today's automated external defibrillators are smaller, lighter, and more durable, and with appropriate training can be used by anyone.
    This past fall the U.S. Food and Drug Administration approved the use of these devices for commercial aircraft. I think it's time to put AEDs aboard all flights.
    I have introduced legislation which would improve the chances of survival for passengers in the case of an in-flight medical emergency such as a sudden cardiac arrest. My bill would require all airplanes to have automated external defibrillators on board and would also require each member of the flight crew to be trained in CPR. It's very hard for many of us to think that that hasn't already been done.
    I would like to note that one commercial carrier, American Airlines, has taken the initiative. The company will soon put AEDs aboard some of their international flights, and by the end of 1998 will have AEDs on all their flights. I commend American Airlines and hope other airlines will follow suit.
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    Most importantly today, Mr. Duncan, I would like to introduce Mrs. Lynn Talit. Mrs. Talit contacted me after her husband suffered a fatal heart attack aboard a commercial flight. This tragedy might have been prevented if adequate medical supplies and equipment had been aboard the flight.
    Mrs. Talit has crusaded on this issue to prevent any other family from suffering a similar tragedy. But, even more importantly, Mrs. Talit came to Washington to see her Member of Congress, to work with her Member of Congress to make sure a piece of legislation could be written by somebody who had experience to see that others would not have to experience this same type of suffering.
    [The prepared statement of Ms. Kennelly follows:]

    [Insert here.]

