Epi-Pens: Discussion

[emtannie]

Now can you kill someone with .5 of epi ... again oh yes you can, just take the next obese cardiopath (that just so happens to "react" to bee stings and is already taching along at 140 bpm ... give him epi instead of benadryl ... because he is still moving air and 15 minutes after the insult ?

[WolfmanHarris]

By Richard in another thread: As a case in point, EMTs in New York are allowed to give nebulized albuterol to asthma patients, but if treatment is started, in the FDNY EMS Command, that means the patient is going to the hospital by either ALS, or BLS, but the patient is definitely going!

So now I'm really confused about the NYC system. As a Basic you can give neulized albuterol but not an epi-auto-injector for anaphylaxis? (Not even talking ampules here) What about ASA or NTG? What's the rationale here?

[Richard B the EMT]

So now I'm really confused about the NYC system. As a Basic you can give neulized albuterol but not an epi-auto-injector for anaphylaxis? (Not even talking ampules here) What about ASA or NTG? What's the rationale here?

FDNY EMS BLS EMTs are allowed to give Albuterol for asthma, 81 Mg chewable aspirin for chest pain/suspected cardiacs, assist a patient in taking the patient's own nitro pills, but at this time, NO BLS EMT is authorized to use an Epi-Pen in the entire state of New York, not just the FDNY EMS.

Again, we're awaiting the NY State DoH to approve a Pilot Program, SOMEWHERE in the state, for EMTs to be allowed Epi-Pens, as per what I have already stated, that we have had the training, but are not allowed to use the training.

[WolfmanHarris]

Weird.

Sorry Richard, not picking on you, just found the whole thing confusing. If I was introducing meds into a BLS system I'd have put epi ahead of ASA (if I had too). It seems to me there's less room for mistakes with the epi for anaphylaxis than there is for ASA. I mean I keep a list of NSAID's above my computer and in my pocket on rideout/lab just to keep pushing memorization of them in case of allergy.

On the flip side, I kinda like that at the state level they are maintaining a tight grip on scope. I get worried when I hear about BLS providers getting too much of an ALS scope with little to no further education through medical direction.

[fiznat]

... and what did OPAL prove ?

Scientific studies don't "prove" anything.

OK some brilliant conclusions in OPALs :

That the sooner you get to an out of hospital arrest (BLS and ALS) then more of then patients survive (ps and old CPR standards) Bloody Rocket Science .... and it only cost 12 million to evaluate that .. sheesh man. Now on the same issue this has given the Fire Departments impudus to purchase AEDs ... huh?

This comment is really very poorly written and hard to understand, but I think you are trying to say that response time is too obvious of a factor to be considered by rigorous research. On that point you are completely wrong. I don't think I should have to explain to you how often so called "common sense" solutions have been proven ineffective, or worse, detrimental to our patients. This is the reason research exists. ...And no, of course they didn't spend all of the grant money on answering this one question. Duh.

And If you look and actually READ the ALS outcomes in Trauma .. you will find a differenet demographic group was evaluated in ALS vs BLS. (ps geriatrics composed more in the ALS group) hmmm again.

Ah, wrong. I did read the study. The mean age was 44.8 for the BLS phase and 47.5 for the ALS phase. Considering the size of this study (2,867 people), the age difference is by definition statistically insignificant. Or are you suggesting that people become "geriatric" when they reach 47.5 years of age? Where are you getting this stuff from?

If I can recall a .8 % difference in to door discharge ... I will look at the study again this just off the top of my head.

Close enough. The point is that the outcome between ALS and BLS was statistically insignificant, meaning that the differences observed could very well have been due to chance alone.

Can You say FLAWED, I can on the groups studied alone !

What? You can? Did I miss something? The OPALS is the largest and longest-running rigorous prehospital study performed to date. I don't think you have any clue what you are talking about.

But look to the success rate of Intubations WITHOUT paralytics about 80% first attempt ... and large bore IVs established .. nice job Ont ACPs !

