EMS and epinephrine administration

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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