    Mrs. KENNELLY. I'd like to introduce now Ms. Lynn Talit, a very brave woman.
    Thank you, Mr. Duncan.
    Mr. DUNCAN. Ms. Talit, before you testify—Ms. Kennelly, what we do, we have the Members testify first, and then, because we know the Members have such busy schedules and because we have chances to ask them questions or talk with them later, I generally let the Members go ahead and leave if they wish.
    What we're going to do now, we certainly appreciate your being here, and we're going to call up the entire first panel, which includes five other witnesses. And so at this—certainly you're welcome to stay, if you wish.
    Mrs. KENNELLY. Thank you, Mr. Duncan, and I will choose to stay because this is something that has become very important to me.
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    Mr. DUNCAN. All right. That's fine.
    The first panel consists of, listed in the order they're listed: Ms. Carolyn McDowell of Montclair, New Jersey; Mrs. Lynn Talit, West Hartford, Connecticut; Ms. Denise Hedges, who is president of the Association of Professional Flight Attendants; Ms. Joan Sullivan Garrett, president of MedAire, Incorporated, in Phoenix, Arizona; and Dr. James M. Atkins, who is from the American College of Cardiology.
    We'll have those witnesses come forward.
    We've now been joined also by Ms. Danner. Ms. Danner, if you have any statement you wish to make—I know you haven't had a chance really to catch your breath yet, but if you'd like to say something you certainly are welcome to at this time.
    Ms. DANNER. Well, it was a long day followed by a short night, Mr. Chairman, and so I am speechless this morning. Thank you.
    Mr. DUNCAN. All right.
    Well, once again let me say I wondered whether I would be the only one here this morning, and I'm amazed. I appreciate very much the fact that so many Members have come here for this hearing, but it is an important topic that we are discussing.
    We'll proceed now with the first panel. I think what we'll do, we'll just proceed in the order that the witnesses are listed on the official notice of the hearing, and that means that Ms. Carolyn McDowell would be the first witness.
    Ms. McDowell, you may begin your testimony.
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    Ms. MCDOWELL. Chairman Duncan, members of the subcommittee, my name is Carolyn McDowell. I want to thank you for the opportunity to speak to you today regarding in-flight medical emergencies.
    There are some changes I think should be considered by the committee in regard to any discussions of new regulations.
    On May 18, 1996, my husband, John, suffered a heart attack aboard Continental Airlines Flight 2000. That was 1 year and 3 days ago today. He died shortly after the plane landed in Nassau. It is my belief that inadequate medical safety procedures, inadequate training of flight crew personnel, and the fact that cardiac medicines and equipment were not available contributed to his death.
    In my husband's case, none of the flight crew that attempted CPR on John could do it properly. Fortunately, there was a passenger on board, Dr. Pinder, who was able to do the CPR; however, since none of the flight crew could perform the CPR properly, Dr. Pinder was forced to continue the chest compressions unassisted for more than 45 minutes.
    If Dr. Pinder had not been on Continental Flight 2000 to assist John, there would have been no one there able to help him.
    I have been told by emergency medical personnel that a person certified in CPR but not routinely practicing it needs interim training four to six times a year.
    The present system seems to rely on there being a passenger on every flight who has medical training and is willing to volunteer their services. In the 1940s, a nurse was one of the flight crew members on all commercial airlines. Studies show that the United States' population is aging. Medical emergencies like John's will occur more frequently in the future.
    Steps should be taken now to ensure that qualified airline personnel, adequate medical supplies and equipment are available when passengers become ill in-flight. To watch Dr. Pinder trying to care for my husband without the medicine and equipment he needed was a frightening experience.
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    For instance, the on-board medical kit contains the heart medication Epinephrine, but the medical kit does not have the proper needle to administer the drug. Dr. Pinder had also wanted to intubate John but did not have the equipment to do this procedure.
    The single-most important piece of emergency equipment for a heart attack victim is the defibrillator, but Continental's planes are not equipped with defibrillators. If Continental Flight 2000 had had these items on board, my husband would be alive today.
    The FAA does not require that an airline report in-flight medical emergencies. This is true even when an in-flight medical emergency results in the death of a passenger. So long as airlines like Continental know they are not accountable for documenting and reporting incidents like the one involving my husband, the public continues to fly at risk.
    The airlines respond that they are not flying ambulances. In effect, they are saying passengers must forsake life-saving medical intervention once they are 30,000 feet in the air. I do not agree with this position. Properly-trained personnel and the proper medicines and equipment could have and would have saved my husband's life.
    I urge you to make changes in the present regulations. It is my hope that future air travelers do not have to go through the trauma I did of having to watch my husband's life slip away as the plane flew on to its scheduled destination.
    I thank you, Mr. Chairman and members of the committee, for your time today.
    Mr. DUNCAN. Well, thank you very much, Ms. McDowell, for that very fine testimony. We're certainly sorry that you did have to go through what you went through with your husband.
    Ms. MCDOWELL. Thank you.
    Mr. DUNCAN. Our next witness will be Mrs. Talit, who has already been introduced.
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    Mrs. Talit, you may begin your testimony.
    Mrs. TALIT. I'm hit with a sore throat, so I beg your indulgence.
    Chairman Duncan, members of the subcommittee, fellow witnesses and guests, I first want to put a very human face on my loss. This is my husband, Ben Talit.
    In the air, adequate medical emergency preparedness is a necessity, not an option. My husband, Ben, a senior analyst and frequent business traveler, died of cardiac arrest on Northwest Airlines Flight 339 from Detroit to Los Angeles in the first class section, where service is supposed to be so attentive. His death and hundreds like his draw attention to the inadequate in-flight medical kits on passenger airlines and the urgent need for training and to make automated external defibrillators, AEDs, mandatory parts of the kits.
    Minutes count when cardiac emergency strikes, and Ben's flight lacked such simple essentials as oxygen canisters, a length of endotracheal tubing, and lidocaine. No life-saving AED was on board, even though the need has been well-known in the airline industry and AEDs have been saving lives on foreign airlines for years.
    Underscoring our family's incalculable loss is that Ben, as you can see from this picture, was a fire/rescue volunteer his whole life. He was a deputy fire chief and an EMT at the advanced level of training. He was dedicated to saving life and property. Typically, the day before he died he was on ambulance duty. So it's bitter irony that at age 43, with no known health problems, on April 23, going into the morning of April 24, 1995, Ben suffered his own emergency—a fatal medical emergency on an airplane.
    A thoughtful, loving husband of 20 years, an exemplary father, a valued professional, a truly good citizen died for the lack of exactly the preparedness he supported and practiced every day of his life.
    The public and most officials like you still have no clear idea of the scope of medical emergencies, because the airlines are not required to keep records. Both Federal and airline industry data, therefore, are so seriously flawed that no airline industry or related agency position against on-board AEDs or medical kit enhancements can be taken seriously.
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    A few examples of the scope of this egregious condition:
    March 1995, Bill Rose, age 57, a Simsbury, Connecticut, fire chief who, coincidentally, my husband knew, died of a heart attack on a Northwest flight from Detroit to Phoenix. His wife told me that his death certificate, like my husband's death certificate, didn't say he died in-flight, but rather the city where the body was removed from the plane; therefore, no in-flight death statistics on either of those men.
    Jamie Soms, widow of Steven Soms of Wellesley, Massachusetts, tells me how the father of two in his late 30s was in first class on a United flight to San Francisco from Boston, October 1995, when he arrested. Doctors aboard told her of their total frustration at losing him because of inadequate supplies.
    April 19, 1997, on Northwest Airlines' Los Angeles to Detroit flight, Mr. Sandy Peters, age 45, of Sterling Heights, Michigan, had cardiac arrest while the plane was on the ground in Detroit, but no AED was on board. CPR by the flight attendant was inadequate, and Mr. Peters' mother tells me by the time the medics got to him on the tarmac he was already cyanotic as far down as his nipples, and he has brain damage now.
    Moreover, the two doctors who tried to save my husband, Ben, one was a cardiothoracic surgeon, the other an intensivist. Both have written to tell me that Ben could likely have been saved with a defibrillator, and both encourage my efforts here today. Furthermore, for the cardiothoracic surgeon, Ben was his second in-air cardiac emergency in a single weekend, having had one on his Detroit to Los Angeles Northwest flight.
    Contrary then to what the airlines would have us believe, these are not rare or occur only to the old and infirm, and the number of people who die in-flight like Ben far exceed airline fatalities from crashes in a single year.
    Enough is enough. The airline industry cannot reasonably expect nor can they be allowed to take millions of people 35,000 feet in the air every day, sometimes for hours on end, with no realistic measures in place to respond to the most common of life-threatening emergencies, cardiac emergency, which alone claims 350,000 lives on the ground and in the air every year, exceeding the annual death toll from accidents or AIDS.
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    I urge an end to this crisis in the sky forthwith and an end to these silent, hidden statistics like my husband, Ben. We can stop this in-flight epidemic tomorrow. We are not asking for flying hospitals. Medical kits just need more, and defibrillators need be mandatory. Portable AEDs have been available since the 1980s. Foreign carriers like Qantas have had them for years. Back then they were the size of a briefcase, maybe weighing 15 pounds, with rechargeable batteries. Maybe they took 5 hours to learn. Today they weigh four pounds, take no recharging, take virtually minutes to learn, only cost $3,000.
    Last year, two AED makers, PhysioControl and Heart Stream, sought and received FDA approval, and American Airlines plans to put Heart Stream Forerunner aboard its overseas carriers. But one airline voluntarily putting them on overseas flights only is not enough.
    Hoping to make a difference, in my community last week I met with local officials to allocate gifts of defibrillators in Ben's memory. If a widow of modest means and her children can manage this, can the United States Government fail to do proportionately more, I ask you?
    I thank you for your time on behalf of myself, my son Ron, who could not be with us, my daughter Amy, who is here, and with sincere thanks to Congresswoman Kennelly for her efforts on our behalf.
    Mr. DUNCAN. Well, thank you very much, Mrs. Talit, for some very compelling testimony. Thank you for being with us.
    The next witness on the list is Ms. Denise Hedges, who is president of the Association of Professional Flight Attendants.
    Ms. Hedges?
    Ms. HEDGES. Good morning, Chairman Duncan, Mr. Lipinski, and members of the subcommittee.
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    My name is Denise Hedges. I'm president of the Association of Professional Flight Attendants, representing the 20,000 men and women of the American Airlines' flight attendant corps.
    On behalf of myself and my fellow safety professionals in the air every day, I am pleased to be able to speak with you on the exciting new medical technology that is available to all airlines today.
    It was on May 15, 1930, that aviation history was made. It was on that date at 8:00 a.m. that Ellen Church, a trained nurse, boarded a Boeing Air Transport—a predecessor of United Airlines—tri-motor airplane to work a flight from Oakland to Chicago. Not only did she become the first ''stewardess,'' but, because she was a trained nurse, she began the chapter in aviation history of the flight attendant as a safety professional.
    Today, through the advent of new technology, we are able to add yet another chapter to that book.
    American Airlines' flight attendants are already trained in first aid instruction for on-board emergencies such as epileptic seizures, burns, choking, and broken bones, just to name a few.
    During flight attendants' initial 6 weeks of training, the majority of the time is spent on safety and health-related procedures. In addition, every year flight attendants are required to attend recurrent training for updates and review.
    Currently, cardiopulmonary resuscitation or CPR is the only tool that a flight attendant has to assist a passenger in cardiac arrest. The nearest medical assistance is normally at least 40 minutes away. On international flights, landing the aircraft is often not even an option.
    In addition, medical personnel at many smaller airports may not have defibrillators. In sudden cardiac arrest, the time it takes to treat an individual is the deciding factor whether that person lives or dies. The victim's chance of survival decreases 10 percent with each minute that passes without defibrillation.
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    An airplane may be the ideal environment for the victim of sudden cardiac arrest, with a defibrillator and a trained flight attendant only seconds away.
    The Association of Professional Flight Attendants was involved very early in the process in determining which defibrillator would be used on American Airlines. The defibrillators are currently being installed on all of American's international aircraft, with a completion date of July 1, 1997. Currently, American Airlines is in the process of training our pursers, or lead flight attendants, on the use of defibrillators. The three-hour sessions will be completed in early June. By that time, over 2,300 American Airlines flight attendants will be trained in the proper use of defibrillation.
    American's flight attendants are considered to be agents of American's medical department; therefore, liability coverage for use of the defibrillator will be an extension of the medical department. While there may be physicians or other medically-trained passengers who can assist when a passenger becomes ill, the flight attendants are being trained to use the defibrillators when a passenger is in cardiac arrest.
    Eventually, all American Airlines' flight attendants will be trained on this device in their yearly recurrent safety training.
    With the first phase of installation of automatic external defibrillators already on board American Airlines' international aircraft and the upgrading of on-board medical kits and provisioning of grab-and-go kits, American airlines' passengers can rest assured that, should the need arise, they will receive the best possible first aid care short of a major hospital emergency room.
    Thank you for giving this opportunity, Mr. Chairman and members of this subcommittee.
    Mr. DUNCAN. Thank you very much, Ms. Hedges.
    Our next witness is Mary Kay Hanke, international vice president for the Association of Flight Attendants.
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    Ms. Hanke?
    Ms. HANKE. Good morning, Mr. Chairman, members of the subcommittee.
    My name is Mary Kay Hanke. I'm the international vice president of the Association of Flight Attendants. We represent 40,000 flight attendants at 26 different U.S. carriers. I'd like to thank you for this opportunity to address you this morning.
    Today flight attendants are no longer required to be registered nurses, yet medical emergencies still occur on airplanes far from hospitals and medical facilities. Often, there is no medical professional available on the flight to offer medical assistance. In these emergencies, flight attendants must rely on their own resources.
    Currently, the FAA requires that every newly-hired flight attendant receive 40 hours of safety instruction. The training must include first aid, emergency evacuation, safety, and aircraft operation procedures. Recurrent training is also required every 12 calendar months.
    The FAA requirements are broad and carriers are left to determine what specific training they will provide. While the FAA must approve carrier-specific training plans, the carriers can readily get exemptions from the regulatory requirements.
    In terms of first aid training, the FAA only requires the carrier to instruct flight attendants on where first aid kits are located, the function of the kits, and when to use them.
    For medical kits, flight attendants are instructed that only a physician or other medical personnel can use the kit.
    If, during a medical emergency, a flight attendant is exposed to blood-born pathogens, they have no training on what to do to protect themselves. The FAA does not require carriers to train flight attendants on such procedures. Because aviation workers are not covered by OSHA and the FAA has not developed a plan to adopt OSHA-type standards, no requirements exist for carriers to protect their employees.
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    AFA believes that, overall, flight attendants do not receive adequate training to manage a medical emergency in the cabin or to protect themselves in case of extraordinary circumstances.
    In our review of the training curriculum of the 26 carriers represented by AFA, we learned that training differs widely.
    Some of our members receive first aid training instruction for fewer than 30 minutes. Some get up to a few hours during initial and recurrent training. During these trainings, flight attendants are instructed according to the following procedure: first, determine the nature of the illness and obtain a medical history; advise the cockpit of the incident; and then attempt to determine if a qualified medical person is on board.
    If necessary, most cockpits can then contact either MedLink or an on-call physician. The cockpit is also responsible for relaying information from the flight attendant attending the emergency to the on-land physician, and then relaying information back to the flight attendant.
    This system of message relay can lead to a potentially serious loss of information as important data is transferred verbally among the three partners.
    In such an emergency, there is little time to consult a manual, but all flight attendants have first aid information in their manuals, which includes general information on in-flight medical problems, and also lists supplies found in the first aid and medical kits.
    In 1986, the FAA wrote new guidelines to add emergency medical equipment and, later, protective gloves to the first aid kits they already carried. Airplanes are now required to have emergency medical kits, an approved first aid kit, and protective latex gloves evenly distributed throughout the cabin.
    The number of the first aid kits on board is determined by the number of passenger seats. On some AFA carriers, this means that only one kit would be required on the airplane. A flight attendant assisting a passenger in distress at the rear of the plane would be unable to quickly get the kit if it was positioned at the front of the aircraft.
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    When medical emergencies occur on flights, flight attendants are trained to monitor and manage medical emergencies, not function as medical personnel.
    In order to manage any first aid or medical emergency effectively, flight attendants need improved training. The FAA must ensure that flight attendants are fully qualified to meet their responsibilities as crisis intervention managers by requiring basic first aid training.
    The Association of Flight Attendants recommends the following improvements in flight attendant first aid and medical training:
    The FAA should survey carriers to identify the best practices in the industry in order to improve standards.
    The FAA should improve requirements for standard first aid training at both initial and recurrent trainings to help flight attendants manage medical emergencies.
    The FAA must develop industry-wide standards for improved medical response to in-flight emergencies.
    The FAA must review its requirements for what should and should not be included in both first aid and medical kits.
    The FAA must assure quality control and should require that gloves and mouthpieces be readily available to protect the flight attendants.
    The FAA should also periodically review the medical kits to ensure that the contents are current and appropriate.
    The FAA should require all planes to place first aid kids and disease protection equipment at the front and the back of the airplanes to assure accessibility by the flight attendants.
    And, absent OSHA protections, the FAA must do its utmost to protect flight attendants from exposure.
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    The FAA must establish a program that will contain procedures to protect aviation workers from exposure to blood-born pathogens similar to OSHA requirements.
    The FAA must ensure that any new medical equipment introduced into the cabin meets high quality control standards and that the flight attendants who will use it are trained to do so.
