EMS and epinephrine administration

[name]

Stay tuned for a first-person perspective fresh from a NREMT accredited BLS EMT-B course taught by a faculty of military and civilian paramedics.  Learned a lot, made some great friends, and discovered how cavernous the divide is between BLS field treatment and allergy. 

Note: USA specific

[name]

Several housekeeping issues for this thread. 

1. As a guest contributor I cannot edit.
2. In the interest of time management efficient snippets will have to do. 
3. EMS is by nature regional protocol despite efforts to standardize.

First, I'd like to correct an earlier statement about accreditation.  Our state education department provides accreditation of EMT basic life support and advanced.  The national accreditation is for the paramedic program.  All are licensed by the state and geared towards standards set by NREMT, and if I understand testing correctly NREMT sets the standards. 

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Epinephrine administration scope is not equivalent to standard allergist Emergency Action Plans. 

FARE's intentions were great to make it possible for EMT basics and above to administer epinephrine.  It helps.  Unfortunately, we (BLS) are taught that anaphylaxis is indicated only by bronchonspasms and / or hypotension by vasodilation.  Anything else is not considered anaphylaxis no matter what two or more other systems present.

Additionally, they seem to teach that 911 is called out to administer epinephrine to patients.  Weird to me considering it says right on the EpiPen they use to train that patients self-administer then call 911.  Almost no time has been spent on rebound reactions.  I'm not sure anyone in the class is at all aware they occur.  Most seem to come away with the idea that we would be dispatched with our vial of epinephrine to administer subcutaneous route if stridor is either auscultated by steph, or heard without it.  My bet is most BLS would focus on your airway instead of BP, GI, or subjective feelings (foggy, weakening, etc.). 

So, what to do?  Plenty of issues created here that might be best solved with FARE's EAP filled out by your allergist.  It would create sort of an offline medical protocol established by a treating physician.  This proactive documentation could solve a few problems, easing tensions.  I'll attempt to explain why in the next post.

[name]

These are short definitions for context.  They are not intended to be complete or all encompassing. 

PCR Patient Care Report is the medic's written narrative.  It documents the response to the patient, scene, etc., so take care this is from the medic's perspective and done to protect the medic and agency. 

Scope is the predefined permissions and limits by state and region a level of practice for any provider.  All regions have a medical control with a medical director.  Offline protocols are essentially written permission to treat or administer similar to our Emergency Action Plans (to provide common point of reference).  When in any doubt we are to radio in to medical control for online direction from a physician most similar to what we would experience on a plane during medical emergency.

Veering from offline protocols threatens the established EMS system.  They have seconds to perform assessments.  Given scope limitations, offline and online medical direction, and very little time to react on scene, preparing to react with the system could help.

Know that the PCR will be the medic's narrative.  Think about how to translate the allergist's EAP into quick, efficient communication that fits in with scope and medical direction.  Does the anaphylaxis grading scale make sense in these circumstances?  No.  But when asked as a patient you can relay that you are following your allergist's standing orders for treatment and hand over a copy of the EAP.  In my mind FARE's infographic EAP cuts through a lot of static.

A good thing to keep in mind is what BLS is mainly trained to do: life support.  If you are walking, talking, following care based on the orders of a very well qualified board-certified allergist, prehospital transportation by EMS is not dialed in to that at all.  They did not attend medical school and they are not going to understand nuanced care.  They are there to package patients up for the hospital and keep you stable until they can transfer you officially into the care of a licensed individual at their level or higher.

We're also trained to focus on airways at BLS.  If it doesn't involve the airway the care understood at BLS level (and arguable ALS, depends) then it may not be a well understood emergency.

I wish allergist and allergy orgs would transfer and train all efforts on EMS systems until they were brought up to speed.  If I can I'll post a copy of my albuterol drug card.  It still states contraindications include peanut allergy though AAAAI debunked this myth years ago. 

[name]

One more related thought: no allergist should be afraid to thoughtfully respond in action and word to patient inquiries on the process of initiating EMS--from administration of epinephrine to arrival at the hospital.  I'd go further, calling it a duty to make contact with regional medical directors, particularly for the large segment of patients with comorbid asthma and anaphylaxis.  Empty platitudes fail to address deficiencies, or worse; put a patient at higher risk needlessly due to condescension.

[Macabre]

Thank you for this thread, Name. Wow. This really hit home with me and reflects my experience--that they are concerned with breathing.

I'm posting a link to a thread where I had to deal with EMT cluelesness about anaphylaxis and the subsequent huge bill for transport.


Chasing my ambulance bill

[name]

In-flight anaphylaxis as experienced by a flight paramedic.  A narrative with lessons learned.  The training to recognize anaphylaxis based almost solely on airway compromise persists.

How I survived in-flight anaphylaxis ems1.com/anaphylaxis/articles/148861048-How-I-survived-in-flight-anaphylaxis/

You might be asking the question I have heard from many paramedics, why didn't she give you epinephrine? Or you're thinking you would have given me epinephrine without a second thought. Or, thinking that everything here seems completely appropriate to you.

I was trained, as was my partner, that epinephrine should be given in an allergic reaction only if there are obvious signs of airway compromise. As I learned through this experience and my research, the newer practice is to give epinephrine at the first sign of a severe allergic reaction or anaphylaxis, with or without a complaint of difficulty breathing.

[Macabre]

SMH

[name]

Medics practice under the license of the medical director, usually a doctor at a larger regional ER.  Our medical director still thinks peanut allergy is a reason to not neb albuterol, although this has been debunked as a myth by AAAAI for years. 

