How many Epi Pens?

[fuji]

My DD14 was diagnosed this summer with a peanut allergy. We live in Eastern Montana with just a tiny little hospital(if you can call it that!) there is an ER, but it takes sometimes as long as 30 minutes for a health care provider to arrive. There is no one standing by! It is 80 miles to the nearest "real" hospital and from there the distance to the next hospital can be even greater depending on which direction you are going! My DD rides the bus with her school team to various towns all over Montana, there is no nut ban on the bus. She so far is not contact or inhalation allergic. What I worry about most is eating out at restaurants and then her having a reaction on the bus. So the question is: How many Epi Pens should she have on the bus? She has 2 she self carries and the coach takes the 2 from the office so she has a total of 4, is that enough?
How many should we have when traveling in the car? We only have the two that she self carries.

[CMdeux]

 


It was at just such a hospital (in small-town So MN) that my DD15 had her first anaphylaxis episode treated at 11mo of age.

So I know exactly what you are talking about.

Here is what I'd recommend that you do--

1.  Discuss the right number to carry with your allergist-- this is something that s/he will definitely want to help you plan.  I'm GUESSING that a minimum of 6 is a good "travel" number under the circumstances-- it's likely double what you'd ever NEED on hand, and that means that using them won't leave her without epipens as she returns home from an overnight hospitalization in heaven-knows-where-and-60mi-to-a-gas-station.  All-night pharmacies aren't on every corner either, KWIM?  Maybe 3 on her, and 3 with an adult.  We generally carry about 6 as we travel in remote Western areas by car, if that helps.  This includes the Cascades, and the eastern deserts-- distances are long with few service points in between, so we figure that we MUST be on our own in treating a reaction-- probably for as long as 30-40 min. 



2.  I think that you may HAVE to ask for a nut-ban on that bus.  The odds of something terrible happening are too high given the relative consequences-- this is a life-flight situation, probably.  Yeah, banning overt nuts on the bus is a pain.  Granted.  But the consequences are pretty dire-- and your DD just demonstrated that her threshold is such that cross-contamination is enough. 

3.  Eating out... yeah, that is a pretty high risk, depending upon where you're eating.  That said, I recommend that your DD or an adult carry a "just in case" emergency stash of something like nut-free energy bars (Enjoy Life brand makes some), or other shelf-stable products that are something for her to eat if they wind up stuck somewhere that there simply ISN'T other safe food.  Weather is also a factor-- so plan for the worst case scenario there.

[fuji]

" in heaven-knows-where-and-60mi-to-a-gas-station." That is exactly right! It would be funny if it wasn't! I always send her with a small snack box that includes Capri Sun, breakfast bar, crackers, beef jerky and sometimes some candy. I also send her with a shoe box with more of the same plus some easy mac, cup o noodles and anything else I can cram in there! I do this on the off chance that they do get stuck somewhere and all that is available are peanut butter granola bars! I called the allergist this morning and meant to ask this very question and forgot, because I had so many questions! I'll have to call back. I asked about a nut ban on the bus and it wasn't well received, but they will have to revisit that in about a year or so because there is a little boy in the elementary school that is inhalation allergic. I think I'll ask the allergist this as well! The coach is working with me to get me the names of the restaurants beforehand and making sure that they eat in a safe place, not sure what that will look like in the end due to availability depending on where they are competing.

[devnull]

We have prepaid memberships to air ambulance.  It doesn't give you the ability to summon one but in a crisis it may be the nudge dispatch needs to get that call out.  I'd try to track down what kicks off that chain of events.  What does dispatch want to hear?  Pediatric patient, severe allergy, need advanced life support, remote location, we are REACH or Lifeflight members, we need pediatric care.

A helicopter will get there faster and hopefully is ALS Advanced Life Support.