Its actually 71.8% success for intubation and 90.3% for IV access, but again you are missing the point. The study shows us that EVEN THOUGH the medics usually got their tubes and lines, in the end it didn't make a bit of difference for these trauma patients.

Look past the very now very dated info and jaded conclusions

lol

...but do look to the recognition of superiour treatment for SOB and Cardiac and outcomes and OPAL researchers conclusions there!

So you want us to ignore the trauma study because it is "dated and jaded," but the results from other portions of the same study are accurate? How is that, exactly?

Honestly' date=' it amazes me just how many pple read the conclusions and political/media spin ... INSTEAD of reading the entire study and draw to their own conclusions.[/quote']

Perhaps you ought to re-read it.

Survival to discharge is the only measurement that matters. That is why we do what we do. ...So people can walk out of the hospital doors.

I think you are referring to Toronto and Hamilton. These were excluded because they had pre-existing ALS systems and it would be impossible to perform a "before and after" procedure for the evaluation of ALS. There isn't anything sinister here. Keep in mind the study did still run in 17 other cities with a total population of 2.5 million people. Are you saying the study is invalid when it looks at 17 cities, but would be valid if it studied 19? Give me a break.

The protocols haven't changed that much. Slightly altered fluid resuscitation guidelines aren't going to shake the foundations of this study, sorry.

[WolfmanHarris]

Hey Squint, I think you might be suffering from something I was when I first read OPALS. The conclusions of OPALS seem very threatening to EMS providers as it seems to conclude that we're somewhat irrelevant and that the grand experiment of EMS will come to an end and we'll all go back to be Ambulance drivers. And yet, that hasn't happened? Why?

There may be many reasons for this, but unlike you and Fiznat I have not read the entirety of the study. I did just download it and it's on my reading list for the end of the week. Either way, I think we need to look at this study as we would any other study as part of the ever evolving world of medicine, interesting. If we're not challenging and reexamining our role in medicine and how we do things we're stagnating and not doing ourselves justice as medical professionals.

Think of it this way, if every physician resisted with fear and unease the concept of delegating medical acts not only would we not have EMS, but would nursing, RT or any other part of medicine look anything like it does today?

[Richard B the EMT]

Weird.

Sorry Richard, not picking on you, just found the whole thing confusing.

Don't worry about confusion.

2 things that you should know about New York City, at least by my observations:

1) New York City is a law unto itself. As one example, everywhere else in the country, including the rest of the state of New York, you can make a right turn after full stop at a red traffic signal, unless there is a sign saying "No Turn On Red". In New York City, you can ONLY make the turn where it is posted that you CAN make the right turn on red. Same setup on a second example, traffic in a traffic circle has right of way over traffic entering the circle, EXCEPT in the city, where entering the circle has the right of way.

2) I posit that, in the City of New York, if it makes sense, it is against someone's rules, regulations, protocols, or the law.

[mrmeaner]

If I was introducing meds into a BLS system I'd have put epi ahead of ASA (if I had too).

I don't know that I'd agree. Granted, in acute anaphylaxis an Epi-pen or epi ampules are a life saving tool. However, if I remember correctly, ASA is the only medication given by any level of EMS proven to increase morbidity and mortality in acute MI. I would think that ASA has saved more lives in acute MI than epi has in anaphylaxis.

In any case, it should not be a matter of one or the other. Both should be available.

[WolfmanHarris]

I don't disagree in terms of ASA and how often we get CP calls over anaphylaxis, my argument was more in terms of training and education that epi's an easier starting point than ASA in terms of contraindications, conditions, etc. If you've got them giving ASA and they have to do such complicated things as remembering NSAID allergies and making sure there's no active bleeds and being cautious if there's Hx of asthma and no previous ASA use than why not give them an epi-pen and show them "pointy end comes from here. This end goes into fleshy part. Don't stick yourself, their wallet or anyone else. Dispose of safely." I've shown eight year old how to do it on themselves...

Anyways, like Richard said, New York's weird and NYC even more so.

[akroeze]

ASA is the only medication given by any level of EMS proven to increase morbidity and mortality in acute MI.

Typos are fun