    The FAA must require carriers to set up a formal system of radio links between the flight attendant and a qualified emergency physician so that direct communication can be made between the flight attendant who is dealing with the emergency and a passenger in distress and the physician.
    The training needed to manage a medical emergency cannot be learned in a few moments. Not to provide adequate emergency medical training to the flight attendants is unfair to passengers and the flight attendants, alike. As the passengers' link to safety, flight attendants must receive the tools to do the job.
    With your support, we urge the FAA to move forward on AFA's recommendations.
    I would like to thank you for this opportunity to testify this morning, and I would be happy to answer any questions.
    Mr. DUNCAN. Thank you very much, Ms. Hanke. I can tell you I've been very supportive of the airlines in many ways, but I think any airline that gives its flight attendants only 30 minutes of minimal first aid training is not doing a sufficient job in this regard, as I think is being pointed out here this morning.
    Our next witness is Ms. Joan Sullivan Garrett, who is president of MedAire, Incorporated of Phoenix, Arizona.
    Ms. Garrett?
    Ms. GARRETT. Thank you, Mr. Chairman and members of the committee.
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    I'm Joan Sullivan Garrett, president of MedAire. Thank you for the opportunity to present information this morning, an analysis of managing in-flight medical emergencies on board commercial aircraft.
    MedAire represents more than 10 years experience in dealing directly with more than 3,000 in-flight medical incidents. Each and every one of them has been carefully managed and fully documented all the way through to the incident's final conclusion.
    With the power of knowing what medical situations are most likely to occur in flight, risk-informed decision-making can lead us to establishing medical preparedness standards in relation and proportion to their likelihood of taking place.
    Our experience base comes from our 24-hour medical emergency hotline, MedLink. Any time a client has a medical situation on board their commercial aircraft, no matter where they are in the world, they can contact our MedLink communications center and talk directly and immediately with one of our 16 board-certified emergency physicians. Our physicians are highly skilled in remote diagnosis and directing non-medically-and medically-trained people to collect data, provide aid, and stabilize situations.
    They will offer advice and treatment recommendations so that pilots can make informed decisions as to whether or not they will divert their aircraft. In the event of a diversion, MedLink has an exclusive worldwide medical services database that is used to assist pilots in selecting a medically-appropriate diversion site airport.
    Additionally, through this database MedLink will notify and manage medical emergency response, transport, and hospital admission at the destination city.
    Through our statistics, we are finding that 80 percent of all medical situations can be attributed to just one of five medical situations: 36 percent of our calls are neurological in nature such as stroke or seizures; 19 percent are cardiac-related, however, that number is steadily climbing and is at 23 percent so far this year; 11 percent are respiratory in nature such as asthma and allergic reactions; 10 percent are gastrointestinal; and 4 percent are primarily diabetic-related issues.
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    Our emergency physicians suggest that, in dealing with the top five medical situations that make up 80 percent of their calls, most would be well-managed if there was an overall greater focus on first aid basics.
    As an example, in the area of CPR and first aid training, they believe more emphasis should be placed on skills such as early recognition, gathering vital signs, emergency airway management, and greater knowledge on risk from blood-born pathogens and the utilization of personal protective equipment.
    For medical kits, our physicians see reoccurring need for airway management tools, IV equipment, and emergency drugs such as injectable Epinephrine, and injectable Atropine; however, this would require monitors and qualified medical professionals on board.
    In the area of first aid kits, our emergency physicians see continual needs for items such as self-injectable syringes of Epinephrine for severe life-threatening allergic reactions and no medical volunteers on board; Albutirol metered dose inhalers for quick relief during asthma attack; and they believe automatic external defibrillators, or AEDs, should be considered, in essence, a part of the first aid kit.
    The American Heart Association says more than 1,000 people die in the U.S. every day from cardiac arrest. It is not unreasonable to expect that some of these people might be on board an aircraft in any given day.
    In the event of sudden cardiac death, also known as ventricular fibrillation, the definitive treatment is rapid defibrillation.
    If the shock comes within 3 to 4 minutes of fibrillation, a patient's chance of survival can range from 50 to as high as 90 percent. If the shock comes after 10 minutes in the case of ventricular fibrillation their chances are virtually zero.
    Additionally, cardiopulmonary resuscitation by itself in such situations has a success rate of less than 5 percent.
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    Today's defibrillators can be used by non-medical personnel who have training in their use. Training ranges from 3 to 6 hours, and from then on can be easily incorporated into ongoing CPR course completion.
    These devices are much easier to learn and administer than the process of CPR. They are designed so that it is impossible for the AED or the caregiver to do harm to the patient, only good.
    In closing, I would like to offer an observation that could soon develop into a disturbing trend. Our MedLink physicians tell us that medical professionals are becoming fearful, even refusing to get involved in offering medical help for fear of legal liability.
    The legal liability to volunteers, airlines, and flight crews is staggering. Today we are finding that in nearly 80 percent of our calls a medical professional has volunteered their services; however, in 1996 we found that physicians volunteered in less than 50 percent of those cases. I predict in the future this willingness will decline.
    I would argue that, unless action is taken to limit liability in these situations, there is little value in worrying about medical equipment or training when everyone is fearful of being sued for using what they know.
    Mr. Chairman and committee, this concludes my testimony. I do have a short, 30-second video that will explain the process of our operation, and then I would be happy to answer any questions you or the committee members may have. Thank you.
    Mr. DUNCAN. That's fine. Thank you very much for your testimony. You may go ahead and show the video at this time.
    [Videotape presentation.]
    Mr. DUNCAN. Thank you very much.
    Our final witness on this panel is Dr. James M. Atkins of the American College of Cardiology, who has been involved in this issue, I think, for several years now.
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    Dr. Atkins, it's a privilege to have you with us.
    Dr. ATKINS. Thank you, Mr. Chairman Duncan and members of the subcommittee.
    I'm James M. Atkins. I am representing the American College of Cardiology. My background is I have been medical director of the paramedic program at Dallas/Fort Worth International Airport and Love Field for over 20 years.
    The management of victims of cardiac arrest poses major challenges on airplanes. Survival from cardiac arrest decreases rapidly from time of the event until a rhythm is restored in the patient.
    In general, survival without proper medical treatment is unlikely after 10 minutes and nonexistent after 20 minutes. Performing manual CPR only slightly improves the results.
    Survival from cardiac arrest is determined mostly from the time of the event until they are defibrillated or shocked. If they can be defibrillated in the first minute, greater than 90 percent survive. If they cannot be shocked until 5 minutes, only 40 percent survive. If they cannot be shocked until 10 minutes after the event, less than 10 percent survive.
    Thus, survival from cardiac arrest occurs when the patient has ventricular fibrillation and is defibrillated or shocked rapidly. On an airplane, an emergency diversion and landing requires at least 20 minutes, with another 10 to 20 minutes to get the plane to where the victim can be removed by appropriate medical personnel if they are available at that airport. Therefore, cardiac arrest on an airplane under normal circumstances is not survivable.
    The incidence of cardiac arrest on commercial airplanes is extremely low, but with the enormous number of travelers, the total is significant.
    Dr. O'Rourke and his co-investigators reported the experience on Qantas Airlines in April 1997, and have estimated that the rate of events would be about 311 cardiac arrests per year for all of the IATA carriers.
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    From this estimate, the number of cardiac arrests on domestic carriers in the United States would be about 70 to 80 per year, with the 72 still being the most widely-accepted number.
    At Dallas/Fort Worth International Airport, the second-busiest commercial airport in the United States, there are 15 to 16 cardiac arrests per year. Half of these events occur on the aircraft and half of them in the terminal. Qantas reported 19 events in their terminals and 27 events in their aircraft.
    From the Qantas data presented by Dr. O'Rourke, 17 of 19 events in the terminal were ventricular fibrillation, and 6 of 27 events aboard aircraft were ventricular fibrillations. Defibrillators are only effective for ventricular fibrillation. Four victims were resuscitated and survived in their terminal group, and two were resuscitated and survived in the aircraft group.
    If this data is extrapolated to the United States, then defibrillators aboard aircraft with trained responders would save about 10 to 20 lives per year. If defibrillators were placed in all terminals with trained responders, an additional 60 to 80 lives might be saved.
    The high incidence of ventricular fibrillations in terminals is probably due to the fact that these events are witnessed and recognized more quickly as the victim is standing or running and suddenly collapses. On an aircraft, the patient may be sitting in their seat and does not fall visibly nor collapse to be recognized.
    It should be noted that many of the victims do have terminal illnesses and are elderly.
    The issue of placing defibrillators in terminals on airplanes has been only partially addressed by several major organizations. The American College of Emergency Physicians and the American College of Cardiology do not have official statements on placing defibrillators on airplanes. The position of both organizations has been to encourage methods that improve survival from cardiac arrest. Both organizations feel that any proposed strategy should be evaluated for the benefit-to-risk ratio and acceptable cost-benefit analysis.
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    The American Heart Association has stated first responder defibrillation should be utilized in many venues and includes aircraft and terminals in those venues.
    Clearly, defibrillators on aircraft and in terminals would improve survival for some individuals. The cost-benefit analysis aboard aircraft is unique. If a system such as the one Qantas uses is utilized, the reduction in aircraft diversion saves more money than equipment and training cost.
    To perform CPR, the victim must be lying on their back in a position where rescuers can compress the chest and ventilate or breathe the patient. To defibrillate the patient, the victim cannot be touching another person or metal. Some aircraft are too small to provide adequate room for treatment.
    To perform CPR and defibrillate the patient, at least two and possibly three aircraft personnel are needed. It would be best to have at least four crew members available: one to perform chest compressions, one to ventilate the patient, one to defibrillate the patient, and a fourth to handle other problems and communication. This could possibly be reduced to two individuals; however, this will take further training and evaluation of the techniques.
    Based upon this present information, my professional opinion is it makes sense to place defibrillators on terminals and on wide-body aircraft, particularly those with long flights who carry older individuals. They have a high incidence, sufficient room, and adequate number of crew members.
    Placing defibrillators on smaller aircraft must be evaluated carefully. Smaller jets that have at least three cabin personnel probably have enough space and personnel to do the job safely and effectively. We need to evaluate smaller aircraft than those with only two cabin personnel.
    With present technology, aircraft with no or one cabin attendant should probably not be equipped with defibrillators. This is a technology that has benefit if properly applied. Further research and evaluation is needed to improve the results obtained in the limited studies to date.
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    Thank you.
    Mr. DUNCAN. Well, thank you very much, Dr. Atkins.
    This has been an outstanding panel, and those are fascinating and impressive statistics about defibrillation.
    You said 90 percent are saved if they're defibrillated in the first minute, and 40 percent if in 5 minutes, and 10 percent if they wait 20 minutes?
    Dr. ATKINS. It falls about 10 percent per minute from the time of collapse of the patient, so it's a very time-dependent period in which you have an opportunity to save their lives.
    Mr. DUNCAN. Right.
    Ms. Garrett, you testified about the decrease in the percentage of medical professionals who are willing to help in incidents of this type. Mr. Merlis on the next panel has some testimony that says in about 80 to 85 percent of the cases, medical professionals or medical rescue workers respond, and that he believes the percentage would be even higher if it were not for the medical professionals' fear of liability.
    You mentioned that the percentage has decreased, I think you said to 50 percent. Do you think part of the answer to the problems we're hearing about would be some type of a Good Samaritan law for these medical emergencies that occur in the sky?
    Ms. GARRETT. Yes. I would like to clarify your statement, however, in that we traditionally do see about 80 to 85 percent of medical professionals volunteering on board our clients' aircraft, and that will be anywhere from a physician, medical doctor, veterinarian, pathologist, to many, many specialties, as well as registered nurses, EMTs, EMT/paramedics. That represents approximately 85 percent.
    What I testified to is the fact that in 1996, out of 680 calls, we had 248, I believe, responses from physicians on board aircraft to respond out of that number, so it was in 1996, alone, that I was referencing with physicians specifically.
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    I do believe, however, that relief from liability would be a big part in making them more comfortable to come forward, because clearly our experience has shown that, where a physician was identified, that they actually refused to get involved, even with our physician telling them that we would extend, as we do always, our professional liability coverage to any medical on-board volunteer.
    Mr. DUNCAN. Ms. Hedges or Ms. Hanke, do you think that's a concern, also, of flight attendants—possible liability? And do you think that if the airlines put defibrillators on their flights, would flight attendants, do you think, be capable of or feel comfortable in handling machines of that type?
    Ms. HEDGES. Mr. Duncan, that was one piece that we were very concerned about when we first started working with American's corporate medical director was the liability. In fact, a letter of agreement was provided in which it is stated that we are agents of the medical department and therefore American covers us for the proper use of defibrillation.
    That has greatly helped our flight attendant corps be desirous of this equipment and this training.
    Ms. HANKE. Mr. Chairman, the issue of legal liability is a concern to AFA and to our members, not only in the use of the defibrillators, but also in the use of any advanced medical equipment on board the aircraft. And so that is one of the issues that we would raise in reviewing any new equipment.
    Mr. DUNCAN. Ms. McDowell, you mentioned, of course, in your very tragic situation there was a doctor on board, but you said that—in your testimony you say that the flight attendants weren't capable of assisting, or words to that effect. Were the flight attendants—did they know what to do, or were they able to assist in some way? What was your situation?
    Ms. MCDOWELL. The doctor aboard was a thoracic surgeon, and his comments were to that effect.
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    Mr. DUNCAN. To what effect?
    Ms. MCDOWELL. To the effect that the attendants were not able to perform CPR. In other words, they weren't able to sustain a pulse.
    Mr. DUNCAN. Right.
    Ms. MCDOWELL. Therefore, their training wasn't working.
    Dr. Pinder—I thought we would lose Dr. Pinder. He had perspiration pouring off his bald head and he worked constantly on my husband for over 45 minutes, and there was no relief for him. There was no one that could take over for him.
    Mr. DUNCAN. Dr. Atkins, one of the uncertainties or problems here seems to be that there are not a lot of accurate statistics or records being kept about how often these incidents occur and of what type. I saw one report that said 40 percent of the medical emergencies are cardiac related, but then we have another report that says 36 percent are seizure or stroke related and 23 percent are cardiac related, and yet we've focused most of the attention on defibrillators.
    Are there other ways in which these medical supplies and equipment are inadequate? Also, do you feel that the flight attendants should be given more—better or more-intensive or extensive medical training?
    Dr. ATKINS. My personal belief is that, first off, on the issue of more training, I think the training of flight attendants in many airlines needs to be increased. I'm familiar with how several different airlines do it, and there is a wide variation in how much time is spent on medical procedures.
    My own personal recommendation would be that an airline really needs to develop a system, not just training. Training and equipment is one piece of a system. They need to have a way of contacting physicians on the ground who know about airplanes and know about the equipment, because I'm a cardiologist, emergency physician, have worked in this area for many, many years. There are certain defibrillators that I've seen on European aircraft that I would have a few minutes to figure out how to work the device, because the device is different enough from what I've ever used. This is a problem.
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    So you need to have a system.
    I also have a certain anxiety about having certain pieces of equipment on board the plane and not having controls. Having been medical director, half of the ''physicians'' who show up at the scene of a disaster or an emergency are not physicians at all. They're doctors of theology. Dr. Donaldson from Qantas said they had a tree surgeon show up recently.
    Dr. ATKINS. This is a problem, so there needs to be some way of controlling it.
    And even if the person is a physician, they may be a pathologist and not have practiced on patients in 30 years. So you need to have communication with someone on the ground. Some of the airlines use a company like MedAire to provide that type of assistance to it.
    So I think you need to have a system. An airline needs to look at its equipment, needs to look at its supplies, look at its communication, and have a control mechanism on the ground where someone on the ground can evaluate the physician's knowledge in the air, and the two of them can communicate.
    I know a number of times where a physician on board, for whatever reason, didn't think it was an emergency and didn't want to divert the aircraft—maybe because they wanted to get to where they were going—whereas the ground control physician felt the aircraft needed to be diverted.
    For these reasons and the complexity of the inter-relationships when you're dealing with volunteers, there needs to be a system and a control mechanism.
    Mr. DUNCAN. I've gone far over my time.
    Mr. Lipinski?
    Mr. LIPINSKI. Thank you, Mr. Chairman. I want to thank every member of this panel for being here. I think all their testimony has been very enlightening, very significant, and I think it will help us in perhaps persuading some people to improve the medical situation on commercial airliners.
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    I have a couple of questions.
    First of all, for the representatives of the flight attendants, are the flight attendants prepared to take on this additional responsibility in the medical area? I know that American, you say that you're already into this on your overseas flights, so I'd like you to go first. Has this been discussed with the flight attendants? Are they prepared to—some have already or will take on the responsibility, others, of course, in the future will be asked to do so. Has this been discussed with them fully?
    Ms. HEDGES. I don't know what you mean in terms of ''discussed with,'' but we certainly have issued notification and communication.
    As far as I know, I only was aware of two complaints from flight attendants regarding an unwillingness to want this state-of-the-art technology on board, and both of those had to do with liability concerns.
    But our flight attendants so far have well-received this.
