Epi-Pens: Discussion

[CTXMEDIC]

From Vegas, Atlantic City, or where?

I wish. Nobody knows 'from where'. I guess we'll just print more. Its like having checks in your checkbook. If you have checks, you have money, right?

[akroeze]

Sorry.... what does any of this have to do with the topic? I notice lately people have been bringing their own agendas and pushing them into threads.

[tniuqs]

... and what did OPAL prove ?

Scientific studies don't "prove" anything.

Funny I thought this is why we do studies ?

OK some brilliant conclusions in OPALs :

That the sooner you get on scene to an out of hospital arrest (BLS or ALS) then more of then patients survive using old CPR standards, conclusions are 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.

[Dragoon]

New York state does allow BLS units to carry epi-pens. The following is taken from the New York state protocols for Anaphylactic Reactions With Respiratory Distress or Hypoperfusion

If either cardiac or respiratory status are abnormal, proceed as follows:

A. If the patient is having severe respiratory distress or hypoperfusion and has been

prescribed an epinephrine auto injector, assist the patient in administering the

epinephrine. If the patient’s auto injector is not available or is expired, and the

EMS agency carries an epinephrine auto injector, administer the epinephrine as

authorized by the agency’s medical director.

B. If the patient has not been prescribed an epinephrine auto injector, begin transport

and contact Medical Control for authorization to administer epinephrine if

available.

VI. Contact Medical Control for authorization for a second administration of the epinephrine

auto injector, if needed.

The REMSCO (NYC region) protocol, #410 for Anaphylactic Reaction is nearly identical to the state's with the assisting and use of the epinephrine auto injector being left up to the agency's medical director.

i. If the patient is having severe respiratory distress or shock and has been prescribed an

Epinephrine auto-injector, assist the patient in administering the Epinephrine (0.3 mg via an

auto-injector). If the patient’s auto-injector is not available or expired, and the EMS agency

carries an Epinephrine auto-injector, administer the Epinephrine (0.3 mg via an auto-injector)

as authorized by the agency’s Medical Director.

ii. If the patient has not been prescribed an Epinephrine auto-injector, begin transport and

contact On-Line Medical Control for authorization to administer 0.3 mg Epinephrine via an

auto-injector, if available.

NOTE: IN THE EVENT THAT YOU ARE UNABLE TO MAKE CONTACT WITH ON-LINE MEDICAL CONTROL

(RADIO FAILURE, NO COMMUNICATIONS) AND THE PATIENT IS UNDER 35 YEARS OF AGE, YOU

MAY ADMINISTER 0.3 mg EPINEPHRINE (ONE DOSE ONLY) VIA AN AUTO-INJECTOR IF INDICATED.

THE INCIDENT MUST BE REPORTED TO ON-LINE MEDICAL CONTROL AND YOUR AGENCY’S

MEDICAL DIRECTOR AS SOON AS POSSIBLE

iii. Contact On-Line Medical Control for authorization to administer a second administration of

0.3 mg Epinephrine via an auto-injector, if needed.

I am only aware of one agency in NYC who's BLS units carry epi pens, New York-Presbyterian. FDNY EMS' medical director has decided that their BLS units will not carry them.

[Krysteen]

Interesting topic. Here in Michigan, Basics are required to have both adult/junior EpiPens and be trained in their usage. In fact, the only other 'drugs' they carry is oral glucose and O2. They can assist a patient administer their own NTG, ASA or inhaler.

As Charlee said, we work the same way. Basics have yearly training to be able to recognize anaphylaxis and the usage of epi-pens. It has been this way for a couple of years now. Some services are limited in ALS and this can be a valuable life saving tool.

[fiznat]

Funny I thought this is why we do studies ?

Its a question of terminology I guess. When we do research we don't say we've "proven" anything, because we haven't. What we've done is provided evidence for, or against a hypothesis. The difference may seem like semantics but it really does go right to the core of the scientific method ideal.

**Note, I'm going to have to "quote" you from here on using italics and underline. I guess this new software doesn't allow multiple quoting**

I am having a difficult time in your theory that common sence has been detrimental to patient care.

