Dilemma

[dScouter15]

As a paramedic, I'll throw my two cents in, for whatever its worth, to clear up some apparent misconceptions:

 

A First Responder or WFR is not trained on the protocols for administering Epi, or any other drug for that matter (with the possible exception of oxygen). Under some protocols a FR may assist a patient showing signs of anaphylaxis in administering the patient's own Epinephrine Auto Injector. FRs are not qualified to determine a correct dose of epi, draw it up into a syringe, etc. Nor are they qualified to administer benadryl, terbutaline, solu-medrol, albuterol, or any other drug (again, with the exception of oxygen). The reason for this is that FRs do not receive enough training in pharmacology, patient assessment or medical patient management to be able to decide whether epi (or any other drug) is indicated or contraindicated in a given situation, what dose of said drug to administer, the route to administer it through, and how to manage the patient if there is some adverse side effect. After all, FR and WFR training is only 40-80 hours in length. In contrast, an EMT course is approximately 140-180 hours in length, while a paramedic course is more than 800 hours.

 

So, as a WFR, say you find a patient with no hx of severe allergic reactions, showing severe respiratory distress. What are you going to do? Before you dive in to your first aid kit and give him a shot of life saving epi, what further assessment are you going to do? What findings would suggest that epi is indicated? What findings would contraindicate epi? What other interventions should you be prepared to perform?

 

That said, if you find a doctor willing to write a protocol for you to carry epi, and administer it on a standing order, than go for it. But I'd be surprised if you find a doctor who will do that, given the lack of necessary training as I described above.

 

I'd advise you to search out a physician who can advise your group, and provide you with some guidance as to what training would be most appropriate, and perhaps help you develop some operating protocols to treat injuries and illnesses you expect to encounter.

[Stosh]

On the other hand a non-trained person is not held to the same level of competence as a paramedic or EMT. Every state has a Good Samaritan Law to protect those who would follow a legal definition of what a reasonable person would do in that situation. If an Epi was in the pocket, as a former EMT-A, no longer certified, no longer at that level, I could quickly figure out a way to assist even an unconscious person to administer their Epi.

 

And while the average person can take comfort in knowing that only very few people die each year from bee stings, the one case in front of you as you look on, pushes that statistic right out the window. Somehow I wonder in a situation like that if one would be sued for doing too much or not enough? I guess if I'm going down for the count, I'd rather be sued for trying to do something than not doing anything, at least I'd sit in prison with a clear conscience.

 

Stosh

 

[GernBlansten]

Scenario:

You are hiking with a group in the wild, 4 hours from emergency response. You have WFA and a complete First Aid Kit. One of your party has a known allergy to bee stings and has a prescribed EpiPen. He has alerted all party members of his problem and his remedy. Another in your party, who has no history of the allergy, gets stung and goes anaphylaxis. You can identify it because of your training. He is going blue and will not survive without intervention.

 

Your choices:

1) You send for help, using your own first aid kit to attempt to keep the air passage open.

2) You send for help, then administer the EpiPen from the other hiker on the victim.

3) You send for help, then stand back and quote chapter and verse on the regulations requiring the administration of prescribed drugs only by qualified medical professionals while taking comfort of complete liability protection because you religiously follow rules.

[Bob White]

The Good Samaritan Act does not protect you for ANYTHING you do. It protects you for reasonable acts within your knowledge and capability.

 

If someone is unable to breath and you give him the Heimlich Maneuver and you break his rib, The good Samaritan Act would likely protect you. But if you take your pocket knife and part of a pen casing and try to do an esophageal airway because you saw it on a MASH rerun, do not expect to be protected by the Good Samaritan Act.

 

Giving an epi dose because someone on a web forum said you could is unlikely to impress anyone charged with determining if you acted within the limits of your knowledge and capabilities.

 

Nor will saying you took a first aid course that didn't cover the specific protocols for administering pharmaceuticals.

 

 

[GernBlansten]

I'd take my chances in front of a jury of my peers. Hopefully, my first witness would be the family of the victim I attempted to save.

[dScouter15]

Bob - you're absolutely right on the good samaratain law - except that I don't think an esophageal airway is what you think it is. But, that kind of proves my point further - a little knowledge can be very dangerous.

 

My primary concern is not necessarily the (completely valid) legal aspects that Bob and others pointed out - its not just about being legally allowed to "store and disburse pharmaceuticals", not about being trained to follow protocols. My concern is that a person with the very limited training provided by FR training presumes to administer dangerous medications to persons without a prescription. Fact is, an FR receives very basic training. The amount of training given is barely adequate to teach a FR to identify anaphylaxis, let alone treat it using medication. In fact, the amount of first aid care that an FR is allowed to provide is barely more than that we teach our scouts to perform. Epi is not some wonder drug that you can just give to magically fix anaphylaxis (assuming that the patient you administer it to is actually suffering from anaphylaxis). Epi causes many different parts of the body to respond in many different ways. There are many situations in which is use is indicated. There are many, many situations in which it is contraindicated. It can have dangerous side effects. If you give it, and it was not indicated, or contraindicated, you could seriously injure or even kill a person. If you give a wrong dose, or give it the wrong way, you could kill a person. An FR just does not have the education necessary to adequately assess and evaluate a patient, and administer a dangerous drug like epinephrine.

