Dilemma

[FScouter]

Such sagacious counsel Ed. What to do is what were debating.

[GernBlansten]

Please keep in mind the context of the scenario. This is not a mild allergic reaction or a case of the sniffles. Or even a serious situation but not life threatening. In that case, yes I agree, don't administer drugs unless qualified. The scenerio I am refering to is a life and death decision where the victim has just minutes to survive. One where if you don't act, he WILL die. I just can't imagine how you could live with yourself knowing you allowed someone to die and didn't do everything possible to save them.

[FScouter]

One could do a tracheotomy too with a pocketknife. Like the epinephrine injection, both should be a last resort. I suspect the ease of use of the epi-pen would translate into completly inappropriate use were it readily available in the firstaid kit of Joe Hiker.

[Gunny2862]

Absolutely,

In the best of all possible worlds the Scoutmaster is also an emergency room doctor and carries a full trauma bag and additional diagnostic equipment in addition to his camping gear. Has a Satellite phone and contacts with all of the applicable air evac services.

 

That is not the scenario any of us have any realistic likelihood to deal with.

 

On the other hand, what will YOU do IF that Scout or Scouter on your trip does lose the lottery and IS in extremis... and YOU lose the lottery and have to make the hard decisions.

Thinking about it now is unarguably the best start.

 

If someone has known allergies it should be their responsibility to 1) notify the leadership of the trip and 2) carry the required meds with appropriate instructions for their condition in a KNOWN and group standardized location in their personal kit.

 

If they run across unknown allergies - then you can only do what you are willing and have the capability to do. Having Benadryl on hand in the group first aid kit seems like a reasonable and fairly safe start. If the victim is gone so far that I don't reasonably see how I can cause any harm then it kind of opens the door a little wider on what I might try. So asking questions and seeking training NOW seems like a good idea. That said, not everyone is, can be, should be or will be trained to EMT standards. (My certifications end at Combat Lifesaver which has NO civilian application in liability standards, I would be treated as a lay person in court.)(But if the Scout/Scouter is dying, I think I have an ethical responsibility to do everything I can for them if other(better) help is not available to them.)

 

But some rationality comes into play and to shift it for some clarity - If a Scout has a three inch pulsing bleeder gash on their leg I'm not going to amputate. It just would be so far out of the realm of things that could help that it really doesn't fall into consideration. In the same way an anaphlytic reaction would have to get a little further along before I would skip other steps like finding out if it is a first time reaction, have they had bad or only moderate reactions before, do they have medications prescribed& if so - with them, calming them, attempting to start an evac, get some benadryl on-board, trying to clear the allergen if practicable/known. I share others concerns with the idea of some that might think - they're having an allergic reaction - shoot them up! There is simply more to most interventions than a process that is that simple.

 

And again the final question becomes would you be MORE willing to tell that family that "I did everything I could for your son?" or "I didn't do some other things that I knew how to do but am not currently (or never have been) certified to do which might have saved him because I was afraid you'd sue me."

[Beavah]

Having Benadryl on hand in the group first aid kit seems like a reasonable and fairly safe start.

 

Yah, but as dScouter pointed out, even this has its traps, eh? The layman isn't qualified to administer any meds. What would your Benadryl dosage be, for a given body weight youth? How 'bout if yeh were substituting chlortrimeton or one of da other antihistimines? In some ways, we should not carry any OTC meds in our first aid kits, at least not for anybody but ourselves. Best legal advice, eh? And good advice, too, in many ways. Lots of OTC meds can interact with a child's other meds, some pose odd low-probability risks, etc.

 

So an interestin' question for all of us would be whether we do carry OTC's, and would administer, for example, a Tylenol to a boy who had an ordinary headache? Knowing it would give him relief and make him comfortable, and also knowing that in certain very-low-probability situations it might make an underlying serious condition worse, or mask symptoms so as to delay evacuation. Do yeh allow a female Venturer to carry and self-administer Midol as a minor? As a female Venturing leader if you have Midol do you provide it to a venturer who is havin' bad cramps? Do we have "zero tolerance" policies that forbid scouts and venturers from even possessing any medications?

 

There's a big, broad grey area here. Da legal community is on one side, givin' the best legal advice. The medical community's view I've found is quite different and more relaxed. Da wilderness medical community's view is fairly hard-nosed practical.

 

This is probably a good discussion to have, at least for Scouting units that do "high adventure" trips.

 

Beavah

 

[Stosh]

Why would anyone with an Epi pen tell anyone else in the group that they carry one in case they get stung by a bee? Surely this information is totally irrelevent because these other people can't do anything about it anyway! I guess it's just their way of saying if they get stung and can't get to their Epi pen in time, they're going to die right in front of your eyes and there's nothing you can do about, so don't worry.