"Common sense" is not a basis for a standard of care. Think about back in the day when they used to bleed sick patients out in hopes of ridding people of the "bad blood" in their bodies, or more recently, MAST trousers. That was a standard of care based upon the common sense of the time. Just because something seems to make sense logically does not mean that it actually works. That is why we do research and why, even today, we must confirm with science even the most basic of our assumptions.

Age is a huge determination in trauma outcomes ... and best re read the study yourself as clearly the type of trauma groups is disimilar.

I know that age is a huge determination in trauma outcomes. Nobody is disputing that. What I am saying is that the differences observed between the two phases of the study were NOT due to age differences within the populations. As I posted, the researchers controlled for that. If you are telling me that the groups are dissimilar in some other way, please tell me where because age is not it. Again, the average age for BLS was 44.8 and for ALS was 47.5.

Exactly ... .8 % is insignifigant in making a conclusion ... but that is what OPAL study conclusions claimed and has very negatively impacted ALS providers in AB.

I don't think you understand the meaning of this reported measurement. A 0.8% difference does not mean that no conclusion can be made. To the contrary, it means that there was no observed difference between the two phases of the trial. This is called "confirming the null hypothesis," which means that the treatment (adding ALS to a BLS service, in this case) made no difference in the measured outcomes.

Best look to inclusion and exclusion criteria before you suggest that I do not have a clue.

If you have an issue with the inclusion criteria please identify it specifically. I'm not sure what you are referring to.

So placing tubes "in hospital" and starting lines "in hospital" is superiour to door discharge positive outcomes ?

Nobody said that. What the study showed is that it didn't help (or hurt) patients to have these things done prehospitally on trauma patients. It made no difference. Be careful about applying your personal feelings when reading research like this. Nobody said paramedics were bad at starting tubes/lines, or that the hospital did it better. The research is only capable of giving evidence about the specific areas it is testing. This research looked at adding ALS to a previously BLS-only system, and it turns out - in this case - it didn't make any difference (for trauma patients).

My point is first attemtpts were far superiour to other studies ie Wang et all and without Paralytics or all the toys available that of us have today, could it be that 100 % of airway capture

Ah, okay, but that really is irrelevant to the subject at hand.

Not really that humerous as the bean counter "pole cat titions" jumped all over this, twisting it in the media and causing a huge step ass backward for advancement of prehospital are in Ontario, for a .8% difference in outcomes .... hey you said it yourself.

Why would the truth result in a huge step backwards? If paramedics really ARENT helping these patients, maybe the money would be better spent elsewhere, right? Remember the goal here isn't to increase funding for EMS, it is to analyze the best way to provide prehospital care for our patients. We should want to perform treatments that are effective, not keep on doing the "same ol' thing" even though rigorous study shows that it doesn't help.

That said, one study alone shouldn't be a basis for policy. It is the caveat of ANY research article that repetition is necessary before we can really start using these results in our daily practice.

I am looking at the damage it did to Advancment of Advanced Care ... it becomes rather obvious that you are using this study to justify the status quo of the PCP in urban areas in Ontario.

Again, we can't be damaged by the truth. If what we're doing isn't effective then we should be eager to change it. I'm not "using this study" to justify anything, I'm just reading the results and thinking about how it applies to our current standard of practice.

Oh but you do have EPI PENS ... and just how many acute anaphlaxis are you seeing in ONTARIO?

Huh? I don't live or work in Ontario....

Survival to door can not be the measurement when EMS is such a small part in the overall treatment of the trauma patient what happens in the hands of ALL of the others in the chain of survival, this should be factored in ... and good grief man, putting a spin on "this is why we do it" is laughable as a justification

Sortof. I think you're right in that there are a lot of confounding factors when you try to evaluate EMS care based on results that occur days (if not weeks or months) later after many other interventions are made. Still though, it can't be ignored that survival to discharge is the only thing that really matters. What difference does it make if our patients arrive with a pulse only to die 10 hours later in an ICU bed?

Sure I will give you a break ... but a question as well ... just why were the 2 largest poulation bases ommited ? Oh thats right because they are totally ALS, and so just what are the combined population of Hamilton and TO ? You do not think this is not sinister ? ... the look to just who provided the funding for this study, honestly a waste of 24 million .

