# Asthma Attack, No Inhaler... What to do?



## IvanD (May 26, 2011)

Hey all,

I hope this isn't a stupid question but I'm curious as I had a debate with my instructor about this the other day. To give you a background I'm a W/MFR and I was taking the exam for ARC Lifeguarding. One of the questions asked were:

You arrive on scene and find a child having difficulty breathing, you determine that it is asthma. However he does not have an inhaler with him, you should:

(I don't remember all the answers but I narrowed it down to two)

a) Use the inhaler provided by a stander by.
b) Call EMS and help child sit in the most comfortable position to help breathing.

I put a) however, what I was thinking was I'd choose A and then bring him to a hospital. I also thought it depends on how bad of a condition the child is in, if he's hypoxic to the point he's cyanotic, then I would not hesitate using someone else's inhaler.

However, ARC's model answer is B and my instructor argued against using someone else's prescription. He also said at "this level of training" we should just call EMS.

My question is, which one would you have chosen? I understand that when I was taught this in my WFR class I was told to use someone else's inhaler, however that's possibly due to the factor of longer exposure and the remoteness of location. In a pool which should be easily accessed by EMS, should the provider (lifeguard) just have sat there and waited for EMS while the child is struggling the breath? Would this still be the case if the child was becoming cyanotic?


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## rwik123 (May 26, 2011)

IvanD said:


> Hey all,
> 
> I hope this isn't a stupid question but I'm curious as I had a debate with my instructor about this the other day. To give you a background I'm a W/MFR and I was taking the exam for ARC Lifeguarding. One of the questions asked were:
> 
> ...



Call ALS. In your scope you can only assist with the administration of a meter dose that is prescribed to the patient. Not a bystander. Urban EMS and wilderness is totally different. In the wilderness the window of care is far longer in time. And unless you are part of a rescue service specializing in remote rescue, you'll be using your wilderness skills with friends or family.. When liability doesn't exist. And usually rescue teams where you would encounter this, would include some ALS element that could deal with it.


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## firecoins (May 26, 2011)

A is a bad idea. Using medication that is not dosed right for a child is BAD.  It was not prescribed for the child.  And its offered by a complete stranger....whose intentions may be less than good and whom may have a communicable disease.

Give the kid O2 if possible, call ALS and wait for medics.


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## nwhitney (May 26, 2011)

I would also choose B.  Never give someones meds. to another person.  On a side note I teach ARC Lifeguarding.


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## mycrofft (May 26, 2011)

*Sounds like we're Monday Morning quarterbacking?*

1. If you are in the middle of nowhere, (and this kid would not have business being there, screen your cohorts more closely), and there is no hope of quick transport and there are other inhalers available, hike your party out as fast as you can to where you can get proper care or dustoff/transport. The kid might need to go with the fastest hikers while the slowest ones wait in place, or the party splits in two (the second is better if the kid is being carried, you may need relief turns). Using another person's MDI, especially if they are of different body size, is not recommended. 

2. If you are at a community pool, no excuse for administering another person's meds. Get the kid upwind from the pool and wash off the pool water if applicable, maybe a reaction to the chlorine or bromine they use. Once a kid has a respiratory episode, out of the pool and into the arms of a caregiver, even if they feel better.

Even as a nurse, I once used a MDI on a minor which was not Rx for her when she had a bad attack thirty minutes from getting help plus ?? minutes or hours to get transport there (at least half an hour to get to a car and half an hour to drive out). I sweated it plenty until we got back to base and her mother took over and thanked me. Could have had me cited just as easily.


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## Icenine (May 26, 2011)

I'm not sure about your area but I don't have mfrs that can transport.  So you should be stabalizing them as best you can (loosen tight clothing, hose them off, help them into a position of comfort) while waiting for the ambulance that your LG partner already called.  If you don't have them enroute chances are it will be uncontrolled by the mdi and they will die in front of you.  Call more help than you need early, its easy to let the pt refuse later if they still have a pulse and respirations.


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## johnrsemt (May 26, 2011)

have them breathe through a cool, wet towel or tshirt.   the cool humid air helps alot.    it has helped me when I haven't had my inhalor,  and before I could convince the Doc I had Asthma.
  Also keep them calm,  and other people away from them  (crowds don't keep people calm).


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## WTEngel (May 26, 2011)

I am an ARC Lifeguard Instructor and Instructor Trainer (in addition to a few more legitimate EMS certs...) So I will weigh in with my professional opinion here.

The correct answer is B, make them comfortable, contact EMS, provide supportive care within your scope of practice.

The rationale is that you never give prescription medication to a person for which it is not prescribed, whether it meets the needs of their condition or not. Physicians prescribe meds, lifeguards do not.