    If I may clarify, all 2,300 of our pursers, which includes domestic pursers, are being trained on this defibrillation, and when I stated that initially American is installing the defibrillators on international aircraft, those aircraft are used both domestically and internationally. To start, it's our larger airplanes, the wide-bodies and the over-water-equipped. And it's my understanding it will be on all domestic airplanes, as well, down the road.
    But it has been very well received by our flight attendants, as long as they feel comfortable that they are not going to somehow suffer great liability for the use of defibrillators.
    Mr. LIPINSKI. Has American offered any additional compensation to your flight attendants for taking on these new responsibilities?
    Ms. HEDGES. No. We see it as an extension of capability. We see it as an extension of our safety and health training, and we generally view that as very progressive and, in fact, helps us personally, as well.
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    I can give you an example. For instance, on another issue I was able to save my son's life in performing the Heimlich maneuver, which is what we are trained to do in the case of passenger choking. So much of our training is rewarding not only at 30,000 feet in an airplane, but it also makes us better individuals in public arenas, as well.
    Mr. LIPINSKI. Thank you.
    Ms. HANKE. Yes. As the Association represents 26 different carriers in the United States, and as safety professionals on board, the flight attendants are prepared to take on the added responsibilities of being the passengers' first link to safety. However, we are concerned with regard to training, with regard to placement of the equipment, protections for the flight attendant in using that equipment, and also with the liability issue.
    As the passengers' first link to safety and as safety professionals, our members are open and receptive to the many advances that have been made over the years in the area of medical emergencies and in-flight training.
    Mr. LIPINSKI. Thank you.
    Ms. Garrett, some people are going to testify here later that we should continue to study this situation to determine if we need additional medical equipment, if we need additional training.
    Based upon your experience and your company's experience in the field, do you think we have enough data collected at the present time to go forward with some improvements?
    Ms. GARRETT. I think, like anything, you oftentimes don't realize what you have available to you, and perhaps the significance of the data that we have been collecting for the past 10 years didn't take on its true form until probably 1993. And so we have become much more sophisticated in the data collection, even more so since October of last year.
    We find that we are looking at everything from the in-flight setting, the volunteer, the volunteer type, the use of the emergency medical kit, the response to the use of the emergency medical kit, and then, of course, the follow up. Were the people admitted or were they even seen at the airport? Did they refuse treatment at the airport? Were they hospitalized? If so, to the critical care unit?
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    Without broaching confidentiality issues, which I think is a very large concern, we are able to at least extrapolate data that will help us understand a more broad picture and make this available to the industry, at large. This is the airline information, not specifically our information.
    So we're getting there. I don't think we're 100 percent there yet because we haven't been that sophisticated in our data collection, but I believe we're getting closer and the information that we do have at this point in time is certainly more than others have.
    Mr. LIPINSKI. Thank you. I thank all the panel members once again.
    My time has expired, but I appreciate your input into this important issue.
    Mr. DUNCAN. Mr. Pease was the first one here, I think, this morning, and I'm going to go to him at this time.
    Mr. Pease?
    Mr. PEASE. Thank you, Mr. Chairman.
    Ms. Hanke, it looked like you wanted to say something, so let's do that first.
    Ms. HANKE. I was just going to add one point, and that is that, because the training that our members receive varies so greatly from carrier to carrier, from 30 minutes to up to 3 or 4 hours, there are different levels of comfortability [sic] in administering first aid. We are trained to monitor and to intervene but not necessarily provide the high level of first aid treatment that may be expected by the passengers on board the aircraft.
    Mr. PEASE. Thank you.
    Ms. HANKE. Thank you.
    Mr. PEASE. Ms. Hanke, in your testimony you advised—I think you said that flight attendants were no longer required to be R.N.s. I didn't understand that they were ever required to be R.N.s.
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    Ms. HANKE. When the aviation industry first started back in 1930, all stewardesses on board the aircraft were required by carriers to be R.N.s. And then, with the U.S. entering into World War II and the need for trained personnel, nurses to participate in the war effort, there was no longer a requirement that R.N.s be on board the aircraft. It was at that point that the airline requirement was lifted.
    Mr. PEASE. Your written testimony seems to imply that it was the airlines that made that requirement. Now do I understand you to be saying that Government required R.N.s?
    Ms. HANKE. No.
    Mr. PEASE. All right. So there was no requirement? There was a practice in the industry?
    Ms. HANKE. There was no government requirement. It was a practice of the industry.
    Mr. PEASE. Okay. Thank you.
    Dr. Atkins, can you tell us—I confess I don't know—what is currently available in medical kits on aircraft in the United States?
    Dr. ATKINS. There is a very limited number of drugs. There is some equipment to try and assist with the ventilation. There is not sufficient numbers of drugs that would be needed if you had someone trained to run a cardiac arrest. There are not sufficient drugs to handle many of the other problems. It's a very limited medical kit.
    Our medical kit on board a U.S. airplane, if I can remember the dates right, has only changed three times in the history of aviation. There was the original kit, which was pre-World War I, I think 1917 was the initial aircraft crash kit, and it was modified in 1927 to add a triangular bandage to that crash kit, and that was what was carried on U.S. carriers until you 10 years ago passed legislation and updated the kit.
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    The requirement now is really what is a first aid kit—bandages, that sort of thing—plus there is a doctor's kit now that is available if there is a physician on board that has a very limited number of drugs and supplies, but it is a very limited list.
    Mr. PEASE. Thank you. It could be that the next panel is better for me to direct the next question to, but can you tell us what the practice is on European airlines?
    Dr. ATKINS. I'm familiar with many of the airlines. Certain airlines have—they vary tremendously. KLM, until very recently, was still requiring their flight attendants to be registered nurses. KLM started out as an air ambulance service and then went into commercial business, so they always had the requirement that everybody in the cabin had to be a registered nurse until just in the recent few years.
    Several of the foreign carriers do have much more expanded medical kits than U.S. airlines do. Several carry defibrillators. Atlantic Virgin carriers defibrillators. I believe KLM has a much more extensive medical kit than what U.S. carriers do. I think Lufthansa also has. I know Qantas, which you're going to see a demonstration of their kit in a few minutes, has thought about this in much greater detail than most other airlines have.
    Mr. PEASE. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. DUNCAN. Thank you very much, Mr. Pease.
    Mr. Poshard?
    Mr. POSHARD. Thank you, Mr. Chairman.
    Just for clarification purposes, Ms. Hanke, you say on page eight in your testimony, on this particular flight that you're referencing, ''Because the flight was in Mexico at this point, MedLink could not be reached.'' Ms. Garrett, you indicated in your testimony that MedLink was worldwide. Why couldn't you reach it in Mexico then?
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    Ms. GARRETT. If I may address that, the majority of our calls come in through an HF radio patch. Now that the more-technologically-advanced communication systems such as satellite communication, that's just like making a phone call. However, with the HF radio communication patches, sometimes it does take an extended period of time for the pilot to get through to the communications company such as Aeronautical Radio, and that is the problem.
    And there are dead spots out in there where, once they make the patch, that it does not connect with the transmission capability to be able to further that patch along.
    So while we're up and available, it does depend on the ability of the communication to take place from air to ground and then through land line.
    Mr. POSHARD. Okay. So it was not just a matter of your being over Mexico then?
    Ms. HANKE. According to the report, this did occur in February 1996, as well.
    Mr. POSHARD. Okay. Thank you.
    Dr. Atkins, if I can just ask you a question on—in your testimony, you were referring to the American College of Emergency Physicians and the American College of Cardiology having no official position on placing defibrillators on airplanes. I wonder why that is.
    And you go on to say that both organizations feel that any proposed strategy should be evaluated for the benefit-to-risk ratio.
    We understand what the benefits are. What are the risks, side-by-side?
    Dr. ATKINS. The risk of a defibrillator on an airplane would be someone coming in contact with the device as it was being fired or in contact with the patient, or if the patient was in contact with metal.
    The potential problem is a defibrillator, when it shocks someone, delivers between 8 and 20,000 volts at 45 amps. This is a tremendous amount of current. It only delivers this current for about three to five thousandths of a second, but it is a tremendous amount of risk.
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    The older style defibrillators—I actually chaired the panel that recommended against defibrillators 12 years ago, and that was because the type of defibrillators we had were manually operated with paddles, and we felt that there was too much risk with that type of system.
    Today's system is much safer in that you have to have sealed electrodes against the patient's chest. So having the electrode against a piece of metal or someone else is practically impossible with these devices. They have to be sealed against the chest to have a low enough resistance for the system to arm and evaluate the patient. So we have moved quite a bit in the realm of safety with this.
    Most of the organizations had taken their positions based upon earlier types of devices. The FDA only this past year has approved these devices for uses on commercial aircraft, and the American Heart Association is the organization that has been taking the lead.
    American College of Emergency Physicians, American College of Cardiology are watching what the American Heart Association is doing and probably will end up supporting them later this year.
    Mr. POSHARD. So without thoroughly-trained people using these, though, is there some risk to additional damage to the person if they are improperly used?
    Dr. ATKINS. To the victim there is—you can't hurt someone who is already dead.
    Mr. POSHARD. Well, I understand, but the person may not be already dead. I'm saying: if they are used improperly, is there a greater risk?
    Dr. ATKINS. If they're used improperly our worry would be someone receiving a shock. Most of the FDA studies have shown that the risk to the aircraft or frame is not a significant risk. So our major concern would be someone touching the victim at the time they were shocked.
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    Now, since the electrodes are sealed to the patient, the shock is going to be delivered at least 90 percent to the victim, so the person touching the victim probably would get a nasty shock but wouldn't be hurt significantly, other than I think he would be rattled for a few hours.
    Mr. POSHARD. May I just, Mr. Chairman, ask one other quick question here? I know my time is out.
    You extrapolated from Qantas the projection that if defibrillators were aboard aircraft with trained responders you'd probably save about 10 to 20 lives per year.
    Dr. ATKINS. That is correct.
    Mr. POSHARD. But then you go on further to say that, ''based upon present information, it makes sense to place defibrillators in terminals and on wide-body aircraft, particularly those with long flights who carry older individuals.''
    Now, is the 10 to 20 lives per year based upon that assertion that you make or that recommendation that you make for where they are placed?
    Dr. ATKINS. If we place them, we do not have the type of data that is needed. Long-haul flights, just because they are longer, are more likely to have events than short-term flights. With 12 hours, you have 12 times the risk as if you are up for one hour. That makes a difference.
    Long-haul flights on wide bodies have a lot older population many times—we have retired individuals flying internationally—so that makes the risk higher. The risk goes up with age. The older we are, the more likely we are going to have a cardiac event in the next whatever period of time you're looking at.
    That would be the reasons.
    If you just put them on wide-body—and this would be a pure guess, because there is no decent data out there to even extrapolate—I would say Qantas saved two individuals in 3 years, I believe, of their study. Multiply it the times of American flights, and we're probably talking about 10 lives if it is done in the international on all the wide bodies. We're probably talking about 20 lives if it's extended to the narrow bodies that have enough flight attendants on board. And that is a guess at best.
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    Mr. POSHARD. Thank you, sir.
    Thank you, Mr. Chairman.
    Mr. DUNCAN. Thank you, Mr. Poshard.
    Vice Chairman Blunt?
    Mr. BLUNT. Thank you, Mr. Chairman.
    Dr. Atkins, are there things about the flight experience that make that more likely for someone that's a potential cardiac victim to have a problem—the anxiety, the altitude?
    I know one of my concerns this morning is, based on your per-minute analysis of the defibrillator device, I'm not sure we can get anybody to this room quick enough to save someone that has a problem. But are there things about flying that make it more likely that this will happen in the flight or the boarding situation?
    Dr. ATKINS. Yes. You are under both physical and emotional stress. You're running. You're hurrying. You're carrying excess weight. You're anxious.
    If we extrapolate—and, again, this is difficult, but the best extrapolation has suggested that for the amount of time that you're in a terminal or an airport, you're 20 times more likely to have an event there than the same number of hours spent at home. So it appears to be a stress-related phenomena.
    But, again, our data is very poor. We don't have enough data. We don't know where many of the events occur, what the age distribution is. We're just extrapolating.
    Mr. BLUNT. Are there other things on airlines that we ought to be concerned about in terms of particular preparation, or is really the cardiac arrest the most likely fatal sort of thing that happens? Airline attendants are handling choking, for instance, well? Are there cerebral hemorrhage/stroke problems or other things we ought to be considering in these hearings that we're not talking about yet today?
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    Dr. ATKINS. I think you have to look at the whole gamut of health care problems. I think there are problems across the board.
    If you have 30 minutes of medical training, which some airlines are doing, that is grossly insufficient to learn to handle any of the problems. So the amount of training helps across the board.
    Certain things like seizures, strokes, the initial risk to the patient is problems with breathing, airway. That's common to cardiac arrest. We have to handle the airway and the ventilation of the victim, regardless if they have a stroke, whether they have a seizure, whether they have a cardiac arrest or just heart attack.
    So there are certain principles that would go across many illnesses, but we have to train the attendants appropriately to handle all of the more common types of emergencies that occur.
    Being a medical director in a major airport, when I see aircraft diversions I often see diversions for the wrong reasons. Half of the aircraft that we meet for the diversion, the plane should never have been diverted. The patient was generally just a little bit drunk and hyper-ventilating a little bit. And about half the time when that occurs, the victim for which the airplane was diverted continues on the flight to their destination, so we have diverted.
    And then we have patients that have cardiac arrest for whom the plane is not diverted.
    So I think we have to go back to ground zero and develop within the airline a system, with whatever their medical department—if they do it internally or have some external medical advice section available to the airlines, give them the proper equipment, give them the proper supplies, and put the adequate training in to do a good job on all the range of illnesses.
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    Mr. BLUNT. If we did something on the basis of the Good Samaritan law to encourage people on the airplane who are health care professionals or some way prepared to be helpful, whose judgment should prevail if they also have a ground source MedLink provider of some kind? How do you handle that conflict of the person on the scene and the person on the ground? Do we handle that in legislation like that, or is that ethically handled in some medical way that we ought to know about?
    Dr. ATKINS. Most States have developed a system by which the authority—in this case the medical department of the airline—has final authority. What we procedurally do when this sort of problem comes in and there's a conflict is we put the physician on the radio in contact with whoever is on—in this case on the aircraft.
    As a medical director of an EMS system, we run into this problem. We go to a doctor's office and we get into a conflict between the doctor and the paramedics, and then we let the doctor at the hospital then make the judgment whether a physician on the scene was being reasonable or not.
    The odds are that the physician on the radio is more knowledgeable about the environment than the person on the scene is, though the person on the scene most of the time has better visual information than, obviously, the person on the radio would have.
    Mr. BLUNT. And you think the State law generally would have the person who is the person on the radio would be the person that would prevail in a disagreement about this?
    Dr. ATKINS. Yes.
    Mr. BLUNT. Mrs. Talit?
    Mrs. TALIT. I just want to add that Congresswoman Kennelly's bill provides Good Samaritan status, and it is highly recommended in the bill that, just as at the onset of a flight people are made aware of oxygen masks falling from the ceiling and how to fasten your seat belt, and they even give you the option of whether or not to sit near an emergency door, in Congresswoman Kennelly's bill part of the package would be that flight attendants could tell passengers, ''in the unlikely event of a medical emergency, any trained person stepping forward who has current credentials will be covered by Good Samaritan laws,'' which will not only eliminate some of the risk of flight attendants who may not have yet received thorough training handling equipment with which they're not familiar, but will also, I think, redouble the public's faith in what they have available to them.
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    In that regard, you have been concentrating on questions about the use of the defibrillator, which I cannot stress enough. Both of my children are EMTs. My brother-in-law is a cardiologist. And, while I have no medical training, I can tell you it takes minutes to learn. The device is idiot proof and it talks to you.
    As far as shocking people goes, there are non-conducting blankets that you can lie patients on.
    So when we talk about the defibrillator only being present if flight crew are trained to use it, we also, just as there are medical kits aboard that the flight crew isn't allowed to open, we have to provide airlines with defibrillators not just on wide body but on every commercial airline where passengers will fly so that when there is a doctor or paramedic or my daughter, Amy, who uses a defibrillator every day of her life, is on that flight, she has the tools.
    Ben Talit could have saved the man next to him if the man next to him was stricken and there were a defibrillator on board.
    I think that, with respect to a conservative physician's opinion, which I support to a certain extent, we must also let light in to have the right tools on hand for the hundreds and hundreds of trained people who also fly and could save lives with the same and the proper equipment.
    And the statistics, as we've all said, are terribly flawed, and the conservative number of 70 a year is simply not valid. We're talking hundreds. Ben Talit and John McDowell would be silent statistics if their widows were not sitting here.
    Mr. BLUNT. Well, we appreciate you and Ms. McDowell being here.
    Mr. Chairman, it has been a great panel. I have lots of questions, and I'm out of time, but I certainly appreciate all of the people on this panel and the information they've brought us today.
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    Mr. DUNCAN. Thank you very much, Mr. Blunt.
    Ms. Danner?
    Ms. DANNER. Thank you, Mr. Chairman.
    This has been very, very enlightening. Ms. Hedges, I couldn't help but think to add just a moment of humor here. When you were talking about the Heimlich, it truly is important that every flight attendant be trained in Heimlich if passengers are going to eat airline food.