Yeah those are two large cities that were excluded. ...But they were excluded for a good reason. They weren't able to adapt to the model being used in the study. You can't ignore the fact that this study is STILL by far the largest prehospital study conducted to date. To say that it is invalid because it wasn't even bigger is a bit ridiculous because if you say THIS was invalid based on size, then NOTHING else is valid, either. No other study touches this one on population size.

If you have an issue with improper funding then please point it out specifically. I'm not aware of any funding issue that might have resulted in tainted results. If you are, please let us know.

I thing you are wrong, the studies in Trauma outcomes in IRAQ and AFGANISTAN and the difference in treatment ARE very different they are not limited to a bottle of the cheap "kool-aid" blend.

You're talking about some VASTLY different populations here, in different environments with different logistical constraints but even still: if you are going to refer to a study, please provide a link. I'm not sure exactly what you're referring to.

Ok now you are blowing smoke ... just how many acute anaphlaxis patients treated just BLS with an Epi Pen survive vs the ability to make a surgical intervention or treat the indivudual with inotropes if there truely not self limiting ... show me the MONEY ... NO study has ever been done in this area of present contraversy.

Do you know how to use pubmed? http://www.ncbi.nlm.nih.gov/pubmed/

The value of epinephrine in acute anaphylaxis has been well established. Searching for terms "epi pen," "anaphalyxis," and "self-administered epinephrine" provides a long list of studies.

[tniuqs]

haha okay, nice gross generalization.

The OPALS study was conducted in Canada. ....That first O stands for Ontario.

This is where the "rational" thread was taken off topic ... but as everyone knows one simple statement or query in EMS has many ramifications, using that concept ... if its possible to go off topic, it will.

My comment was quite Clear I thougt, as did mobey's comment as well, there is no subversive agenda other than all trucks in Canada should be ALS ... is that a bad thing ? NOPE it should be the standard of care no mater where you live and anything less is an excuse to give substandard care.

As I have stated before, chipping away one drug at a time is a waste of bloody time ... no clear research has ever been undertaken as to the the incidents of true anaphlaxis and the outcomes BLS vs ALS ... the whole philosophy of "supposedly" improving care without ALL the tools required to do the job correctly this is not only folly but the duck walk mentality and we are setting precedence to never become accepted as highly trained proffessionals, just ambulance drivers that can take care of "some" issues.

Point being that carring Epi vs actually TREATING the Acute Anaphlaxis patient ... do you see the point because if not its just daft thinking.

So to sway off topic look to one of the largest call type .. seizures ... should BLS providers start packing benzos too ... because one person died ... again a huge error IMHO.

cheers

[emtpro87]

on my volunteer squad we have been issued Epi Pens on the rigs , our squads has 3 ambulances each ambulance contains 2 pedatric doses and 2 adult doses.

We had to get additional training to better recognize the signs and symptoms of a anaphylaxis reaction,

we are only allowed to give a single does of the epidephrine, any addition medication must be give by paramedics or by doctor at the hospitals..

as i understand it the program has been successful reducing deaths from anaphylaxis shock ...

i believe its a reasonable solution for situations when medics are not available.

[Kiwiology]

Adrenaline is a Paramedic or Intensive Care Paramedic skill here; our Ambulance Technicians do not carry it in either ampoule form or autoinjector.

By contrast in Canada it is a PCP skill (analouge to Technician) and in Australia (specifically NSW, Vic and Qld) it is a Paramedic (base level) skill becuse they do not have Technicians.

Some of our ambulances have a Paramedic, some have an Intensive Care Paramedic and some just have two Technicians (although they are getting less) so its a bit hit and miss.

[Suburban/Rural Medic]

Here in Newfoundland and Labrador, EMR's (two week course) can administer 160mg ASA for Ischemic Chest Pain and Cardiogenic Shock, Oral Glucose for Symptomatic Hypoglycemia (can't check blood sugar) and can only assist a patient in administering their own Epipen for moderate or severe allergic reaction (Epinephrine is not carried by EMR's).

In a perfect world, we could say that no medication would be administered by anyone who doesn't extensively understand how it operates at the cellular level in various types of patients, all of its side effects and potential complications, indications, contraindications and precautions. Fact is, it will continue to happen as long as there is a lack of fully trained providers (or money) and where the pros of administration outweigh the potential cons.