 

Yep, makes sense to me.

 

Correct me if I'm wrong, but if one waits until the person is "dead" before administering the Epi, there's no circulation to send the med's to the swollen areas so it's too late at that point anyway.

 

Stosh

[dScouter15]

If we find ourselves in a situation where a scouts life is on the line, I hope that we'd all use the most of our available resources, training and common sense to do our best to keep that scout alive.

 

However, WildernessStudent asked whether or not persons with standard first aid or first responder training should be allowed to carry Epi in a first aid kit, and administer it to persons without a prescription. I do not believe that this should be allowed, as a first responder lacks the necessary amount of education to adequately assess and treat a patient using a drug like epinephrine.

 

Based on my experience in emergency medicine, I can say with some certainty that untrained personnel administering dangerous drugs to others is not the "industry standard." While certain WFR or WFA courses may teach participants HOW to administer Epi, that does not mean that they have the necessary training to know WHY and WHEN to administer it. It also does not give them the legal capability to carry or administer it. I bet, Beavah, that if you look into any situations where Epi was administered on a standing order, you will find that it was administered by medical personnel with more education than the first responder level. But, for those who lack the necessary education to be able to administer medications correctly and safely, they should not be allowed to carry it with the intent to administer it as they see fit. Fortunately, you don't have to take my word for it - I'm pretty sure every emergency physician in the country would agree with me.

 

But, jblake - what a FR is trained to do is assist someone in administering their own EpiPen, which is why someone carrying an EpiPen may want to inform leadership of their condition.

 

That said, I am fully supportive of all efforts to put the necessary lifesaving equipment and medication into the hands of our scouters. But, if you decide you want to carry Epi, you also NEED to get the necessary education to know why, when and how to properly administer it - and this education is not covered in FR training.

 

(This message has been edited by dScouter15)

[Stosh]

Having been in these kinds of situations, I know what to expect, but one must also realize that with two deep leadership of BSA policy, nowhere does it say one of them has to be a first responder or medically trained. On any given weekend of all the units in the woods, how many have medically trained personnel on the trip? And how many of the participants of these trips carry Epi's? Hopefully the boy/scouter can get to his meds in time, if not...?????? So goes the dilemna!

 

Stosh

[dScouter15]

jblake - what do you want me to tell you? If you find yourself in that kind of situation, and you have someone else's EpiPen handy, you need to decide what to do. No one can tell you what you should or should not do in that situation. I can tell you that it would be illegal to do that. I can also tell you it might save someone's life. But, its still illegal. So that's a decision you need to make. However, this is a completely different question that what WildernessStudent asked when she started this thread.

[Beavah]

I can tell you that it would be illegal to do that.

 

Yah, we gotta be a bit careful here, dScouter. Hard cases make for bad law. It may very well not be "illegal" for someone to do that dependin' on what state they live in, eh? And even in the other states, I can't see a county prosecutor pursuin' the matter, or the courts not dismissin' it on public policy grounds and the like. Despite folks who like tellin' ghost stories, the law by and large is a reasonable fellow, eh? The trend in legislation has moved to includin' epi explicitly in Good Sam laws.

 

For da first case, the trend is also sharply in favor of supportin' lay responder access to lifesaving meds. For example, way back in '99 the state of New York began making epi available to medically untrained (not even FR level) camp and school staff for emergency use. Naturally, they get trainin' on epi administration. Massachusetts has done somethin' similar through regulation. I can't say how many states have gone that route overall, eh?

 

Interestingly, I found an American Academy of of Allergy/Asthma/Immunology position statement directly on point, which I copy below. These folks are docs who specialize in this area, eh?

 

Qualified lay personnel in positions of responsibility for public safety (e.g.,lifeguards, park and forest rangers, scout leaders, paramedics, school and industrial nurses, teachers, camp counselors) should be educated in the appropriate use of epinephrine and should be authorized to administer epinephrine for suspected anaphylaxis in conjunction with arrangements for complete medical management of the reaction... Epinephrine for injection should be included in all emergency medical treatment kits. (http://www.aaaai.org/media/resources/academy_statements/position_statements/ps26.asp

 

So again, da medical community is ahead of the law a bit on this, eh? I was actually a bit surprised that they even specifically recommend that scout leaders be authorized to administer epinephrine. This is how "standards of care" develop, eh, and we have to keep pace or be held accountable.