 

If you perform some medical procedure, or give some medication, and cause a person greater harm, or death, I'd certainly hope a jury would consider whether or not you had sufficient education to know how to do the procedure you attempted, or to know whether to give the medication you gave. The education required to give Epi - a drug powerful enough to restart your heart during cardiac arrest - is much more than what standard first aid or first responder courses provide.

 

I guess if you feel that its so important that epi be available to be given to hikers without a prescription, you have a couple of options:

1) Bring a medical professional along with you who has the necessary education, and certification or licensure to treat patients using dangerous medications.

2) Have some of your group leaders receive education and certification necessary to administer epi

3) Find a doctor who will write a protocol allowing you to administer epi at your current level of training and certification. I doubt this will happen, and I think its a VERY bad idea, but all you need to do is find one doctor who disagrees with me.(This message has been edited by dScouter15)

[GernBlansten]

So, we are to just stand there and watch the victim die whilst holding the very technology that just might save their life?

[dScouter15]

GernBlaster - If you ask me, if you are "holding the very technology that just might save their life" - you should have the education necessary to know when, where and how to use it. If you don't have that education, you shouldn't be have that "technology" in your possession. There are a lot of types of medical equipment, and a lot of medications that "just might save a life." However, before using any of them, you need to know when, where, why and how they are used. First aid and first responder training teaches how to use a number of pieces of equipment, and a handful of medications, to potentially save someone's life. Epinephrine is not one of these medications. Giving drugs, or performing medical procedures, because you think they "just might help", is a very dangerous approach to first aid and medical care - if you're wrong, you could easily make a situation much, much worse.

[Bob White]

That does it I will never base my first aid training on MASH reruns again!

 

Germ what we are trying to say is that unless you have the appropriate training you really don't know that using the epi pen is going to make things better, you could in fact be making the situation worse. You could even possible cause a death that without your intervention may not have happened.

 

You should not administer medications that you are not properly trained to use.

 

Did I mention that someone is more likely to be struck and killed by lightning than die from a bee sting? In fact far more people will win the lottery than die from a bee sting and think of the astronomical odds of winning the lottery.

 

This is not the medical emergency issue that some people want to make of it.

 

 

[GernBlansten]

After the victim suffocates and his heart quits beating, can I then inject the EpiPen? Or does it take a coronor to declare death before we can play with alternative rescue methods?

[Beavah]

Aw, shucks. I was respondin' to dScouter off-line because I figured this thread had run its course, and here it reared up again.

 

dScouter is correct that epi administration is not part of da DOT First Responder curriculum. My bad for not bein' clear. It is part of all the WFR courses I'm familiar with, and some of da WFA classes as well. Not cardiac injections, of course! Just standard-dose sub-q or IM stuff. Field use of that has been a recommendation of the Wilderness Medical Society for years, so it really is not hard to find an outdoor program physician to supervise and train. As I mentioned, it has been common in professional and volunteer outdoor programs for many years.

 

From a legal perspective, da situation is a furball across da several states. That's not really an issue for anyone operatin' under physician direction, of course. But the trend is clear, eh? Because of the "peanut parent" lobby, states are increasingly authorizing even lay persons to administer epinephrine in pre-measured doses. That's particularly true for schools and camps, where often such emergency protocols (under a supervising physician) are being mandated.

 

The prescription medication carried more commonly by wilderness trips is epinephrine, most often in auto-injectors, for life-threatening allergic reactions. Its use is supported by the Wilderness Medical Society, and other experts on anaphylaxis, yet it remains a prescription medication, and as such there are legal constraints to its use. Most commonly the epinephrine administered is the patients, and the care giver assists the patient. However, there are examples of new onset anaphylaxis in outdoor programs that have been treated by epinephrine carried by the program.

 

We teach [WFA and WFR] students to recognize a severe allergic reaction and to correctly administer the epinephrine. There are an increasing number of state laws that allow for the administration of epinephrine by a lay person to an individual experiencing a life threatening allergic reaction. This is likely to be an area of continued discussion and evolving laws and regulations in ensuing years.

 

Tod Schimelpfenig, Curriculum Director

Wilderness Medicine Institute of NOLS

 

 

Moral of the story is quite naturally, get trained! Establish and follow protocols! Learn more, understand why da pros have made this a standard of care for wilderness programs, and do what you can within your level of commitment to be a strong adult leader.

 

Folks who are trained, and in fact all of us, have to exercise our own best judgment when confronted with a genuine emergency, eh? I think that's Gern's only point. Someone in severe respiratory distress is in a world of hurt, eh? If mechanism and other symptoms reflect anaphylaxis, then yeh have to make your own decision as Gern suggests.

 

The potential for harm following administration of subcutaneous epinephrine is extremely small but not nonexistent, and primarily involves the inappropriate administration to patients who are not actually experiencing anaphylaxis. There are several case reports of adverse effects following field use of SCE, but no formal studies document any systemic hazards from SCE, and concerns regarding cardiac effects in the elderly appear to be unfounded.