I understand that you are trying to say that sitting around and watch the child struggle when the inhaler may likely help is a bad idea, however what sort of liability do you incur by making the decision to just up and give someone else's medication to a person who it is not prescribed to? You do not know the dosing information, specific medication (their are quite a few inhalers out there, and all of them do not contain albuterol) and additionally you do not know what kind of exposure you are risking by sharing someone else's inhaler.

At the lifeguard or WFR level, you do not get to decide to give someone a medicine that has been prescribed to someone else. It is just that simple.


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## medicdan (May 26, 2011)

Bottom line. You don't know (cannot confirm) the child is indeed suffering from an asthma attack, as opposed to other respritory aioments, cannot confirm what medication (and route) is prescribed for the patient, don't have parental consent in what is not currently a life-threatening situation, cannot confirm the quality, content, stability and purity of the bystander's prescription, and you have no method of monitoring (or treating the complications) from the medication.

Keep it simple, and call EMS.


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## Akulahawk (May 26, 2011)

IvanD said:


> Hey all,
> 
> I hope this isn't a stupid question but I'm curious as I had a debate with my instructor about this the other day. To give you a background I'm a W/MFR and I was taking the exam for ARC Lifeguarding. One of the questions asked were:
> 
> ...


Answer B is correct. At a pool where there's good access for EMS, the lifeguard should do exactly "make the child as comfortable as possible and wait for EMS to arrive." If you are authorized to administer oxygen, you should do so, within the limits of what you're authorized to do. The lifeguard should _not_ use someone else's MDI because that MDI is set for the person that it's prescribed for. That's both the medication (could be a specific blend) and dose to be delivered. 

WFR is a completely different beast (different environment and considerations) than urban lifeguarding. Administering someone else's MDI to that kid would open you up to tremendous liability personally, professionally, and possibly criminally (especially if) in the event of an adverse result because you acted out of scope _and _beyond the limits of your training/education. 

I know of what I speak. I have the ability to work in two completely different medical environments, with scopes of practice that are usually incompatible with each other, yet the knowledge gained from each field can (and does) compliment each other pretty well.


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## EMSrush (May 26, 2011)

I agree with others. If I had the two options that you provided, I would choose B. You would never want to give anyone someone else's prescription.


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## IvanD (May 26, 2011)

Thanks for all previous replies!

So curious, if you are in the backcountry. Same situation.

Would you give someone else's inhaler to the child?

Would not doing anything to the child be considered negligence? And there's definitely liability if you do give the child someone else's MDI. What would you do?


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## medicdan (May 26, 2011)

IvanD said:


> So curious, if you are in the backcountry. Same situation.
> 
> Would you give someone else's inhaler to the child?
> 
> Would not doing anything to the child be considered negligence? And there's definitely liability if you do give the child someone else's MDI. What would you do?



For good reason, there are no written protocols for wilderness emergency medicine, there are guidelines, and common practices, but not broad-ranging rules. 
A good part of Wilderness medicine is preparation, but that aside, it would depend on the situation-- severity of attack, work of breathing, lung sounds, distance to nearest road, distance and time to definitive care, level of training and capacity of medical personnel, availability of spacer device, details of prescription (medication, expiration date, quantity of drug left), etc. This is not a simple yes or no question. Generally, however, it's my policy to avoid the sharing of meds.

And no, in an urban environment, not giving the MDI would not be negligence or abandonment, as long as you are providing the standard of care otherwise (assessment, oxygen administration, rapid transport if warranted).


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## fafinaf (May 28, 2011)

aside from the test question... what can you do for someone when they are having an asthma attack with no inhaler.. obviously call ems if its really bad but what simple on the fly trick can you use? someone said breathing through a cold wet towel/shirt. is there anything else?


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## Melclin (May 28, 2011)

*Euuuugh*

I understand that a body like arc can't recommend such a thing officially, but reasonably I wouldn't have any issue with using someone else's puffer.

That said our situation is different. Firstly salbutamol is not a prescription drug here. It was made available OTC because people kept dying because they'd run out without a repeat, forget to pick prescriptions etc. Secondly, anybody giving a person salbutamol would be covered under good Samaritan leg.

I don't know why people have that much of an issue with it. It's a pretty harmless drug in most ways, certainly more harmless than a nasty asthma attack, or the vague posibilty of a communicable disease. Like I said, I get that  professional body can't recommend it as such, but with a little good judgement thrown in I don't see much of an issue with it.