 

Da legal world is catchin' up, and in the meantime I don't reckon anybody's gonna get hanged if they respond in good faith in an emergency. Even if da legal world is slow to catch up, each person has to ask whether we want lawyers or doctors to determine our medical practice, eh?

 

Now da question is what do we do about givin' that kid with the headache a Tylenol?

 

Beavah

(This message has been edited by Beavah)

[Bob White]

I don't believe that anyone has said that people who are legally allowed and trained should not administer epi.

 

But you said that Wilderness Student by virtue of having WFR was certified to for the use of epi...and that wasn't correct was it?

 

Until the law changes or until there is a person in the group who meets the current criteria, then they should not be taking epi with them.

 

There are several far more likely life endangering things that can happen in the outdoors that they can prepare for, and do so legally, that epi-pens should not be the priority that it is being given here.

 

This is a rare and unlikely emergency.

 

(This message has been edited by Bob White)

[OldGreyEagle]

So, what is the result of the debate? That perhaps the new medical form should have a section that directs the physician to have the patient stung by a hornet, wasp and honey bee to determine if an epi-pen should be brought along?

 

And I thought the uniform effected recruiting

[dScouter15]

Beavah - as far as I know, it is illegal in every state to administer someone's prescription medication to another person. But, as you point out, you may not be prosecuted - but that doesn't mean its not illegal. I realize that when you're out in the woods facing a life or death situation, "you gotta do what you gotta do." And, as a healthcare provider myself, I wanted to give information as objectively as I can about what I understand of both the medical and legal aspects relating to this topic. I figure that the important thing is that we all know the objective information, and then can make our own decisions, and take responsibility for them. I'd imaging that this would be preferable to saying, "well, some guy called Beavah don't recon' anyone's gonna get hanged." Either way, that's not the point I was addressing.

 

OGE - My final position is that we all should provide first aid and/or medical care up to our level of training - no more, no less. Certain people are trained to administer epi and other drugs - most of us are not.

 

Please understand that I've been gearing my responses towards WildernessStudent's original question, which involved FRs carrying epi with them in their first aid kits, intending to administer it to youths without a prescription. This is not at all the same situation as whether to, in the heat of the moment, use someone else's epi pen on a potentially anaphylactic scout.

 

The trend in legislation has moved sharply in favor of supportin' lay responder access to lifesaving meds. For example, way back in '99 the state of New York began making epi available to medically untrained (not even FR level) camp and school staff for emergency use. Naturally, they get trainin' on epi administration.

 

So, if they're getting training, then they're not untrained, right? That's what I'm saying - FR training does not cover medication administration. An FR is no more qualified to administer epi than is a lay person. But, if anyone - lay person, FR, EMT, whatever - gets training to recognize what a drug like epi does, when it is indicated, when it is contraindicated, and how to properly assess a patient, administer the drug, and continue to care for the patient until definitive care is available - then by all means, get a doctor to write you a protocol and stock up your first aid kit with epi!

 

And, I'd like to re-direct your attention to some other key words in that quote you provided:

 

Qualified lay personnel in positions of responsibility for public safety (e.g.,lifeguards, park and forest rangers, scout leaders, paramedics, school and industrial nurses, teachers, camp counselors) should be educated in the appropriate use of epinephrine and should be authorized to administer epinephrine for suspected anaphylaxis in conjunction with arrangements for complete medical management of the reaction... Epinephrine for injection should be included in all emergency medical treatment kits.

 

Again - getting the education and training is key. It doesn't matter who you are or where your going, but you should NOT be performing healthcare related tasks on other people, such as giving medication, unless you are adequately educated and prepared to treat a patient in this way. Its also worth noting that this is a recommendation, not law. Again, as a medical professional myself, I am very familiar with the screwed up medical-legal system in this country, but I cannot in good conscience advise someone to do something that is illegal - regardless of whether or not I feel it should be illegal.

 

In summary, and I promise this is the last time I'm going to say this:

 

1) If you're in the woods, facing a life and death situation, you got to do what you think is best. There may be consequences, but, at that point, its your call.

 

2) There are regulations as to who may carry and administer certain medications, like epi. Persons not trained in their actions, uses, indications, contraindications, side effects, and related patient assessment and management should not and are not qualified to carry and administer these medications. First Responders fall into this category. That's not just my opinion - that's the law, and there are perfectly good medical and legal reasons for this, which I and others have already discussed at length.

 

3) Trained personnel should, by all means, take whatever first aid and medical equipment they can into the field with them. Epi is a wonderful drug that may indeed save someone's life - but it needs to be administered by someone educated in its use, and by someone who is legally and medically authorized to carry and administer it.