- David C. Cone, MD, for the National Association of EMS Physicians

 

Beavah

(This message has been edited by Beavah)

[dScouter15]

Gern - I think that because many people carry easy-to-use EpiPens, lay people get the impression that Epi is a relatively "easy" drug, like Tylenol or Aspirin, that can just be given to someone who we think might need it. But, without having the education to even know what Epi does, how would you decide when to give it? A bunch of drugs could potentially stop someone from dieing. Atropine, Sodium Bicarbonate, Lidocaine, Dopamine, D50, Glucagon, Narcan, Norepinephrine and Lasix (just to name a few off the top of my head) are common drugs that could save someone's life. Do you think that all of those should be carried with us in our first aid kits? Do you think that you could just give them to someone you perceive to be "dieing" in the off chance that they might work?

 

I've made most of these points already, so I'll try to say them clearly here for the last time:

 

1) Epi is a dangerous drug. We use it to get someone's heart to start beating again following cardiac arrest. It is NOT something that we can administer "just in case," or if we think that it "just might help" the patient. It simply does not work that way.

 

2) For these reasons, only educated medical professionals should be administering it. Medical care needs to be provided based on a thorough, accurate assessment of the patient. A lay person, or even an FR or EMT does not have the education necessary to perform this type of patient assessment. A lay person, FR or EMT cannot decide whether Epi is indicated, or whether some other form of treatment should be used instead.

 

3) If you're so concerned about having Epi available, you need to bring someone with the necessary education, equipment, certification and license along to evaluate the patient, and administer it. At the very least, you need to have a physician provide you with some type of protocol for administering a dangerous drug - a drug you don't have sufficient knowledge of, a drug whose potential side effects you cannot manage.

 

Honestly, if you're this concerned about being able to give Epi, there are far more common, serious issues that you could also be worrying about. Perhaps, rather than trying to be allowed to administer dangerous medications without the necessary training, you should plan activities that keep your scouts close to professional EMS and hospital services, if this is a serious enough concern for you.

 

EDITED TO ADDRESS BEAVER'S POST:

I agree with what you say - trained, educated personnel should administer life-saving medications to sick people. Untrained persons should not.

 

Just a few things in that quote you provided: being trained in a WFR course to perform a certain skill, such as administering Epi, does not mean you are legally allowed to carry Epi, and actually administer it to a patient. The ability to carry and administer epinephrine is determined by state laws, and the physicians whose medical direction you operate under. As that quote said, Epi is a prescription medication, and is regulated.

 

Just to be clear, if you are adequately trained in administering Epi, and have the state's and a physician's approval, go for it. But, I'd wager that these "examples of new onset anaphylaxis in outdoor programs that have been treated by epinephrine carried by the program" were actually treated by medical personnel with more medical training that the First Responder course.(This message has been edited by dScouter15)

[FScouter]

"Somehow I wonder in a situation like that if one would be sued for doing too much or not enough?"

 

You might be sued if your strategy was to ignore rules and sage advice, stash a few epi-pens in your first aid kit, and at the first sign of trouble stab your "patient".

 

 

[Beavah]

You might be sued if your strategy was to ignore rules and sage advice, stash a few epi-pens in your first aid kit, and at the first sign of trouble stab your "patient".

 

Yah, and yeh might be sued by an upset parent if their kid died and yeh didn't have da industry norm standard of care in place, eh?

 

I don't reckon anybody is breakin' into the local pharmacy, stealing 1:1000 epinephrine ampules, and stashin' them in their first aid kits itching to shoot people up. Gern's a kind of funky guy and a liberal, but I don't reckon he does burglary . Fact is, many lay folks and even professionally trained folks in a true emergency fail to start CPR when they should, let alone whip out a syringe.

 

To have access to the drug, a physician had to write a scrip with instructions eh? So this really falls into only two possible categories. A trained person is operating under a physician's direction according to an established protocol, or a semi-trained person (like someone who has a severe allergy or a child with a severe allergy) is considerin' using their personal medication on someone in distress. The former is just fine, and shows good risk management, thoughtfulness, and prudence. The latter is a lay person put in an awful situation over their head and tryin' to do their best in good faith to help someone in dire need.

 

No problem with da former. For the latter, it's an awful circumstance we all hope never to be in, eh? That's why gettin' trained and establishing protocols in advance is worthwhile, and why Wilderness is on da right track thinkin' about this stuff in advance. But if someone's in that awful place, it's a personal choice. Remember they aren't without trainin' or experience at least with their own/their child's condition, and they're tryin' to balance an apparently life-threatenin' condition against a risk that is described by a panel of EMS physicians as "extremely small." Intervenin' would not be the best legal choice. But it might be an acceptable moral choice.

 

All this is fairly far afield from Wilderness's question, which was definitely da first case. It perhaps makes for an interestin' ethical dilemma to share with older scouts and crew members.

 

Beavah

 

[evmori]

You're gonna get sued by someone no matter what you do so the best thing to do is what is best for the victim.