    Ms. HEDGES. I won't argue with that.
    Ms. DANNER. Actually, I'm going to address this to you, Dr. Atkins, and perhaps to Ms. Garrett, because we really don't have anyone here, so far as I know, from the airlines. And, of course, no one airline speaks for the rest of the airlines. But, from what I am hearing you all say, it seems to me as though we need some standardized training and standardized kits so that, as a flight attendant moves from a 737 to a 100 and back and forth, it's going to be the same, and so that when your people in MedLink—and that's an excellent approach. I was unaware of that. When they're talking with the flight attendants, they'll know what equipment is available. It seems to me that that might be possible.
    Would that be possible, do you think? And I know it's speculation on your part and every airline likes to be autonomous and do their own thing. We have too many different pieces of equipment flying around up there, it seems to me, for you and your group to deal with.
    Ms. GARRETT. If I may, I'd like to offer a different perspective in that I am also a flight nurse with 8 years flying in rotor wing and fixed-wing aircraft taking care of critically ill patients and 15 years as an emergency nurse.
    Outside of this industry, I can tell you that to maintain those level of skills and comfort in taking care of patients on a frequent basis is critical.
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    I have some reservations about training flight attendants to the extent that they can handle each and every emergency that could possibly occur. I don't see that as being realistic.
    Furthermore, with the amount of exposure that they have to the different incidents, there is no way that they can maintain any level of comfort. That does not say, however, that to really hone in the skills such that they can provide the basics, again, in early recognition and assessment skills of observing an emergency and relaying that.
    From our physician's position, in receiving the calls we speak to flight attendants and on-board medical doctors, and they do qualify the physicians prior to their use of the emergency medical kit to ensure that no harm is done to the passenger.
    But I do want to also make a point that, whether a diversion is made or not made, that decision rests with the captain of the plane; that he has many other lives on that plane that he must consider or she must consider prior to a medical diversion. So it is a much more complex issue than what we're dealing with today. Everything must be considered to the gain of flight safety in the overall perspective.
    Ms. DANNER. Very good. However, in any training, whether it's Red Cross training someone to be a life saver, there is a basic training that people can have, and then beyond that, obviously, they can expand upon it.
    I made some inquiries when I was flying, since I knew we were going to be doing this, and the particular airline I was on does not permit the dispensation of an aspirin. I expect that's true, perhaps, in many airlines.
    Dr. Atkins, are there various levels of what the different airlines permit their personnel to do?
    Dr. ATKINS. Generally, most airlines probably do not allow giving out of any medication unless they have a physician order either on board the aircraft or on board the ground.
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    This does vary somewhat from airline to airline. I have seen airlines give out aspirin, and I have seen others that would not allow that to be done. So it varies tremendously.
    Ms. DANNER. What do you think, in your opinion, this panel should to do address this issue?
    Dr. ATKINS. Well, I think that my recommendation to you is to encourage the airlines, through legislation, to develop a system, put together the components, as I've said—the equipment on the aircraft, defibrillators on most of the aircraft would be a portion of that. Put in the ground control system to help the people on the aircraft in making the decisions and using the equipment properly. That is the approach I would do.
    I have seen too many efforts where just a piece of a system is put in place and we don't get any benefit of it.
    These are complex interactions, and I'm not opposed to putting defibrillators—in fact, I'm in favor of putting defibrillators in many, many locations, but it needs to be a part of an organized system—training, education, medical control, and the equipment and supplies.
    Ms. DANNER. One last question. Ms. Garrett, of the so-called ''majors'' in the United States, what percentage would you say take advantage of the benefits that your company offers?
    Ms. GARRETT. We have five airlines at the present time, the U.S. carriers. I haven't given thought to what percentage those are.
    Ms. DANNER. Thank you. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. DUNCAN. Thank you very much.
    Dr. Cooksey?
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    Dr. COOKSEY. Thank you, Mr. Chairman.
    Dr. Atkins, a couple of quick questions. I'm a physician. In fact, I'm probably the only one in the room that had occasion to administer CPR Monday. I gave a speech, and about 30 minutes later the moderator of the meeting passed out, but he survived. So it is an important issue, and I'm glad that these ladies brought it to the forefront.
    What would happen if you had a person that had a seizure, had a convulsion, normal heart, no tachycardia, no atrial or ventricular fibrillation, and you put the defibrillator on them? What would the effects be?
    Dr. ATKINS. Depends on the device. Most of the devices will pick up motion artifact and will not analyze. The equipment does vary a little bit from one vendor to another. But one of the safety precautions of these new automatic devices is they must measure between 50 and 100 ohms of resistance. Fifty to 100 ohms resistance is a very unusual resistance. Most things are much higher resistance or much lower resistance than that. Living tissue is about the only thing that is between 50 and 100 ohms, or recently-living tissue, so it must see that impedance or resistance across the chest before it starts the analysis.
    Some brands of defibrillators then have a motion detector system in, so if the resistance is changing rapidly then that might be seizure or other muscle activities. Other defibrillators do not do this.
    I would say most defibrillators would not do anything to someone having a seizure, but there are a couple of them that have not been adequately tested in that situation, and I would like to see them tested in that particular scenario first.
    Dr. COOKSEY. So you're saying if a flight attendant made a misdiagnosis and decided the patient had atrial fib or ventricular fib when they did not, in fact, it really would not have any adverse effect?
    Dr. ATKINS. The error rate of the devices is extremely low.
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    Dr. COOKSEY. Good.
    Dr. ATKINS. It's sensitive. It errs on the side of sensitivity. It's specificity virtually is 99.9999 percent.
    I was involved in some testing for ECRI, a testing company of medical devices, where we were purposefully trying to foul up the defibrillator with every method known, and, though we on two occasions out of several thousand attempts did get the devices to fire when they shouldn't have, it was—those were at extremes and things that I would not normally expect to see on an airplane.
    Dr. COOKSEY. Another quick question. We are always administering oxygen. We have oxygen devices and air bladders, and there was an accident that we spent a lot of time with last week, ValuJet, because of the oxygen devices. Would there be any risk of the defibrillator causing a spark that could cause a problem within the plane with added oxygen?
    Dr. ATKINS. You are delivering 8 to 20,000 volts at 45 amps. If you—and this was our reason against recommending it with the older style defibrillators where there was a possibility of directly putting the paddles on something metal. In that situation you would create quite a spark that would be sufficient to ignite things.
    With the sealed electrode systems that we now have, that risk is supposedly zero. At least in every way we have tested it we have not been able to make it spark in a dangerous way with that type of device.
    Dr. COOKSEY. Good. So we won't have a hearing about a plane that exploded because someone that was inadequately trained sparked——
    Dr. ATKINS. This was the concern, particularly with the older devices.
    Dr. COOKSEY. Good. Question to the two ladies who lost their husbands—and I am sorry to hear about that. What was your trip? Where were you departing from? What was your destination? Would it have been practical to have diverted?
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    Ms. MCDOWELL. We departed from Newark Airport, and the destination was Nassau.
    Dr. COOKSEY. So you had a long trip?
    Ms. MCDOWELL. Yes.
    Dr. COOKSEY. Where was yours?
    Mrs. TALIT. My husband had changed planes in Detroit, and he was traveling from Detroit to Los Angeles, and I have been led to believe—I have discovered that, although two physicians aboard, the cardiothoracic surgeon and the intensivist, worked on him feverishly and requested diversion, it was 45 minutes before the plane diverted and landed in Las Vegas, by which time my husband was dead.
    Dr. COOKSEY. Thank you, Mr. Chairman.
    In closing, I'd like to make the comment, I feel that the airlines that have chosen to be smoke free have done a great deal to save a lot of lives and probably saved more lives than anything else we can do today. The man that was the moderator at this meeting that I was addressing this past week was a three-pack-a-day smoker, but he told me when he was on the floor that he's reduced to one pack a day. So that smoke-free environment is going to save a lot of people.
    So I really think that if we had a smoke-free environment and a lawyer-free environment in airliners, everyone would be a lot better off, we'd save a lot more lives.
    Thank you, Mr. Chairman.
    Mr. DUNCAN. Thank you.
    Mr. Cummings?
    Mr. CUMMINGS. Thank you very much, Mr. Chairman.
    Dr. Atkins, tell me this: you're familiar with this American Airline training?
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    Dr. ATKINS. I'm sorry, sir?
    Mr. CUMMINGS. You're familiar with the American Airline training?
    Dr. ATKINS. Yes, I am.
    Mr. CUMMINGS. You, in answering the questions, over and over again stated that training, among other things, is extremely important. Do you consider the American Airlines training sufficient with regard to these issues that we're talking about today?
    Dr. ATKINS. Yes. They have a very good program that was put in place for training their pursers, which is where their starting point is.
    I know Dr. Richard Cummings, who worked with American Airlines on that, is Chair of the American Heart Association's Emergency Cardiac Care Committee, the committee that looks into this area and makes recommendations.
    Mr. CUMMINGS. Ms. Hedges, other than American Airlines, are there other airlines that are doing the same thing?
    Ms. HEDGES. I'm not aware of any U.S. airlines. I do know Qantas has had defibrillators for several years. And maybe I'm misunderstanding. Are you——
    Mr. CUMMINGS. First of all, I'm talking about the training that American Airlines provides. I'm just trying to find out—discover how extensive it is and whether—and, since Dr. Atkins has now given his blessing and said that it is sufficient, the question becomes whether other airlines are doing it. And, if they are not doing it, why do you think they're not?
    Ms. HEDGES. As far as American Airlines' initial safety training, it is—I can safely say over 50 percent of the 6 weeks of training that initial flight attendants go through is devoted to safety and health. But there is another piece to that, because I'm not sure if Dr. Atkins was talking about our defibrillator training, which to my knowledge is the only training in the United States. It's 3 hours, 2 of which I believe—and Dr. McKenas in the next panel can probably be more specific—is devoted to the training on the use of that particular device, with one hour of workshop. So it's the only training in the United States if it's regarding defibrillator training.
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    So I'm not aware of any other airlines that are doing it, but it appears to be very satisfactory training.
    Mr. CUMMINGS. So you all—maybe it's the next panel I should ask this question of—other than American, American does this training, but it's the only airline that you know of that does this training, and there is no one else that is actually doing it? In other words, not just the training, but actually have people who have been trained by American since American is the only airline that does it.
    Ms. HEDGES. On defibrillators that's correct. In other words, it's not mandatory, and it's American—American has taken the lead in this.
    Mr. CUMMINGS. Dr. Atkins, let me just go back to another issue that you talked about—ground control systems. How significant is that?
    Dr. ATKINS. I feel it's fairly significant, in my involvement with EMS. The problem that you get into is you may have a very good physician on board, but a piece of equipment is different than what they're used to, and sometimes they need advice on how to use this.
    You have the problem that the person who says they are a physician may not be a physician. You also have the problem that the physician may be in a specialty where he has really not taken care of any critical illnesses in many, many years.
    So, often if you have someone in that situation and you can talk to them over a radio, you can at least find out the information. You can give them the information they need where they're willing to proceed.
    Some physicians, when they haven't done something in years, are very afraid to do it. But if someone else on the ground is talking to them, then they're more likely to go on and perform whatever the maneuver is.
    Mr. CUMMINGS. So is that done by way of some type of phone?
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    Dr. ATKINS. Phone, radio. We have fairly sophisticated—most of the airlines now have satellite communication systems so they can talk around the world.
    I got in the bizarre situation about a year ago that we have an open channel on our radio communication system that runs our paramedics, and we got a call from a plane that was out over the Atlantic and, because of his altitude, for some reason we were receiving him loud and clear, and it was a medical plane trying to get to Houston and was still out not yet in the Caribbean. We were able to communicate with them and we were able to help them until they got to Houston, which was about 2 1/2 hours after the initial call that we got.
    With the communication systems we've had one of our paramedics who was in our system call us up one night from an oil rig in the Persian Gulf working for Sedco, just used Sedco's satellite system to send us the EKG and a television picture of what the patient looked like to get advice.
    So we have communications systems that can work wherever the victim is.
    Mr. CUMMINGS. Thank you very much.
    Mr. DUNCAN. Thank you very much, Mr. Cummings.
    Mr. Fox?
    Mr. FOX. Thank you, Mr. Chairman.
    The FAA now requires, as I understand, 40 hours of training for all types of safety instruction for flight attendants. How much time specifically is dedicated to first aid training and what does the training consist of?
    Ms. HANKE. You are correct in that the FAA does require 40 hours, but the requirements in the FARs are so broad that it requires instruction in first aid and really doesn't designate a particular amount of time or even the specific topics that must be covered, and that is one of our concerns in that the FARs are broad and the requirements for training are so broad and will vary from carrier to carrier.
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    In that 40 hours of training, every aspect of the emergency operations must be covered, from emergency evacuation to fighting fires to medical emergencies to the security issues. So within that 40 hours it covers all aspects of anything that might be considered an emergency.
    Mr. FOX. Well, to avoid the kinds of tragedies we have heard today, would you recommend that we have CPR and defibrillator training and other training to address these in-flight emergencies?
    Ms. HANKE. I think that improved training is necessary or more uniform standards are necessary for flight attendants, because it does vary so greatly from carrier to carrier and there are expectations amongst the passengers that are not being met. But to jump to CPR, I believe there is something beyond perhaps 30 minutes of basic first aid training that barely touches upon the subjects and being CPR certified.
    I think it is an important issue that we need to look at to determine what level of training is going to be required, and recognize the fact that at the current time flight attendants are onboard more to monitor and to intervene in an emergency and not to administer and to perform medical procedures.
    Mr. FOX. I guess this question is for Ms. Sullivan Garret, but also for others. Would you suggest that every flight have a flight nurse in order to be able to have the qualified person be able to handle the emergencies?
    Ms. GARRETT. No, sir, I don't. I think that would be definitely overboard. But, again, the reality is the frequency with which the exposure occurs such that you maintain competence. And, again, I believe that my testimony recommends back to the basics. CPR is the foundation of first aid, for sure.
    Mr. FOX. I bet if the victim would be in a flight tomorrow and we had an election of paying extra money to make sure you were on that plane, there wouldn't be a potential victim that wouldn't want to pay for your services. I mean, cost aside, is there any other reason why you wouldn't want a flight nurse on the plane?
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    Ms. GARRETT. If we lived in a perfect world I'd say sure, other than the availability.
    Mr. FOX. I guess for some of us we want to make sure there are less victims and more people healthy and get to the next destination.
    Ms. GARRETT. I believe that is a part of the bigger picture——
    Mr. FOX. Yes.
    Ms. GARRETT.——the system approach that Dr. Atkins was referring to, and it should not take a Band-Aid approach.
    I would urge the committee to look at this from not only statistically significant information, but from logic, and certainly with the legal implications, as well.
    Mr. FOX. What I'm suggesting is the back to basics idea is very commendable that you've suggested. I would just also like to have someone like you in my plane.
    I guess the next question I would ask, based on the testimony I have heard, is: is there a bias for pilots—captains, those in charge of the plane—against diversion because of on-flight records of being on time to the next destination and the monthly statistics that are produced?
    Ms. GARRETT. I can tell you, sir, that in my company's 10 years experience in managing anywhere from 3 to 12 calls a day right now, that the overwhelming result to that type of question is whatever is going to benefit the passenger is what they are going to do. They have no reluctance whatsoever to divert that plane. If anything, they divert far more often than they should. As Dr. Atkins pointed out, they would rather err on the side of caution than not land the plane for a medical emergency.
    The problem is that we have seen, through our service, that, more often than not, the decision to divert is not medically warranted.
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    Mr. FOX. This is related back to the testimony of Lynn Talit. Her testimony with regard to the fact that, in her case, her husband could have hopefully—it seems like there could have been an earlier diversion.
    Mrs. TALIT. Yes.
    Mr. FOX. Is that your testimony?
    Mrs. TALIT. Yes, that is. There are people on the plane who felt sure that there could have been a much sooner diversion, and the physicians were very exact in that it was 45 minutes before the plane diverted until it landed in Nevada, and my husband was dead on the plane for that time.
    Mr. FOX. All right. Thank you for your testimony.
    I have no further questions, Mr. Chairman. Thank you.
    Mr. DUNCAN. Thank you very much, Mr. Fox.
    Let me just say, ladies and Dr. Atkins, this has been a really outstanding panel. We need to move on to the second panel at this time, but I can tell you that, despite all of us being bone tired from a long night last night, there has been a lot of interest in this, and I think that you are going to see some action out of this, either from this subcommittee or the FAA or the airlines, themselves, or a combination thereof.
    Thank you very much for coming and testifying and being with us today.
    The second panel consists of—and I'd ask them to come forward at this time. The second panel is: Dr. Jon L. Jordan, who is the Federal air surgeon for the Federal Aviation Administration; Dr. Russell Rayman, who is with the Aerospace Medical Association; Mr. Edward Merlis, who is vice president of the Air Transport Association; Dr. Eric Donaldson, who is general manager for aviation health services for Qantas Airlines; and Dr. David McKenas, who is director of corporate medical department for American Airlines. So we have four medical doctors and Mr. Merlis.
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    Mr. MERLIS. Mr. Chairman, I once worked at the Public Health Service.
    Mr. DUNCAN. Good. Thank you very much for being with us. We particularly—we appreciate all of you being here, but, as was mentioned at the start of this hearing, Dr. Donaldson has come all the way from Australia to be with us, and we certainly appreciate that.
    I did mention that we generally proceed with the witnesses in the order they're listed on the official notice of the hearing, and that means the first witness on this panel will be Dr. Jon L. Jordan, who is the Federal air surgeon for the Federal Aviation Administration.
    Dr. Jordan?

