By Samara Friedman, MD

A hungry college student was on a plane flying to Italy. She was alone, as her parents had bought her a ticket to join them on the trip, but their own flight had been sold out. About an hour after take-off, the flight attendants came down the aisle with their carts to serve dinner. She chose the chicken and quickly ate the entire meal. It was Indian-style cuisine, an odd choice for a flight between the U.S. and Italy.

Shortly after eating, she started browsing movie options and noticed that the back of her throat felt a bit itchy. She drank some water, but that didn’t make much difference. As they had not yet come by to collect garbage, she took a closer look at the label for the chicken and then saw in the fine print: “chicken with cashew.”

She thought to herself, “Why the f*** would they serve this on an airplane?” She had a nut allergy, and while accustomed to reading ingredients, she assumed that they would never put someone at risk by serving nuts in a meal in the air.

She thought perhaps it was just an itchy throat, nothing more, but then she felt her heart racing as well. Maybe it was just panic. She decided to pull out her EpiPens just in case her symptoms progressed any further. As she rummaged through her bag, she couldn’t find them. She emptied the entire bag and still did not see the EpiPens. Now, she was getting worried. She must have forgotten to grab them from her parents before boarding her flight, and they were now somewhere over the Atlantic, probably about an hour closer to Italy than she.

She rang the bell for flight attendant assistance. She told them about her allergy and the food she had eaten and that she was alone, had no EpiPen, and wasn’t sure what to do. They brought her to the back of the plane, away from the other passengers.

Shortly after that, the call for a doctor on board was made overhead. I raised my hand. An EMT a few rows behind me did as well. A flight attendant came by, asked my qualifications, wrote down my seat number, and said they would let me know if they needed me, without indicating the nature of the medical issue.

Being a pediatric orthopaedist, it would be pretty rare that any medical issue mid-flight would be within my particular area of expertise. Kids on airplanes are generally strapped in, making it highly unlikely that they would have the opportunity to jump off the seat Superman-style and sustain a supracondylar humerus fracture. Perhaps at worst, a stubborn toddler might get their arm pulled mid-tantrum and need their Nursemaid’s elbow reduced — that I could do.

Just as we were reaching the airspace over the most Eastern edge of North America, and having figured the medical issue was fully resolved at this point via the expertise of a medical doctor, the flight attendant appeared at my seat. “You were the doctor, right?” I responded affirmatively. “We found a nurse on board and had her look at this passenger, as we didn’t want to bother a doctor if it wasn’t necessary. But she is specifically requesting a doctor now. We’re sorry to have to bother you.”

I really don’t consider it a bother to help someone else on a flight, and I suspect most of my colleagues feel the same. We go into medicine for altruistic reasons. There are much easier careers to choose from if your goal is to accumulate wealth. My own children were sitting next to me on the flight, and I like to set an example for them to help others as well. Even if it wasn’t my wheelhouse, and I fulfilled my oath to forget the rest of medicine upon entering orthopaedic residency, I still did remember from my days as a volunteer EMT in college to start with Airway – Breathing – Circulation. That alone served me well the last time I helped out on a flight to revive a patient whose blood pressure had dropped precipitously low.

They brought me to the back of the plane, where this young girl was sitting, clearly shaken. The nurse had given her two doses of Benadryl, about 20 minutes apart, and when she didn’t respond, suggested that she probably was just having a panic attack. She was told to go back to her seat and to try to calm down. She did so for about 15 minutes, but she knew something wasn’t right and wanted to talk to a doctor. She was also apologetic for having “bothered” me and suggested that maybe she just had a panic attack. But her throat still felt itchy, her heart was racing, her nose was particularly runny, and she had eaten a meal containing a known allergen.

This scenario is my worst nightmare. That frightened college student, having an allergic — most likely anaphylactic — reaction on an airplane with limited medical resources, without EpiPens, and without parents or anyone else who cares for them, could have easily been my own son.

My son had his first anaphylactic reaction at two years old, on his very first exposure to nuts — pistachio, to be specific. I can recall every moment of that evening and how his reaction progressed, including calculating that I could probably drive to the hospital faster than an ambulance from across town could make it to my door. I was that panicked mother who ran into the ER holding her baby, who was barely recognizable with his eyes swollen shut and audibly wheezing as he tried to exchange air, that you see dramatized on medical TV shows.

It is now 15 years later, and every moment of that night is etched in my brain. He will be leaving for college at the end of the summer and has a penchant for travel. There is no question in my mind that no matter how responsible he is, he could be the one paging for a doctor on the airplane.

She was panicked, but she could easily converse with me. Her blood pressure was stable, and her pulse was 104. Her nose was running copiously, and the itchiness in her throat was still significant. While this wasn’t an orthopaedic issue, it was an issue I had been educating myself on and managing for the last 15 years, and I certainly felt qualified to make the call that needed to be made. If this was not anaphylaxis and I made the wrong call, she’d get a shot of epinephrine (a very safe medication with very few side effects) that she didn’t actually need. If this was anaphylaxis and I made the wrong call, she would die. Decision-making becomes much easier 35,000 feet in the air when your worst-case scenario is death. You choose the other scenario.