 

If we can all remember back to WildernessStudent's original question, she asked, as Wilderness First Responders, would her staff be qualified to carry Epi in their first aid kits to administer to others without a prescription. The simple, objective answer to this question is NO. However, if her staff decides to pursue more medical training, so that they can safely and appropriately carry and use epi, or any other drug for that matter, by all means, go for it!(This message has been edited by dScouter15)

[Beavah]

But you said that Wilderness Student by virtue of having WFR was certified to for the use of epi...and that wasn't correct was it?

 

Yah, BW, it's a bit tough to be clear because I think you're just not familiar with da issues and language, eh? Like there's no such thing as bein' "certified for the use of epi", leastways not in most jurisdictions. Dat's just not how the system works. If you're interested, I'd encourage yeh to take an EMT-W course. That's also a great thing to have as a scout leader.

 

Nobody should be carryin' epi without appropriate trainin' and physician direction (or state approval). I completely agree. To get it, they'd have to rob a pharmacy, and I figure that's against da Scout Law in some way, eh? But that wasn't Wilderness's question. Wilderness's question was about pursuin' somethin' fairly ordinary - carryin' epi under standing orders as trained WFRs. In fact, they already had a physician identified who had agreed, eh? (I think yeh missed that, dScouter...)

 

Now, if yeh back up, what I said was that WFR trainin' and certification includes epinephrine trainin'. That's true, I stand by it, and I've presented evidence from da major providers of that certification. I also said that it was common for outdoor education programs to carry epi for use by trained leaders under physician's standing orders. Dat's also true, I stand by it, and have presented statements from both professional and collegiate programs, eh? Yeh now have da formal position statement of the board of physicians with the most experience in the matter which says that even volunteer scout leaders should be trained and should carry epi in their first aid kits.

 

So I don't think I've been misleadin' anybody in any way.

 

I think it's important not to get stuck on da fatality rates for bee stings. Medical pros aren't just concerned about fatality rates and bee stings, eh? There are a lot more allergies out there! Food allergies, asthma with triggers that can result in severe anaphylaxis, exercise-induced anaphylaxis, latex allergies to da gloves in a scouting first aid kit or drug allergies to neosporin that we might put on the wound and the like. Kids don't always carry their meds, nor do parents always report what's relevant (especially in split families). And there are a lot of very bad things that happen to someone's body goin' through that kind of reaction which may stop short of fatality. Is it acceptable to watch a lad suffer and be hospitalized, when we could have provided proactive treatment? Anaphylaxis overall is in da range of tens of thousands of hospitalizations each year, and a significant and growin' percentage of the population at risk.

 

Finally, if we dig a bit deeper in the stats, we realize that the risks are greatly elevated for adolescents and for remote areas. 1-2% of the population is allergic to bees, but most of 'em don't go out where there are a lot of bees, eh? That keeps the incident numbers low overall. However, scouts and outdoor programs like Wilderness's do go out. A lot. 1-2% means that there's a pretty good chance scout units and outdoor programs are gonna run into this, eh? And that's not countin' other allergies.

 

Until yeh get that EMT-W, BobWhite, I wouldn't recommend that you carry epi, eh? But I'll stick by da notion that Wilderness is doin' her "due diligence" (as you put it), which all good outdoor leaders should.

 

Includin' Scouters, eh?

 

Beavah

 

[dScouter, I think we're in complete agreement, eh? I think yeh just might have misread Wilderness's circumstances and background](This message has been edited by Beavah)

[Beavah]

So, what is the result of the debate?

 

Missed this while I was bein' longwinded, eh?

 

I don't think there was any debate. Wilderness and her group should pursue acquirin' premeasured epi kits under da direction of the physician they've identified, eh?

 

Scoutin' is a tougher game. I just don't know, myself. I'm fully supportive of da troops and crews who carry Rx meds under standing orders (and with appropriate training) for high adventure and international trips, eh? I think dat's a standard of care we should aspire to in many ways, especially as da nation's preeminent outdoor program for youth. I think we, like da schools, also owe it to kids with disabilities to be properly prepared to deal with da issues those disabilities may generate. That means gettin' better trainin', and bein' more savvy about having established protocols in place, eh? There are probably some risks if we do not.

 

Where it's hard, I figure, is that our volunteer pool doesn't consist of bright college kids with time and interest in training, eh? Plus we've established a culture of safety-by-control rather than safety-by-knowledge, especially with respect to meds.

 

That's why I was curious about da OTC meds, without gettin' into Rx stuff, eh? Perhaps a different thread...

 

Beavah