    Dr. JORDAN. Thank you very much, Mr. Chairman.
    Mr. Chairman, members of the Subcommittee, I welcome the opportunity to appear before the Subcommittee this morning to discuss emergency medical kits on board passenger-carrying aircraft.
    Before I describe for you FAA's ongoing effort to monitor and evaluate the appropriateness of the requirements setting forth the contents of the emergency medical kits, I would like to provide you with some background that I hope will be useful to you in establishing a context for the testimony that you have heard and will hear today.
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    Current regulations calling for emergency medical kits date back to 1986, when the FAA promulgated a final rule requiring large passenger-carrying aircraft operating under part 121 of the Federal Aviation Regulations to carry such kits beginning in August of that year.
    The FAA set a minimum standard for kit contents requiring the following: a sphygmomanometer, which is an instrument for measuring blood pressure; a stethoscope; three different sizes of airways, or breathing tubes; syringes; needles; and latex gloves, which were added to the kit's minimum contents in 1995.
    The emergency medical kit is also required to contain, at a minimum, these basic pharmaceuticals: 50 percent dextrose injection to be used for treating hypoglycemia or insulin shock; epinephrine, which is used for asthma or acute allergic reactions; diphenhydramine, commonly known as Benadryl, which is used for allergic reactions; nitroglycerine tablets used for cardiac-related chest pain; and basic instructions on the use of the drugs.
    These supplies are in addition to those contained in the required first aid kit, which include: adhesive bandages, antiseptic swabs, ammonia inhalants, bandage compresses, arm and leg splints, roller bandages, adhesive tape, and bandage scissors.
    As of January 1996, commuter aircraft with between 10 and 30 seats also have been required to carry emergency medical kits in addition to the first aid kits that they have always carried. This change came as a result of our ongoing harmonization of parts 121 and 135 of the regulations.
    At the time the rule mandating the contents of emergency medical kits was promulgated, there was controversy over what types of instruments and pharmaceuticals the FAA should require they contain. Commenters to the rule, as well as your counterparts in the Senate, in the form of report language, expressed concerns about controlled substances and potentially dangerous weapons being stowed on board any passenger aircraft.
    These and other commenters also argued that an aircraft should not be a flying hospital, but that the proper course of action in the event of an on-board medical emergency is to put the aircraft down on the ground and get the ailing passenger to the nearest hospital facility.
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    As a result of these concerns, as well as the views expressed by a substantial number of professional medical organizations that more statistical information on the frequency of occurrence and types of medical emergencies on board aircraft was necessary before requiring additional equipment or pharmaceuticals to be contained in the kit, the FAA scaled down its original proposal in terms of the contents that would be required of medical kits.
    The rule promulgated was designed to ensure that, at the very least, U.S. aircraft would have the basic minimum equipment on board to handle medical emergencies. That regulation also required airlines to report to the principal operations inspector, for a period of 24 months after the effective date of the rule, information on each medical emergency occurring during flight time and resulting in the use of the emergency medical kit or the diversion of the aircraft.
    That 2-year collection of data resulted in the generation of two reports by our medical experts at the Civil Aeromedical Institute, better known as CAMI, in Oklahoma City. The final comprehensive report published in 1991 analyzed the 2,322 in-flight emergencies reported during this period. There were 33 in-flight deaths, with reports indicating that physicians responded to the call for help 85 percent of the time the request was made.
    The report noted that airlines were provided a great deal of regulatory latitude in terms of the data they were required to report and the form in which they were to report it.
    The report suggested that, based upon the data obtained, the kit's medical contents might selectively be expanded to include analgesics, antiarrythmics, antiemetics, and bronchial dilators to address those symptoms—which include pain, difficulty breathing, nausea, and heart conditions—that occurred most often.
    The report also suggested that some of the more clinically serious cases might be helped with a more complete medical kit that included a wider range of cardiovascular, diagnostic, and treatment tools.
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    The report concluded, ''because the final chapter of consensus building on in-flight medical care has not yet been written, FAA and the private sector must continue to explore alternatives for improvement. Ongoing voluntary evaluation of in-flight health care experience by individual carriers will be especially useful as evidence to support action. ''
    This pooling of data will be needed to most efficiently meet the joint FAA-industry mandate to define the optimal medical kit and applications.
    Over the course of the next several years the FAA did receive cooperation from industry in terms of reporting medical emergencies. However, the data were not sufficient to determine what, if any, changes should be made in the contents of the medical kit.
    Therefore, in late 1995 the FAA convened a working group to coordinate our efforts with industry and the medical community to obtain the information necessary to make an informed decision concerning medical kits.
    The Civil Aeromedical Institute will have two new sources of data to enable it to more effectively analyze the contents of the kit.
    The Aerospace Medical Association has solicited information on medical emergencies from airlines in the form of questionnaires that have been provided to the Civil Aeromedical Institute for analysis. The data will include information regarding the usefulness and limitations of existing in-flight medical capabilities.
    In addition to the Aerospace Medical Association questionnaires, a contract medical assistance company, MedAire, has agreed to provide anonymous prospective data to the Civil Aeromedical Institute through October 1997. The MedAire data will include information on the individual having the medical emergency, the medical equipment needed and used, the responding treatment provider or consultant, the final ground-based diagnosis, and the outcome of ground-based medical treatment.
    These new sources of information should facilitate a report by CAMI expected by the beginning of next year. I anticipate that the working group I have formed will review this information and recommend whether additional rule-making to require more equipment and/or supplies as part of the emergency medical contents is warranted. In the meantime, we recognize the efforts of carriers like American Airlines, which recently elected to equip its overseas aircraft with and to explore the utility of automatic defibrillators, and of those of other carriers who choose to exceed the minimum regulatory requirements posed by the FAA.
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    Mr. Chairman, we at the FAA recognize that this issue is important to many people. This morning you and I have heard from the family members of people who, tragically, passed away aboard aircraft.
    The FAA, in conjunction with industry and the medical community, is committed to resolving the issue.
    If, at the conclusion of our current efforts, we find that regulatory action is appropriate, FAA will take that action.
    This concludes my prepared statement, Mr. Chairman. I would be pleased to respond to questions at any time.
    Mr. DUNCAN. Thank you.
    Dr. Rayman?
    Dr. RAYMAN. Mr. Chairman, members of the committee, the Aerospace Medical Association appreciates the opportunity to submit this statement to the House Aviation Subcommittee on the important issue of in-flight medical kits.
    I am Dr. Russell B. Rayman, executive director of the Aerospace Medical Association, representing approximately 3,600 physicians, scientists, and flight nurses engaged in the practice of aerospace medicine or related research.
    I would like to address medical kits and then defibrillators.
    First, medical kits—in 1986 the FAA mandated that the contents of U.S. air carrier in-flight medical kits include four medications: 50 percent glucose, epinephrine, diphenhydramine, and nitroglycerin. Although this kit appeared to be adequate for a number of years, a reexamination of the medical kit with an eye toward expanding it is now in order because of the increasing number of travelers, including those of advanced age.
    It is our overall impression at this time that more medication should be added. However, in order to design a proper medical kit, it is necessary to have basic information such as the frequency of in-flight medical events.
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    Although there are some articles in the open medical literature on in-flight illness and death, they are few, far between, fragmented, and certainly not comprehensive nor necessarily accurate.
    Consequently, the Aerospace Medical Association strongly recommends that the airlines anonymously report all in-flight medical events and deaths for a period of just 12 months to a designated central repository. At the end of 12 months, no further reporting would be necessary.
    If the airlines would do this, aerospace medicine practitioners could, with this comprehensive data, design a medical kit based upon rationale rather than best guess or partial data.
    Regarding automatic external defibrillators, or AEDs, the Aerospace Medical Association has not yet taken an official position on this issue. However, we recognize there are clearly cogent arguments in favor of carrying AEDs on board commercial airliners, at least on some routes.
    Again, a decision based upon rationale would be possible if we had the 12-month database recommended above.
    Our conclusions: designate a central repository to which all U.S. air carriers would report for a period of 12 months all in-flight medical incidents and deaths. The reporting form should be extremely brief, requesting only essential information, and should be anonymous.
    After the 12-month reporting period, convene a board of aerospace medicine practitioners and other clinical specialists to make recommendations regarding in-flight medical kits and AEDs.
    We also urge that liability legislation in the form of a Good Samaritan law be enacted, as alluded to in previous testimony.
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    The Aerospace Medical Association stands ready to assist the Congress or any Federal or non-Federal agency on the issue of in-flight medical kits and AEDs. That is of utmost importance to the flying public.
    Thank you.
    Mr. DUNCAN. Thank you very much, Dr. Rayman.
    Mr. Merlis?
    Mr. MERLIS. Mr. Chairman and members of the subcommittee, I'm Edward Merlis, senior vice president of the Air Transport Association of America. I appreciate the opportunity to appear before you this morning.
    When a medical incident occurs on the commercial aircraft, it is the flight attendant who has the primary initial responsibility for dealing with the events, and we can all be thankful that our professional flight attendants are trained to provide first aid and temporary care until professional medical care can be obtained.
    When medical emergencies occur on a commercial flight, chances are good that a physician will be nearby. In about 80 to 85 percent of cases, medical professionals or medical rescue workers respond to the in-flight medical emergency. We believe that this percentage would be even higher if it were not for the medical professionals' fear of liability for the actions which they may take in this setting.
    In-flight medical emergencies are handled on a case-by-case basis. Most airlines maintain air-to-ground access to a physician through either a contract service or a network of physicians that's on call 24 hours a day to provide guidance to the captain regarding the medical emergency and to advise whether an unscheduled landing is necessary.
    Moreover, these medical consultants work with the on-board medical professional to determine appropriate care and treatment that should be rendered during the time that the flight is still in the air.
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    Federal aviation regulations require airlines to carry in their medical kits equipment for use in the diagnosis and treatment of medical emergencies that might occur during flight. This medical kit is in addition to a first aid kit which contains bandages, compresses, antiseptic swabs, arm and leg splints, tape, and scissors.
    As Dr. David McKenas will describe, American Airlines plans to introduce enhancements to their medical kits, as well as equipping their international airplanes with a small, light, battery-operated defibrillator that the FDA recently approved for use on board aircraft.
    American's experience will be particularly critical in evaluating the efficacy of these devices, which were approved based upon utilization in a medical setting, not an aircraft environment.
    Concurrently, ATA member airlines are conducting a review of the contents of required medical kits and gathering data on emergency medical diversions. We are working with the Aerospace Medical Association, whose members have considerable expertise in this area, in order to ensure that the data collected is relevant and any changes that may be proposed for medical kits are safe and appropriate.
    There is concern that inclusion of some items in a medical kit, if used inappropriately, might exacerbate the condition of the ill individual. Therefore, we must act cautiously in evaluating the information collected and perform the appropriate due diligence before making changes.
    It is our view that these two studies should provide important information necessary for determining whether and what medical kit enhancements are necessary.
    One last area of concern which we think the subcommittee needs to explore is the issue of liability. Our medical consultants have told us of instances in which trained medical personnel traveling as passengers would not offer concrete opinions and recommendations as a result of their fear of liability.
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    Moreover, carriers and our in-flight personnel share that concern. We recommend that the subcommittee explore this issue in greater depth to establish a regime which provides the traveling public, as well as the Good Samaritan or care giver, the protection necessary in our litigious environment.
    Mr. Chairman, I'd be pleased to respond to any questions which you or the subcommittee may have.
    Mr. DUNCAN. Mr. Merlis, thank you very much for being with us again.
    Dr. Donaldson?
    Dr. DONALDSON. Good morning, Mr. Chairman and members of the subcommittee. I'm Eric Donaldson from Qantas, and I greatly appreciate the opportunity of giving Qantas' experience with the on-board, semi-automatic defibrillators.
    I apologize that I haven't been able to provide a written report at this stage, because I only knew I was coming here a day or so ago, and I've been coming ever since. And, on top of that, I didn't quite know what to expect. I'll remedy that as soon as I get back, Mr. Chairman.
    Now, if I could just have the first slide, please, this—I'm only speaking from Qantas' experience, but 4 years ago we looked at the reasons we were having emergencies on board the aircraft, and these diagnoses are given by the physician on board, so that's our level of severity of the incident.
    You can see there—well, you probably can't see it very well, but I'll mention to you that the cardiac events we were having, we were losing approximately one passenger from an unexpected cardiac death every million passengers. We were losing approximately four a year.
    Now, these were unexpected. Our population that we have on board is selected because anybody that is sick or has a recent medical history must be cleared through our medical department, and if we have any suspicion that they're going to die on board we don't let them board, so these were unexpected deaths, and they're very distressing from a number of points of view.
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    The victim, of course, doesn't want to die. His relatives are distraught on board the aircraft when this happens because they think perhaps if he wasn't on board the aircraft he might have lived. Cabin attendants are people who have the job because they want to help people. They are distressed or upset because they can't do anything about it. And the passengers, of course, are all involved in this incident, whether they like it or not.
    So what could we do about it? We decided that—and I'd read now just an advisory statement from the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation. This is a recent report, but what they say is that, ''valid scientific evidence supports only three interventions as unequivocally effective in adult cardiac resuscitation: basic CPR, defibrillation, and tracheal intubation.''
    In our experience, tracheal intubation is beyond most physicians, if you took them in a random group, so we couldn't see much of a future in that.
    All air cabin attendants are trained on CPR. We take them. They must have a certificate when they come in. They're refreshed every year on CPR on their skills. So there wasn't much we can do there.
    That left defibrillation as the possibility. We were lucky at about this time a public-spirited citizen had supplied all the ambulances in New South Wales with semi-automatic defibrillators, and the people that were using these were not paramedics. They'd had one day's training, and the figures were comparable with the paramedics' figures. So we have a group of people on board Qantas that we call the ''flight service directors,'' the senior cabin attendant. Most of them have flown for more than 15 years. I've got the greatest admiration for them. They handle emergencies almost on a daily basis—not all medical, but other sorts of emergencies. They're mature and very capable people. So we couldn't see any reason why we wouldn't let these people do the defibrillation.
    That was 5 years ago. We put them on. If I could have just the next couple of slides, please, we'll show you the results.
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    We do have with our defibrillator a monitoring device. You can see we've had 27 cardiac arrests on board the aircraft in the last 5 years. We also have our nurses at our major terminals that carry the defibrillators, as well, and we've had some cardiac arrests there.
    Next slide, please.
    Those are our results on board the aircraft. The people down at the bottom there, you can see that of the ventricular fibrillation we've had six people defibrillated—six people that were fibrillating on board the aircraft. Five of them were defibrillated, and we've had two long-term survivors.
    On the ground figures, most of the people that we got to were fibrillating, and we've got a number of survivors there. We actually saved another one the other day, so those figures went up a bit.
    What can I say about it? From our point of view, we're a little bit disappointed that, although we're observing a number of the arrests on board—16, in fact, were observed—we would have hoped to have more fibrillating. If they're not fibrillating, of course, you can't save them with the defibrillator. The ones that were fibrillating, our results are as good as the best out-of-hospital defibrillating figures anywhere in the world.
    That was one point of view.
    The actual having the trays on board has actually assisted physicians that we've had. They are tremendous in making diagnosis with the patient, and we've had nothing but compliments from the physicians that have been able to use this equipment.
    From the cabin attendants' point of view, they have been very supportive—in fact, very enthusiastic about the use of the equipment.
    From the passengers' point of view, those that have survived, of course, are very, very appreciative. Their relatives, even in cases where the patient has died, felt that everything was done that could have been done for their father or mother, whoever was with them, and we're very happy about that, as well.
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    And the unexpected plus for the airline, we expected, in fact, to be diverting more aircraft because we would be saving more people. As the figures turn out, because we've been getting more information, in fact we've had less diversions.
    So from this company's point of view, anyway, it has been a very successful program.
    Now, at some stage, if you'd like, we have a seven-minute video of what goes on. I could show that.
    Mr. DUNCAN. Thank you. Certainly your airline is to be commended, Dr. Donaldson. Let's go ahead and show the video at this point.
    Dr. DONALDSON. I apologize for my colleagues here who have seen this video probably as many times as I have, but I think it does show the training that we've put on for the people and a couple of the survivors with their opinions on what went on.
    [Videotape presentation.]
    Mr. BLUNT [assuming Chair]. Thank you, Dr. Donaldson.
    Do you have any final comments?
    Dr. DONALDSON. Nothing. Thank you.
    Mr. BLUNT. What about your kit there? Do you want to tell us a little about how it differs from what is available in the kit we're requiring?
    Dr. DONALDSON. The kit actually is a fairly extensive kit. Initially we had the drugs to meet the emergencies that would happen on board, but once we put on the defibrillator, of course, we had to add drugs and equipment that a physician who was on board might be able to use should the patient be defibrillated.
    So we do have a list of the equipment, plus the indications, the generic names, the trade names, the side effects. So even if the physician has forgotten most of the things he'd like to remember, it's all here for him in the equipment, in the actual kit.
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    The only problem about this is that there is so much in it, it's difficult to put it together again once you take it apart.
    Mr. BLUNT. Well, we won't ask you to do that.
    Dr. DONALDSON. I can certainly do it.
    Mr. BLUNT. We may have some questions on that, and possibly Mr. McKenas may enlighten us a little on that very topic. I see he's got a couple of kits there by his side, as well.
    Dr. McKenas?
    Dr. MCKENAS. Thank you, Congressman Blunt, Congressman Lipinski, and members of the subcommittee.
    I'm Dr. David McKenas, and I'm corporate medical director for American Airlines. I'm very pleased to be here today.
    Recently American Airlines purchased automatic external defibrillators for installation on its over-water aircraft. Over-water aircraft are those which fly international routes such as Europe, Latin America, and Japan, and on certain domestic flights that cross over water.
    The defibrillator units are expected to all be on board by July 1st, and by the end of the year we plan to enhance our on-board medical kits so that a responding physician may handle at least the first hour of any medical emergency.
    As we are forging new ground with this new technology, we do want to monitor the program for a suitable period before committing to expand the program to domestic flights.
    In the meantime, American is training 2,300 of its flight attendants on when and how to use these defibrillators by the summer of 1997. At your invitation, we will address why American Airlines made what appeared to external observers to be a dramatic move and how we are planning to construct our program.
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    As many of the preeminent speakers here have said, one must first understand the epidemiology of sudden cardiac arrest.
    This is the condition that can be treated by automatic external defibrillators, although our defibrillator, which I have a demonstration here, will also treat certain forms of ventricular tachycardia, or another lethal kind of heart rhythm.
    According to the American Heart Association, more than 1,000 people per day in the United States suffer from sudden cardiac arrest. In most cases it is all but impossible to predict who will have a sudden cardiac arrest or where or when it will happen.
    The chances of surviving sudden cardiac arrest are less than one in ten, with most persons dying before reaching a hospital.
    Those people who do survive a sudden cardiac arrest have a good chance of living many more years. Approximately 80 percent are alive at 1 year, and as many as 57 percent are alive at 5 years.
    With sudden cardiac arrest, the lifesaving shock of defibrillation must be virtually given within minutes or the person will die. The chance of survival decreases 7 to 10 percent for each minute that defibrillation is delayed.
    Even if a passenger experienced a sudden cardiac arrest immediately after a plane leaves the gate, the time it takes for the plane to return to the gate to receive defibrillation from a responding paramedic team would be too late.
    Technology has come a long way in recent years to help the medical profession deal with sudden cardiac arrest. Many physicians, nurses, and paramedics have used the large hospital defibrillators. These are called monophasic defibrillators. It's the form of defibrillator that Dr. Donaldson has for the Qantas Airlines. Other folks have seen them in movies and in television, other hospital emergency room settings.
    Those units, with the exception of the Qantas unit, are cumbersome. They require a physician or trained medical personnel to interpret heart rhythms and to use the device.
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    Today's generation of automatic external defibrillators are smaller, lighter, more durable, and easier to operate and maintain, and are now a natural fit for use in the commercial aviation setting.
    American Airlines has been watching development of the automatic external defibrillators for the past few years. This past fall, the U.S. Food and Drug Administration approved the use of these devices for commercial aircraft. Everything was then in place for American Airlines to complete its program to improve the medical environment for its passengers.
    American also carefully studied its internal medical event and medical diversion data to reach its conclusion that automatic external defibrillators and enhanced medical kits were worthy of implementation, beginning with over-water flights.