[fuji]

Please explain the prepaid air ambulance? I'm not sure we need this or why we would? Unless there is something that I don't understand. We have a small hospital (clinic) with an ER, and they do life flight out of here as a matter of fact the field behind my house is where they land. I'm not sure that having a prepaid would get us one any faster, the nearest large airport is over 200 miles away. Our PA told us that life flight usually gets here within 30 - 45 minutes. Explain please, I think I'm missing something. 
Thanks!

[devnull]

It doesn't get one faster, necessarily.  On paper it does not "do" anything as far as dispatch is concerned. Neither do you need to do it, similarly to any firemed program run by the city that offers a prepaid membership.

But dispatch controls the calls for service and who responds.  Not even the doctor or the fire department or ambulance, air or ground, controls it.  And not all ambulances are the same.  The best resource would be FARE's 911 Lottery webinar to explain the patchwork of service areas, possible response types in terms of EMS personnel and ambulances, and how to work with dispatch when you call to drop key phrases likely to get the right team with the right equipment.

There's a difference between ALS and BLS ambulances.  When I call, and just this last week I had my youngest present with a lightning fast spreading reaction that landed us in the ER, I transmit the following: pediatric patient, age, request Advanced Life Support, history of anaphylaxis, and whether or not I've administered epinephrine.  When my older child travels more out of range of even our regional small ER, I know there is an air ambulance that could be dispatched from where we live.  I confirmed with them that it is advanced life support and equipped to handle a pediatric patient and roughly the time to response by helicopter in comparison to a ground crew out making it up old forestry roads to research or ranger stations for school field trips.

The local air crew is pretty helpful, as are the full medics.  Much like MedicAlert works with EMS to coordinate on language and appropriate response I communicate directly with the response teams in my area both ground and air.  Our city offers prepaid firemed for ground, and REACH is our regional service provider for air.  In a pinch I would do as I played out the hypothetical with the air crew on how I would communicate in a way that would knock down any barriers of financial concern for dispatching an air unit that could reach a remote forested area in 15 minutes rather than 30-45 by ground, if at all, then direct transport on ALS with pediatric equipment to a larger hospital set up to handle a pediatric patient who may need life support.

Both the city run firemed memberships for ground and air med cover the ambulance overage not covered by insurance.  For us, having to make as many ambulance runs as we have, it helps stave off the sort of medical debt that might ultimately crush us. 

You're not required to do it, and I apologize for not making that clearer.  On topic of remote field trips and needing epinephrine as a function of response time of EMS and ultimate transport to a facility that could handle a pediatric patient needing adjunctive therapy to epinephrine this is how we've refined our scripts to communicate effectively with dispatch and helped control costs that could easily spiral even with our cadillac insurance policy.

However, calls for service are not given uniform response, nor are service areas and personnel and equipment uniform.  Communicating with the dispatcher who does have authority over the call for service can affect response.  The 911 Lottery webinar has a better explanation.

[devnull]

Because we probably have more lurkers that may want to know more about the 911 Lottery webinar, a link.

Food Allergy, Anaphylaxis & the 911 Lottery - FARE Webinar

Picture the scene. You, or your child, are experiencing symptoms of a severe allergic reaction. You go to grab your auto-injector from your purse and it's not there. After a moment of panic, your pull out your cell phone instead and call 911. The dispatchers reassure you an ambulance is on its way. Everything's going to be OK. Right?

This webinar takes a look at some of the issues of epinephrine availability and administration by EMS providers, including the legislation, guidance documents, and some individual state initiatives. Results from a recent survey of almost 1,000 pre-hospital caregivers are also presented. Finally, it provides some tips to help you navigate the 911 lottery.

Judi Miller is a registered nurse, EMT and EMS educator. She is a co-author of the 2013 publication: "Customizing Anaphylaxis Guidelines for Emergency Medicine" and a tireless advocate for ensuring that all ambulances and emergency medicine personnel are authorized to carry and administer epinephrine.

For anyone wanting FireMed coverage just Google or go down to main fire station.