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## BEorP (May 28, 2011)

fafinaf said:


> aside from the test question... what can you do for someone when they are having an asthma attack with no inhaler.. obviously call ems if its really bad but what simple on the fly trick can you use? someone said breathing through a cold wet towel/shirt. is there anything else?



Can you explain how breathing through a cold wet towel/shirt would help? Air will always be warmed and humidified as it enters the body, so I can't see why you would want to make that process more difficult for the body by cooling the air before it enters. Maybe someone can enlighten me...


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## BEorP (May 28, 2011)

Melclin said:


> I understand that a body like arc can't recommend such a thing officially, but reasonably I wouldn't have any issue with using someone else's puffer.
> 
> That said our situation is different. Firstly salbutamol is not a prescription drug here. It was made available OTC because people kept dying because they'd run out without a repeat, forget to pick prescriptions etc. Secondly, anybody giving a person salbutamol would be covered under good Samaritan leg.
> 
> I don't know why people have that much of an issue with it. It's a pretty harmless drug in most ways, certainly more harmless than a nasty asthma attack, or the vague posibilty of a communicable disease. Like I said, I get that  professional body can't recommend it as such, but with a little good judgement thrown in I don't see much of an issue with it.



Completely agree. 

I realise that it is "wrong" by the standard of "never give someone someone else's rx" but we also need to be reasonable.

If you were off duty and had a friend have an anaphylactic reaction when they didn't have their EpiPen with them but someone else had one, would you tell your friend to use it? I certainly hope so.


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## Sandog (May 28, 2011)

BEorP said:


> Can you explain how breathing through a cold wet towel/shirt would help? Air will always be warmed and humidified as it enters the body, so I can't see why you would want to make that process more difficult for the body by cooling the air before it enters. Maybe someone can enlighten me...



I have had asthma since I was a kid, long before inhalers were available. Back then, when I had an attack my dad would take me to the ER for a dose of EPI. Anyways, my parents put a humidifier in my room while I slept, it was thought that the moisture would help break up the mucus in the chest. Now as an adult, if it is at night, and I feel an attack coming on, I will step outside. The cool night air seems to help.

With that said, when I am having an attack, the last thing I want in my face blocking my airway is a wet shirt. I need all the air I can get.


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## johnrsemt (May 28, 2011)

Don't know how or why it helps,  but if it is hot outside,  breathing cool air through a wet shirt or something does help.  Also stepping outside if it is cool out helps,  but not when it is 100 deg outside

  As to why it works,  maybe to just keep calm and concentrate,   not sure.


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## paramedic911 (Jun 13, 2011)

b) Call EMS and help child sit in the most comfortable position to help breathing.
 is the right answer


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## Joe (Jun 13, 2011)

the 5 r's of medication? never give someone elses meds. its not your problem that they dont have the medication that they are susposed to have. remember its not your emergency. just call als and give him o2


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## Outworld (Jun 14, 2011)

*Backcountry asthma*

In the backcountry?  No question. If the child has a hx of asthma, is having an asthma attack and uses an albuterol MDI and you have a similar MDI available then hand it to the kid, he / she will know what to do. There are MDI's that are NOT 'rescue inhalers' and YOU need to know the difference. (many patients do not). The dosage for an albuterol MDI is not a big issue, without the use of a spacer half the drug is wasted anyway. 
Kids die every day from asthma attacks and if he/she cannot break the attack then you may well end up on the wrong side of the curve...
As for other options in the wilderness...
Coffee may help relieve some of the symptoms. Since many attacks are related to allergies an antihistamine may help. In some cases inhaling steam from boiling water will loosen secretions. There is often some combination of mucous buildup and bronchoconstriction. Keep the patient hydrated. Calming measures are very effective. Have the patient focus on slowing their breathing down, taking deeper breaths, holding for a moment then blowing out through pursed lips. Epinephrine from your epi-pen if the symptoms become acute. All of these assume that you have the baseline knowledge and skills to use these interventions appropriately. 
If you want to be effective providing medical care in the backcountry then learn the types of medical events that kill (like asthma) and research the drugs and S&S that go along with these medical issues. Become 'informed' beyond your scope of practice and you will make better decisions overall. 

As for your question about not doing anything being negligence? You cannot be held liable for choosing not to do something outside of your scope of practice and / or training. 

At the poolside, 02 and calming / breathing measures are your choices. Spend some time with someone with chronic asthma and ask them to show you how to talk / calm someone through an attack...



IvanD said:


> Thanks for all previous replies!
> 
> So curious, if you are in the backcountry. Same situation.
> 
> ...


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## Sandog (Jun 14, 2011)

When in the back country, there is the legal issue, and then there is the moral issue. This is a call you will have to make. An inhaler could be the difference between life and death. Your call on this one.


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