    First, we noted a mismatch between the contents of the existing FAA kit—and the contents are depicted on Exhibit No. 1 here. I also have a sample of the kit, if you would like to review it at a later time. And, as others have described, there is fundamental medical equipment. The dextrose would help if somebody had an insulin reaction and their blood sugar fell. There are needles and syringes to administer the medicine. The diphenhydramine and epinephrine are for primarily allergic reasons and asthma. And nitroglycerine is for angina, or heart-related chest pain.
    But if you look at Exhibit No. 2, the medical events experienced by airline customers, you'll immediately see a mismatch. Exhibit No. 2 shows the kinds of medical events our customers experienced, and these were so serious as to prompt a medical diversion. This is based on 1994 data.
    As you can see, cardiac events consisting of angina, myocardial infarction, and sudden cardiac arrest—and some of the other categories are psychiatric, gastrointestinal, seizure, and asthma disorders accounted for a very high proportion of the events.
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    For those not medically versed, angina, chest pain, results when there is insufficient blood flow or oxygen received by the heart muscle. This can result from partial cholesterol blockages in the coronary arteries that supply the heart.
    Also, lower partial pressures of oxygen at cabin altitude contribute to less oxygen getting to the heart in some passengers.
    A heart attack or myocardial infarction results when a full blockage of the coronary arteries occurs or the heart muscle is so starved of oxygen that heart muscle actually dies.
    The dying heart muscle can cause the heart rhythm to go haywire and cause blood pressure to fall. A sudden cardiac arrest is the abrupt cessation of the pumping action of the heart. It can be due to a heart attack, angina, or other insults to the heart or lungs.
    Further, American reviewed the number of times that cardiopulmonary resuscitation was performed by flight attendants, and this is demonstrated in Exhibit No. 3.
    Cardiopulmonary resuscitation is administered by flight attendants for passengers who become unconscious, have no pulse, and no breathing. This certainly is a clinical definition of death; however, the outcomes of these customers in the past were not tracked through conventional procedures.
    Please also note the increasing trend, based on American Airlines' data, over the past few years. These findings demonstrated that our customers could be better served and kept out of harm's way with more advanced medical response capability.
    The defibrillator, as you can see here, also has a heart monitor which would permit an on-board physician to interpret the heart rhythm and to administer advanced medications and procedures using our enhanced medical kit to save the person's life.
    Lastly, we noticed an increase in our medical diversions over the last years, and you'll see this in Exhibit No. 4. This is tracking—1991 is in red, and tracking medical diversion rates throughout the year. The year 1992 is in blue, 1993 is in grey, 1994 is in blue, and 1995 is in black. We've seen similar increasing trends in our airline since.
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    Basically, Qantas is able to screen passengers for boarding, whereas, with our Air Carrier Access Act, domestic U.S. carriers are not able to do so, and we can only speculate this might be one reason for the increase in the diversion rate.
    Although it was clear to us that medical events were occurring on board that were of an emergency nature and their frequency was clearly increasing, therefore American wanted to be prepared for those events in the best interest of the welfare and safety of the customer.
    The above factors are then what prompted American to move forward in providing defibrillators on over-water flights and enhancing on-board medical kits.
    A few words about program logistics.
    The market value for automatic external defibrillators is in the $3,000 to $4,000 range. Initially, 262 aircraft will have the system, and we are purchasing 300 devices for stocking and replacement purposes.
    Lead international flight attendants, also known as pursers, are being trained to use the devices, and the training could not be going better. The flight attendants are universally accepting the training, and it's going very well. They're already trained in first aid and CPR. They're receiving a three-hour course given by the internal medical department physicians and nurses. It consists of one hour of lecture, demonstration, video, question and answer, and then 2 hours of hands-on training using resuscitation manikins and training defibrillators. They will also receive recurrent training on the device yearly.
    The company fully covers the liability of the flight attendants in the use of defibrillators or any other emergency procedure, nor are we stopping with this program.
    American Airlines also has a 24-hour-a-day physician on-call service provided by the corporate medical physicians of American Airlines. Our physicians respond instantly by radio link to the cockpit and cabin crew for real-time review and advice on medical emergencies.
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    Also, since responding on-board physicians do play a pivotal role in our program, American places a great emphasis on honoring these professionals. We do feel that a responding physician, though he or she voluntarily comes forward seeking no reward, should be recognized in some form.
    However, American concurs with the American Heart Association in urging some form of universal Good Samaritan legislation guaranteeing a qualified immunity from liability to responding physicians, and the air carrier would serve to enhance such programs as American's and further encourage physicians to respond.
    Finally, American continues to pioneer and explore on-board medical telemetry systems, and we have recently conducted successful tests in coordination with NASA and academic university centers. These systems would relay, via video, pulse, blood pressure, blood oxygen, EKG, and other vital medical data in real time to a ground-based physician, from which advanced medical care can be directed.
    In closing, if there was one singular premise that was the foundation of our decision to place this lifesaving capability on board, it was the medical aphorism primam non naturae or, ''first do no harm.'' Aviation medicine deals not only dealing with the health concerns of people, but the unusual environments in which those people go.
    In commercial air travel, that environment is temporally remote from medical care. By not having the tools available to respond to a medical crisis, we felt we were not doing our best to be responsive to one of the most fundamental principles of public and medical health practices; therefore, placing defibrillators on board and enhancing our medical kits follows from a very simple review of the public health statistics pertaining to American Airlines and from the tenets of medicine, itself. We felt it was the right thing to do.
    Being the public health physicians for a tremendously large traveling public, we are constantly and consciously making sure that on every flight every day our passengers are kept clear of harm's way. This summer, that will extend to situations that are out of American's or anyone's control, such as sudden cardiac arrest. It is certainly the right thing to do for our customers, which is of paramount importance at American Airlines.
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    I'd like to close, sir, if there's time, with just a 30-minute demonstration of the defibrillator—30-second, not 30-minute.
    Mr. BLUNT. I think we can allow a 30-second demonstration.
    Dr. MCKENAS. The defibrillator is fully automatic. The battery lasts for 14 months. And it's in a training mode, so unless we have volunteers I won't shock anybody.
    Mr. BLUNT. Well, Mr. Pease was here first this morning, if he wants to——
    Dr. MCKENAS. The pads are very easy to interpret and read. The machine keeps talking until the person does the right thing, which is to plug in the connector. You have the wisdom of a cardiologist in this box analyzing the heart rhythm.
    And that's what will save somebody's life. Thank you.
    Mr. BLUNT. Thank you, Dr. McKenas.
    Mr. Oberstar is suggesting we needed some of that on the House floor last night.
    Mr. BLUNT. Or, more significantly, about 3:30 this morning when we were casting that final vote.
    I want to thank the panel for being here. Mr. McKenas, I think certainly we want to thank American for your efforts to lead the way in setting what I hope would be a standard here.
    Could you quickly give us again the dates on when you're going to have this equipment on international flights and then the second plan to expand to other domestic wide-body flights?
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    Dr. MCKENAS. The equipment—we're planning a July 1st implementation. The equipment will be kept in a locked bracket in first class and in what's known as ''the dog house.'' The bracket installation is what is taking the time. We should have all of the brackets installed by July 1st for a July 1st implementation.
    As this is new technology, we do want to observe the program for 3 to 4 months before I brief Mr. Crandall and our Planning Committee in regard to our decision to go to the rest of our fleet. We do want to watch the program for a while, assure basically that we're able to provide the logistical support for the defibrillator and that we're doing some good with the program, as we fully expect that we are.
    Mr. BLUNT. I think we'll go right to questions. We have a vote scheduled within the hour, and so I know there are folks here who want to ask questions of this panel, and we'll see how quickly we can move on with that.
    Mr. Merlis, how much does the medical kit that we now put on planes—what's the cost of that kit? Mr. Donaldson, I'm going to ask you the same question about your kit.
    Mr. MERLIS. I believe that the kit, last time FAA data was developed, was about $100. Whether or not, because some of those drugs have become generic, it's gone down or inflation has taken it up remains to be seen.
    Mr. BLUNT. What about the kit you're using on Qantas, Dr. Donaldson?
    Dr. DONALDSON. It costs about $700.
    Mr. BLUNT. About $700?
    Dr. DONALDSON. That's the total kit.
    Mr. BLUNT. And the defibrillator devices you're using?
    Dr. DONALDSON. Well, 5 years ago they cost somewhere around $15,000. Now they're $3,000.
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    Mr. BLUNT. That's a point well made and should be well taken here today.
    Dr. Jordan, the medical kits were first introduced, I think, in 1986. We saw some indication there that this kit does not really match up with the airplane needs. What's the FAA going to do about that?
    This is literally an issue, it looks like, from what we're hearing this morning, that you can study to death, and we need to move quickly. I know this committee is going to want that to happen. What are you doing to try to make this kit make more sense and pretty quickly make some recommendations on this defibrillator device?
    Dr. JORDAN. Well, as I mentioned in my opening statement, Mr. Chairman, we're in the process of gathering data that we think is necessary or may be necessary to pursue any rule-making in this particular area.
    I should mention—and as I did, I think, mention in my opening statement, when we implemented the requirement for the medical kit 10 years ago—it's a little over 10 years ago now—we did go through the rulemaking process, which involves gathering information from the public.
    We got a number of comments from medical associations and medical personnel regarding what should be contained in the kit. We had originally proposed a fairly extensive kit containing many of the medications I think that Dr. Donaldson has exhibited to you today.
    Based on the comments that we got back, including comments from the American College of Emergency Physicians and the American Medical Association and others, we decided we needed to limit the contents of the kit, and the concern was that some of the contents of the kit that had originally been proposed, if misused could be to the detriment of the passenger, and we did not want to do harm to the passengers.
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    That's how we ended up with the kit that we currently have.
    Again, we are looking at this issue. We're gathering the information. We've been in contact with the Air Transport Association, the medical directors for the airlines on an individual and group basis. We're working with MedAire for the collection of the data that we think would be necessary to go forward with any possible rule-making.
    Mr. BLUNT. When did you decide you were going to have to do this study?
    Dr. JORDAN. Pardon me, sir?
    Mr. BLUNT. When did you decide that this study was going to be necessary and——
    Dr. JORDAN. As far as formalizing a study, we started that about a year-and-a-half ago.
    Mr. BLUNT. So a year-and-a-half to formalize the study, and another year to do the study, and then we'll have some results at that time?
    Dr. JORDAN. Yes, sir. The first thing we did, of course, is we looked at the medical literature that might be available in respect to medical emergencies and certain technological advances that have occurred over the years in respect to medical equipment and drugs. Thereafter, we went after the information that was already available within the system and we queried members of the ATA and individual airlines, as well as MedAire and other ground-based medical providers.
    That information was retrospective information, which is not the best information for making prospective determinations, and so we have now gone back to MedAire to get that prospective information, which will carry us all the way through the medical emergency that occurs on board the aircraft to the treatment that was provided the individual on the ground in case there was a diversion or otherwise, and the outcome of that medical event.
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    Mr. BLUNT. Dr. Rayman, I think you're recommending the 12-month study, as well. What I'm wondering about is we know there's—the cardiac problem is well documented. The American Airline response to that is significant. Why couldn't we go ahead and move forward with that part of—do you have any advice for us or the FAA, either one, on that topic except to wait 12 months?
    Dr. RAYMAN. Well, sir, I'm not convinced it's all well documented. There are individual reports, certainly, as we heard today.
    You could certainly put together a committee today and lock us in a room for a day and I think we could come up with a reasonably good kit, including recommendations for defibrillators, for the airlines, but that would be based, again, on our intuition, best guess, and judgment. If that's satisfactory, I think that could be done by tomorrow close of business.
    However, if you want to design any kind of medical kit based on some rationale, you need to have the data, and we just don't have that.
    What I suggest is that this be done over a specific period of time, 12 months, start, stop. Once you have that, you've captured it. You've got a snapshot of what's going on in the air, and then, with rationale, you're going to design a good kit very quickly.
    Mr. BLUNT. Dr. McKenas, did you think it was necessary to change the kit you have on board now to add the defibrillator and the training for that?
    Dr. MCKENAS. We did, based on a review of American Airlines statistics, and, based on our statistics, which are very obsessively kept for our airline, it was the right thing to do.
    We had an increasing number of sudden cardiac arrests, plus the existing kit did not provide medical capability for asthma, seizures, other life-threatening emergencies that could occur on board.
    And this was a decision made for American Airlines, and we know that it's right for our carrier based on our statistics.
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    Mr. BLUNT. It just seems to me that American Airlines is ahead of where the FAA is on this, and I think we need to be more proactive. But we're out of time for those questions and we'll go to Mr. Lipinski, the ranking member on the committee.
    Mr. LIPINSKI. Thank you very much.
    I thank all the members of the panel for being here, particularly you, Dr. Donaldson, flying all this way from Australia.
    Did you fly on United or American Airlines?
    Mr. LIPINSKI. You don't have to answer that. I don't want you to incriminate yourself. You don't have to answer that.
    I thank you very much for being here, and I certainly compliment you and Qantas in what you are doing in this particular area.
    I want to say to Dr. McKenas, I want to compliment my good friend, Bob Crandall, for his once again being an advanced thinker in the aviation industry.
    Dr. MCKENAS. Yes.
    Mr. LIPINSKI. I'd like to know, though, how soon are you going to go to Mr. Crandall and recommend to him that you are going to implement this on your domestic flights? I know you already testified to all of that, but just between you and me and Bob, how soon do you think you're going to be able to do that?
    Dr. MCKENAS. It will be probably after our enhanced medical kits are finalized and in place. That should be—we'll have a finalization on the kit and the vendor, etc., by August, and then at that point we'll have 2 months of experience. We would go back to our Planning Committee and say it's time to move on.
    Mr. LIPINSKI. Very good. How much does your defibrillator cost?
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    Dr. MCKENAS. Market value is $3,000 to $4,000. We got——
    Mr. LIPINSKI. You buy them in quantity, so I assume you'll get them a little less expensive, and Bob's a good negotiator, so he probably even gets it less.
    Dr. MCKENAS. Right. Actually, he was not in on the negotiations.
    Mr. LIPINSKI. He wasn't in on that? He was busy with the pilots probably at the time.
    Dr. MCKENAS. He picked a very shrewd medical director, though.
    Mr. LIPINSKI. Where do I want to go next? I wanted to go to Dr. Rayman. I like your scenario, Dr. Rayman, where you say that with instinct, intuition, common sense, and the data that you have at the present time you could all go into a room and sit down and come up with this. I recommend that's what you do, because I really think we've had plenty of studies. We have plenty of information. And since we already have an airline like Qantas and American stepping out here, I think that if you went in a room with your associates and did what you said you could do and what I just recommended you do, we could move quickly.
    Do you have any comment on that?
    Dr. RAYMAN. It's very doable, sir.
    Mr. LIPINSKI. It's very doable. Well, good. I don't want to waste any more time, because I'd like to get this done as quickly as possible, Mr. Chairman, so I'll relinquish the rest of my time and you can give over that time to someone else. Thank you.
    Mr. BLUNT. Relinquish your time in the interest of moving on and getting some conclusion to the study, Mr. Lipinski.
    Mr. Pease?
    Mr. PEASE. Thank you, Mr. Chairman.
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    Dr. Donaldson, I regret that I was absent during your presentation and I hope I don't duplicate things you've already touched on. If I am, tell me and I'll talk to you after the meeting.
    How long has Qantas had the defibrillators on board on your flights?
    Dr. DONALDSON. Five years.
    Mr. PEASE. Okay. Have you done any—I realize there is no way to study the emotional and human sensitivity impact of that, and therefore I'd like to talk a little bit about whether you've done any financial studies of, for instance, has there been an effect on the number of flights diverted because of the change in your medical equipment on board? Have you had any sort of analysis before and after of the financial costs and benefits, I assume, to Qantas as a result of your decision?
    Dr. DONALDSON. Yes. Could I just say, about the emotional side of things, first, we do have a system where the doctors at Qantas are 24-hours available for air flight service directors on board air flight, because if they do use this defibrillator and it hasn't been successful, they do want to talk about it, you know, so we do provide emotional support for them in situations.
    If it has been successful, then the whole aircraft cheers. I mean, it's a very uplifting experience for everybody involved. But we are conscious of the emotions that are involved in it.
    We anticipated, when we started this, really that we would be diverting more aircraft because if you do defibrillate somebody it's important, if there is some way that we can put the patient into an intensive care unit as soon as possible, we would be diverting to do that.
    In fact, everybody that was actually fibrillating, we did divert all those aircraft.
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    But, as the report showed, unfortunately, we're not finding as many people fibrillating or in the other rapid ventricular tachycardia as we anticipated, even though we are getting to them quickly. And so there's no point in us diverting aircraft now when we know that there is no chance of that patient surviving.
    So our figures are showing that we're actually diverting less aircraft, which, of course, is an unexpected result but it's financially rewarding—although that wasn't the reason that we put on defibrillators.
    Mr. PEASE. Thank you. That's helpful. One of the other witnesses mentioned the fact that Qantas was able to screen your passengers for disability prior to their entry on the craft. Is that Australian law? I guess I'm not familiar with that.
    Dr. DONALDSON. Well, it's an international—if somebody has recently been in the hospital or has an unstable medical condition—and we're relying on the passenger, of course, to advise the travel agent of that, but those passengers then must fill in the form and that's cleared by our medical department.
    So if there is a passenger who we think either the flight or the time is a risk to him, well, we deny boarding until we're happy he'll provide the oxygen or whatever support the passenger might need. In some cases it may be we demand a doctor to travel with the patient, or they might travel on a stretcher or in intensive care on board the aircraft, but we do have the ability to say we will only allow you to fly under these conditions.
    Mr. PEASE. Thank you. I'm obviously learning on this subject. This is not the case for domestic American flights?
    Mr. MERLIS. We are prohibited by Federal law from asking those kinds of questions. Dr. McKenas can go into this in greater detail. There are many instances when carriers—and I'm sure flight attendants are very upset and concerned too—that signs and symptoms suggest that somebody shouldn't be flying, but we're not allowed to make an appropriate inquiry.
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    Mr. PEASE. We can deny boarding to a potential passenger that's intoxicated, but we can't deny boarding to a passenger that looks in imminent risk of a heart attack?
    Mr. MERLIS. Dr. McKenas is the vice chairman of the ATA Medical Committee, which has, of course, been very concerned about this, and perhaps is far more articulate than I on the specifics.
    Mr. PEASE. Dr. McKenas?
    Dr. MCKENAS. In essence, our goal is to always get customers and passengers to fly, disability or not. Whenever we can accommodate their special needs, we're always glad to do so.
    In essence, if a passenger freely volunteers or discloses that they have a medical problem, that case will be referred to a special assistance coordinator and onto a corporate resolution official who is in liaison with the medical department.
    We make a case-by-case assessment in regard to whether or not they are stable for air travel and how we might enhance their air travel by adding extra equipment. We work one-on-one with the physician in that regard.
    Many times when we do deny boarding it may only be with a communicable disease such as chicken pox or a meningitis where the rest of the public could be at harm, and even that is a very carefully-tailored, case-by-case, individualized kind of approach.
    If there is any way we can get the customer to safely fly without affecting the safety of the traveling public, we will do so.
    Mr. PEASE. But is that because that's your practice or because by regulation that's what you're required to do?
    Dr. MCKENAS. it is our practice only in those cases where passengers disclose a medical problem. Many passengers do not. And we cannot ask those questions.
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    Mr. PEASE. If I might, Mr. Chairman, proceed?
    Mr. BLUNT. Go ahead, Mr. Pease.
    Mr. PEASE. So if you have reason to believe that a passenger has a problem, but the passenger says, ''I'm not going to tell you about that,'' there's nothing you can do?
    Dr. MCKENAS. In essence that's correct, sir.
    Mr. PEASE. Thank you.
    Mr. BLUNT. Dr. Cooksey?
    Dr. COOKSEY. Dr. Donaldson, a question: did you say you have had one in one million passengers that have had a cardiac problem, or did you say you had had one in one million passenger miles?
    Dr. DONALDSON. Passengers. On our international flights, we——
    Dr. COOKSEY. One in one million.
    Dr. DONALDSON. Of that one per million. I mean, that's an average. I mean, a bad year we had 11, and then a good year we might have 2, but normally it's——
    Dr. COOKSEY. It's one in a million.
    Dr. DONALDSON.——about one to one million. Yes.
    Dr. COOKSEY. Okay. That's fine. There are other physicians on this panel, and I'd like to ask you the question. It's my understanding that, of the people that have a heart problem, the only ones that will really benefit from this are people that have had ventricular fibrillation. A person that has had a pulmonary embolism or some other reason is not really going to benefit from this defibrillator; is that correct?
    Dr. MCKENAS. I'll take the initial response to that one.
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    This defibrillator will check for ventricular fibrillation and shock for that and forms of ventricular tachyarrythmias. It will also assess for that.
    The real advantage, in our mind, is having the monitor on the defibrillator, because with the enhanced medical kit the responding doctor would be able to look at the heart rhythm and provide advanced cardiac life support based on what they're actually seeing.
    We'll be having the laryngoscopy and advanced cardiac medicines, as well.
    Dr. COOKSEY. This is a physician in the plane or a physician at a remote site that's——
    Dr. MCKENAS. This would be a responding physician on the plane.
    Dr. COOKSEY. Okay. I have no further questions, Mr. Chairman. Thank you.
    Mr. BLUNT. Thank you, Mr. Cooksey.
    We are grateful to the panel today. I think we're going to conclude this hearing. Certainly these two panels have been extremely helpful to us as we look at this issue. We're encouraging the FAA to move forward rapidly, and certainly encouraging other airlines to look at what American is doing and look at the value that folks are traveling.
    Thank you all for being here today.
    [Whereupon, at 12:30 p.m., the subcommittee was adjourned, to reconvene at the call of the Chair.]