The flight attendant didn’t know off-hand if their med kit contained epinephrine. I had three EpiPens on me, and while I was unquestionably willing to use one if it meant saving this woman’s life, I was very uneasy about being one EpiPen down without access to replacements on day 1 of a 10-day trip, where almost every restaurant uses pine nuts and pistachio in their kitchens.

It turns out that to use someone else’s medication on the plane, they have to get in touch with their own medical director for approval. And they were having trouble reaching him because of the distance from land. The message gets sent from plane to plane like a literal game of telephone until one plane is close enough to reach the medical director on the ground. The lack of approval would not have deterred me had she needed epinephrine imminently.

The med kit was placed in front of me with a dizzying array of medications, most being foreign to an orthopod. I found the epinephrine. It was not an auto-injector. It was in a long, thin box that said “Epinephrine 0.1 mg/mL.” I opened the box and found a syringe with no needle and an odd-appearing vial, which looked like a tiny graduated cylinder. The graduated cylinder had a blue plug on the top, and another threaded blue plug inside that looked as though it was supposed to screw onto the syringe, although it didn’t.

I found out much later that this device is called a Bristojet. It is not only meant for hooking up to an IV line to administer epinephrine to someone in cardiac arrest, but it is also meant to be difficult to use for other purposes — and it was. This is where my orthopaedic training/tinkering abilities came in handy. I figured out how to lever off the first blue plug and jammed an 18g needle through the second one to extract the epinephrine. I knew the dosage by heart — clearly written on my son’s EpiPens — 0.3 mg. I drew up 3 mL of fluid without recognizing that this was a pretty large volume.

The young college student lay down on the floor, on top of one of those flimsy airline blankets. She had a history of vasovagal responses to needles. The flight attendant pulled me aside and said, “Do you definitely think she needs this, or are you doing it more as a precaution?” Essentially the answer was yes to both. “Because our protocol is that if you give her a shot of epinephrine, we have to divert the plane to Canada. Your call, doctor.”

Well, that doesn’t add any pressure to the situation at all.

I told the flight attendant, “Yes, I believe she needs the epinephrine. However, she is stable right now. Her symptoms have not been progressing (yet), and if she responds to the epinephrine, I think we can reasonably observe her on board. But it is your protocol, so if we have to divert, then we divert. I’m injecting her regardless.”

She pulled down her pants, and I poked the needle into her upper outer thigh. She screamed so loud that I think the entire plane may have heard her, including the pilot.

At this concentration of epinephrine, it required 10x the volume of fluid, and given IM, it hurt like hell. She laid there for a few minutes. She felt less panicked. She sat up and had some hot tea. Her runny nose started to improve, as did the itchiness in her throat. The flight attendants still could not reach their medical director, so they decided to continue onto Italy. I watched her myself for the first hour until they suggested I get some sleep, and they promised they would let me know right away if her condition changed. We landed uneventfully 5 hours later, and she was escorted off the plane by medical personnel.

As I’ve had a few weeks to reflect on this experience, both as a doctor and as a mother of a child deathly allergic to nuts, it has become clear to me that the airlines need to do better. Approximately 1 in 14 children in the U.S. have food allergies, peanut being the most common.

While the airline cannot account for every food allergy or sensitivity out there, it astounds me that they would serve for their main course, a dish that could potentially kill a sizeable percentage of the population. They accommodate vegetarians, which is a lifestyle choice, and kosher food for religious observance, but they won’t make an effort to accommodate people who could quite literally die from eating their food? Why are their priorities so skewed?

My son was unable to eat any of the food on that flight. He subsisted on the junk food I had found in the airport. Yes, I should have planned better, but sometimes you have patients that need extra time and other last-minute things that come up prior to travel, and you count on being able to buy a snack pack (all with labeled ingredients) on the plane. Spoiler alert: They don’t sell those anymore on international flights because people don’t buy them when there is free food.

Perhaps this was unique to my flight, but I also don’t understand the concern of “bothering” a doctor. That is not a reason to avoid the highest level of care. If a doctor volunteered to be bothered, then there is no reason to select someone with less training.

While a nurse could be very helpful, the training is just different. This is a situation with limited medical resources, and the most highly qualified person there is exactly who they should bother. They clearly have medical protocols (the one regarding diverting to Canada being overruled in this case). So why no protocol regarding accepting the help of the highest trained volunteer?

What is much more concerning is that it took me about five minutes to figure out a Bristojet and convert it into an IM epinephrine injection. That is way too long, and I’m guessing that it could take some even longer.

People developing anaphylaxis will not always have five extra minutes to spare. I do appreciate that auto-injectors are expensive, but it is not at all expensive to have an ampule or vial of epinephrine on board, which can be drawn up in five seconds. Those also come in a much friendlier concentration of 1 mg/1 mL.

The chances of using epinephrine to treat a cardiac arrest patient are astronomically small compared to the chances of needing it to arrest an anaphylactic reaction, particularly if they continue to serve food containing nut products.

Parents in the nut allergy community have advocated for these changes for years. And while the airlines have taken the important step of no longer serving packets of nuts on board, little else has been done to make air travel safer for the food-allergy community. I call upon the major airlines to revise their medical kits and to offer allergy-safe meals for those in need. It is such a simple measure, and you can quite literally save a life.

Samara Friedman is a pediatric orthopedic surgeon.