It always comes back to scope and region.  Calls for allergic reactions are few compared to major trauma or cardiac events.  A lot gets truncated in order to reduce it to muscle memory under extreme stress and time constraint.  Being a better informed medic doesn't negate orders from medical control, or defined scope.  Say you get me responding to a call for a reported allergic reaction.  I can't base my decisions on what I know personally about anaphylaxis and epinephrine.  A patient vomiting with hives may be presumed to be anxious about the hives.  Many would reach for diphenhydramine if it's within their scope.  I would have to justify administering epinephrine according to the offline standing orders with protocol.  Did I arrive at the decision to administer epinephrine according to agency guidelines?  FARE has a couple of webinars on this topic.  It's not as if they are unaware of this gap in conventional best practices and initiating EMS according to EAPs. 

No one should get discouraged by this.  Problems don't go away for lack of identification.  EMS is an extremely difficult job with a high burnout rate.  If no one is going to address the gap we will have to do our best as patients to work within their system and liability to implement our EAPs. 

[name]

These posts are not in any order of importance.  They are more based on available time to post.  Just something to keep in mind.

I'd like to emphasize first that EMR and EMT-B are the most restricted scopes.  This is typically defined at the state level involving drug administration and procedures allowed.  National standards are considered and of course the regional medical director calls the shots--literally and figuratively.

What else would I add for patient consideration?  Aside from scope and experience, medics come from a wide variety of backgrounds.  We are trained to rapidly assess mechanism of injury or nature of illness (among a host of other things) to determine if we must treat disease, injury (trauma), or combo.  The biggest gains in prehospital transport has been trauma care.  There are medics who are battlefield trauma gods.  If I were hit during a mass casualty incident you bet I'd want that sort of experienced medic.  For anaphylaxis, perhaps not.  Depends.

Medics can get stuck in tunnel vision where calls get categorized.  I would say despite the best of intentions, and these are not only good people but they really are determined to render the best care to each and every patient, they may just not be able to sync up with what allergists would do under the same circumstances.  There are so many different types of trauma and disease signs and symptoms to treat, and each call has its own challenges (physical obstacles, gathering information, # of patients on scene, danger, etc.).

FARE, Allergic Living, and the community can and should do more to address the communication gap.  I'm using this thread as a platform to log some thoughts and communicate with other stakeholders.  An ideal outcome for me (and I hope some of you) is a targeted business communication with our concerns clearly outlined. 

When I can do so properly I will address asthma and anaphylaxis.  I think those remain riskier prehospital treatment.  In my EMT course, which used very industry standard textbooks, not one portion of instruction for drugs or treatment mentioned comorbid asthma and anaphylaxis.  The only association presented to us was aspirin 'sensitivity' correlated with asthma and peanut 'sensitivity' as a contraindication for albuterol administration.

[name]

None of this is medical advice.  Although this is MDI (patient prescribed metered dose inhalers) in testing this was lumped in with albuterol, and hence my error in the previous post.  Please take note.  I will revise in the next post.   

aaaai.org/conditions-and-treatments/library/asthma-library/peanut-soy-inhaler

PEANUT-ALLERGIC AND SOY-ALLERGIC PATIENTS CAN SAFELY USE ASTHMA INHALERS

Information has been circulating that a lot of inhaled medicines for asthma also contain soy and that some children with peanut allergy can also cross react to that, implying that asthma inhalers may be dangerous for patients with peanut or soy allergies. Where did this idea come from?

Ipratropium bromide is a bronchodilator medication used frequently for COPD (chronic obstructive pulmonary disease, mostly from smoking) and less often for asthma. The old formulations of two inhalers containing ipratropium, brand names Atrovent and Combivent, contained soy lecithin as an inactive ingredient and the product labeling warned that the medication should not be used in those with "hypersensitivity to soy lecithin or related food products such as soybean and peanut."

There have been a handful of reports in the medical literature of adverse reactions to these inhalers. In some cases, the authors of the reports speculated that the reactions were due to soy allergy because the inhalers contained soy lecithin. However, none of these reports demonstrated an actual allergy to the soy lecithin in the inhalers and in some cases, the patients were demonstrated to not be soy-allergic. Thus, despite the warning, there have been no substantiated reports of patients having any sort of adverse reaction to these inhalers because of soy or peanut allergy.

Lecithin is a fatty substance found in some plants. One of the sources of lecithin used in pharmaceutical agents is soybean oil. Patients who are allergic to foods, including soy and peanut, are allergic to proteins in the foods and are not allergic to the fats or oils in the foods. Soy lecithin may contain a trace amount of residual protein, however no allergic reactions have been demonstrated to be caused by this. Although peanuts and soybeans are both in the legume family, the overwhelming majority of peanut-allergic patients are not clinically allergic to soy, and even if they were, would not be expected to react to soy lecithin.

Many asthma inhalers used to contain chlorofluorocarbon (CFC) as a propellant. All inhalers containing CFC have been phased out because they are harmful to the environment. This includes the Atrovent and Combivent inhalers that contained soy lecithin. The new, currently available Atrovent and Combivent inhalers do not contain CFC and do not contain soy lecithin.

Thus, it appears that the concern regarding asthma inhalers and peanut or soy allergy is due to the combination of misperceptions explained above.

[spacecanada]

Thanks for posting that, name.  I was really twisting my brain to figure out how a peanut warning was ever issued for albuterol, as I have heard that reference a few times previously as well.