    [Insert here.]

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MAY 21, 1997

Printed for the use of the

Committee on Transportation and Infrastructure


BUD SHUSTER, Pennsylvania, Chairman

THOMAS E. PETRI, Wisconsin
HOWARD COBLE, North Carolina
JOHN J. DUNCAN, Jr., Tennessee
JAY KIM, California
STEPHEN HORN, California
BOB FRANKS, New Jersey
JOHN L. MICA, Florida
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SUE W. KELLY, New York
RAY LaHOOD, Illinois
FRANK RIGGS, California
CHARLES F. BASS, New Hampshire
JACK METCALF, Washington
ROY BLUNT, Missouri
JOSEPH R. PITTS, Pennsylvania
JOHN R. THUNE, South Dakota
CHARLES W. ''CHIP'' PICKERING, Jr., Mississippi
JON D. FOX, Pennsylvania
J.C. WATTS, Jr., Oklahoma

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NICK J. RAHALL II, West Virginia
ROBERT A. BORSKI, Pennsylvania
ROBERT E. WISE, Jr., West Virginia
BOB CLEMENT, Tennessee
ROBERT E. (BUD) CRAMER, Jr., Alabama
ELEANOR HOLMES NORTON, District of Columbia
PAT DANNER, Missouri
JAMES E. CLYBURN, South Carolina
BOB FILNER, California
FRANK MASCARA, Pennsylvania
GENE TAYLOR, Mississippi
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BILL PASCRELL, Jr., New Jersey
JAY W. JOHNSON, Wisconsin
JAMES P. McGOVERN, Massachusetts
TIM HOLDEN, Pennsylvania

Subcommittee on Aviation

JOHN J. DUNCAN, Jr., Tennessee, Chairman

ROY BLUNT, Missouri Vice Chairman

RAY LaHOOD, Illinois
CHARLES F. BASS, New Hampshire
JACK METCALF, Washington
JOSEPH R. PITTS, Pennsylvania
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CHARLES W. ''CHIP'' PICKERING, Jr., Mississippi
JON D. FOX, Pennsylvania
J.C. WATTS, Jr., Oklahoma
BUD SHUSTER, Pennsylvania
(Ex Officio)

NICK J. RAHALL II, West Virginia
ROBERT E. (BUD) CRAMER, Jr., Alabama
PAT DANNER, Missouri
JAMES E. CLYBURN, South Carolina
(Ex Officio)

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    Atkins, Dr. James M., M.D., American College of Cardiology

    Garrett, Joan Sullivan, President, MedAire, Inc.

    Hanke, Mary Kay, International Vice President, Association of Flight Attendants, AFL–CIO

    Hedges, Denise C., President, Association of Professional Flight Attendants

    Jordan, Dr. Jon L., M.D., Federal Air Surgeon, Federal Aviation Administration

    Kennelly, Hon. Barbara, a Representative in Congress from Connecticut

    McDowell, Carolyn, Montclair, NJ

    McKenas, Dr. David K., M.D., Director, Corporate Medical Department, American Airlines
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    Merlis, Edward A., Senior Vice President, Government Affairs, Air Transport Association of America

    Rayman, Dr. Russell B., M.D., Executive Director, Aerospace Medical Association

    Talit, Lynn, West Hartford, CT


    Costello, Hon. Jerry F., of Illinois

    Kennelly, Hon. Barbara, of Connecticut

    Poshard, Hon. Glenn, of Illinois

    Atkins, Dr. James M

    Garrett, Joan Sullivan

    Hedges, Denise C

    McDowell, Carolyn

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    Merlis, Edward A

    Talit, Lynn


McKenas, Dr. David K., M.D., Director, Corporate Medical Department, American Airlines:

In-Flight Death Patterns
Comparison of Domestic U.S. Carriers with International Carriers
Other Airline Comparisons, Medical Diversion/Billion RPM
FAA Required Medical Kit
Summary of Emergency Medical Landings, 1991–1995
Medical Reasons for Diversions

Talit, Lynn, West Hartford, CT:

Airline Passenger Safety, Enhancing In-Flight Medical Kits and Preparedness

Study: Illness Rate Doubles on U.S. Airlines FAA Reveals, by John Crewdson, Chicago Tribune, May 11, 1997, article


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    American Academy of Pediatrics, statement

H.R. 1670, to amend title 49, U.S. Code, to require air carriers to establish procedures for responding to in-flight medical emergencies, and for other purposes, text of bill

Aerospace Medical Association, Dr. Russell B. Rayman, Executive Director, letter to Hon. Barbara B. Kennelly, a Representative in Congress from Connecticut, September 24, 1997

    National Air Transportation Association, statement

    Boros & Garofalo, P.C., Moffett B. Roller, supplemental statement by Dr. Eric Donaldson

Letter from Hon. John J. Duncan, Jr., Chairman, Aviation Subcommittee, and Hon. William O. Lipinski, Ranking Member, Aviation Subcommittee, to Carol B. Hallett, President and CEO, Air Transport Association of America, September 19, 1997

Department of Health & Human Services, Thomas J. Callahan, Ph.D., Director, Division of Cardiovascular, Respiratory, and Neurological Devices, Office of Device Evaluation, Center for Devices and Radiological Health, letter to Lori J. Glastetter, Vice President, Regulatory Affairs and Quality Assurance, Heartstream, Inc., September 10, 1996

    Aerospace Medical Association, Dr. Russell B. Rayman, Executive Director, Report of the Inflight Emergency Medical Kit Task Force

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H.R. 2843, to direct the Administrator of the FAA to reevaluate the equipment in medical kits carried on, and to make a decision regarding requiring automatic external defibrillators to be carried on, aircraft operated by air carriers, and for other purposes, text of bill